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Frailty in hospitalized older adults : a clinical practice guideline Gill, Rupali 2018

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    FRAILTY IN HOSPITALIZED OLDER ADULTS: A CLINICAL PRACTICE GUIDELINE by RUPALI GILL BSN, University of the Fraser Valley, 2012   SCHOLARLY PRACTICE ADVANCEMENT RESEARCH PROJECT  SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF     MASTER OF SCIENCE IN NURSING     in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)    March 2018 © Rupali Gill, 2018   ii   Abstract  Frailty is a key geriatric syndrome in older adults. As the number of older adults increases, so does the recognition and treatment of frailty. Older adults are the largest population to use the healthcare system, including admission to hospital. Nurses at the point of care are situated in the right place to assess and intervene for frailty. If frailty is not assessed and interventions are not initiated in a timely manner, older adults are at risk for many adverse events and functional decline. Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners and patients to make decisions about appropriate healthcare for specific clinical decisions and situations. In addition, clinicians who use practice guidelines can draw upon the collective work and experience of many researchers, clinicians and patients instead of relying solely on their own personal knowledge and experience to guide their clinical practice decisions. The ‘Frailty in Acute Care’ CPG in this paper, based on a literature review of the current state of knowledge, guides practice and assists nurses, frail patients, and families to understand and act towards frailty.     iii   Table of Contents Abstract ........................................................................................................................................... ii Table of Contents ........................................................................................................................... iii Acknowledgements ......................................................................................................................... v Chapter 1: Introduction ................................................................................................................... 1 Geriatric Syndromes ................................................................................................................... 2 Frailty as a key Geriatric Syndrome ........................................................................................... 3 Challenges for Hospitalized Frail Older Adults.......................................................................... 4 Clinical Practice Guidelines ........................................................................................................ 6 Purpose ........................................................................................................................................ 7 Chapter 2: Review of Literature ..................................................................................................... 9 Definition and Models ................................................................................................................ 9 Applicability to Nursing Practice.......................................................................................... 13 Screening and Assessment ........................................................................................................ 13 Applicability to Nursing Practice.......................................................................................... 16 Interventions ............................................................................................................................. 16 Applicability to Nursing Practice.......................................................................................... 19 Summary ................................................................................................................................... 19 Gaps in Current State of Knowledge .................................................................................... 20 Chapter 3: Clinical Practice Guideline – Frailty in Acute Care.................................................... 21 Focus ......................................................................................................................................... 21 Background ............................................................................................................................... 21 Definitions................................................................................................................................. 22  iv   Expected outcomes ................................................................................................................... 23 Screening and Assessment ........................................................................................................ 23 Interventions ............................................................................................................................. 26 Education .................................................................................................................................. 32 Evaluation ................................................................................................................................. 33 Chapter 4: Discussion and Recommendations .............................................................................. 34 Discussion ................................................................................................................................. 34 Recommendations ..................................................................................................................... 38 Research ................................................................................................................................ 38 Practice .................................................................................................................................. 39 Education .............................................................................................................................. 40 Leadership ............................................................................................................................. 41 Conclusion ................................................................................................................................ 41 References ..................................................................................................................................... 