Frailty in Canada — Dr. Kenneth Rockwood

Avis Favaro

As Canada’s population ages, it’s expected that more of us will become frail, and frailty comes with the higher risk of ending up in emergency, being hospitalized with longer hospital stays. And many frail adults are waiting for a long-term care bed.

But it doesn’t have to be this way, says our guest today from Halifax, geriatric specialist Dr. Kenneth Rockwood.

Ken Rockwood

I am certain that if people were more appropriately managed with a view to frailty, that we wouldn’t have nearly so many people wanting to go into, or being told they need to go into long-term care.

Avis Favaro

He’s a member of the Canadian Frailty Network, who helped design the nine-point frailty index, which we’ll talk about, and is now trying to quickly find ways to guide hospitals as they help frail patients get better and home quickly.

Ken Rockwood

The first thing we need to do is they have to get better at recognizing illness in people who are frail. We have to get better at managing illness. And we have to get better at the routines of hospital care, which are unnecessarily risky.

Avis Favaro

Hello, and welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation.

A note, the opinions expressed here don’t necessarily reflect those of CIHI, but this is an open discussion, and this one is about frailty, how to measure it, how to better treat those living with it, and how to, maybe, prevent it.

Welcome, Dr. Rockwood. Thanks for joining the podcast.

Ken Rockwood

My pleasure.

Avis Favaro

So what we’re talking about here in this conversation is about frailty. Frailty is a medical condition. It isn’t normally discussed. Why is it important that we talk about this?

Ken Rockwood

So it’s important we talk about frailty because, otherwise, we have no way to adjudicate between various stereotypes that go with age. One stereotype is, you know, the 80-year-old who’s out for a run, and another stereotype is the 80-year-old who’s lying in bed, dying. And both things happen to 80-year-olds. Both of them are true.

So it’s not the age that’s the important part of what we’re seeing with an aging population. It’s how well people are, how fit or how frail. And the reason to talk about frailty is because we can quantify it. We can talk about degrees of frailty. Someone’s really fit, but someone can be very frail.

Avis Favaro

Do you notice that the rates of frailty that are running into the medical category are increasing?

Ken Rockwood

One of the ways that we know that to be the case is because an attribute of many people who have, sort of, more than mild frailty is that, in addition, they have a number of things wrong with them, which sometimes goes by the awkward term, multimorbidity.

And so they’re more likely to get ill because they’ve got 5 things going on, and 1 of them’s going to go awry. And so they wind up coming in, say with their diabetes this week, in 3 weeks’ time with their kidney function, and 6 weeks after that with a heart problem.

Avis Favaro

How do you know if you’re frail? Or your loved one is frail?

Ken Rockwood

So one way that people can recognize frailty is by thinking about all the things that, as humans, we have evolved to do. So we stand upright, and we walk around and don’t fall down. So people who are having problems with their walking, they’re not moving as quickly as they used to, the chances are that there’s going to be some degree of frailty there. People who are having problems with falls, particularly if they’ve got more than one in a short period of time, it’s highly likely that they’re frail.

People in whom their function is impaired. Right? We’ve evolved to have opposable thumbs, but what that translates into is the ability to do things for ourselves. Some of them are complicated, like to write a cheque or drive a car or take a pill. Some of them are very simple, like to get dressed, and then so on into intimate personal care.

So we do all these things without thinking about them until a time comes in which people understand that, for whatever reason, they can’t do these things as well as they used to.

Avis Favaro

Is there a checklist that families who might be listening in can go to, to see where they would rank on this frailty scale?

Ken Rockwood

So there is a thing called the Clinical Frailty Scale.

Avis Favaro

You helped design that one.

Ken Rockwood

I did, yes. And in many of the forms in which it’s made available, it’s mostly for health care professionals, but there are wee icons that give people a general understanding of what someone is like. They go from being fit — extremely fit, to what we call managing well and then very mild frailty.

And the hallmark things with very mild frailty are people often, themselves, feel that they’re moving a bit more slowly than they used to, or they’re not quite as confident in the things that they would like to do as they have been. Or often, they find that things that didn’t tire them out before are tiring them now. Those are the sorts of things. They certainly have trouble walking outside with confidence, happy to do things inside, can go up and down stairs and such, but it’s these small things.

Avis Favaro

That’s a marker. You can see the decline. Is it important for us to keep track of our frailty and the frailty of those around us?

Ken Rockwood

I think it’s worthwhile being aware. I think it’s worthwhile being aware to make targets for how to make it better. One of the reasons to be aware of frailty is to see what things you might do to mitigate it, to prevent yourself from becoming more frail, the person you care for from becoming more frail.

