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Palliative Care for Frail Older Adults: Kenneth S. Boockvar, MD, MS, discusses palliative care for frail older adults.
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Palliative Care for Frail Older Adults: Kenneth S. Boockvar, MD, MS, discusses palliative care for frail older adults.
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>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspective Section. Today I have the pleasure of speaking with Dr. Kenneth Boockvar on palliative care for frail older adults, which is discussed in Chapter 8 at "Care at the Close of Life," which Dr. Boockvar co-authored. Dr. Boockvar, why don't you introduce yourself to our listeners. >> Hi. I'm Dr. Ken Boockvar. I'm a practicing geriatrician and associate professor at Mount Sinai School of Medicine in New York City, as well as an attending physician at the VA Hospital in the Bronx and at the Jewish Home Life Care, which is an academic nursing home in New York City.
>> Dr. Boockvar, how would you characterize frailty in older adults? >> So frailty is conceptualized as an overall diminished capacity to withstand stress. This diminished capacity to withstand stress places older adults at increased risk for poor health and poor health outcomes. Frailty is progressive. So it worsens with age and is often associated with a transition from being independent in self-care activities to being dependent on caregivers for care, and it's also associated with chronic diseases.
Frailty has several core clinical features. These include loss of strength, or weakness; weight loss; low levels of activity; poor endurance, or fatigue; and slowed performance. And typically in the scientific literature, having three or more of these core features is defined as frailty. >> That probably would lead into my next question, which is how can clinicians assess physical frailty in older adults, and also what challenges might clinicians face in recognizing physical frailty?
>> So assessment for frailty includes assessment for these core conditions or features of frailty as well as some associated features. So practitioners or clinicians can simply ask patients about declines in strength -- again, this is a core feature -- endurance, weight loss, or decreased physical activity. And some of the recommended questions are based on research studies. So for example, weight loss is defined as losing 10 pounds or more in the last year not on purpose or losing greater than 5% of their body weight.
Fatigue can be ascertained by asking how often did you feel that everything you did was an effort. Other symptoms that are associated with frailty should also be assessed, and these include things such as pain, depression by asking are you depressed, or falls, so asking if somebody has fallen or is afraid of falling. There are challenges, though, in this assessment, including the fact that frailty doesn't fit into a classic disease model that we're used to asking about.
So it may not be evident to either the patients themselves or family members, or even clinicians that there is a decline in health. And since the decline is typically gradual in frailty, that may also be an obstacle to recognizing it. And many patients, family members, and even clinicians may attribute these subtle, gradual declines to old age and not appreciate that a clinical response is indicated. >> Why is timely recognition of frailty important in palliative care?
>> Timely recognition is important because it may allow the clinician to identify and even treat conditions that underline frailty. Sometimes frailty is associated with diseases such as an infection, a stomach or gastrointestinal disorder, even something such as depression or medication adverse effects. So recognizing frailty and its features may lead to a response to one of these conditions.
But also frailty may not have an obvious underlying cause. And in all cases, early recognition of frailty is important to introduce geriatric care approaches and palliative care approaches that focus on optimizing patients' quality of life and reducing symptom burden. So some of the palliative care services that may be appropriate at this time for a patient who is frail include establishing goals of care, providing home care services.
It may be the right time to recommend financial planning and to talk to family. >> Once a patient has been identified as frail, what questions can clinicians ask to help establish the goals of medical care? >> What I like to do in initiating these conversations is to take advantage of reflective moments that occurred during the patient encounter. These occur naturally when patients talk about their concerns, maybe their past experiences and relationships.
And during these reflective moments, it may be possible to then enter a conversation about goals of care. And it's important as a physician and a clinician to listen more than to speak. And some of these questions might be how do you think about balancing quality of life with the length of your life. What are your most important hopes or goals? How is your quality of life now? Would there be any conditions or circumstances under which you would find life not worth living?
It's during this conversation and after it that you can establish overall goals, and then these goals can be used to construct the more medical advance directives such as no CPR or no hospitalization. >> What role does hospice play in frailty? >> Most typically with patients with what we call late-stage frailty, which might be defined as when a patient with frailty has a life-threatening complication or repeated hospital admission or just simply severe decline in their ability to take care of themselves, these are all indications of what we call late-stage or advanced frailty when it seems that management of symptoms and care coordination are more important than diagnosis or perhaps cure.
And so in these patients, both palliative care and hospice are important possible services for them. Hospice provides palliative care for patients with a life expectancy of six months or less, who are willing to forego insurance coverage or Medicare coverage for life-prolonging treatments. And referral to palliative care and hospice have been shown to be beneficial for patient symptoms, may reduce hospital costs, and high levels of patient and family satisfaction as compared to usual care and usual services.