43        v   Acknowledgements First and foremost, I dedicate this work to my husband who has been my support through this journey. Thank you for your belief in me, you were my motivation to complete this SPAR project. I would like to express my sincerest appreciation to my SPAR supervisor Dr. Jennifer Baumbusch, PhD. Your continuous guidance, support, and positive encouragement has helped me immensely throughout this entire process. Thank you for helping me develop and make this paper into what it is today. I would also like to express my gratitude to Dr. Alison Phinney, PhD, who was my committee member for this SPAR project. Your recommendations helped me refine this work considerably. Thank you for all your contributions. To Karen Koch, my mentor, who has been a wonderful inspiration, I also dedicate this SPAR to you. Thank you for being my role model as I was starting out my nursing career and for your ongoing support. Finally, to my parents and mother-in-law. Without your love and support, my education endeavours would not have been possible. I cannot thank you enough for all that you have done for me. Thank you!    1   Chapter 1: Introduction  As the first of the baby boomers turned 65 in 2011, older adults account for an increasingly large portion of Canada’s population (Canadian Institute for Health Information [CIHI], 2011). It is estimated that by 2036, 25% of Canadians will be 65 and older. In 2016 in Canada, seniors outnumbered children (Statistics Canada, 2017) for the first time. Children aged 0 to 14 represented 16.6% of the total population while older adults 65 and older represented 16.9% in the latest survey (Statistics Canada, 2017). According to an examination of the health status of these older adults, they are living longer than seniors from previous generations and are healthier than ever before (CIHI, 2011). Yet, advanced age is also associated with many chronic illnesses such as heart disease, cognitive impairment, arthritis, diabetes, and cancer (Britt & Day, 2016). Due to these chronic illnesses and many more, older adults are the largest population to use healthcare services (CIHI, 2011). Older adults are more likely to have higher rates of chronic illness, which are costly to treat and manage, compared to their younger counterparts. Medical management, including hospitalization, is initiated for older adults with acute and chronic illnesses. Hospital stays for older patients tend to cost more than those for younger patients with similar health problems (CIHI, 2008). Denton and Spencer (2010) estimated that people with chronic illnesses have an increased length of stay (LOS) in hospitals and more usage of resources. These older adults may also take a longer time to heal or recover from treatments (CIHI, 2008). In 2011, of the $220 billion spent on healthcare in Canada, 45% was spent on people over 65 years old, although they were only 15% of the population (CIHI, 2011). Additionally, Canadian seniors account for 40% of acute care services and occupy 85% of acute  2   care beds (Canadian Frailty Network [CFN] 2013; CIHI, 2011). As evident from these statistics and research, this older adult population is increasing the demand for health care. Geriatric Syndromes Care of older adults tends to differ from that of younger persons in that multiple problems are the norm rather than the exception. Decline typically occurs in multiple systems, leading to a sometimes subtle increase in dysfunction and disability with aging. When looked at in isolation, the decline may seem modest, but accumulated, the results can be devastating (Ham, Sloane, Warshaw, Potter, & Flaherty, 2014). This buildup of multisystem decline is responsible for the existence of geriatric syndromes – problems that typically have a multifactorial etiology and therefore are rare in younger persons and common in older adults (Ham et al., 2014). These geriatric syndromes occur from the added effects of impairments in multiple domains and aging (Tinetti, Speechley, & Ginter, 1988; Ham et al., 2014). There are many geriatric syndromes, including delirium, dementia, depression, mobility and functional decline, falls, incontinence, weakness, and frailty (Inouye, Studenski, Tinetti, & Kuchel, 2007; Ham et al., 2014). In geriatric syndromes, it is multiple abnormalities that “run together” to cause a single phenomenology (Flacker, 2003). Ham et al. (2014) state geriatric syndromes typically reflect the loss of a person’s physiologic reserve. Many common geriatric syndromes are described as biomedical and physiologic in nature. A number of geriatric syndromes have been shown to predict mortality (Kane, Shamliyan, Talley, & Pacala, 2012). These geriatric syndromes are highly prevalent and associated with poor outcomes and morbidity (Inouye et al., 2007). Furthermore, their effect on quality of life and disability is substantial (Inouye et al., 2007).   3   Frailty as a key Geriatric Syndrome In 1995, Tinetti, Inouye, Gill, and Doucette stated frail older adults were at particular risk of experiencing geriatric syndromes, due to the increased vulnerability resulting from impairments in multiple systems. Similarly, Inouye et al. (2007) discussed the high prevalence of geriatric syndromes in older adults, especially frail older adults. Later in 2007, frailty itself was coined as an emerging geriatric syndrome (Ahmed, Mandel & Fain, 2007). The prevalence of frailty in Canada is steadily growing as the number of older adults increases (CFN, 2013). In 2011, approximately 25% of people over age 65 and 50% past age 85 – over one million Canadians – were considered to be medically frail (CIHI, 2011; CFN, 2013). Additionally, in 10 years, well over two million Canadians may be living with frailty (CIHI, 2011; CFN, 2013). Older Canadians living with frailty are over-represented in all parts of the healthcare system: primary care, community and long-term residential care, acute care, and palliative care. (CIHI, 2011; CFN, 2013). The risk of becoming frail increases with age, but the two are not synonymous (CFN, 2013); those living with frailty are at higher risk for negative health outcomes than is expected based on age alone. These frail older adults have more complex health challenges and care needs. Independent of age, frailty has been found to be predictive of hospitalization, institutionalization, and worsening health status (Hoover, Rotermann, Sanmartin, & Bernier, 2013). In fact, frail older adults are at high risk for many adverse effects some of which include acute and chronic illness, disability, and mortality (Gillick, 2014). There are many definitions and models of frailty in the literature. Some definitions emphasize the biomedical, physiological domain, while others include the psychosocial domain.  