What Are the Special Needs of Older Adults With Serious Illness?

Frailty

Frailty syndrome in older adults is characterized by progressive decline in physiological reserve, increased vulnerability to stressors such as an acute illness or injury, and adverse clinical outcomes. Several operational definitions of frailty have become widely accepted and validated in population studies of older adults. The frailty phenotype described by Fried and colleagues characterizes frailty as a syndrome of compromised energetics with five core clinical features: low grip strength, slowed walking speed, low physical activity, self-reported exhaustion, and unintentional weight loss. Frailty is present when three or more of these clinical features are met, and prefrailty is present when one or two criteria are met. The frailty index (FI), developed by Rockwood and colleagues, is another commonly used tool to assess frailty and conceptualizes frailty as an at-risk state characterized by the age-associated accumulation of deficits. The FI calculates risks for frailty in older adults by accounting for deficits across a range of problems including difficulty completing activities of daily living and instrumental activities of daily living, diseases, physical and psychosocial risk factors, and geriatric syndromes identified through a comprehensive geriatric assessment (FI-CGA). Embedded in both of these definitions is the concept that age-related multisystem accumulation of physiological decline underlies frailty, and that the sum of these deficits increases vulnerability to adverse clinical outcomes due to a loss of physiological reserve. Frail older adults, as identified by these operational definitions, have poor clinical outcomes that include worsened mobility, decreased independence, and increased falls, hospitalization, and mortality. Thus frailty syndrome exemplifies serious illness in older adults, and its clinical manifestations closely mirror the definition of serious illness. More specifically, frailty reflects the increased morbidity and mortality risks, increased symptom burden, and functional dependence due to fatigue, and worsened quality of life and caregiver strain that typify the care of an older adult with serious illness.

While there are no expert consensus guidelines on the treatment of frailty syndrome, exercise intervention and patient-centered interdisciplinary care models, which have shown benefits in the care of frail patients, are often recommended (see Chapter 54 ). Aerobic or progressive resistance training exercise performed two to three times per week improves muscle strength, gait velocity, aerobic capacity, endurance, balance, mobility, and functional performance, and reduces falls in older adults. Moreover, the benefits of exercise extend to the frailest subset of older adults including those who are homebound or institutionalized. Implementation of patient-centered, geriatrics-focused comprehensive assessment and management improves clinical outcomes and quality of life in frail older adults. This approach utilizes an interdisciplinary team consisting of a geriatrics-trained physician, nurse, social worker, occupational and physical therapists, and others to provide comprehensive care, with particular emphasis on setting goals of care, improving or maintaining function, and improving quality of life. Both outpatient (Geriatric Evaluation and Management [GEM], Comprehensive Geriatric Assessment [CGA], Program for All-Inclusive Care of the Elderly [PACE]) and inpatient (Acute Care for Elderly [ACE]) care models have been shown to reduce functional decline, home health care utilization, hospital length of stay and readmission, and mortality in frail older adults. Given these benefits, exercise interventions and geriatric care models should be incorporated into the treatment of frail older adults in order to optimize their care.

Falls

Falls and fall-related injuries increase with age and lead to poorer physical functioning and increased institutionalization, morbidity, and mortality. The etiology of falls is multifactorial and includes risk factors such as prior history of falls, gait impairment, use of walking aid, cognitive impairment, urinary incontinence, visual and hearing impairments, and polypharmacy. The treatment approach for falls in older adults centers on identifying and addressing these risk factors in order to prevent future falls. As such, the intervention approach is multicomponent and tailored to meet the unique needs of each patient. For instance, clinicians need to be mindful that medications including benzodiazepines, opiates, antipsychotics, and anticholinergics can increase the risk of falls; therefore appropriate deprescribing (e.g., withdrawal or reduction of medication) of these medications is indicated and needs to be considered in conjunction with the patient’s care goals.

Mobility Impairment

Mobility impairment in older adults encompasses declines in gait, balance, or transfer skills that lead to adverse outcomes including falls. The “Get Up and Go Test” is a commonly used method to evaluate functional gait. The clinician observes a patient rising from a seated position in a chair, walking (noting stride length, gait speed, and symmetry), turning, and sitting once again. Balance, such as semi- and full-tandem stances, is commonly assessed by using the Berg Balance Scale or Short Physical Performance Battery. When mobility deficits are identified, referral to physical and/or occupational therapy should be made in order to begin individualized interventions aimed at reducing these deficits. These interventions include gait, balance, transfer and strength trainings, education and prescription on appropriate use of assistive devices, and evaluation for appropriate footwear. Because environmental hazards such as poor lighting, cluttered walking surfaces, or lack of support railings are common in the homes of older patients, corrective strategies need to be applied to remedy these hazards. Examples of these strategies include improving lighting in poorly lit areas and at night, decluttering areas in the home where the patient frequently traverses and spends time (e.g., bedroom, bathroom, living room), removing tripping hazards (e.g., loose rugs), and installing support fixtures that facilitate transfer and balance (e.g., stair railings, shower grab bars, elevated toilet seat).

Dementia

Dementia is a chronic decline involving one or more cognitive domains (e.g., learning and memory, attention, language, visuo-spatial, or executive function) causing a deficit in at least one instrumental activity of daily living. The prevalence of dementia increases as people age, and it is underrecognized by families and clinicians alike. If within a patient’s care goals, reversible causes of cognitive impairment including side effects of medications, electrolyte abnormalities (e.g., hyponatremia and hypercalcemia), vitamin B ₁₂ deficiency and hypothyroidism, normal pressure hydrocephalus, and depression should be ruled out. The risks and benefits of medications that can worsen cognitive impairment (including antipsychotics, benzodiazepines, sedative-hypnotics, and opiates) need to be carefully evaluated and discussed with patients and families. Neuropsychiatric symptoms including agitation, depression, apathy, and psychosis are nearly universally present in patients with dementia and are among the most distressing symptoms for caregivers and family members. The medical team should educate caregivers on nonpharmacological interventions to address these distressing symptoms, including providing calm reassurance, assisting with reorientation, and addressing unmet needs (e.g., pain, hunger, thirst, boredom, uncomfortable temperature). If dementia is identified at an early stage, the patient may still have the capacity to participate in advance care planning, including identification of surrogate decision makers and completion of advance directives. In addition, patients and families must be made aware that patients will progressively lose their ability to independently complete instrumental activities of daily living and eventually activities of daily living, and plans should be made regarding anticipated increased caregiving needs or placement in a higher level of care. Dementia is covered in greater detail in Chapters 41 and 42 .