The Chronicle Herald, Nov.21, 3013, Page A12
By Kenneth Rockwood
Frail patients need better health care. Frailty is a common face of aging, but one that does not get the respect it requires. Better care for frail patients is in our best interest: it is not just better, period, it can also be more cost-effective.
Here is how frailty happens. As people get older, on average, they have more things wrong. People who are frail have many things wrong: many illnesses, many pills, and many problems — with hearing, sight, even walking and caring for themselves.
This fact of having many things wrong is a challenge. Modern health care commonly focuses on which one thing a person has wrong (in hospital terms, it is their “most responsible diagnosis”). That does not work when people are frail.
For decades, a narrow focus in health care has succeeded. Success comes with understanding illnesses in great detail. Most people with heart attacks, for example, now survive. A detailed understanding of what happens in heart attacks has yielded emergency stents, clot-buster drugs, and drugs for blood pressure and cholesterol and for how heart muscle repairs itself.
Building on such success, a lot of health care, especially in hospital, is organized around single-organ systems. Many people with single-organ illness are fit enough to withstand the challenges of being admitted to hospital. Challenges like hospital bacteria, disrupted sleep, powerful medications, lack of privacy, noise, and the strangeness of it all.
This is less successful for frail patients. Especially when they get sick, they are less able to resist new stresses. They sleep less, but need it more. A minor infection in a fit person can be a catastrophe for a frail person. The same drug dose for a fit person can harm someone who is frail. Often when frail people come to hospital, they don’t need more drugs; they need fewer drugs. But the fewer drugs they need must be chosen with great skill.
Sorting out what is wrong with a frail older person, and what they need, especially when they get sick, is often tricky.
The speciality of geriatric medicine is devoted to the care of frail older adults: geriatricians are specialists in the complexity of frailty.
Compared with the rest of Canada, Nova Scotia has a goodish number of geriatricians. But with no more than a dozen, almost all in Halifax, we have less than half of what we need. And with the five years post-MD training they require, and our rapidly aging population, we need to start right now. Likewise, for gerontological nurses, and with extra training for family doctors.
Nova Scotia is not alone: everywhere, the challenge of frailty is about the biggest problem in health care. This is a challenge and an opportunity that we should address strategically.
Any strategy for aging should look first at why we now seem to require so many beds. Any strategy will soon see that we can afford to change. We spend enough. The much tougher issue is where and how we spend the money.
We must act. Although following can seem safest, the risk is too great. If we cannot care for our biggest constituency, we will lose support for medicare.
This is not easy. Our system of hospital and long-term care is a big ship to turn. Systems adapt, so that many people benefit, at least for now, by keeping us on the present course. That gives pressure to keep doing more of the same. Instead, we need manageable reform, focused on the needs of patients and families.
There is good reason to hope. In fact, Nova Scotia can lead in frailty care. We have the highest proportion in Canada of older adults who are frail. We have long innovated in geriatric medicine: three decades ago, two pivotal clinical trials, which laid the foundation for geriatrics worldwide, were done here. Many young doctors want to do geriatric medicine, and we can reallocate training positions for them, if we wish. It is possible to prevent frailty and lessen its impacts.
Care for the frail puts the focus on the whole patient, which helps everyone. But none of this is possible unless we decide to face up to frailty.
Kenneth Rockwood is a Halifax geriatrician.