4   In general, frailty has been defined as a clinical physiological syndrome (Fried et al., 2001). Other scholars have stated that frailty comprises personal, social and environmental factors (Kaufman, 1994; Raphael et al., 1995). A prevalent definition of frailty states frail persons are those in whom the assets of maintaining health and the deficits threatening it are in precarious balance (Rockwood, Fox, Stolee, Robertson, & Beattie, 1994). In nursing, Nightingale has emphasized a holistic conception of care and healing that extends beyond the biomedical to encompass the patient as a person within a life context (1969). The Royal College of Nursing defines nursing as a holistic knowledge and practice (2003). Therefore, from a nursing perspective and for the purpose of this paper, I will be defining frailty using a holistic approach with multiple domains, instead of the physical or biomedical domain alone. Challenges for Hospitalized Frail Older Adults There are several hazards of hospitalization for older adults, including falls, incontinence, delirium, and adverse drug reactions (Gillick, 2014). Hospitalization can potentially affect quality of life, ability to return home to live independently, and sometimes survival (Hickman, Newton, Halcomb, Chang, & Davidson, 2007). Furthermore, a hospitalized older adult is more likely to have an increased length of hospital stay, higher mortality, and persistent decline after discharge including loss of ability to perform activities of daily living (ADLs), recurrence of illness leading to readmission, and placement in long-term residential care (Sager et al., 1996). Among older hospital inpatients, those who show signs of frailty are at particular risk of adverse outcomes such as death and institutionalisation (Parker, Fadayevatan, & Lee, 2006). Arnett, Lait, Agrawal and Cress (2008) introduced the concept of functional reserve which is defined as the difference between the maximum physical or mental capacity of an individual and the minimum necessary to perform daily functioning. Frail older adults with limited functional  5   reserve fare even worse compared to non-frail older adults in hospitalized settings. When admitted to acute care with an illness episode or medication side effect, which might seem inconsequential in younger patients, frail older patients can present with steep and sudden functional or cognitive decline (Oliver, 2016; Rockwood, 2005). Frailty is also associated with increased LOS in hospital (Khandelwal et al., 2012). The presence of frailty is also associated with other key clinical geriatric syndromes in disease presentation. These clinical syndromes are recognized as foundational to geriatrics, namely loss of mobility, falls, confusion, incontinence, and polypharmacy (Parker et al., 2006). Often times, frailty is not recognized or is misdiagnosed as depression, failure to thrive, and other diagnoses. This contributes to deterioration of physical and cognitive functioning, decreased quality of life, as well as increased costs of care and resource utilization (Parker et al., 2006). Frailty is a common geriatric syndrome among hospitalized older adults, with several studies indicating prevalence between 40-87.1% depending on the frailty measure used (Bieniek, Wilczyński, & Szewieczek, 2016; Chong, Baldevaroma-Llego, Chan, Wu, & Tay, 2017; Gregorevic, Hubbard, Katz, & Lim, 2016; Juma, Taabazuing, & Montero-Odasso, 2016; Perna et al., 2017). Furthermore, this prevalence increases as age increases (Bieniek et al., 2016; Juma et al., 2016). For example, out of 232 medical patients 75 years and over, 55.6% were considered frail (Oo, Tencheva, Khalid, & Ho, 2013). In addition, patients over the age of 85 were more likely to have frailty compared with those aged 75-85 (Oo et al., 2013). As the population demographics continue to change, providing effective inpatient care for frail older adults is a key issue. These frail hospitalized older adults stand in need of specific and effective intervention (Parker et al., 2006). They require holistic approaches that treat the entire  6   person and the presenting symptoms in a coordinated, caring manner instead of as a collection of separate illnesses (CFN, 2013). However, nurses do not have expertise in caring for the frail older adults. Frailty is poorly understood, pervasively under-recognized, and under-appreciated by healthcare professionals and the public (CFN, 2013). Recognizing frailty is key to improving patient care and to making patients and families feel better about the care their relatives receive (CFN, 2013). Nurses have important roles in caring for older adults in hospital as part of an interdisciplinary team (Parke et al., 2014). Conroy and Turpin (2016) argue that clinical staff, including nurses, need to be educated on the needs of frail older people in order to improve outcomes. Frail older adults have complex and multifaceted needs and nurses must to be able to foresee complications these individuals may experience and intervene accordingly (Heath & Phair, 2009). A hospitalized older adult in acute care is already at risk for functional decline and other adverse effects. Being frail increases this risk and therefore, nurses should be educated on assessing frailty and intervening in a timely manner. Clinical Practice Guidelines Field and Lohr (1990) define clinical practice guidelines (CPGs) as systematically developed statements that assist practitioners and sometimes patients to make decisions about appropriate health care. These guidelines evolved from the evidence-based medicine and evidence-based practice movements in the 1990s as a way to facilitate knowledge transfer from researchers to health care providers. CPGs also expedite the application of new knowledge into clinical practice. Barker (2013) states clinical guidelines have become an important aspect of clinical governance. They are seen as promoting clinical and cost effectiveness, and providing a bridge between research and practice. Similarly, Polit and Beck (2017) state practice guidelines  7   are evidence-based and combine a synthesis and appraisal of research evidence with specific recommendations for clinical decisions. CPGs can provide practitioners a common knowledge base and a framework within which to practice. Clinicians, including nurses, who utilize CPGs can draw upon the collective work and experiences of researchers and other practitioners, instead of relying solely on their own personal knowledge and experience to guide their clinical practice decisions. CPGs, therefore, are an appropriate way to distribute useful and practical information to clinicians, patients, and families. Currently in British Columbia, there is no standardized CPG on frailty in hospitalized older adults. Due to the rise in the older adult population and subsequently a rise