The Grey Zone / Alex Handyside
Halifax Local Xpress
A seasoned journalist wrote recently that an elderly gentleman was “sharp as a tack, but feeble.” I wanted to shout out: “No! That’s an oxymoron.” You see, in the clinical sense, our well-meaning scribe was confusing feeble with frail. Feeble is far more commonly used to describe declining mental acuity, whereas frailty describes age-related physical and physiological changes.
Frailty is obviously not an on-off switch: you don’t just wake up frail one morning. In the clinical sense, frailty is a range of increasing risk. The risks include: further decline, additional health-care use, institutionalization and even death. For families, it usually means more care.
Let’s dispel two myths: frailty does not describe one’s disease status, nor does it describe one’s approaching mortality. It is possible to have a life-threatening condition or to be palliative (within the last six months of life) and not be frail. It is also possible to be very frail yet live for a number of years: frailty does not predict mortality.
Much of the work on frailty in seniors has been done on our doorstep, at the division of geriatric medicine, Dalhousie University, in Halifax. World-renowned gerontologist Dr. Kenneth Rockwood and his team have produced a nine-point Clinical Frailty Scale that is now widely used.
Rockwood’s is not the first frailty scale, but it is unique in its simplicity and use of straightforward language: thus it can be read, understood and used by non-clinicians such as you and me. With Dr. Rockwood’s permission, the Clinical Frailty Scale is printed in full below.
1. Very Fit — People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.
2. Well — People who have no active disease symptoms but are less fit than those in Category 1. Often, they exercise or are very active occasionally, e.g. seasonally.
3. Managing Well — People whose medical problems are well controlled, but are not regularly active beyond routine walking.
4. Vulnerable — While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up,” and/or being tired during the day.
5. Mildly Frail — These people often have more evident slowing, and need help in “high-order instrumental activities of daily living” (e.g. finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.
6. Moderately Frail — People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
7. Severely Frail — Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (not within the next six months).
8. Very Severely Frail — Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
9. Terminally Ill — Approaching the end of life. This category applies to people with a life expectancy of less than six months, who are not otherwise evidently frail.
The Clinical Frailty Scale is incredibly useful for those of us in the industry, but it is also helpful if you have a loved one who is in decline. That’s because it grants you insight into what might come next for your loved one, and what decisions will need to be made. Let’s face it; taking any surprises out of health-care planning will always be welcome.