Frailty in Canada — Dr. Marcel Émond

Jeanie Lacroix

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, Dr. Marcel Émond.

Marcel Émond

The health care system currently needs to consider alternative care pathways for these frail patients, either to prevent frailty, or in the case of faster deterioration, to ensure that the usual pathways of transporting them to a hospital or acute care resource aren’t the only alternatives. So we’re going to need all stakeholders to be trained in recognizing frailty — and this is what I’m hoping for.

Jeanie Lacroix

An emergency physician at Hôpital de l’Enfant-Jésus, as well as a researcher at the Centre de recherche sur les services de première ligne, the Centre d’excellence du vieillissement, and the Centre de recherche du CHU du Québec/Université Laval. He’s a member of the Canadian Frailty Network, who helped design the nine-point frailty index, which we’ll talk about. He’s now trying to quickly find ways to guide hospitals as they help frail patients get better and return home quickly.

Hello and welcome to the Canadian Health Information Podcast. I’m Jeanie Lacroix, the host of this conversation. 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. Émond, and thank you for joining the podcast. Today we’re talking about frailty. It’s a medical condition that isn’t usually discussed. Can you tell us why it’s important that we talk about this?

Marcel Émond

Well, I think it’s a very important topic, Jeanie, for the elderly, to be able to qualify frailty. It’s not something that’s ordinarily done, as you were saying, but that now needs to be taken into account, both on a medical and societal level.

Frailty is a condition that could interfere with patient care, or change patient care, because frailty is now included in several screening tools that allow us to stratify patients. The aging of the population in Canada, in Quebec, isn’t happening all in the same way. Aging occurs at different levels and at different speeds.

So, frailty status allows us to stratify this population to a certain extent. That’s why we feel that over the last 10 years, it’s been really useful for population studies, scientific studies, but especially in terms of adapting our care and perhaps making it more appropriate and specific to the patients we’re seeing as clinicians, but also in terms of the home care and acute care that’s provided.

Jeanie Lacroix

Are we seeing, do you notice that the rates of frailty that are running into the medical category are increasing?

Marcel Émond

I think the rates are indeed rising. We’re seeing in the studies that the frailty scores that we can use have trended upward in recent years as the population ages. There are perhaps two effects related to that. The first thing is that since we’re talking about it more, we’re now more frequently measuring something that we weren’t measuring before. And by measuring, we’re measuring people who we perhaps hadn’t considered that frail, but who, by actually putting them on a proper scale, are more frail than we thought.

Also, the aging population means that, in say the last 30 years, our seniors have been aging longer, therefore reaching higher frailty scores, which weren’t being reached some 30 years ago in the aging population. And for better or for worse, not everyone reached these higher frailty scores involving more acute frailty. Death would occur before these frailty scores were reached.

Jeanie Lacroix

Okay. You mention frailty scores. So, how do you know if your friend or loved one is frail? Could you describe this for us?

Marcel Émond

Yes, there are several frailty scoring systems and scales. The one most widely used in Canada is the Canadian Frailty Scale, developed by Dr. Rockwood several years ago. It’s a very useful scale because it’s also visual and descriptive. So, it’s now used increasingly in clinical practice. And I’d say for the last 5 or 10 years, it’s even been used in clinical tools, in emergency acute care and in primary care. It’s available and accessible to the public, too.

And with the descriptions, you can categorize a friend, loved one or family member who you’d like to categorize. And as clinicians, we can categorize them too. So, it’s useful to be able to discuss and describe that status, and ultimately provide a care trajectory for these patients.

Jeanie Lacroix

We know from data that CIHI recently released that frail patients are 3 times more likely to be high users of hospital beds, and 3 times more likely to be hospitalized for a month or longer. They are twice as likely to be readmitted to hospital or long-term care. So, does this tell us that perhaps there’s a connection between this and hospitalization and hospitals? Is there something that could be done about this at the hospital level?