in frail older adults, it is a critical time to develop guidelines to assist practitioners and improve patient outcomes. These guidelines will inform practice and guide clinicians in making clinical decisions related to frail older adults when they are hospitalized and most prone to functional and cognitive decline. Purpose The purpose of this Scholarly Practice Advancement Research (SPAR) Project was to 1) complete a literature review to expose the best evidence on the definition, assessment and interventions for frailty; 2) on the basis on this evidence, develop a CPG for frailty in hospitalized older adults; and 3) discuss the implications of the above for nurses. This paper is timely as the number of older adults is increasing, and maintaining their autonomy and wellbeing is pertinent. Instead of being an unavoidable consequence of accumulating years, frailty has been recognized as an independent geriatric syndrome (Clegg, Young, Iliffe, Rikkert, & Rockwood,  8   2013). This CPG will provide resources, skills, and education to nurses and other clinicians, thereby informing practice and improving care for frail hospitalized older adults.                       9   Chapter 2: Review of Literature  This chapter is a literature review of the definition and models, screening and assessment tools, and interventions for frailty. Definitions and models that demonstrate the diversity of frailty are reviewed among many in the literature and critiqued. Next, screening and assessment tools that are most appropriate for use in acute care settings are selected and reviewed. Lastly, the interventions most applicable in acute care settings for frailty are discussed. The literature is synthesized, critiqued, and the applicability of this literature to nursing practice is considered. Gaps in the current literature are also put forward. The literature review in this chapter informs the CPG for frailty in hospitalized older adults in the next chapter. Definition and Models Frailty is a complex and multifactorial geriatric syndrome. There are multiple reasons as to why it is so difficult to define frailty including its etiology, the independent work of frailty researchers, and the inherent difficulty in distinguishing frailty from ageing and disability (Dent, Kowal, & Hoogendijk, 2016). Sternberg, Schwartz, Karunanathan, Bergman, and Clarfield (2011) concluded in their systematic review that a clear operational definition of frailty would enable the appropriate older adults to be targeted for interventions that help to preserve functional status and prevent, delay, or decrease adverse outcomes. In the following paragraphs, various definitions and models of frailty will be discussed consecutively and critiqued. Best known for their work with frailty, Fried et al. (2001) completed a study to provide a standardized definition of frailty. These authors state frailty is a clinical syndrome that results from a mix of many factors in a cycle associated with decline in energy and reserve. They define frailty as a syndrome resulting from cumulative decline in multiple physiologic systems. This  10   syndrome of frailty, with its own underlying pathophysiology, is held to be a construct distinct from disability or comorbidity (Sternberg et al., 2011). Fried et al.’s (2001) widespread operational definition of frailty is the occurrence of three or more of the following: unintentional weight loss, self-reported exhaustion, weakness (reduced grip strength), slow walking speed, and low physical activity. The Cardiovascular Health Study tested and validated this definition of frailty in 5317 community-dwelling men and women aged 65 years and older. This frailty phenotype model was independently predictive of incident falls, worsening mobility or ADLs, hospitalization, and mortality over 3 years, even after adjusting for health status, socioeconomic status, and disability (Fried et al., 2001). However, this definition and model of frailty disregards the multifaceted nature of frailty. Fried et al. (2001)’s definition, although widely used for research purposes, has so far proven impractical in the clinical setting (Rockwood, 2005). Some clinicians have suggested adding cognition, depressed mood, and pain to the operational definition (Ham et al., 2014). Another common critique is that the definition itself relies on only a few domains, which is surprising when thinking about the multi-systemic nature of frailty (Rodriguez-Manas & Sinclair, 2014). There can also be other non-physiologic factors added to this definition and as it stands, it does not provide a holistic view of frailty. Due to these reasons, this definition of frailty has received scrutiny over the years and can be impractical for clinical settings. Another widely known definition of frailty states frail persons are those in whom the assets of maintaining health and the deficits threatening it are in precarious balance (Rockwood et al., 1994). This definition was the basis for the cumulative deficit model or frailty index (Mitnitski, Mogilner, & Rockwood, 2001; Rockwood & Mitnitski, 2007). The original model identified 70 deficits (signs and symptoms, laboratory values, disabilities) that occur as frailty  11   develops (Mitnitski et al., 2007). There have been modifications of the frailty index containing lower numbers of variables ranging from 12 to 40 from the original 70 (Maxwell & Wang, 2017). A frailty index is created by dividing the total number of deficits by the number of variables examined. The Rockwood et al. (2005) frailty index has been demonstrated to be highly predictive of mortality and hospitalization in older adults. This model provides a more holistic view of frailty compared to Fried et al. (2001); however, critics argue that this perspective is a more difficult concept to operationalize (Maxwell & Wang, 2017). Both Fried and Rockwood models are predictive of frailty and useful for frailty identification; however, clinical application is often based on usability and practicality (Maxwell & Wang, 2017). The Fried et al. phenotype model is more commonly used for screening purposes, whereas the Rockwood frailty index provides a more precise method of quantifying frailty and differentiating between different levels of frailty (Maxwell & Wang, 2017). Although Rockwood et al.’s definition is more holistic compared to Fried et al., it can be confusing as there are multiple deficits to consider and it is not practical for use in acute care settings. A frailty definition by Raphael et al. (1995) encompasses a public health behavioral sciences model on frailty. Raphael et al. define frailty as a condition of lived experience that reflects the intersection of unique individual factors as well as distal and proximal environmental