Registed Nurses' Association of Ontario

Frailty Assessment and Management for Older Adults in North Simcoe Muskoka

Lorraine Kelly
Saint Elizabeth

Goal: My overall goal was to learn about Frailty, how to assess it and what interventions are effective for the front line health care provider to assist clients and their caregivers to live with this condition.

Background: Canada’s population is aging at an accelerating rate. Older adults require services that are designed to meet their unique physical, emotional, intellectual and social needs. Of concern, is the system’s ability to support the needs of older adults and their families living with age related diseases (e.g. dementia, cognitive impairment, physical disease) or changes in situational circumstances (e.g. personal or physical loss of function, and support systems). It is anticipated that as care continues to shift from hospital to home, the need for home care will continue to rise. Recently the Living Well, Living Longer report1 highlighted the necessary resources and supports to enable older adults to live independently in their homes for as long as possible.

Methods: Knowledge of Frailty was gained through a number of methods including conducting a literature review, reviewing relevant best practice guidelines, and presentations and discussions with my Primary Mentor and other SE clinical experts such as our Geriatric Medical Advisor, Continence Care Nurse and the Program Development Leader for Dietetics. Additional knowledge and skills in undertaking assessment and developing appropriate interventions were gained through shadowing: a Geriatric Emergency Nurse (GEM), a family health doctor who does home visits, the Integrated Falls Network staff and Home Health and Long Term Care nurses.

Findings/Outcomes: I learned that everyone views frailty differently; this was even more pronounced when I conducted a literature review on frailty and seniors. It appears that frailty is deemed important but is not always defined or measured in the same manner. It does appear that frailty impacts client overall health, independence and self-worth.

I also learned about frailty scales with the Rockwood’s Frailty Index Scale being the easiest to understand and utilize. I used the best practice guidelines from the RNAO- Dementia, Delirium and Depression in Older Adults and Fall Prevention to develop a more in depth view of the evidence in these areas and how these factors can be incorporated in their initial and ongoing frailty assessment of clients in the community.

Deliverables: Based on my new knowledge, I developed an annotated bibliography and power point presentation on Frailty and Seniors’ Care that can be used for ongoing education and training for the Saint Elizabeth (SE) Clinical Practice Coaches (CPC) (educators) and other clinical champions in the Seniors’ Care program. This information could also be added to the SE online

At Your Side Colleague (AYC) education for all staff including nurses, PSW, therapists, and supervisors, in order to promote greater understanding of frailty and the effective interventions that can promote wellbeing, independence and increased coping.

I also developed 3 questions that could be added to the general chart audits at SE in order to evaluate the education that the nurses have receive regarding frailty and its components. The Frailty Score is supposed to be determined on admission but it is not usually addressed by the nurses. I hope that through the education that has been developed, that the importance of frailty will be emphasized and chart audit questions will determine its use to drive clinical assessment and practice.

As well, a generic care plan was developed with a focus on care of a senior with a wound; quite often this is how a client comes on service with SE, and if used, the care plan helps demonstrate the components of the frailty assessment and the corresponding interventions that can be utilized by the nurses when caring for clients in the home. The care plan is a tool designed to assist staff with the application of knowledge gained through the power point presentation and other eLearning resources on the AYC website. It is my intention, to continue to implement this education within SE, as well as transferring the knowledge outside the organization whenever the opportunity presents itself. For example, the mentoring team assisted me in the development of an abstract for the CGNA conference in 2015 in the hopes of bringing the knowledge to a wider contingency of health care professionals.

Conclusion: This fellowship was extremely valuable in my understanding of frailty, how frailty impacts the lives of our senior population and what we, as health care professionals can do to assist the frail elderly to live with this condition. In my new role as Clinical Practice Resource Nurse with a specialty in Seniors Care, I will be able to utilize this new knowledge and skills in my ongoing practice by promoting a comprehensive geriatric assessment through education and mentorship with the CPCs and other providers.

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