Marcel Émond

Yes, I think the usefulness of frailty scores or frailty status will become increasingly popular in the coming years. For example, frailty will be taken into account more and more in screening tools, whether for pre-hospital transport, community paramedicine or even for assessments at the emergency department. Frailty will also be included in shared decisions regarding the level of care and patient evolution in our system. So, I think it’s going to be very important.

Indeed, the increase in frailty in recent years has added a layer of complexity to the health care system. The health care system — hospitals and especially the acute care system, meaning primary and emergency care — is not designed for the aging population, because frailty and frailty status involve a complexity of care that doesn’t involve just one specialty. When emergency medicine was first conceived, emergency departments were designed for... for example, you have a sudden sprain, you’ve fallen, you’ve sprained your knee, you come for a consultation to see if it’s a fracture or a sprain, so just one system.

With the increasing levels of frailty, patients often have more of a multi-system situation, and our emergency system is not currently designed, adapted for this and that’s where frailty is going to be very significant for us. Should a very frail patient in a vulnerable state be taken to the emergency department if a subacute situation is detected pre-hospital, for instance something that’s not jeopardizing the patient’s life or safety? Should they be directed to alternative resources?

And this is where frailty scales could help us in the future. Work is under way in Quebec and Canada on whether paramedics could ultimately use these frailty scales to say “You may not require the emergency department, but an alternative approach instead” as they do in other countries and in Europe. This would mean transporting patients who need care, or directing them to alternative subacute or primary care resources that are better suited to the concept of a multi-system situation.

The other advantage is that the frailty scale can also be used to guide intra-hospital care, to decide who needs to be assessed and who doesn’t, because it allows for stratification. So this will be used. There’s a Canadian regulation that’s just come out precisely for elderly patients who’ve fallen and sustained head trauma, where the frailty scale is used in part to determine “Do I need to do brain imaging and evaluation” or “Since this patient is robust and has no criteria, I can let them go without any imaging.” So this also reduces the length of the stay.

Our current problem is that frail people enter a system that is ill-adapted, and this probably adds to the complexity and to longer stays.

Jeanie Lacroix

So, we can see the benefits you were mentioning in terms of planning and shorter stays. You mentioned screening tools. Are there other things that could be done as well, in terms of training, in geriatrics or other things to better prepare the system for frailty?

Marcel Émond

That’s a very good question. I’d say that this concept of frailty has been under discussion among researchers for about the last 20 years. It probably gets discussed a lot more in geriatrics. But these days, the geriatric population isn’t being treated only by geriatricians. With the aging population and this “grey wave” (which I’m putting in parentheses here), I think everyone, all health care professionals, should have at least some training, and frailty is probably the most valuable training to introduce in the coming years to help stratify the patients we’re seeing.

Often, when we’re talking to patients, they can strike us as fairly robust but when we categorize them properly based on the criteria, we realize that they’re actually more frail, and this allows for a better discussion with both the patient and the family.

I think that this frailty scale is an indicator. I’m referring to the one we discussed earlier, the Canadian Frailty Scale, and there may be others. Establishing the frailty status and having this data for both home care and primary care, could be useful with a view to preparing patients and the elderly for a transition to appropriate care, rather than ending up with an acute event in an ill-adapted system. The person has a fall, it turns out that their frailty is actually much more significant because it hadn’t been measured, so then there’s a cascade effect where the patient can’t return home because this level of frailty hadn’t been anticipated. So, then we’re dealing with an alternative level of care, as it’s called. So, patients end up hospitalized, as you mentioned, for several weeks, while they recover.

So, should this be part of an annual check-up that we do? It’s probably going to be a health condition that we’ll have to measure, especially at the primary care level, with a view to preparing for it. It’s probably something that was done in clinical practice by people providing primary care using a clinician’s judgement, with elements.

What we’re doing by adding frailty scales is measuring, like we do for cognitive impairment, where we have instruments to do an initial screening for cognitive impairment, and then we can use the instruments to monitor the evolution of the impairment. So, I think that eventually, in primary care, whether through nursing care, home care workers, family doctors or hospital physicians, this categorization will ultimately have to be done for all our geriatric and aging patients, with the aim of measuring, projecting and using these scores to improve our care trajectories.

