2018-04-18 المؤتمر العلمي الثاني للمعهد القومي لعلوم المسنين جامعة بني سويف بعنوان" التحديات والمستجدات العالمية في رعاية المسنين" http://www.bsu.edu.eg/ShowConfDetails.aspx?conf_id=217

1. Challenges and Solutions for Care of
Frail Older Adults
Dr. Bothaina Hussein Hassan, Assistant
Professor
Dr. Abeer Abd El-Rahman Mohamed, Lecturer
LecturerDr. Nancy Mahmoud El-Sakhy,
Gerontological Nursing
Faculty of Nursing
University of Alexandria

2. What is frailty?
Frailty is difficult to define, but most
definitions consider it in terms of vulnerability
which can relate to physical, emotional and social
factors. In relation to physical factors, this often
means;
 having a general lack of strength;
 being more vulnerable to disease (e.g., one or
more chronic diseases) or disability (e.g., lack of
mobility); and
 deteriorating in health more quickly as a result of
diseases and disability (including cognitive
deficits and/or dementia).

3. What is frailty?
Frailty is not something that is formally
diagnosed. People with frailty are likely to
experience problems maintaining independent
living, including decreased ability to self care.
Frailty, chronic disease and disability are related but
not the same. This means that some older adults
can be frail without having a chronic disease or
disability. As a result, frailty can precede chronic
disease or disability, or be the result of it. It has
been well established and clinically recognized that
frailty increases the risk for falls, disability,
hospitalization, iatrogenic complications, and
mortality.

4. The following figure
outlines that frailty
can be understood
across a broad
spectrum from
being mostly
healthy, to being
vulnerable or at-risk
for frailty (what is
sometimes called
‘pre-frail’), to more
severe forms of
frailty (e.g., being
completely
dependent on
others for personal
care).

5. Fall Increasing number of falls High number of fall and/
or loss of mobility
Depression/loneliness Acute illness or infection Very acute illness and
increase in number of
serious infection
One or more long-term
conditions
Long term conditions
exacerbation
Late stage dementia
Nutritional factors as
obesity
Dementia /confusion Accumulation of risk
factors and deterioration
of physical and/ or mental
health
Changes in financial
circumstances
Incontinence treated/
untreated
Frequent hospital
admission
Moving from home care
into assisted living
Frailty factors tipping an older person from low to
high risk of needing enhanced levels of care

6. Family as a care
giver
Frail older adults have significant care needs, and often rely
heavily on caregivers to support them. A caregiver may be
an intimate partner, family member, friend, or volunteer who
may also themselves be frail or at-risk of becoming frail.
Family caregivers play a vital role in care for frail older
adults. Too often they are operating in isolation from the
efforts of formal providers, and without support.

7. Family as a care
giver
The roles of caregivers of frail older adults can be
significant and may take various forms, such as:
 Providing emotional support
 Transporting or accompanying patients to medical
appointments
 Reporting or managing side effects
 Giving medicines
 Keeping track of interventions (e.g., for nutrition and
exercise), medicines, test results and papers

8. Family as a care
giver
The roles of caregivers of frail older adults can be
significant and may take various forms, such as:
 Providing physical care (e.g., feeding, dressing and
bathing);
 Coordinating care (including navigating the system and
advocating on behalf of their loved ones)
 Keeping family and friends informed
 Making legal and financial arrangements.

9. The "sandwich generation" provides support to both
younger and older family members, while at the same time
dealing with competing demands of employment and other
activities. With multiple role commitments, the ability of adult
children to manage rests upon finding a balance point
among competing demands. The rewards and strains of
caregiving have been well documented and include a sense
of meaning, meeting interpersonal obligations, pleasure in
providing care to a loved one, and satisfaction, as well as
feelings of burden and emotional stress. Responses to the
caregiving situation vary considerably, depending on
caregiver vulnerability and strengths, the demands of the
care situation, social support, characteristics of the care
recipient, the type and quality of the dyad's relationship, and
health.

10. Challenges in the care of frail older adults
Different studies have highlighted the complex nature
of health care challenges for frail elders, including
chronic diseases, acute episodes of disease,
functional disability, and the need for support in daily
life to meet basic human needs and to optimize
socialization, nutrition, and general well-being. Risks
for frailty, besides old age, include ethnicity, poverty,
and lower educational attainment, each of which
independently predicts poorer health and inferior
treatment by the health care system.

11. Challenges in the care of frail older adults
While frail older adults constitute a minority within
their own age cohort, they are disproportionately
represented as the majority of consumers within the
health care system and as recipients of nursing care.
Due to declines in biological reserve, the ability of a
frail elder to withstand and rebound from
physiological or psychosocial challenges is limited.
Frail older adults requiring considerable support
from caregivers who also need support given
increased demands placed on them

12. Challenges in the care of frail older adults
Frailty is challenging to define and ‘diagnose’,
there is a lack of consensus on how to define frailty,
and whether it is distinct from chronic disease and
disability, and the natural aging processes. The lack
of agreement about how to define frailty makes it
difficult for clinicians to 'diagnose’ or identify frailty in
their patients and clients. The lack of clear criteria
can make it difficult for care providers to monitor
people who are already frail and prevent further
deterioration, hospitalization and institutionalization.

13. Challenges in the care of frail older adults
The complex needs of frail older adults requires care
providers to consider both medical and non-medical
factors such as physical and mental functioning,
symptom burden, survival and life expectancy,
nutrition, social networks/supports, and housing.
Frail older adults having complex needs, which often
leads to care that is fragmented; and this
fragmentation can increase the risk of medical error
and poor coordination of services (e.g., being over-
or mis-prescribed drugs).

14. Challenges in the care of frail older adults
Several cultural factors potentially influence frailty
trajectories and health service utilization, including
race and ethnicity, and rural residence. Rural
populations are older and have a higher rate of
chronic illnesses and disability than their urban
counterparts. In many rural communities, options for
community-based long-term care and professional
resources for appropriate management of chronic
illnesses are limited.

15. Creative solutions
Effectiveness of the system and better outcomes for
frail older adults would be promoted by greater
attention to the goals and preferences of older adults,
improved person-centered information flow, greater
flexibility in care delivery related to need rather than
site, management of the illness trajectory, and greater
integration of multiple care goals across disciplines
and settings

16. Creative solutions
To foster equitable service organization with
accountability of services to the population, it has
been proposed that a range of appropriate and
accessible long-term care services be created
through partnerships between individuals, families,
and service providers, assuring that services meet
the needs and are able to respond to changes in
needs or expectations.

17. Creative solutions
Furthermore, a number of specific solutions are
underway to address the discontinuities in the health
care system, to improve clinical effectiveness, and to
increase the capacity to meet the growing needs of
older adults. These include intensive case
management programs, targeting at risk older adults,
partnerships with families, enhanced use of
telemedicine and assistive technology, and promoting
healthy aging.

18. Creative solutions
Recent advances in "gerontechnology" have focused
on designing technologies to improve the lives of the
elderly and are changing the possibilities for
assessing and supporting older adults in their homes.
Assistive in-home technologies, such as tools for fall
prevention and medication management, have been
demonstrated to positively impact health outcomes
and the quality of life of autonomous older adults
living in the community. Past research has
demonstrated the adoption of technology for home
care support is beneficial in retaining older adult
independence while reducing the risk of falls,
medication errors, and caregiver stress.

19. Creative solutions
Health promotion is another critical factor in
optimizing outcomes for older adults, by delaying the
onset of diseases, managing chronic illnesses,
maximizing function, and alleviating symptoms. Even
in late life, health promotion matters.
The growth of palliative care as a standard of
practice for frail older adults brings potential relief
for many.

20. Nurses in almost all specialties and settings come into
contact with older adults on a regular basis. Knowledge of the
particular needs and ways to promote positive outcomes for
older adults is therefore core knowledge for the profession,
and not simply an area of specialty for a small subgroup of
gerontological nurses.
Implications for Nursing

21. Nurses have the potential to improve elder health across
settings through effective screening and comprehensive
assessment, facilitating access to programs and services,
educating and empowering older adults and their families to
improve their health and manage chronic conditions, leading
and coordinating the efforts of other members of the health
care team, conducting and applying research, and influencing
policy.
Implications for Nursing

22. In the long-term care arena, where either family
caregivers or unlicensed workers provide most of the direct
care, nursing has a particular leadership role in working
through others to promote optimal clinical outcomes,
functional ability, and quality of life. As consumers desire a
greater voice in their care delivery, the role of nursing is
evolving toward greater partnerships with individuals and care
providers to meet goals of independence, autonomy, dignity,
and a meaningful life.
Implications for Nursing

23. Leaders in gerontological nursing have a formal and
explicit agenda, and are working diligently to increase the
capacity of the nursing profession to meet the growing needs
of the population. This agenda includes assuring appropriate
basic gerontological education for all nurses and preparation
of advanced practice nurses (Clinical Nurse Specialists,
GNPs, and Geropsychiatric Specialists) for complex,
population and system level practice.
Implications for Nursing

24. In addition, by building nursing research in gerontology,
nurses can articulate best practices and subsequently
improve care for older adults across settings. Finally, the
agenda prioritizes developing future leaders for this growing
field. Nursing practice has its roots in a community-based
approach to caring for the most vulnerable members of
society. The aging of the population calls upon nursing to
build on this solid foundation in new and creative ways,
powered by a growing knowledge base and a strong societal
commitment.
Implications for Nursing