The Frail Hospitalized Patient

Key Clinical Questions

How do you identify frail, hospitalized older patients?
What adverse outcomes are common among this population?
How can an interdisciplinary team prevent adverse outcomes for frail older patients?
What are the opportunities to improve long-term health outcomes?
What are the steps for establishing a safe and thorough discharge plan?

Introduction

Older patients disproportionately face many complications during hospitalization, including deconditioning from immobility, nosocomial infections, pressure ulcers, falls, and delirium. Hospital-associated deconditioning may lead to rapid functional decline. One in three older hospitalized patients loses the ability to perform at least one activity of daily living (ADL) by the time of discharge. Losing the ability to bathe or toilet independently may result in discharge to a nursing home for a patient who has previously lived independently. One in five hospitalized older patients is discharged to a nursing home due to a new loss of function. The frailest patients are at highest risk for hospital-associated functional decline and institutionalization.

If asked what a frail older patient looks like, many physicians would say, “I know it when I see it.” The thin older person who slowly ambulates with a walker is easily identified as frail. Nevertheless, recognizing frailty in clinical practice may not always be so straightforward. Frailty does not fit into classic organ-specific models of disease, and it may not be evident to clinicians, patients, or family members that there has been a decline in health. Declines in strength, mobility, cognitive function, and nutrition may be gradual. Patients or clinicians may attribute these changes to old age and not appreciate that a response is indicated to reverse the process.

Frailty may be particularly difficult to identify in the hospital setting. A physically robust older patient may be indistinguishable from a frail older patient at first glance if they are both acutely ill, dressed in hospital gowns, and lying in hospital beds. Without asking the right questions and assessing important factors such as mobility, cognitive function, and nutritional status, the health care team may fail to identify the frail patient and take appropriate steps to reduce the hazards of hospitalization.

Pathophysiology

Frailty manifests with a variety of clinical features including loss of strength, weight loss, low levels of activity, and slowed performance. The biological basis of frailty involves a combination of age- and disease-related physiological changes including skeletal muscle loss, changes in endocrine function, and chronic inflammation. Endocrine changes include decreases in estrogen, testosterone, growth hormone, and insulin-like growth factor, each of which has been implicated in muscle loss. Frail older patients have been shown to have increased levels of proinflammatory cytokines, such as interleukin-6 and C-reactive protein. Although these laboratory findings contribute to our understanding of the physiologic basis of frailty, they are not useful for diagnostic purposes, especially in hospitalized patients who have changes in inflammatory markers and endocrine function stemming from acute illness. Frailty remains a clinical diagnosis based on history, physical examination, and functional assessment. Frailty is perhaps best assessed in the absence of acute illness, thus making the diagnosis in the hospital particularly challenging.

While frailty is a clinical syndrome associated with physiologic changes, the most clinically useful way to conceptualize frailty among hospitalized patients is by asking the question, “Is my patient fragile?” Frailty may be broadly defined as a diminished capacity to withstand stress that, in turn, places individuals at risk for adverse health outcomes. Hospitalization is one of the greatest stressors an older patient may face. Therefore, in the context of the hospitalized older patient, frailty may best be defined as the patient characteristics most highly associated with adverse outcomes. Frail hospitalized patients are, therefore, those who are the most “fragile.”

The Fragile Patient: A 4-Step Approach

Caring for a fragile patient in the hospital has much in common with caring for any fragile entity. We propose a 4-step approach for managing the fragile older patient and demonstrate how each step compares to caring for a fragile vase. In step 1, we recognize that our patient is fragile and at risk for adverse events. This is analogous to receiving an heirloom vase from a relative and recognizing that its ceramic characteristics increase the likelihood of breaking. In step 2, we outline a plan for protecting the patient from adverse events in the hospital, similar to how we plan to keep our vase from breaking. In step 3, we identify the ways that we can promote positive health outcomes analogous to polishing the vase, optimizing its beauty and well-being. In step 4, we prepare a safe discharge plan, just as we decide how we will safely transfer our vase to another home.

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Case 169-1

Is this patient frail?

An 88-year-old man presents to the hospital with confusion and decreased appetite over 3 days. Past medical history is significant only for hypertension and benign prostatic hypertrophy, and his medications include tamsulosin, amlodipine, and diphenhydramine for insomnia. He wears glasses but did not bring them to the hospital. He lives with his wife of 60 years. She prepares his meals and he has not lost any weight over the past 6 months. This couple has three daughters who live locally and shop for them.