Jeanie Lacroix

What should we do so that there are fewer frail people in hospital and/or in long-term care facilities, so that they’re at home or getting home care? Do they have better outcomes when they’re in these settings?

Marcel Émond

What’s being increasingly shown is that home hospitalization does indeed have major advantages. Some advantages have been put forward. If you look at the data collected in Europe, in places like France, they have mobile geriatric units that strive to keep patients at home. I was an evaluator for a research project in Quebec that developed an alternative, mobile clinic for elderly, vulnerable people in frail condition, allowing for short hospital stays or even avoiding hospitalization altogether.

This project, called La clinique des aînés, showed that by using alternative models with a mobile unit, a shorter hospital stay — it’s safe to do — the patients return home, not necessarily for the next 10 years, but for a certain period, a couple of months, an extra year, with the aim of being able to prepare a transition of care. The benefits to the health care system are considerable.

In that study, we reduced hospitalization time by an average of about 15 days, without necessarily increasing the number of return visits to the emergency department. Patients might return for acute situations, but we weren’t increasing the number, so it’s safe, and patients don’t necessarily suffer any further functional decline. So we’re shifting the phenomenon of hospitalization toward more home-based hospitalization, in addition to the home care that’s already available. So, these mobile or dedicated teams are probably going to be an advantage in the coming years, and it will really give patients a better transition from home, prepared with mobile support teams, toward a setting with more substantial resources for personal care.

Jeanie Lacroix

So, there are many lessons and examples in other countries for learning how to better plan for and treat frailty. As an emergency physician, do you frequently see frailty in your hospital? Is it something that’s on the rise?

Marcel Émond

Absolutely, the answer is that we’re seeing more and more frailty in our emergency departments. The aging population means that a large proportion of the adult populations we currently treat are the elderly. In some emergency departments, up to 30 to 40% of the stretcher and ambulatory patients are elderly people, many of whom have significant comorbidity but, above all, a high level of frailty.

To such an extent that frailty status is now included in the Canadian Triage Scale for emergency departments. So, if you refer to the Canadian Triage Scale used in emergency departments, the frailty indicator for elderly patients is a triage modifier. We use the frailty scale to screen people who should be seen a little more quickly. These patients, these elderly people, may often have significant conditions but that are somewhat masked by their frail state or a lack of contact or previous discussion about their condition, so it’s more of a hidden condition. Detecting frailty during triage then enables nurses to escalate.

So, we’re seeing more and more of them in our emergency departments, which is why I mentioned that perhaps emergency isn’t the place to receive these people under certain conditions. Alternative levels of care or alternative methods for treating these patients will therefore be needed because when you see them in emergency in the current context of our Canadian health care system, we can adapt to these conditions of vulnerability, but we’re limited because we’re so wide-ranging. Other than creating geriatric-only emergency departments, like some places in the U.S. where some emergency departments only receive geriatric patients, emergency departments have to respond to a continuum of patients.
So, we’ll never be able to have fully adapted emergency departments. Behaviours will be adapted. So it will remain that, for emergency patients, a state of frailty could pose consequences in emergency departments. In an ill-adapted setting, frailty becomes both a screening tool, but also a detrimental factor for the patient, because care may not be fully tailored to these frail patients.

Jeanie Lacroix

So it’s a complex problem, and I imagine there are costs too, costs to the system when these patients aren’t well managed?

Marcel Émond

Yes, because if we go back to your initial question, if we could measure this initial frailty, if it starts getting worse, we could shift the care to less costly resources than ending up having to hospitalize the person on an urgent basis because they had become too frail.

So, these resources, which could prevent more serious consequences, mean that in the end our return on investment, the early return on investment, will be greater than having to compensate once the situation has become too unbearable or dangerous for the patient. And using alternative systems could enable us to cut costs, because current hospital emergency systems generate higher costs than simpler, upstream solutions that enable us to avoid such outlays in the system.