Avis Favaro

Do you get a sense that frailty as a health problem is increasing in Canada?

Ken Rockwood

Yeah. So the number of people who are coming to the hospital, who have unrecognized frailty, is definitely increasing. And the dilemma with frailty is really important because it challenges the very ways that we become successful in health care.

So one of the ways we become successful in health care is by having really precise understandings of common conditions. So the dilemma we’ve got in health care is that what made us really good was being very skilled in particular problems. And what we’re suffering with right now is we haven’t become skilled in people who have a lot of problems all at once.

Avis Favaro

The frail?

Ken Rockwood

People who live with frailty is what we say with patient-first language. They live with frailty.

Avis Favaro

Live with frailty? Okay. That brings me to a quote that I saw one of your colleagues say. “Frail seniors do not do well in hospital, and our hospital system is not equipped to deal with frail seniors.” True?

Ken Rockwood

Amen to that.

Avis Favaro

Amen? So is that part of the problem that we’re hearing in news stories from across the country, that ERs are full, they can’t get patients upstairs, the beds are full, and a large proportion of the people in hospital are waiting to go to other levels of care, home care, long-term care. Is that part of the problem?

Ken Rockwood

Yeah. I want to reframe that a bit. So it’s clear that we have people who’ve been assigned to go to long-term care, on whom we have given up and said there’s nothing more that we can do. But I’m certain that, if people were more appropriately managed with a view to frailty, that we wouldn’t have nearly so many people wanting to go into or being told they need to go into long-term care.

Avis Favaro

One of the bits of data that CIHI recently released is that frail Canadians are 3 times more likely to be high users of hospital beds, 3 times more likely to be hospitalized for a month or longer, twice as likely to be readmitted within a month of being discharged, and twice as likely to die within a year of discharge. So there is a bad connection between frailty and hospitalization.

Ken Rockwood

Yeah. And what I’m trying to say is that it needn’t be as bad as it is. What I’m trying to say is that the dilemma we’ve got right now is when frail older adults get sick, they’re a poor fit for a system designed for people who should only have one thing wrong at a time. And it’s not up to them to get sick in a way that’s more convenient for us. It’s up to us to change to tackle this problem.

Avis Favaro

What do you feel when you look at the system that is a mismatch?

Ken Rockwood

So I’m a geriatrician. Right? We’re optimists. I feel a sense of regret that I’m part of the generation that failed to persuade successive governments of all stripes that we need to invest in programs like geriatrics, and general internal medicine, and general psychiatry, and geriatric psychiatry, and those sorts of programs in which we don’t expect people to only have one thing wrong.

In fact, it was always my goal, when I ran the consult service in the emergency department, to point out to people that a young person with just one thing wrong was not that interesting compared with a person, they got 3 or 4 things wrong at a time, and whom you can make them better.

And when I see a frail older adult in the emergency department, I see a lot of opportunity, almost always. But I also have a sense of regret that I know that I’m going to be dealing with an audience, even of learners, in whom there’s be great skepticism about any room for optimism.

So in terms of how I feel about it, I have a certain regret for people who haven’t made this clearer. I feel the motivation to help that person, but I also feel a motivation, even an inspiration, to help make sure that other doctors and health care workers get to understand the joy of geriatrics.

Avis Favaro

What is it that drew you into geriatrics?

Ken Rockwood

So I went to medical school to become a geriatrician. So the way that I got into it, I was working as a policy analyst for the Department of Health in Saskatchewan in the mid-70s. And that was a very cool place to be if you’re a policy wonk because they’re the people who’d invented Medicare 10 years ago.

Right?

So it was really interesting. It was a well-run, well-funded, pragmatic, but still stimulating place to work. And when I arrived there, they said, why don’t we get you to work on this and this and health care of the elderly? And I thought, health care of the elderly? That’s … No! I’m here to do all these other things.

But it turned out that Saskatchewan wanted to be first in everything for health care back in those days. So they had gotten out the guy who, at the time, was one of the leading geriatricians in the world to start an academic division of geriatric medicine at the University of Saskatchewan, and I just fell into it. And I started to work with him. And he had someone who — he went back after a year, but the man he brought with him who stayed, Duncan Robertson, who just retired now, was a leading geriatrician in the country and stimulated me and other people to do this work.

Avis Favaro

So if you had been able to achieve your dream of convincing governments to invest in geriatric care, where would we be compared to where we are now?