On examination, he appears thin and well groomed. His body mass index is 22. He is mildly tachypneic and has crackles at the left base on lung exam. His attention is poor, and he frequently drifts off to sleep during the interview. His speech is disorganized. He knows his name but is not oriented to time or place. He is unable to recall three words in 5 minutes, and is unable to draw a clock.

His laboratory tests are notable for an elevated white blood cell count, a blood urea nitrogen level of 42, and a creatinine of 1.5. His chest x-ray reveals an infiltrate consistent with a left lower lobe pneumonia.

History from patient’s wife

Although the patient was apparently walking without difficulty up until 3 days ago, he now requires assistance to walk due to an unsteady gait. He had an abrupt decline in his thinking and appetite 3 days ago, but prior to that he was “fine.” He was independent in all of his basic activities of daily living and walks regularly with his wife in the neighborhood. He has no history of a dementia diagnosis.

On detailed questioning, his wife admits that her husband has had a mild decline in his memory over the past several years and that he is no longer able to manage the couple’s finances. He has difficulty with short-term memory and frequently repeats questions. She has to remind her husband to take his medications each morning. She has begun to feel nervous letting her husband go outside by himself for fear that he might get lost. She is with her husband all the time and takes care of the cooking, cleaning, and laundry.

Assessment of frailty

In addition to his advanced age, he has multiple characteristics of frailty:

Delirium, as demonstrated by his poor attention, acute worsening of cognition, and disorganized speech; risk factors include dementia, dehydration, pneumonia.
Likely underlying dementia
Functional impairment, as evidenced by his dependence in an IADL, ie, needing assistance with medication management and his unsteady gait, a departure from his baseline
Dehydration on clinical exam and laboratory tests

Due to his acute delirium, it is not possible to pursue a vision or depression screening at this time. He does wear glasses and should be encouraged to use them during his hospitalization.

Prevention of adverse outcomes

Key interventions to limit the course of his delirium and also reduce the risk of falls and fall-related injury

Promote hydration
Provide glasses
Mobilize early on during hospitalization
Avoid psychoactive medications, indwelling urinary catheter, physical restraints

Nursing team

Provides him with a low bed
Initiates a toileting schedule, every 2 hours during the day

Physicians

Determine that the patient lacks decision-making capacity
Identify his wife as next of kin and surrogate decision maker
Address goals of care

Family

Clarifies his wishes that he “loves life” and continues to take great pleasure in his daily life with family. Although his wife knows he would not desire prolonged artificial life support if his prognosis were poor, she does not desire limitations on his health care at this time.

Promotion of this patient’s long-term health and well-being with a safe and effective discharge plan

Assess effectiveness of appropriate treatment—resolution of pneumonia and delirium with hydration and 3 days of appropriate antibiotics.
Assess cognitive function—he is oriented to place, month, and year and knows that he is in the hospital. He has a general but not detailed understanding of his medical conditions. His wife confirms that this is his baseline level of cognition.
Assess functional status—despite working closely with physical therapy, his ambulation has remained unsteady. He can ambulate independently and safely over 100 feet with a rolling walker. He needs assistance with bathing but is otherwise independent in basic ADL.
Review medication regimen—stop diphenhydramine, as this is likely to increase fall risk and confusion. Add only a short-course of oral antibiotics to his discharge medications.
Provide written instructions to his wife regarding both these changes.
Refer to a home care agency that can provide him with home physical therapy under his Medicare benefit. The agency will also provide short-term home health aide support for the duration of his home physical therapy benefit that will give his wife some respite from caregiving.
Educate family about community services such as community adult day health programs that can provide the socialization for the patient and respite for his wife.

Diagnosis

Step 1: Identify Frail Patients

Recognition is the first step in caring for the frail hospitalized patient. Although there are many potential adverse outcomes of hospitalization for frail older patients, outcomes commonly studied include functional decline, delirium, and institutionalization. These outcomes not only greatly impact on patients’ quality of life, but they incur high costs to society.

Despite the absence of a simple diagnostic test for frailty, this clinical syndrome manifests signs and symptoms that can be identified at the time of hospital admission. Table 169-1 lists 10 “frailty characteristics” and methods to assess each one. Each of these characteristics is associated with at least one major adverse outcome, including hospital-associated delirium and/or functional decline. Assessing for these ten frailty characteristics at admission facilitates identification of potentially treatable conditions and implementation of preventative measures.

Table 169-1 Step 1: Is My Patient Frail/Fragile? Assess at Hospital Admission

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