In addition, hospice can provide medication, equipment, around-the-clock home coverage, nursing coverage, and also bereavement support. So it's a comprehensive approach to end of life that's not covered by other payment mechanisms. And in fact, hospice and palliative care have even been shown to improve the health of patients. So in other words, they may actually survive a little bit longer in some cases. And what clinicians need to do to refer patients to hospice is to certify that the patient is likely to die within six months if the disease follows its usual course.
Also, patients are eligible for hospice if they have a caregiver -- often, they may need to have a caregiver who can interface with the hospice team. Now in frailty, there are some guideline criteria supplied by the National Hospice and Palliative Care Organization that may help physicians identify these patients. So for example, they have recent multiple emergency department visits or hospitalizations, decline in ability to take care of themselves or decline in functional status, and an unintentional weight loss of more than 10% during the prior six months.
These are all indicators of advanced frailty and appropriate referral to hospice. >> Do you feel that hospice is an underused option in patients with frailty? >> I think so. As I said earlier that patients who have a more recognizable condition are more often referred to hospice, such as cancer or advanced heart disease. Even those patients are often not referred when they should be. So yes, I think that overall, clinicians could do more to recognize advanced disease and advanced frailty and refer, not just to palliative medicine and hospice, but also I was going to recommend that they refer to geriatrics specialist if that's available.
>> Is there anything else you would like to tell our listeners about palliative care for frail older adults? >> I think the other common problem that older adults, and especially frail older adults, have is susceptibility to adverse medication effects. And so as part of the evaluation of frail older adults, a very close medication review by the clinician or pharmacist to eliminate medications that may be causing more harm than good is really important. Another part that I would say is that as patients become frail, the traditional clinic visit doesn't serve them well where they have to make a trip to the doctor's office.
They may see the doctor for 10 minutes, and that's not adequate. It may be that clinicians have to provide a longer visit or a visit with other disciplines such as nursing or social work. There may be an indication for home visits if that's something that is available and as well telephone support. Again, for a frail, older adult who has trouble with mobility and transportation, this traditional clinic visit or office visit is really not adequate.
I would just add, in closing, that providing geriatric care and palliative care for frail, older adults, as much as it requires extra time and effort and really sophisticated communication, it is very rewarding and results in close professional and personal relationships. >> I can imagine that is the case. Well, thank you, Dr. Boockvar, for your insights into palliative care for frail older adults. And for additional information about this topic, JAMAevidence subscribers can consult Chapter 8 of "Care at the Close of Life." This chapter was co-authored by Dr. Boockvar.
This has been Joan Stephenson of JAMA speaking with Dr. Kenneth Boockvar for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspective Section. Today I have the pleasure of speaking with Dr. Kenneth Boockvar on palliative care for frail older adults, which is discussed in Chapter 8 at "Care at the Close of Life," which Dr. Boockvar co-authored. Dr. Boockvar, why don't you introduce yourself to our listeners. >> Hi. I'm Dr. Ken Boockvar. I'm a practicing geriatrician and associate professor at Mount Sinai School of Medicine in New York City, as well as an attending physician at the VA Hospital in the Bronx and at the Jewish Home Life Care, which is an academic nursing home in New York City.
>> Dr. Boockvar, how would you characterize frailty in older adults? >> So frailty is conceptualized as an overall diminished capacity to withstand stress. This diminished capacity to withstand stress places older adults at increased risk for poor health and poor health outcomes. Frailty is progressive. So it worsens with age and is often associated with a transition from being independent in self-care activities to being dependent on caregivers for care, and it's also associated with chronic diseases.
Frailty has several core clinical features. These include loss of strength, or weakness; weight loss; low levels of activity; poor endurance, or fatigue; and slowed performance. And typically in the scientific literature, having three or more of these core features is defined as frailty. >> That probably would lead into my next question, which is how can clinicians assess physical frailty in older adults, and also what challenges might clinicians face in recognizing physical frailty?
>> So assessment for frailty includes assessment for these core conditions or features of frailty as well as some associated features. So practitioners or clinicians can simply ask patients about declines in strength -- again, this is a core feature -- endurance, weight loss, or decreased physical activity. And some of the recommended questions are based on research studies. So for example, weight loss is defined as losing 10 pounds or more in the last year not on purpose or losing greater than 5% of their body weight.
Fatigue can be ascertained by asking how often did you feel that everything you did was an effort. Other symptoms that are associated with frailty should also be assessed, and these include things such as pain, depression by asking are you depressed, or falls, so asking if somebody has fallen or is afraid of falling. There are challenges, though, in this assessment, including the fact that frailty doesn't fit into a classic disease model that we're used to asking about.
So it may not be evident to either the patients themselves or family members, or even clinicians that there is a decline in health. And since the decline is typically gradual in frailty, that may also be an obstacle to recognizing it. And many patients, family members, and even clinicians may attribute these subtle, gradual declines to old age and not appreciate that a clinical response is indicated. >> Why is timely recognition of frailty important in palliative care?