Ken Rockwood

First of all, geriatrics would not be niche. It would be a mainstream service. In the UK, it’s the number one internal medicine subspecialty, for example. You wouldn’t have to have some sort of missionary understanding of the work in order to want to do geriatrics. It would be an acceptable, well-paid, engaging bit of work that no one would question. Why would you choose …? Like you don’t have to do geriatrics. You’re clever. You could actually be a cardiologist, is the sort of advice that you hear. It would be a respectable, well understood way to proceed. And we would actually set ourselves up so we’d be less hospital-centric. Hospital care would not be as unnecessarily hazardous as it is right now.

And we would be very much patient-focused. We’d be very much understanding that, for a lot of people, the most important thing is to get them back home, functioning well. The universal geriatric outcome, if we’re doing something, if we’re going to test an intervention in geriatrics, what’s the outcome going to be? Alive and in your own home at one year. Right? That’s what we aim for.

Avis Favaro

In terms of frailty in Canada, is this a big reason that we’re seeing the crisis that we’re discussing around hospitals right now? Because we’re not able to handle frailty and prevent it? Or manage people before they become frail?

Ken Rockwood

So one of the reasons that we’re facing the dilemma that we’ve got right now with so many people who are in the hospital, in the emergency department, trying to get upstairs, and then upstairs, not being able to go home, is frailty. Frailty coming on top of a bad season for respiratory viral infection, coming on top of all the ways in which COVID-19 has had lingering impacts on the robustness of health care.

But here’s a thing to be aware of. The chance of being frail, the prevalence of frailty goes up dramatically after the age of 75. And in 2021, the leading edge of the baby boom began to turn 75. So what we need to be aware of is that we’re actually in the good old days right now because this wave will not crest for years to come yet.

And so trying to blame things on, we need more long-term care beds; yeah, we do, but we need to use the ones we’ve got dramatically better. We need to get over the legacy issues that have to do with the stress put on the system by COVID. Yes, we do. We need to be careful about this flu season. Yeah, but there’s going to be another one next year.

Avis Favaro

What’s the key?

Ken Rockwood

The key thing is we’ve got to do a better job at managing frailty.

Avis Favaro

What do we need to do right now so that we don’t have as many frail people in hospital? Or in long-term care?

Ken Rockwood

So the first thing we need to do is they have to get better at recognizing illness in people who are frail. We have to get better at managing illness. And we have to get better at the routines of hospital care, which are unnecessarily risky.

In terms of how we recognize illness, it was for many years said that one of the challenges of frailty is that people present atypically. So what they meant was they’d have pneumonia, but they don’t have a cough. Or if they’ve got a cough, they’ve always got a cough. There’s nothing new about that cough. And the shortness of breath, and they don’t have a temperature, and their white cell count doesn’t go up in the way we expect it to. And all those things that we’d say is what pneumonia looks like in a young person or someone who’s only got one thing wrong, they don’t have that. And they’ve got other things that look like other things too, so they get confused.

The technical word is delirium. And we still have people coming to the hospital with delirium, and you hear the discussion or reading the chart and say, well, they must have had a stroke. No. Like that’s not what stroke looks like. Well, it could, but this delirium has a very characteristic look and feel. And why are we not doing a better job of understanding that’s what we see and approaching it from that standpoint?

Avis Favaro

So does the solution start at the hospital level?

Ken Rockwood

We have to do a better job at the pointy end of care. There’s a whole thing in primary care that is a huge challenge as well, and then there’s a whole thing in terms of the alternatives to hospital admission. So I’m very nervous about talking about that because where it seems to work well, in the UK, they have a really robust system of primary care. Now they’re under huge stress for various reasons, but I can’t say we have a very robust system of primary care.

We have outposts of primary care and the sorts of teams that we need to deal with the people who are ill, but we don’t have the ability to say we can have an ambulance diversion scheme. So instead of being brought to the hospital, you go back home, we wrap around some care, and then the GP and their team will be out in 6 hours. Like our system doesn’t work like that. So we have to figure out how to do the things that our system can do.

Avis Favaro

So if you’re saying that primary care is the first line of defence against frailty, that would be home care. And I think, in PEI, they had an experimental program called COACH Program —

Ken Rockwood

Mm-hmm.

Avis Favaro

— where they were able to identify seniors who were at risk of being frail and take care of them there. And they noticed that ER visits decreased by 30%, visits to doctors decreased by 40%, and the hospital admissions decreased by 70%. Is that a route that other provinces should look at?

Ken Rockwood

Yeah. We should look at ways in which we can employ what happens when people are reasonably well but clearly frail. Right? So what I’m not going to be talking about is primary prevention, where someone’s got nothing wrong. I’m looking at people who are  are frail, and we’re trying to mitigate the risk so they don’t get frailer.

