Thread by @Krockdoc

Great question. Most key trials preceded the Clinical Frailty Scale. @GrahamEllis247 will know best, but here’s my read. (A 7-part thread; forgive me.) Back in the late ‘70s (when I got into all this) a key question was “who benefits from a Comprehensive Geriatric Assessment?”/2

https://twitter.com/drkimahmud/status/1309756027529760768

2/This consumed much effort, and some weird terminology (e.g. “the targeted elderly”). One early line that I resisted was “too frail to benefit”. This struck me as a failing of the measures more than CGA. Fortunately @paulstolee sorted this (early 90s) in his PhD thesis. There/3

3/he introduced #GoalAttainmentScaling and individualized outcome measures to geriatrics (PMID: 1587973).Ultimately we did an RCT of CGA using this as the primary outcome (10983907 - the poor title (my bad) made it obscure despite @AGSJournal publication. I digress.) It taught/4

4/me that a good death is a good outcome; that “approved” exercises that no one follows are pointless; that getting a hearing aid doesn’t mean better hearing (or didn’t then). Mostly that there’s lots that we do to help frail older adults that goes unmeasured in standard trials/5

5/and that RCTs are very, very hard to do (for all the EBM/meta-analysts who’ve never done one. I digress again.) So my sense is that anyone with any degree of frailty (at least from CFS5 on) can be helped. Better than ordinary care? Dunno. Where we usually make a difference:/6

6/ includes a good chance to get:
A. Patient-centred, negotiated goals (navigating between adventurism and nihilism).
B. Sensible medications, and med regimens.
C. Multidimensional interventions that consider social circumstances and offer do-able, graded exercise programs./7

7/7 Mostly though,
D. Useful diagnoses that clarify, and for which treatment has meaning (cf. “old age”, “must have had a stroke”, “what do you expect”, “UTI”).
Not most often, but not rarely, the greatest of these is “I suspect that you’re [this person you love is] dying”.