What does a raw egg have in common with lace or even a new relationship? Each of them tends to be frail — delicate and easily damaged.
An older adult can also be frail, diagnosed with conditions that greatly increase their chance of injury and even death. Once a person is identified as frail, it can be difficult to rehabilitate him or her out of frailty.
But there is hope. Before a person becomes frail, they are pre-frail, showing changes in physical and mental health, socializing and quality of life that make them likely to become frail, often within three to seven years.
“If we can intervene at this point,” said Heather Fritz, Ph.D., an assistant professor of occupational therapy and gerontology at Wayne State’s Institute of Gerontology, “we could possibly delay the descent into frailty.”
Fritz won a $256,000 grant from the Michigan Health Endowment Fund to test an occupational therapy-based intervention on 150 pre-frail African Americans. Her team is halfway through their two-year timeframe and seeing positive results in the 75 people enrolled so far. “Patient satisfaction has been very high. They are telling us it is very useful,” Fritz said. “Even when they don’t do exactly what we ask them to do, they seem to be receiving good benefit.”
Doctors at the Rosa Parks Geriatric Center of Excellence and Senior ER screen patients 55 and older for pre-frail symptoms. Potential enrollees learn about pre-frailty and why it’s important to stave off frailty as long as possible. “Most of the people we talked to never heard about frailty before, never had a health care provider explain it to them,” Fritz said. “They had no idea how serious it could be.”
Once enrolled in the study, patients receive four visits from an occupational therapist over four months. Each visit, “takes as long as it takes,” according to Fritz. “We don’t rush anyone. Many of our patients say, ‘You guys actually take the time to talk to me.’ We think that’s the way it should be.”
The first visit includes a comprehensive OT evaluation that can take up to two hours, including medication management, activities of daily living, pain management, home safety and sexual satisfaction. The person’s strength, balance and range of motion are tested. The OT notes any special home care equipment in use. The visit takes place in the clinic or in the home, whichever is more convenient for the patient.
On the second and third visits, the focus is either physical activity or diet, as selected by the patient. If it’s physical, the OT reviews any physical deficits uncovered during the first visit and prescribes a tailored home exercise program to alleviate them. If it’s diet, to reduce cholesterol for example, the patient learns about food choices and substitutions. Recommendations are highly personalized to the person’s abilities, needs and motivation.
The OT works with the patient to set small, achievable goals linked to an environmental trigger. If you want to replace butter with olive oil, you write it down and then take the butter off the counter and put a carafe of oil in its place. The same approach would apply to replacing salt with a salt-free seasoning mix. “We use the principals of habit formation — make specific changes to the environment to help support goals,” Fritz said.
The fourth and last session provides a wrap-up to talk through goals that have not been achieved and create new goals if needed. Since patients are being asked to make lifestyle changes, the OT tries to establish a long-term maintenance plan. Consistently enforced small changes can improve health.
Three and six months after the final visit, the patient is evaluated for any decreases in their original indicators of pre-frailty. Two and three years later, Fritz’s team will examine their medical records to see if they have moved into frailty. “It’s hard to measure something not happening,” Fritz said, “but pushing back the descent into frailty for a few years is a good start.”
Is it feasible?
Fritz wants to ensure this approach is feasible not only with patients, but also providers and insurers. Her team will analyze costs and benefits to determine whether the program’s expenses can be reimbursed by insurance carriers so it is self-sustainable. She thinks the OT approach to frailty is a good fit.
“OTs are trained to address issues of diet, physical activity, pain management, social interaction, balance, falls and safety — everything this plan requires,” Fritz said. “We could become the one-stop shop for preventing frailty.”
Frailty is a significant cause of health care use and personal suffering in later life, and much harder to reverse than pre-frailty, yet almost no current programs target pre-frail persons.
“Frailty can be slowed or reversed if we catch it soon enough and have the wherewithal to do something,” Fritz said. “We must develop programs to prevent frailty progression on a national scale, because soon we won’t have the resources to care for all our frail older adults. Let’s help them now rather than pay for it ten-fold later.”
This story originally appeared in the spring 2019 edition of Transitions.