Frail older adults deserve guidelines that take frailty into account while assessing the potential benefit and risks of treatment.
Specifically, our group—the Dalhousie Academic Detailing Service (ADS) and the Palliative and Therapeutic Harmonization (PATH) program—recommends that physicians strive to achieve more liberal treatment targets for elderly frail patients who have high blood pressure,1 as evidence does not support an aggressive approach in the frail elderly and the potential exists for harm.
This article reviews the evidence and reasoning that were used to develop and promote a guideline for drug treatment of hypertension in frail older adults. Our recommendations differ from other guidelines in that they focus as much on stopping or decreasing therapy as on starting or increasing it.
FRAILTY INCREASES THE RISK OF ADVERSE EFFECTS
The word frail, applied to older adults, describes those who have complex medical illnesses severe enough to compromise their ability to live independently.2 Many have multiple coexisting medical problems for which they take numerous drugs, in addition to dementia, impaired mobility, compromised functional ability, or a history of falling.
Frailty denotes vulnerability; it increases the risk of adverse effects from medical and surgical procedures,3 complicates drug therapy,4 prolongs hospital length of stay,5 leads to functional and cognitive decline,6 increases the risk of institutionalization,7 and reduces life expectancy8—all of which affect the benefit and harm of medical treatments.
Guidelines for treating hypertension9–11 now acknowledge that little evidence exists to support starting treatment for systolic blood pressure between 140 and 160 mm Hg or aiming for a target of less than 140 mm Hg for “very old” adults, commonly defined as over the age of 80. New guidelines loosen the treatment targets for the very old, but they do not specify targets for the frail and do not describe how to recognize or measure frailty.
RECOGNIZING AND MEASURING FRAILTY
A number of tools are available to recognize and measure frailty.12
The Fried frailty assessment13 has five items:
- Unintentional weight loss
- Self-reported exhaustion
- Weakness in grip
- Slow walking speed
- Low physical activity and energy expenditure.
People are deemed frail if they have three or more of these five. However, experts disagree about whether this system is too sensitive14 or not sensitive enough.15,16
The FRAIL questionnaire17 also has five items:
- Resistance (inability to climb stairs)
- Ambulation (inability to walk 1 city block)
- Illness (more than 5 major illnesses)
- Weight loss.
People are deemed frail if they have at least three of these five items, and “prefrail” if they have two.
These and other tools are limited by being dichotomous: they classify people as being either frail or not frail18–20 but do not define the spectrum of frailty.
Other frailty assessments such as the Frailty Index21 identify frailty based on the number of accumulated health deficits but take a long time to complete, making them difficult to use in busy clinical settings.22–24
The Clinical Frailty Scale7 is a validated scale that categorizes frailty based on physical and functional indicators of health, such as cognition, function, and mobility, with scores that range from 1 (very fit) to 9 (terminally ill).7,12
The Frailty Assessment for Care-planning Tool (FACT) uses scaling compatible with the Clinical Frailty Scale but has been developed for use as a practical and interpretable frailty screening tool for nonexperts (Table 1). The FACT assesses cognition, mobility, function, and the social situation, using a combination of caregiver report and objective measures. To assess cognition, a health care professional uses items from the Mini-Cog25 (ie, the ability to draw an analog clock face and then recall three unrelated items following the clock-drawing test) and the memory axis of the Brief Cognitive Rating Scale26 (ie, the ability to recall current events, the current US president, and the names of children or spouse). Mobility, function, and social circumstance scores are assigned according to the caregiver report of the patient’s baseline status.
The FACT can be completed in busy clinical settings. Once a caregiver is identified, it takes about 5 minutes to complete.
Our guideline27–31 is intended for those with a score of 7 or more on the Clinical Frailty Scale or FACT,7,12 a score we chose because it describes people who are severely frail with shortened life expectancy.8 At this level, people need help with all instrumental activities of daily living (eg, handling finances, medication management, household chores, and shopping) as well as with basic activities of daily living such as bathing or dressing.