Jeanie Lacroix

For the average person listening to the podcast or who has a loved one at risk of frailty, what can they do to prevent it or to be more aware of the risks?

Marcel Émond

I think if you have a loved one, a senior who’s aging, the first thing is to look at the Canadian Frailty Scale — which you could perhaps post on the podcast page or somewhere else — so that together with your loved one you can categorize the frailty and initiate a discussion. This frailty status allows you to talk about care levels for patients, what you’d want to do if they eventually reached that point, or what would happen if they sustained a fracture in their frail condition, because, voiced or not, frailty conditions are connected to an increased need for support. So, qualifying the frailty status can open up the discussion with your loved ones about whether it’s time to consider the need for home care, because it’s often difficult. 

Elderly people often feel it’s taboo to ask for support. Whereas, if their relatives come along and say “let’s do an exercise,” it’s a bit like doing an exercise for cognitive impairment. We’ve been doing this exercise for several years now, because relatives tend to refer patients with memory problems more easily in order to detect cognitive impairment. And frailty often involves cognitive impairment, so these people often have associated frailty. But there are people without cognitive impairment who may be in frail condition, so I think it’s important to do both in parallel. People tend to open up the discussion more when the patient has cognitive impairment than when they are just generally frail.

There’s a difference between saying “Well, my mother’s aging so she’s losing her abilities, but is this loss of ability normal for her age, or is she actually in a more advanced state of frailty?” And this is where I think family members could use these kinds of tools in the future, to initiate this discussion about “Have we reached a stage where we need home care in order to remain at home?” and to prepare for the future.

Jeanie Lacroix

There are other signs as well, where we see when people living at home have company, because if they’re on their own, there’s more risk. And are there other things too, with physical activity or mobility that people can be aware of so they can see the signs?

Marcel Émond

Yes, I think in terms of frailty, one of the proven tools is there is no miracle pill for halting frailty. There is no miracle pill for “reversing.” So, you have to forget about what you might call standard medical treatment, where you go to see a doctor, you have an infection, they give you an antibiotic, and then generally the infection goes away. As I said at the beginning, frailty often involves a multi-system situation.

And what’s been shown in the literature, what we’ve studied in the past, is that if you detect frailty, even detecting an initial state of frailty in the emergency department, the fact of adding exercise, physiotherapy, occupational therapy — basically early rehabilitation — can help limit the evolution of frailty and slow it down. Stopping it completely is maybe impossible, but at least slow it down. And so I think for older people and your loved ones, or if you have a loved one who’s affected, the important thing is to stay active.

Communities offer a number of ways to stay active, and rehabilitation should also be considered. Physiotherapy, occupational therapy, adaptation, kinesiology and physical activity programs are all going to be very useful in the future for counteracting frailty and limiting its evolution for all the patients and elderly people we see in Canada.

Jeanie Lacroix

Yes, so physical activity and mobility are really valuable, and we’re always striving to improve our health. Another hot topic in this field is resistance training. Is there any evidence about this?

Marcel Émond

I have to say that in terms of resistance training, there’s been a lot of data in recent years showing that it may indeed be beneficial. I’m not a specialist in resistance training, but what we can see is that in recent years it’s one of the approaches being explored in research, to create specific programs. And technology will likely help as well. There are also physiotherapy programs that can be done at home remotely with technology now. Just like watching a movie on your favourite streaming platform, you have a similar platform that gives you the ability to do adapted exercises, whether that’s resistance training or other exercises that are adapted to your condition.

Technology is going to give seniors in Canada and Quebec alternatives to the standard approach of having to go to a specific location for training or fitness, or for reducing the onset of frailty. So, we’ll have to think a little outside the box, as we say, and make sure that we look at what can be done on the periphery to ensure that patients living at home, patients who are in vulnerable and frail condition, can access this training, whether that’s resistance training or other exercises, based on the best approaches identified through scientific research, but mainly it’s the access that’s going to be particularly interesting to look at.