So the largest groups will be very mild and mild, and what we’re trying to do is prevent the very mild from becoming mildly frail, and the people who live with mild frailty from becoming moderately frail. That’s where the biggest return should be.

Avis Favaro

Is there enough being done across the country on this?

Ken Rockwood

I don’t have a complete inventory of what’s being done where, but I’ll — and I’ll tell you there are outposts that are doing a really good job, like the way that, in Peterborough, the way that they’ve organized care with geriatricians there, I hear about it every time I go to the Geriatrics Society meetings. Outstanding, but it’s still outposts. It’s not the routine way we do things now.

Avis Favaro

So we’re missing an opportunity.

Ken Rockwood

We are.

Avis Favaro

So then the second spot, and one of the passionate points you brought up to me as we prepared for this, was hospitals. What do hospitals need to do?

Ken Rockwood

We need to do a better job than we’re doing in the emergency department right now. And again, like I worked emerg for years. I love the people who work there. I love the emerg culture. I really enjoy the approach and such. But I still understand that, generally, we’re missing opportunity to intervene there, and so that has to be done.

But the other thing that we’ve got to do is there is a lot of routine hospital care that is unnecessarily risky. So we’ve gotten away, for the longest time, with not leading-edge practices for prescribing intravenous fluids, shall we say. We’ve gotten away with people who are malnourished in hospital. They’re not getting enough to eat when they come in, and we don’t have a way to draw that to attention.

We’re getting away with sleep deprivation, or we used to get away with that, more or less, but we can’t do that. You can’t sleep deprive an older person who’s frail to start with, and now ill, and expect they’re going to recover.

Avis Favaro

Are you saying that hospitals are possibly, unintentionally, making frail patients worse?

Ken Rockwood

There’s no doubt that frail people can’t withstand the routines of not being mobilized, which is often routine in a bunch of places, of being sleep deprived, which is often a part of routine care, of having trays they can’t reach, or trays that they can reach but don’t touch, and never comes to attention, and no one feeds them.

Those simple, basic things, we’re not doing a good job of that everywhere, and we need to do a good job of that everywhere if we’re going to make the level of impact that we need on people who live with frailty, to prevent them from going into long-term care.

Avis Favaro

Your message for this conversation was to persuade. What do you want to persuade people to do?

Ken Rockwood

So I’ve given a lot of thought to this because I have, right now, what in many ways is a dream job for me. I run a thing called the Frailty and Elder Care Network in Nova Scotia. And we looked at everything that we could do that would be acceptable, that we could implement, that would not bankrupt things, that wouldn’t stress out existing staff.

And we said if there’s one thing to do, the lowest-hanging fruit is a mobilization strategy. And so we have, with this government, invested in a strategy to mobilize patients, starting in the regional hospitals, targeting not all grades of frailty, but very mild, mild, and moderate, because that’s where the data suggests the biggest challenge and the biggest opportunity is.

Avis Favaro

Making them walk?

Ken Rockwood

Getting them up to walk 3 times a day. And we’re just starting the evaluation process for all of this now, but we’re offering people touch. Right? Someone comes in and touches you, and helps you to get up, and is interested in you, and talks to you, and helps you move around, and encourages you. Hey, we got 10 feet this morning. Let’s go for 15 feet now.

And as a person who’s come in, who we’ve added to the care team, so we haven’t gone to overburdened front-line staff, say, hey, do this too. We bring people in who can do that. And the mobilization is something that we are anticipating a good result, in terms of getting more people home in better shape, sooner.

Avis Favaro

Is it working? Do you have any evidence yet?

Ken Rockwood

We’re just in the first months of this now. I’ve got anecdotes, but I’m an evidence guy. We are going after a proper evidence base for this.

Avis Favaro

Okay. So what is the fastest solution to dealing with frailty and the cost to hospitals and the health system?

Ken Rockwood

So we are hoping that, soon, we can deliver a package developed here in the province called the Dignity of Risk. And what the Dignity of Risk does is it helps front-line care staff get away from the notion that they’ve got to keep people safe in hospital. Well of course they do, but you can’t cocoon them.

And people need to walk, and there’s going to be some risk that’s involved in that. And the data show that there’s fewer falls, if you actually will mobilize the person, particularly if you mobilize people with a care team.

But you can imagine how precarious the whole enterprise is because what if someone falls? Well, someone is going to fall with the care team. But we are asking people to do things differently from what they’ve done, in a way in which, for some people, that will bump up against a threshold of risk that they’re uncomfortable with.