factors. They further define frailty as a declined ability to carry out important practical and social ADLs. Raphael et al. argue that frailty should be placed on a frailty-hardiness continuum and the position on this continuum is dependent on an individual’s personal and environmental factors. Raphael et al.’s definition of frailty includes the social domain, considers an individual’s environment, and mentions function, different from Fried et al. (2001)’s phenotype model and  12   Rockwood et al. (2005)’s frailty index. However, it does not mention the physiological or psychological nature of frailty and therefore, does not provide a multifaceted view of frailty. Morley et al.’s (2013) definition of frailty has gained agreement over the last few years. In a consensus conference aimed at defining frailty operationally, a group of delegates from major international, European, and American societies agreed on the following definition: “frailty is a clinical state in which there is an increase in an individual’s vulnerability for developing increased dependency and/or mortality when exposed to a stressor” (p. 392). A stressor is a health problem or life event that can happen to an individual, such as a new diagnosis, hospitalization, or death of a loved one. Frailty can occur as the result of a range of diseases and medical conditions, states Morley et al. This definition of frailty demonstrates the multifaceted nature of frailty utilizing concepts such as vulnerability and dependency. Although the authors describe that frailty can occur because of medical conditions and diseases, the definition itself provides a holistic and all-encompassing view on frailty. Boers and Jentoft’s (2015) new definition of health gives a new meaning and definition to frailty. They define frailty as “the weakening” of health, where health is defined as “the resilience or capacity to cope, and to maintain and restore one’s integrity, equilibrium, and sense of wellbeing in three domains: physical, mental, and social” (Boers & Jentoft, p. 430). The concepts of resiliency and equilibrium help define frailty more clearly in this definition. Furthermore, compared to the Fried et al. (2001) and Raphael et al. (1995) definitions of frailty, this definition uses a much more holistic approach with multiple domains, instead of the physical domain alone.    13   Applicability to Nursing Practice Of all the definitions and models discussed, none were able to provide a nursing view on the concept and definition of frailty. Therefore, two current definitions in the literature that are holistic, all encompassing and mention multiple domains to define frailty are chosen as most appropriate for acute care settings. The definition by Morley et al. (2013) and Boers and Jentoft (2015) are the most relevant to include in a CPG on frailty. Morley et al. define frailty using concepts such as vulnerability, dependency, and stressors. Although they do not mention all the domains, they do not disregard them either. For example, a stressor can be a physiological stressor or a social stressor. Boers and Jentoft define frailty using a new definition of health, discussing concepts including resilience, capacity, integrity, equilibrium, and wellbeing. This definition is inclusive of the physical, psychological, and social domains of frailty. Screening and Assessment  Identifying and assessing frailty in older adults begins with established screening processes and standardized frailty screening in clinical settings (Maxwell & Wang, 2017). Screening for frailty should be straightforward and efficient in acute care settings where older adults are often in pain, sedated, in a delirium, or unable to undergo physical testing (Maxwell & Wang). Ease of use, amount of time, and training required for screening need to be considered within clinical settings and abilities of older patients. There were many screening tools for frailty in the literature, such as the Reported Edmonton Frail Scale (Hilmer et al., 2009) and the Edmonton Frail Scale (Rolfson, Majumdar, Tsuyuk, Tahir, & Rockwood, 2006). The use of Fried’s (2001) phenotype criteria in daily clinical practice can be an obstacle (Rodriguez-Manas & Sinclair, 2014). Woo, Leung, and Morley (2012) concluded that Fried’s phenotype model has low Positive Predictive Value which  14   prevents its use in daily clinical practice. The screening tool that was most commonly referenced and well researched was the Clinical Frailty Scale (CFS) by Rockwood et al. (2005). This scale is accessible and readily available online (Geriatric Medicine Research, 2009). The CFS takes less than five minutes to complete, is a visual and written scale that includes 9 graded pictures (Rockwood et al., 2005). It is scored on a scale from 1 (very fit) to 9 (terminally ill) and is based on clinical judgement. Each point on this scale corresponds with a written description of frailty, complemented by a visual chart to assist with the classification of frailty (Rockwood et al., 2005). A score ≥5 is considered frail. The CFS is a well-validated frailty measurement, and has been validated as an adverse outcome predictor in hospitalized older adults (Basic & Shanley, 2015; Wallis, Wall, Biram, & Romero-Ortuno, 2015). This scale does not require special equipment and is appropriate for use in clinical settings (Dent et al., 2016). Furthermore, the CFS can be extracted from data from medical charts and therefore can also be derived from Comprehensive Geriatric Assessments completed in the community. Ritt, Bollheimer, Seiber, and Gaßmann (2016) concluded among those frailty instruments that were evaluated, the CFS-9 emerged as the most powerful for prediction of one-year mortality. Chong et al.’s (2017) study found that the CFS may identify older adults at highest risk of adverse outcomes of hospitalization. Gregorevic et al. (2016) argue that although other frailty measurement tools have been validated in the acute care setting, their features limit their use in patients who do not speak English, or who are hearing or vision impaired (Hilmer et al., 2009).  