Although there is no definitive consensus, frailty is characterised by progressive physiological decline in a number of organs, resulting in loss of function, and, with that, an increased susceptibility to disease and falls. Falls often lead to reduced or hesitant mobility, which is accompanied by withdrawal from socialisation. Therefore, the prospect of loneliness is more likely in those who are likely to fall. According to Fried et al (2001), frailty is synonymous with old age, but can also be present in those with multiple comorbidities, making it more threatening (in terms of safety) for those living in the community and/or alone. It is, therefore, appropriate to claim that episodes of frailty are more commonly associated with old age and may increase the chances of poor survival. These factors may contribute to decisions about care for the older adult and, if not carefully considered, the frail adult may end up being admitted to hospital, leading to unwanted institutionalisation and even early death.
The philosophy driving the provision of palliative care asserts that it should be available to all (Stow et al, 2019) regardless of age, diagnosis, cultural and religious persuasion. It is not yet abundantly clear today whether the frail adult is always considered for palliative care support, as evidence suggests that, traditionally, older adults receive less palliative care than younger people (Davies and Higginson, 2004). Older adults may present with multiple comorbidities, making it harder for hospital clinicians to identify their palliative care needs clearly enough to make the necessary referral to specialist palliative care services. Despite the challenges posed, hospital settings remain ideal for a thorough holistic assessment, leading to advance care planning (ACP) with the patient and family about future preferences for care and even dying. It can be argued that holistic assessment is similar to comprehensive geriatric assessment (CGA), wherein all the biological and physiological systems are assessed (not just a single system), and it is, therefore, synonymous with palliative care practice. Doing it this way may enable clinicians to hone their skills in identifying the palliative care needs of older adults, leading to appropriate referrals being made to palliative care services. The important point here is to ensure effective communication with the patient and family, during which the prognostic implications of frailty are clearly explained, any problems or issues to bear in mind are stated and the patient and their family are made aware of all available support. Stow et al (2019) claimed that some patients and families want to know clearly about probable outcomes. For example, an explicit statement such as ‘Your uncle Donald is now sick enough to die’ clarifies any uncertainty over the seriousness of the condition. Indeed, a different approach is required for those who may not be ready to openly know about the possible outcome.
Need for palliative care
It is to the benefit of patients if all services worked together, and, where two services (e.g. CGA and palliative care) have much in common, that the needs of the patient at the time determine who takes the lead in supporting the patient. As the patient's condition deteriorates and their symptoms become more burdensome, the decision can be taken to increase palliative care input. Palliative care is most effective when there are complex and multiple symptoms, including persistent and refractory ones. Frailty has a tendency to progress into a worse state rather than improving with time. Therefore, assessing for palliative care support among frail older adults is important (Stow et al, 2019). As the old adage in palliative care goes, palliative care should be introduced at diagnosis of any life-threatening disease; this should also apply to diagnosis of frailty among older adults. The use of a multidisciplinary approach that includes geriatricians helps to relieve the symptom burden including social, psychological, emotional and spiritual concerns, and ultimately, enhances quality of life for the patient. What is important to always remember is that providing palliative care for frail older patients does not only enhance quality of life, but ensures dignity in their dying.