Frailty in older adults: Implications for end-of-life care
ABSTRACTFrailty has important implications for the care needs of older adults and how those needs are met. By recognizing frailty and measuring it objectively, clinicians can better engage patients and their loved ones in difficult discussions about treatment plans and prognosis, and ultimately deliver better palliative care.
KEY POINTS
- Frail older adults are more susceptible to delirium, functional decline, impaired mobility, falls, social withdrawal, and death.
- Evaluating the health care needs of people who are frail requires assessment of their cognition, function, mobility, balance, and social circumstances, in addition to understanding their medical problems.
- When people are so frail that they cannot withstand interventions that can cause significant injury, such as surgery or chemotherapy, then appropriate end-of-life care should focus on maintaining their highest-order functions.
- End-of-life care can include curative treatments of some episodes if they threaten cognition, mobility, or function or cause pain and suffering, even in the context of an overall palliative care plan.
FRAILTY AND END-OF-LIFE CARE
Frailty is progressive, and as it worsens, integrating a palliative approach is appropriate, with a focus on optimizing quality of life and relieving symptoms.4 This principle holds true regardless of the care setting, from acute care hospitals to hospice facilities and long-term care residences.
The principles of end-of-life care are applicable to frail individuals with progressive conditions from the time of diagnosis throughout the course of decline. As the population ages, more people suffer and die from progressive chronic conditions such as cerebrovascular disease, respiratory disease, and dementia.23 An interdisciplinary team approach can ensure all components of palliation are effectively delivered, such as easing symptoms, providing psychosocial and spiritual support, and improving quality of life.24
Pain management
Pain is widely underassessed and undertreated in older patients. Its management at the end of life is particularly challenging if the patient’s language is compromised, as in dementia.23,25,26
A recent cross-sectional analysis of self-reported pain in a longitudinal study of community-dwelling older adults showed an independent association between moderate or higher pain and frailty. The authors propose that persistent pain goes beyond physical discomfort in that it may contribute to homeostenosis (progressive diminishment of homeostatic reserve) and directly worsen frailty.27
Examine the medication list
In palliative care, medical interventions focus on optimizing quality of life.
This especially includes reexamining long medication lists that increase the chance of adverse drug effects.28 Many patients are on disease-modifying medications that may or may not help control symptoms—and might well exacerbate them. For example, betablockers for ischemic heart disease and angiotensin-converting enzyme inhibitors for diabetic nephropathy both can cause hypotension-induced lassitude or even falls due to orthostasis.
A sensible approach is to keep the drugs that may still contribute to quality of life, while discontinuing other drugs that may be causing side effects or that are unlikely to provide meaningful benefit in terms of prevention in patients who have limited life expectancy.29 Discontinuing ineffective, poorly tolerated, and duplicated medications also makes it easier to introduce new medications to manage symptoms—there will be fewer drug interactions, and fewer pills to take, an increasingly important issue in the setting of gastrointestinal symptoms such as dysphagia and gastroparesis or compliance issues as frequently encountered when cognitive impairment is present.29,30
In managing symptoms, start low and go slow—but get there
In managing symptoms in frail elderly patients we use the same classes of medications as in younger patients. The trick is to use appropriate doses.
The concept of “start low and go slow” is key, but so is “get there”—ie, reach the therapeutic goal. The principal drugs for symptom control, such as opioids for pain and dyspnea and anxiolytics for anxiety and restlessness, are associated with a higher rate of and more severe adverse effects in frail older adults.
Even so, most frail older adults appear to be undertreated in this regard, particularly if they are cognitively impaired.23 This fact, coupled with the reality that behavioral symptoms associated with advanced dementia can represent unmet care needs including undertreated pain, highlights the critical need to control symptoms optimally in frail seniors.
This is particularly relevant for those who can no longer verbally articulate their symptoms. Nonverbal pain scales and vigilant assessment of behavioral signs of pain are paramount skills for clinicians providing palliative care to patients with cognitive impairment. Caregivers and loved ones should be included in the assessment process.26,31
Adjunctive therapies for pain control
Maximizing adjunctive therapies can optimize pain control in this drug-sensitive population. Heat and cold packs to affected areas, acupuncture, massage therapy, and structured exercise regimens are some options that can improve quality of life. Cognitive behavioral therapy may offer coping strategies, provided the patient can participate in this process from a cognitive perspective.26,27 Topical preparations are often well tolerated and may include medicinal ingredients that are helpful without systemic effects, such as anti-inflammatory drugs or analgesics.
Optimal use of nonopioid drugs may help reduce the need for narcotics, particularly in the presence of musculoskeletal pain. An example is acetaminophen in regular doses—we would recommend no more than 3 g per day. Acetaminophen is preferred for older adults rather than nonsteroidal anti-inflammatory drugs, given the potential gastric and cardiovascular side effects of the latter medications.
Antidepressants and anticonvulsants such as gabapentin can also be considered as adjuncts for pain control, particularly in the setting of neuropathic pain, with careful monitoring for tolerance.25
When opioids are used, vigilance for constipation is essential.
Establishing goals of care
Goals of care need to be established incrementally along the course of clinical decline and as early as possible so that palliative support can be promptly implemented as symptoms worsen.32
End-of-life care can still include treatments with curative intent, depending on the overall prognosis and the state of the underlying terminal illness. On the other hand, frail older adults who are subjected to invasive treatments that are unlikely to provide cure, such as Whipple surgery, need special intervention postoperatively if they are not to suffer complications such as persisting delirium and functional decline.33
In this regard, geriatric palliative care is frequently about not “crossing a threshold.” Patients may still be receiving active management and be hospitalized for acute exacerbations of progressing chronic conditions, such as chronic obstructive pulmonary disease and heart failure, while palliative principles are introduced and increasingly become the focus of care.
To align goals of care with frailty burden, it is crucial to quantify frailty and to review the patient’s comorbidities. Particularly when dementia is present, lack of communication between the patient’s doctors or between the doctor and the family about disease burden can lead to inappropriately aggressive care.
Many family members and even clinicians do not recognize that advanced dementia is terminal.34,35 In light of this, a palliative approach to care may not even be considered as an appropriate plan when hallmark complications associated with progressing cognitive decline occur, such as aspiration pneumonia or dehydration. Education about dementia and other conditions with progressive organ failure should be done as soon as possible after diagnosis and readdressed at intervals throughout the patient’s clinical decline.
Earlier discussions also ensure that patients themselves can be involved in decision-making more often before cognitive impairment advances to the point where proxy discussions take over.16