>> Timely recognition is important because it may allow the clinician to identify and even treat conditions that underline frailty. Sometimes frailty is associated with diseases such as an infection, a stomach or gastrointestinal disorder, even something such as depression or medication adverse effects. So recognizing frailty and its features may lead to a response to one of these conditions.
But also frailty may not have an obvious underlying cause. And in all cases, early recognition of frailty is important to introduce geriatric care approaches and palliative care approaches that focus on optimizing patients' quality of life and reducing symptom burden. So some of the palliative care services that may be appropriate at this time for a patient who is frail include establishing goals of care, providing home care services.
It may be the right time to recommend financial planning and to talk to family. >> Once a patient has been identified as frail, what questions can clinicians ask to help establish the goals of medical care? >> What I like to do in initiating these conversations is to take advantage of reflective moments that occurred during the patient encounter. These occur naturally when patients talk about their concerns, maybe their past experiences and relationships.
And during these reflective moments, it may be possible to then enter a conversation about goals of care. And it's important as a physician and a clinician to listen more than to speak. And some of these questions might be how do you think about balancing quality of life with the length of your life. What are your most important hopes or goals? How is your quality of life now? Would there be any conditions or circumstances under which you would find life not worth living?
It's during this conversation and after it that you can establish overall goals, and then these goals can be used to construct the more medical advance directives such as no CPR or no hospitalization. >> What role does hospice play in frailty? >> Most typically with patients with what we call late-stage frailty, which might be defined as when a patient with frailty has a life-threatening complication or repeated hospital admission or just simply severe decline in their ability to take care of themselves, these are all indications of what we call late-stage or advanced frailty when it seems that management of symptoms and care coordination are more important than diagnosis or perhaps cure.
And so in these patients, both palliative care and hospice are important possible services for them. Hospice provides palliative care for patients with a life expectancy of six months or less, who are willing to forego insurance coverage or Medicare coverage for life-prolonging treatments. And referral to palliative care and hospice have been shown to be beneficial for patient symptoms, may reduce hospital costs, and high levels of patient and family satisfaction as compared to usual care and usual services.
In addition, hospice can provide medication, equipment, around-the-clock home coverage, nursing coverage, and also bereavement support. So it's a comprehensive approach to end of life that's not covered by other payment mechanisms. And in fact, hospice and palliative care have even been shown to improve the health of patients. So in other words, they may actually survive a little bit longer in some cases. And what clinicians need to do to refer patients to hospice is to certify that the patient is likely to die within six months if the disease follows its usual course.
Also, patients are eligible for hospice if they have a caregiver -- often, they may need to have a caregiver who can interface with the hospice team. Now in frailty, there are some guideline criteria supplied by the National Hospice and Palliative Care Organization that may help physicians identify these patients. So for example, they have recent multiple emergency department visits or hospitalizations, decline in ability to take care of themselves or decline in functional status, and an unintentional weight loss of more than 10% during the prior six months.
These are all indicators of advanced frailty and appropriate referral to hospice. >> Do you feel that hospice is an underused option in patients with frailty? >> I think so. As I said earlier that patients who have a more recognizable condition are more often referred to hospice, such as cancer or advanced heart disease. Even those patients are often not referred when they should be. So yes, I think that overall, clinicians could do more to recognize advanced disease and advanced frailty and refer, not just to palliative medicine and hospice, but also I was going to recommend that they refer to geriatrics specialist if that's available.
>> Is there anything else you would like to tell our listeners about palliative care for frail older adults? >> I think the other common problem that older adults, and especially frail older adults, have is susceptibility to adverse medication effects. And so as part of the evaluation of frail older adults, a very close medication review by the clinician or pharmacist to eliminate medications that may be causing more harm than good is really important. Another part that I would say is that as patients become frail, the traditional clinic visit doesn't serve them well where they have to make a trip to the doctor's office.
They may see the doctor for 10 minutes, and that's not adequate. It may be that clinicians have to provide a longer visit or a visit with other disciplines such as nursing or social work. There may be an indication for home visits if that's something that is available and as well telephone support. Again, for a frail, older adult who has trouble with mobility and transportation, this traditional clinic visit or office visit is really not adequate.
I would just add, in closing, that providing geriatric care and palliative care for frail, older adults, as much as it requires extra time and effort and really sophisticated communication, it is very rewarding and results in close professional and personal relationships. >> I can imagine that is the case. Well, thank you, Dr. Boockvar, for your insights into palliative care for frail older adults. And for additional information about this topic, JAMAevidence subscribers can consult Chapter 8 of "Care at the Close of Life." This chapter was co-authored by Dr. Boockvar.
This has been Joan Stephenson of JAMA speaking with Dr. Kenneth Boockvar for JAMAevidence.
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