And what we’re trying to do through the Dignity of Risk program is to help them reframe that risk, to not look at just this next 2 or 3 days, but the context of what’s likely to happen, you know, over this year with the goal of having them alive in their own home.

Avis Favaro

And how long before that? A year or 2? Or 6 months?

Ken Rockwood

It’s more a year than 6 months. It’s more a year than 2 years.

Avis Favaro

But do you feel an urgency to do this?

Ken Rockwood

Oh, yes. Very much.

Avis Favaro

For the average person who’s listening in and either wants to not be frail or doesn’t want their loved one to be frail, what things that are verifiable can people do?

Ken Rockwood

So in ascending order of the evidence, so these things. And we’re going to start with the weakest evidence thing, that there’s still evidence for it, and go to the strongest. So eat well, and learn well, and exercise, and do it all in groups.

Avis Favaro

Groups? Why groups?

Ken Rockwood

So if you set out to make a group of people frail, you’d have them act on their own. You’d isolate them. You’d make them lonely. So, you know, as humans, we’ve evolved to socially engage with other people and to move.

Avis Favaro

One of the other hot topics, though, is resistance training. Good evidence? Or not?

Ken Rockwood

It’s reasonable. Generally, if you have a basis of some cardiovascular fitness to work from, and you do graded resistance exercises, that that looks like you get a good combination with that.

Avis Favaro

Two more questions. What do you do to prevent frailty?

Ken Rockwood

I’m a big believer in exercise. So I’ve had a trainer for years, and I’m not a natural athlete at all, at all. And I want to work with someone who can make sure I’m doing things correctly because I’m at an age where it’s easier to injure yourself than seems reasonable and takes longer for it to get better.

Avis Favaro

Oh, I totally know that, having dealt with some injuries. But so frailty is on your mind. You’re taking it on as something you need to do for yourself?

Ken Rockwood

Yes, ma’am.

Avis Favaro

What’s your hope? I mean, we know where things stand based on the CIHI data, that there’s a lot of frail people in hospital. The outcomes are not good. You’ve warned us that there are more frail people coming because of age. What’s your hope?

Ken Rockwood

My hope is that we don’t lose Medicare, actually, because what’s happening right now is you have — I mean, even here, we see a springing up of private services to do surgery, contracted by the government and such, often. And they run, you know, pound the chest and say, look at the patient outcomes we’ve got.

Well, yeah, like you’ve cherry-picked the people that are going to do well. You can’t say that it’s a procedure that you’ve done, right, and you’re so skilled at it. You’re pretty good at picking folks out who are unlikely to have anything bad happen to them.

And so my fear is that if we let that happen and then have incentives that are saying, well, you can go, you can get upsold at the place, that we will wind up with a parallel private system that the minute something bad happens, they’ll send them over to the public system. And in the meantime, the public system will erode the support that it has right now and, therefore, the opportunity to innovate in the way we need to do.

That’s my hope is we do a good enough job that we reduce the current threat to publicly funded medical care in Canada.

Avis Favaro

And frailty being a key.

Ken Rockwood

Frailty is the key, from my standpoint. It’s where all the dissatisfaction lies, is for the bad outcomes that are visited upon people who live with frailty. I mean, I know just from social conversation that if I hear a friend has got a parent in hospital, I don’t begin a conversation with them in the anticipation that it’s all worked out fine.

And we’re seeing every day that we’re not getting the outcomes that we should be able to get. And it’s because we don’t know how to manage people in the way, with the skill set, with the insight, with the approach that would allow a better outcome for them. We give up too soon and have them go to long-term care when they don’t need to, and we don’t do the things that allow them to have the best success in the things that we offer.

Avis Favaro

And that worries you?

Ken Rockwood

Yes, ma’am.

Avis Favaro

I didn’t expect that last answer, but that’s a very good point.

Listen, thank you so much, Dr. Rockwood, and I really appreciate your dedication to geriatric medicine.

Ken Rockwood

My pleasure.

Avis Favaro

Did you know that more than 1.6 million older Canadians are living with frailty right now and, within a decade, it could be more than 2.5 million?

So we have a link to the CIHI report on frailty and Dr. Rockwood’s frailty index on our website at cihi.ca. That’s C-I-H-I-dot-C-A.

Thanks for joining our discussion. Our executive producer is Jonathan Kuehlein. Our production assistant, Heather Balmain. And a shout-out to Alya Niang, the host of our French show, with special thanks to Jeanie Lacroix, this month’s special guest host.

And please subscribe to the CHIP wherever you get your podcasts. I’m Avis Favaro. Talk to you next time.