Juma et al. (2016), in a prospective cohort study, examined the CFS in older adults admitted to the acute medicine unit and its association with LOS. They concluded the CFS predicted LOS in their study. The CFS was easy to apply and time efficient, validating its clinical  15   applicability in their setting (Juma et al., 2016). Additionally, the CFS has practical applicability to detect those older adults at risk of increased LOS in a general medicine unit. Being able to screen and recognize frailty and its severity early on during admission may allow nurses and clinicians to determine the level of risk for frailty-related outcomes and plan interventions accordingly to decrease future complications, which may decrease LOS (Juma et al., 2016). After an older adult is screened for frailty, a comprehensive assessment is vital. Parker et al. (2006) argue that assessment for frailty should be multifactorial and include daily review of physical, cognitive, and psychosocial function. Comprehensive geriatric assessment (CGA) was developed in response to concern that problems experienced by older adults who require hospital-level care are not recognized and acted on (Ellis et al., 2017; Rubenstein, Stuck, Siu, & Wickland, 1991). CGA is “a multi-dimensional diagnostic and therapeutic process that is focused on determining a frail older person’s medical, functional, mental, and social capabilities and limitations with the goal of ensuring that problems are identified, quantified, and managed appropriately” (Ellis et al., 2017, p. 6). CGA is both a diagnostic and therapeutic process delivered by an interdisciplinary team. CGA aims to identify, quantify, and manage problems experienced by older adults. These problems are often multiple and may span over several areas such as physical and mental health, functional domains, and social domains (Ellis et al., 2017). CGA has the potential to improve health outcomes while reducing the costs of health care and social care (Rubenstein et al., 1991). Pilotto et al. (2017) state CGA is capable of effectively exploring multiple domains in older adults, being the multidimensional and interdisciplinary tool of choice to determine the clinical state, risk, and short- and long-term prognosis to facilitate clinical decision making on the personalized care plan of older persons. Oo et al.’s (2013) study indicated that due to the high  16   prevalence of frailty in older adults admitted into acute care, it is important to have access to a frailty tool in daily acute care practice in hospitals. The interdisciplinary clinical team managing these older patients must be able to undertake a complete CGA and apply the results effectively (Oo et al., 2013). Applicability to Nursing Practice Screening and assessment are essential components needed to care for frail older adults. For nurses in acute care settings, the CFS (Rockwood et al., 2005) is an appropriate tool to screen frailty. Acute care can be a fast-paced environment and the CFS takes less than five minutes to screen older adults over the age of 65. In Gregorevic et al. (2016)’s prospective cohort study, the CFS was seen as an attractive tool as it can be completed based on routine clinical admission and no additional equipment is required, so there are minimal barriers to its’ implementation. They found that despite lack of training for staff, an increase in frailty correlated with functional decline and mortality in older adults, thus, supporting the validity of the CFS as a frailty screening tool for clinicians. After an older adult is screened for frailty, a comprehensive assessment is vital. Nurses play a key role in CGA (Ellis et al., 2017) by gathering assessment data on a frail older adult’s physical and mental health, functional domains, and social domains. The holistic review can then be used to create an individualized, person-centered care plan. CGA provides a holistic assessment to the needs of the older adult and is applicable in acute care settings for nurses and potentially other healthcare professionals. Interventions  Cesari, Calvani, and Marzetti (2017) state the identification of frailty should lead to a CGA and personalized plan of care. Interventions should include daily review of physical,  17   cognitive, and psychosocial function and the use of protocols to improve self-care, continence, nutrition, mobility, sleep, skin care, mood, and cognition (Parker et al., 2006). Similarly, Conroy et al. (2016) state interventions are necessary in the following areas: diagnoses (multiple interacting comorbidities, polypharmacy); physical function (ADLs); psychological function (especially confusion and mood); and environment and social support networks present or required to maintain ongoing function. Multi-domain interventions are needed against frailty; however, interventions should be prioritized and carefully chosen to avoid overtreatment and adverse events (Cesari et al., 2017). Ellis et al.’s (2017) Cochrane review states different healthcare settings have different models of CGA in order to meet differing patient needs. Not only is CGA a multi-dimensional assessment tool, it is also an intervention in itself for frailty. CGA includes formulating of a plan of care, delivering that care plan, and reviewing its progress. Ellis et al. (2017) list some key features in the interventions for frailty that demonstrate their effectiveness. These features are: specialty expertise; multi-dimensional assessment and identification of medical, functional, mental, social, and environmental problems; and co-ordinated interdisciplinary rounds. Key components that have been reported to be associated with improved CGA outcomes include ability to implement treatment recommendations provided by the multi-disciplinary team and target the intervention to patients who present with frailty (Ellis, Whitehead, O’Neill, Langhorne, & Robinson, 2011; Stuck, Siu, Wieland, Adams, & Rubenstein, 1993). Ellis et al. (2017) also concluded older adults are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital. There was no difference in effect between ward- and team-based CGA, as this analysis was underpowered (Ellis et al., 2017).  18   In his review, Ko (2011) states curative treatments for frailty are currently unavailable; however, exercise intervention and geriatric interdisciplinary assessment (CGA) and treatment models can improve clinical outcomes for frail older adults. Likewise, Maxwell and Wang (2017) in their publication “Understanding Frailty: A Nurse’s Guide” recommend physical activity as the overarching intervention for preventing and managing frailty. Several systematic reviews support the value of exercise interventions (Cadore, Rodriguez-Manas, Sinclair, & Izquierdo, 2013; Theou et al., 2011). Exercise interventions should be repeated at least 3 times per week for 30 to 45 minutes and sustained for more than 5 months (Daniels, van Rossum, de Witte, Kempen, & van den Heuvel, 2008; Theou et al., 2011). Maxwell and Wang state the World Health Organization supports these recommendations. Although this is true for community, in acute care, existing recommendations indicate that older adults should be mobilized daily, multiple times a day. They should be up in a chair for all meals, in order to avoid further deterioration. Staying in bed unnecessarily can have detrimental effects on an older adult’s overall function (State of Victoria: Department of Health, 2012). An essential element of good practice in this area is regular interdisciplinary team rounds (Parker et al., 2006). Responsibility for team rounds, coordination of care in hospital and during transitions is usually allocated to a nurse (Lowthian, 2017). Maxwell and Wang (2017) found communication is crucial as providers connect and engage in ways that promote shared decision-making. Consistency in communication and support through transitions of care is also important because some frail patients may transfer to other facilities after hospital discharge.  