Review of electronic medical records best way for family doctors to detect early signs of frailty, study shows
Family doctors are in the best position to identify aging patients at risk of frailty early enough to stop—or even reverse—mobility and other function loss, say University of Alberta researchers.
In a recently published study, U of A elder-care specialist Marjan Abbasi, family physician Sheny Khera and their research team recommend primary care physicians check their electronic medical records to identify patients who are at risk of frailty so they can prescribe early intervention.
Frailty is a combination of physical, psychological and social deficits linked to falls, disability, hospital admission and death. Twenty-five percent of Canadians over age 65 are considered frail, and 50 percent over 80 have the condition.
While it is easy to identify bedridden individuals with end-stage frailty, the best time to start treatment is much earlier, when two or more deficits begin to accumulate, said Abbasi, who is also an associate clinical professor in the Division of Care of the Elderly.
"With mild or even moderate frailty, intervention actually has more impact," she explained. "As frailty progresses there is increased vulnerability and less reversibility."
The researchers tested three tools: a walk test, a questionnaire completed by patients, and a 36-point review of the patient's electronic health record to plot them on an "electronic frailty index."
They found the review was most convenient for doctors, and thus most likely to be used.
"All the tools were valid and reliable," said Marjan. "But our experience indicated the electronic frailty index is going to be more accepted and more feasible."
In the study, the researchers reported that most frailty identification tools currently in use were developed for research or specialist settings and require additional time, training or specialized equipment to use in a family doctor's office.
The researchers found that while most family doctors know their patients well, they need an objective tool to help flag the accumulation of early signs of frailty, including hearing loss and foot problems, high blood pressure, osteoporosis and social isolation.
"Primary care has the unique position of seeing people when they are well and helping them to maintain that wellness," said Khera.
Abbasi said patients respond best when the conversation is framed as a way to maintain their health, rather than stop a decline.
"Patients don't want to hear about frailty," she said. "But if you frame it as what can be done to increase their vitality, then their response is, "OK, what can I do?""
Abbasi and Khera did their research at the Seniors' Community Hub, which was named the top innovation of 2018 by the Canadian Frailty Network. Started as a pilot program at Covenant Health's Misericordia Family Medicine Centre with six family physicians, it has now been adopted by the Edmonton Oliver Primary Care Network, where 170 doctors serve more than 200,000 patients.
Abbasi said patients report improvements in their ability to do day-to-day chores, walking speed and mood, and she expects to see a reduction in ER visits and hospital admissions as well.
The model will now be offered to 20 locations across the country, thanks to funding from the Canadian Frailty Network and Canadian Foundation for Healthcare Improvement.
Abbasi and Khera will coach staff at the new clinics and share the best practices they've developed at the Seniors' Community Hub to engage patients in exercise programs, review food intake and streamline medications.
The multidisciplinary team includes primary care physicians, pharmacists, nutritionists, chronic disease management nurses, mental health therapists and kinesiologists, and also connects patients with community resources such as the SAGE Seniors Association.
"I always say, "Don't ask for more funding, ask for more integration,"" said Abbasi. "We need to make sure the resources that we have are working at their best potential."
Abbasi and Khera are now working with U of A computer scientists to automate the review of medical records for frailty in Canada. She said it is standard procedure in Britain, where any patient who scores moderate or higher for frailty triggers an in-depth assessment and intervention.
She said early intervention can save both personal and system costs.
"Frailty is associated with aging, but it's definitely not an inevitable part of aging. You can see people who are 85, 90 years old, still doing exercise, and we have 40- and 50-year-olds who are losing function," Abbasi said.
"There's no typical old age."