In Hong Kong at Hospital Authority conf, speaking on frailty & illness acuity. As with work from @CamGeris the frailer someone is, the more lethal is illness acuity. And the longer the recovery time. It’s almost as if frailty degree estimates resilience. Or intrinsic capacity.
Of course there’s more to it than that. Social vulnerability (in relation to education, occupation, safe environment, supportive community) and personal health practices (exercise, not smoking, etc.) explain variability in the relationship between FI and mortality.
And more yet. Where do biomarkers come in? (As predictors, likely as a package.) And as @dr_shibley warns, how do we put all this together in ways that do not stigmatize, but still allow the complexity of #frailty to be taken seriously? (vs common sense? or harmful stereotype?)
• • •
Missing some Tweet in this thread? You can try to
force a refresh
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
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
Marshall EG, Clarke B, Burge F, Varatharasan N, Archibald G, Andrew MK. Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents. J Am Board Fam Med. 2016;29(2):201‐208.
@barry86136315@DrEmilyMarshall CGA The for LTC ref is: Marshall EG, Clarke BS, Varatharasan N, Andrew MK. A Long-Term Care-Comprehensive Geriatric Assessment (LTC-CGA) Tool: Improving Care for Frail Older Adults?. Can Geriatr J. 2015;ncbi.nlm.nih.gov/pmc/articles/P…
The authors also took on the issue of why LTC transfers to acute care were seen despite advance care directives to the contrary. (Spoiler alert: it had to do with falls.) Even so, many more residents are able to be managed on site, as per their wishes, avoiding hospital transfer.
Mad-as-hell must give way to careful analysis. Think about this. In ordinary time disproportionately more older people die in LTC than at home. What fraction of all deaths is that? I don’t know, nor, I’d bet, do many others feeling outrage now. So what to do? We need clear-eyed/2
expert help. My (amateur) guess would ask first about excess mortality, by site. Not all COVID-19 deaths are the same: people can die with it, not just of it. (Think of dying while being cared for till the end vs dying neglected.) Much-needed reform will quickly be obscured if /3
we get this wrong. Who’ll come out best? Not the five workers packed in a car when public transit cutbacks left them with a 90-minute, 3-change bus ride to a 12-h shift. They’ll soon be demonized for inadequate social distancing. So too the 6 nurses sharing a 1-bedroom apt,/4
It’s fair to say that I didn’t see its use in a pandemic. Had I done so, I hope that I would’ve tested a guidance for non-frailty experts sooner than the one we’re just trying now. If I’d been asked back then, I suspect I’d say that it beats stratifying risk by age. I recognize/2
that in a pandemic inevitably care will be rationed not by patient preference, but by likelihood of benefit. Some, reckoned as unlikely to benefit will be denied; further, with treatment, some of them possibly could have lived. That’s a hard truth, and not the only one. Even so/3
I haven’t seen the 3-part tool in question, only its description. (It looks like one proposed in Wales; @csubbe knows more, and pointed out the double/triple counting that seems arbitrary on its face.) Another hard truth: frailty and illness acuity interact. An algorithm that /4
Great question; requires some detail. People accumulate deficits across their lives. In young people, many disabilities are “single system” eg spinal cord injury, trauma, cancer +/- chemo. There are many exceptions: intellectual disability, autoimmune disorders that show more/2,
deficits at any age, ie progressive deficits, “accelerated ageing”. This will be reflected in deficit-associated disabilities, occurring at younger ages. So the first point is that disability means something different in most young people - single system disability shows fewer /3
deficits, and isn’t accelerated ageing. That’s why the CFS isn’t so good in younger people whereas the frailty index is. Now to split hairs. You say that in the young “it’s not about frailty”. I disagree. Yes it’s less about high-order failures in function, mobility, cognition./4
1/6 Tweetorial Even in peaceful Nova Scotia disputes are not rare, especially in the Emergency Dep't. Here, I've distilled an approach that I've found helpful: I Have Something Interesting To Talk To You About: Speaking To Disagree, Agreeably cgjonline.ca/index.php/cgj/…
2/6 It's not mine: I was taught this decades ago, as a newly minted health policy analyst. It obliges you to address four questions. 1. What is the problem? As with the rest, this should be stated precisely. Stopping to get the words right is calming, clarifying, and empowering.
3/6. Second, why is this problem important? Saying this aloud make your basis for disagreeing to be understood. Sometimes it allows the agreement to be resolved: what is upsetting to you might be immaterial to your interlocutor. Those of good will can readily back off. Third: