NUR3500 Chap.7 Advanced Frailty and Dementia in Older Adults
Advanced Frailty and Dementia in Older Adults
Frailty as a clinical state
Frailty is a recognisable clinical state in which an older person's ability to withstand everyday or acute stressors is reduced, because reserve and function have declined across several organ systems with age. It is not the same as being old and not the same as having many diagnoses. It is defined in two main ways.
A physical phenotype counts five components: unintentional weight loss, low grip strength, self reported exhaustion, slow walking speed and low physical activity. A frailty index instead accumulates deficits across a long list covering disease, function, mobility, senses, mood and social vulnerability.
A brief questionnaire on fatigue, stairs, walking, illness count and weight loss gives a rapid screen.
Roughly one in ten community dwelling people aged sixty five and over is frail, but published estimates range from about four per cent to nearly sixty, and the reason is the definition rather than the population.
When a question supplies a prevalence figure, the examinable point is usually that the criteria decide the answer.
What frail older people suffer
Compared with people dying of other advanced illnesses, frail older people report a broadly similar physical burden and in some studies a heavier psychological one: pain, fatigue and weakness, pressure injury and delirium, alongside hopelessness, anxiety, emotional distress, poor wellbeing and a wish to die.
Immobility, falls, incontinence, constipation, poor appetite, swallowing difficulty and full dependence complete the picture. Much of this is missed because it is attributed to age or recorded as a care need rather than as suffering.
Why frailty is the hardest planning problem
Frailty has no clear trajectory.
The decline is a prolonged dwindling with no identifiable terminal phase, and instead of a turning point there are periods of instability in which deterioration and partial recovery are both possible. Families are almost impossible to prepare, because every honest statement is conditional, and specialist resources should be neither over-committed nor withheld, since many people outlive their prognosis.
Continuity across transitions of care matters more here than anywhere else in the course.
Advanced dementia
Only a minority of people whose primary diagnosis is dementia are referred to palliative services, partly because end stage dementia is hard to diagnose and partly because the decline is read as ordinary ageing.
A functional staging scale describes the order in which abilities are lost, ending with speech reduced to a few words and then one, loss of walking, of sitting up, of smiling and of holding the head up; hospice input is generally considered from that final stage.
Pain affects a large proportion of people with dementia and comes from the same causes as in anyone else, chiefly arthritis, constipation and infection.
Assessing what cannot be reported
Where a person cannot self report, observation replaces the numeric scale. Pain is scored from breathing, negative vocalisation, facial expression, body language and consolability.
Breathlessness is scored from heart rate, respiratory rate, restlessness, paradoxical breathing, accessory muscle use, grunting, nasal flaring and a frightened expression, with a total below three indicating comfort and three or more indicating distress. Behavioural change late in dementia is usually delirium, hyperactive or hypoactive, and the first step is to exclude pain and infection rather than to sedate.
What this chapter covers
- 01
Phenotype, index and screening definitions of frailty
- 02
The symptom and psychological burden of frailty
- 03
Why no terminal phase makes planning hard
- 04
Functional staging in advanced dementia
- 05
Observational scoring of pain and breathlessness
The resident who is not herself
- 3List the reversible causes you would exclude and how.
- 1Say which tool replaces a self reported pain score and why.
- 2Give your answer to the family.
Key terms
- Frailty
- A clinical state of reduced reserve across multiple organ systems that leaves an older person unable to withstand everyday or acute stressors.
- Frailty phenotype
- A definition counting five physical components: weight loss, weakness, exhaustion, slowness and low activity.
- Frailty index
- A definition that accumulates deficits across disease, function, mood and social circumstances to give a graded measure.
- Functional staging
- Description of dementia by the order in which abilities are lost, from complex tasks through to holding the head up.
- Observational pain scale
- A tool scoring pain from breathing, vocalisation, facial expression, body language and consolability in someone who cannot report.
- Hypoactive delirium
- The quiet, drowsy form of delirium, easily missed because the person appears settled rather than distressed.
- Respiratory distress score
- An observational score for breathlessness built from vital signs and visible signs of effort and fear.
Advanced Frailty and Dementia in Older Adults FAQ
How do I assess pain in someone who cannot speak?
Use an observational scale rather than a guess. Score breathing, negative vocalisation, facial expression, body language and consolability, observe for several minutes, and repeat the observation during movement or personal care when pain is most likely to be visible.
Why is dementia so rarely referred for specialist input?
Because the end stage is hard to identify and the decline is widely read as ordinary ageing. Functional staging helps by converting a vague impression into a described level of dependence that the whole team can act on.
Is agitation in late dementia treated with sedation?
Not first. Behavioural change at this stage is usually delirium, and the first step is to exclude pain and infection. Where medication is needed an antipsychotic may be used and a benzodiazepine only with great caution, alongside music, comfort, a familiar carer and speech that preserves dignity.
Exam move
Write the five phenotype components and the screening questions from memory, then draw the staging sequence for dementia as a ladder. Beside each observational tool, write the symptom it measures and the cut-off, and rehearse when you would score it.
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