Along with multiple interventions mentioned for frailty, other considerations are important in the care of older adults. An integrative review of supportive care approaches for frail older adults in acute care settings identified several priorities (Nicholson, Morrow, Hicks, &  19   Fitzpatrick, 2017). Hospitalization is a stressful event for frail older adults and families as it often highlights functional decline and approaching end of life (Maxwell & Wang, 2017). Nurses and other clinicians can assist with understanding of frailty and its trajectory by providing information and helping patients and families understand what to expect in terms of gradual decline in function. Applicability to Nursing Practice Nurses have an integral role in caring for frail older adults in hospital settings as part of the interdisciplinary team. Heath and Phair state the responsibilities of nurses working with older people are “to recognise the need for urgent intervention, and deliver care that supports bodily systems and individual resources to prevent deterioration” (2011, p. 53). Once a CGA is completed, interventions should be initiated for the older adult. These interventions are initiated by point of care nurses and the interdisciplinary care team. Interdisciplinary team rounds are important for communication and collaboration, and nurses should be involved in them. The care plan should be initiated by nursing and the interdisciplinary team keeping the older adult’s goals in mind. Nurses should also do a daily review and documentation of the care plan to measure changes in frail older adults. The patient and family should be involved in the care planning and intervention process by primary nurses and the interdisciplinary team. Summary From this literature review and for the purposes of this paper, two definitions of frailty were identified as being the most comprehensive and holistic. Firstly, frailty is “a clinical state in which there is an increase in an individual’s vulnerability for developing increased dependency and/or mortality when exposed to a stressor” (Morley et al., 2013, p. 392). Secondly, Boers and Jentoft (2015)’s definition of frailty as “the weakening of (health; health is defined as) the  20   resilience or capacity to cope, and to maintain and restore one’s integrity, equilibrium, and sense of wellbeing in three domains: physical, mental, and social” (p. 430). The CFS was identified as the most appropriate screening tool for frailty in acute care. Once an older adult is screened as being frail, CGA should follow as the assessment and intervention guide. The literature on interventions for frailty emphasize their multifactorial nature. The use of interdisciplinary rounds and care planning is essential, as is input and involvement of the patient and family. Gaps in Current State of Knowledge The literature reviewed in this chapter is the current state of knowledge about frailty in acute care. This literature has largely been developed and researched by physicians. Frailty has previously been seen as a state of physical decline and this is a distinctly biomedical perspective. These perspectives highlight deficits rather than the nature of the person as a whole. This view of frailty is opposite of nursing perspectives on health and the view of an individual as a whole (Nightingale, 1969). In nursing, Nightingale has emphasized a holistic concept of care that extends beyond the biomedical to include the patient as a person within a life context. The major gap in the current state of knowledge is a nursing perspective on frailty. Understanding care for frail older adults through a nursing lens can provide an alternative to the common biomedical emphasis on physiological abnormality and functional loss. There is potential opportunities to change the view of frailty by intervening in older adult’s health behaviors and promoting self-care. Research gaps include nurse-led research on the definition of frailty, and comprehensive screening and assessment tools that can be used by nursing. Nursing-specific interventions for frailty is also a key gap in the literature.    21   Chapter 3: Clinical Practice Guideline – Frailty in Acute Care Focus 1. Identify patients at risk for frailty. 2. Screen and assess for frailty promptly. 3. Manage (and prevent) symptoms and adverse outcomes of frail patients by implementing interdisciplinary interventions. 4. Consistently evaluate the management of frailty. 5. Provide education and resource materials to nurses, patients, and families. Background Frailty is a common geriatric syndrome that increases the risk of many adverse events and can be preventable. The concern of frailty in Canada is steadily growing as the number of older adults grows (CFN, 2013). Additionally, in four years, well over two million Canadians may be living with frailty (CIHI, 2011; CFN, 2013). When assessing frailty in hospitalized acute care older adults, several studies indicated the prevalence is 40-87.1% depending on the frailty measure used (Bieniek et al., 2016; Chong et al., 2017; Gregorevic et al., 2016; Juma et al., 2016; Oo et al., 2013; Perna et al., 2017). Furthermore, this prevalence increases as age increases (Bieniek et al., 2016; Juma et al., 2016; Oo et al., 2013). Frail patients are at high risk for many adverse effects, including acute and chronic illness, disability, and mortality (Gillick, 2014). The risk of an older adult developing a new disability related to activities of daily living (ADLs) during hospitalization is estimated to be at least 30%, and about half of all older adults’ disabilities develop during a hospitalization (Gill, Allore, Gahbauer & Murphy, 2010). The presence of frailty is also associated with other key clinical geriatric syndromes in disease presentation. These clinical syndromes are recognized as  22   foundational to geriatrics, particularly loss of mobility, falls, confusion, incontinence, and polypharmacy (Parker et al., 2006). Oftentimes, frailty is unrecognized or misdiagnosed. This contributes to deterioration of functional and cognitive functioning, decreased quality of life, as well as increased costs of care and resource utilization (Bakker & Olde Rikkert, 