Given the number of seniors in rehabilitation, re-education and training, we’re going to have to turn to alternative models rather than the standard models of going to physiotherapy or going to a standard training class. I think it’s going to be very interesting to follow in terms of the type of training, how it’ll work in terms of perception and reception, and how we’re going to deliver this training to frail individuals.

Jeanie Lacroix

What do you hope can be done in the short term to prevent frailty? Because we know, based on CIHI data, that the numbers are growing, that some of the results aren’t good. What can the system do in the short term to address frailty?

Marcel Émond

I think the first thing, like we’re doing right now, is to talk about it so that people recognize it. It’s the same phenomenon that we saw with cognitive impairment, such as Alzheimer’s disease. When it started being discussed, people paid a lot more attention to their loved ones in terms of the onset of cognitive impairment. So, I think that in this context, the fact of having a phenomenon, of opening up the concept that aging exists, that there is normal aging, that some aging involves more frailty or acute frailty, and being able to identify these people will increase our ability to treat them more effectively and to better direct these people at an early stage. That’s the first thing.

The second thing is that we need to find alternative care pathways, as I mentioned. The health care system needs to consider alternative care pathways for frail patients, either to prevent frailty, or in the case of faster deterioration, to ensure that the usual pathways of transporting them to a hospital or acute care resource aren’t the only alternatives.

So we’re going to need all stakeholders — and this is what I’m hoping for — to be trained in recognizing frailty, meaning the attendants, nurses, residents, and relatives too, who can do this because the scales aren’t complicated to use, there are descriptions and criteria to tick off. Also, that stakeholders such as paramedics start to help, because they’re often the ones called. Paramedics are the ones who likely make the most home visits across the entire country, by going into homes, and they should be asked to use alternative care and not just go to one place and one model that works, saying “There’s been an acute event, the only model we have is to go to the emergency department.” The hope is that the government, both the provincial governments and the national or Canadian government, will quickly set up alternative systems for these frail patients.

After several years of doing research in this field, I often say “Ideally, they shouldn’t go to the emergency department” because, as things currently stand, once they get there, these patients aren’t getting the care they need. We have to try to adapt the care upstream, and continue to adapt care in emergency departments, but adapting emergency departments will be limited by the fact that we treat a general population in emergency, and we have to basically adapt to the population as a whole, not just the elderly, so we’ll never have perfect care for our elderly in our emergency departments. We’re going to aim to improve them, and so we need to avoid transporting as much as possible when it’s not a dangerous situation or a situation that could jeopardize a patient’s life or personal integrity.

Jeanie Lacroix

That’s interesting, as you said, the problem is at different levels, and the solutions are across the system at all levels. Do you have any other key points or things to share about frailty?

Marcel Émond

I’d say it’s a very useful indicator, and to think that, yes, patients who are aging have the right to age naturally, but aging has different speeds, so that’s why it’s useful to introduce the concept of frailty throughout the population.

Now that baby boomers have reached the 65-and-over age group, we’re seeing that the profile of people aged 65 and over — since 65 and over is still our guide for identifying a senior — is not as frail as 65-year-old patients 20 years ago. 20 years ago, patients aged 65, who are now 85, likely had a very different level of frailty, if we’d measured it, and that’s why it’s useful to adapt, because among our young patients aged 65 to 75, there are some who are frail and others who are robust, and we won’t be able to give the same care to the same patients.

So, I think the hope is that we’ll start looking at patient-specific care, with appropriate scales and a guide to evaluating a patient based on frailty.

Jeanie Lacroix

It’s very important for the patient experience too when you’re talking in that context as well, so it’s a really interesting point. Thank you very much, Dr. Émond, for joining our discussion. I really appreciate that you’ve shared your ideas and your dedication to this important field. Thank you very much.

Marcel Émond

It was a pleasure, see you again.

Jeanie Lacroix

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? We have a link to the CIHI report on frailty and the 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. Special thanks to Heather Balmain and a shout-out to Alya Niang, the regular host of this podcast, and to Avis Favaro, the host of our English podcast. And please subscribe to the podcast wherever you get your podcasts.

I’m Jeanie Lacroix.

Talk you next time.