Interdisciplinary topics in gerontology and geriatrics最新文献

Consideration of ethical and legal themes relating to frailty must engage with the concern that frailty is a pejorative concept that validates and reinforces the disadvantage and vulnerability of aging adults. In this chapter, we consider whether a greater focus on frailty may indeed be part of the solution to the disadvantages that aging adults face in achieving equality and maintaining their autonomy within systems that have used their frailty to deny them equality and autonomy. First, by examining equality both as an ethical norm and as a requirement for protections against discrimination, we raise questions about the grounds on which health providers and health systems can be required to give equal concern and respect to the needs of frail older persons. Second, we explore autonomy and identify the tension between meaningful self-determination and prevailing ethical and legal norms associated with informed choice. Third, we argue that a proper understanding of frailty is essential within both of these themes; it respects equality by enabling health providers and systems to identify and address the distinct care needs of aging adults and helps to align informed choice theory with appropriate processes for decision-making about those needs.

Both intrinsic and extrinsic factors contribute to health. Intrinsic factors are familiar topics in health research and include medical conditions, medications, genetics and frailty, while extrinsic factors stem from social and physical environments. This chapter builds on others in this volume, in which a deficit accumulation approach to frailty has been described. The concept of social vulnerability is presented. Social vulnerability stems from the accumulation of multiple and varied social problems and has bidirectional importance as a risk factor for poor health outcomes and as a pragmatic consideration for health care provision and planning. Importantly, the social factors that contribute to overall social vulnerability come into play at different levels of influence (individual, family and friends, peer groups, institutions and society at large). A social ecology perspective is discussed as a useful framework for considering social vulnerability, as it allows for attention to each of these levels of influence. Tying together what we currently understand about frailty (in medical and basic science models) and social vulnerability, the scaling potential of deficit accumulation is discussed, given that deficit accumulation can be understood to occur at many levels, from the (sub-)cellular level to tissues, organisms/complex systems and societies.

This chapter underscores the importance of interprofessional collaboration in the care of frail older patients. Hospital-based care is emphasized because interprofessionalism is difficult in that setting since the setting is constantly changing and since multiple healthcare professionals care for many complex, very ill patients, only some of whom are frail older people. Interprofessionalism is particularly important and challenging in teaching units in the acute care setting, where many health professionals practice and learn together and team membership changes frequently. Learning is enhanced and interprofessionalism can enhance learning by viewing the patient as a key part of the teaching team. While 'best practice' interventions have been identified for frail older adults who are hospitalized, these interventions are not easily implemented in routine hospital care. Three interdependent processes in clinical practice--representation, sense-making, and improvisation--are described, which contribute to an understanding of how practices change when implemented in a way that takes the local context into account and keeps person-centered care as the central consideration.

Animal models have contributed greatly to our understanding of the biology of aging and have been used to test new potential interventions to enhance survival. However, whether these interventions can modify frailty in animals is not yet clear, in part because until recently, frailty had not been considered in animal studies of aging. This review is focused on investigations that have attempted to address the issue of frailty, or aspects of frailty, in animal models, including invertebrate and vertebrate models. Some studies have used skeletal muscle weakness or sarcopenia as a surrogate for frailty in aging animals. Others have used genetically altered mice, in which components of human frailty such as inflammation are enhanced. This review also explores a novel approach to quantify frailty with a 'frailty index' based on deficit accumulation in aging animals. The concept of the frailty index is well established in the clinical literature, but recent work suggests that this approach can also be used to measure frailty in aging animals. The ability to quantify frailty in animals is a major step forward in the effort to understand the biology of frailty and to develop new clinical interventions.

Cells age in association with deficit accumulation via mechanisms that are far from fully defined. Even so, how deficits might scale up from the subcellular level to give rise to clinically evident age-related changes can be investigated. This 'scaling problem' can be viewed either as a series of little-related events that reflect discrete processes--such as the development of particular diseases--or as a stochastic process with orderly progression at the systems level, regardless of which diseases are present. Some recent evidence favors the latter hypothesis, but determining the best approach to study how deficits scale remains a key goal for understanding aging. In consequence, approaching the problem of frailty as one of the scaling of subcellular deficits has implications for understanding aging. Considering the cumulative effects of many small deficits appears to allow for the observation of important aspects of the behavior of systems that are close to failure. Mathematical modeling offers useful possibilities in clarifying the extent to which different clinical scales measure different phenomena. Even so, to be useful, mathematical modelling must be clinically coherent in addition to mathematically sound. In this regard, queuing appears to offer some potential for investigating how deficits originate and accumulate.

Rehabilitation approaches to frailty are in the early stages of development. Frailty also shows promise as a prognostic indicator for rehabilitation programs, similar to its application in other areas of medicine. However, care should be taken not to exclude frail older people from rehabilitation, as has been the case at some centers for people with cognitive impairment or very severe disability. There are clear theoretical reasons to expect that a rehabilitation approach will be effective. Some experimental data are also available suggesting that rehabilitation is effective in frail and pre-frail older people. The principles of a frailty intervention program that have been demonstrated to be clinically and economically effective are as follows: first, frailty can be mitigated; second, support needs are individually addressed; third, the interventions aim to improve physical, cognitive and social functioning; fourth, support has to be delivered over a long time period; and finally, systems must facilitate consistent management. Most frail older people are encouraged and supported to adhere to their intervention plan. It is important to recognize the needs of families and/or carers and to engage with them.

Much of the acute care provided in hospitals is for elderly people. Frailty is a common clinical condition among these patients. Frail patients are vulnerable to undergoing adverse events, to developing geriatric syndromes and to experiencing functional decline during or due to hospitalization. The strategy for providing specialized geriatric care to these hospitalized frail elderly patients currently consists of care provision either by specialized departments or by specialized teams who adopt comprehensive geriatric assessment. Even so, financial and human resources are insufficient to meet the needs of all hospitalized frail elderly patients who require comprehensive geriatric assessment. New innovative and more efficient geriatric interventions, in which the priorities of the patients themselves should be the main focus, should be developed and implemented, and professionals in all specialties should be educated in applying the fundamentals of geriatric medicine to their frail elderly patients. In the evaluation of such interventions, patient-reported outcomes should play a major role, in addition to the more traditional outcome measures of effectiveness, quality of care and cost-effectiveness.

In this chapter, we consider how health and social care can best be organized for older people with frailty. We will consider the merits of routine frailty identification, including risk stratification methods, to inform the provision of evidence-based treatment and holistic, goal-oriented care. We will also consider how best to place older people with frailty at the heart of health and social care systems so that the complex challenges associated with this vulnerable group are addressed.

Frailty is a still-evolving concept of a complex phenomenon. There are several algorithms and strategies for assessing frailty syndrome, but currently, no universally accepted definition or measurement protocol has been determined. Consequently, the biological cause(s) of frailty are also poorly defined. Much circumstantial experimental data point to the dysregulation of several key physiological systems, including the neuroendocrine, musculoskeletal, metabolic and immune/inflammatory systems, resulting from alterations in functional reserves. Immune dysregulation and inflammation as causes of frailty have gained some support from the results of longitudinal studies, but a true causal relationship has not been established. This chapter will describe the immune/inflammatory alterations found in frailty and their putative causal relationships with this state.