2015; Nicholson et al., 2017; Theou et al., 2011). Recognizing frailty is key to improving patient care and to making patients and families feel better about the care received (Heath & Phair, 2011; Juma et al., 2016). Definitions There are multiple definitions of frailty in the literature, but for the purposes of this CPG, two definitions best fit. Firstly, frailty is defined as “a clinical state in which there is an increase in an individual’s vulnerability for developing increased dependency and/or mortality when exposed to a stressor” (Morley et al., 2013, p. 392). A stressor is a health problem or a life event that occurs to an individual, such as a new medical diagnosis, hospitalization, or a death of a loved one. Frailty can occur as the result of a range of diseases and medical conditions (Morley et al., 2013). Boers and Jentoft’s (2015) new definition of health gives a new meaning and definition to frailty. They define frailty as “the weakening of health”, which in turn is defined as “the resilience or capacity to cope, and to maintain and restore one’s integrity, equilibrium, and sense of wellbeing in three domains: physical, mental, and social” (p. 430). These two definitions together define frailty in a more holistic and all-encompassing manner. The first definition mentions key concepts related to frailty such as vulnerability and stressors involved while the second definition includes the multiple domains of frailty. Baseline status is the patient’s usual cognitive, functional, and social status in the months and weeks prior to the acute illness/hospitalization. Clinical Frailty Scale (CFS) is a  23   validated screening and measurement tool for frailty (Geriatric Medicine Research, 2009; Rockwood et al., 2005). Comprehensive Geriatric Assessment (CGA), is “a multi-dimensional diagnostic and therapeutic process that is focused on determining a frail older person’s medical, functional, mental, and social capabilities and limitations with the goal of ensuring that problems are identified, quantified, and managed appropriately” (Ellis et al., 2017, p. 6). CGA is a multi-dimensional assessment tool and an intervention in itself as it includes formulating, delivering, and reviewing the plan of care for frail patients. Expected outcomes The patient should return to their cognitive, functional, and social baseline status (or as close as possible to baseline pre-hospitalization status). When possible, baseline data should be collected from the older adult’s primary care provider and family members. 1. Nurses should have the opportunity to be educated in defining frailty. 2. Nurses should have the opportunity to be educated in screening, assessing, and managing frailty, e.g. utilization of the CFS and CGA. 3. Nurses, other staff, patients, and families should have the opportunity to access best practice resource materials. Screening and Assessment 1. Older adults frequently have complex healthcare needs due to a higher prevalence of multisystem comorbidities (Ham et al., 2014). Frail older adults are at particular risk of negative health outcomes in hospitalized settings; therefore, it is important to complete an initial assessment (Oliver, 2016; Rockwood, 2005). The admitting nurse should complete an initial assessment on admission to hospital that identifies the current health needs and predisposing conditions of the older adult that may heighten the risk of healthcare  24   associated harm (Healthcare Improvement Scotland, 2015). This initial assessment includes identifying all health problems contributing to their admission and current presentation (Healthcare Improvement Scotland, 2015).  2. Clinical Frailty Scale 2.1 The admitting nurse (once educated in screening frailty) should use the CFS for all admitted patients over the age of 65 to screen for frailty. 2.2 Complete the CFS (Rockwood et al., 2005), scoring on a scale from 1 (very fit) to 9 (terminally ill), based on clinical judgement and assessment. The admitting nurse can complete the CFS, as can physicians (Gregorevic et al., 2016; Wallis et al., 2015). A score ≥5 is considered frail. 3. Comprehensive Geriatric Assessment 3.1 If the patient is considered frail using the CFS, the primary nurse should inform the most responsible physician and consult a social worker in order to initiate a CGA (Pilotto et al., 2017). The most responsible physician should then consult a geriatrician.  Note: Although there are many ways to initiate a CGA, the core team of nurse, geriatrician, and social worker is used in many settings and the same approach will be used for this CPG (Pilotto et al., 2017). This core team should complete a multi-dimensional assessment and identify medical, functional, mental, social, and environmental problems.  3.2 The primary nurse, geriatrician, and social worker thoroughly assess the frail patient’s medical, functional, mental, and social capabilities and limitations within their scope. The social worker should assess the frail patient for social and environmental  25   problems in their assessment. The social worker should also coordinate and support discharge planning. The geriatrician focuses on a medical assessment and may complete a functional and mental assessment of the frail patient. The core team should then share their assessment findings and plan of care with one another. 3.3 The CGA can occur on a unit, such as an Acute Care for Elderly (ACE) unit, or as an interdisciplinary team in any acute care area. 4. 48/6 Model of Care 4.1 The primary nurse should also gather additional baseline information on the six care areas: bowel and bladder management, cognitive functioning, functional mobility, medication management, nutrition and hydration, and pain management from the older adult and family (British Columbia Provincial Seniors Hospital Care Working Group [BCPSHCWG], 2014). This is also known as the 48/6 Model of Care where these six key areas are assessed within the first 48 hours of admission (BCPSHCWG, 2014). These key areas are addressed to ensure a full assessment of the older adult is completed. These areas are related to frailty and inform the nurse of additional assessment findings. 4.2 Frail patients are at risk for functional impairment and other adverse outcomes.  Assessing bowel and bladder management is relevant for frail patients because inability to maintain usual bowel and bladder function as well as use of urinary catheters restricts independent ambulation and may increase prevalence of a urinary tract infection (UTI), as well as delirium (BCPSHCWG, 2014). Frail older adults can present in acute care with steep and sudden functional or cognitive decline (Oliver, 2016; Rockwood, 2005). Therefore, cognitive functioning assessment and functional  26   mobility assessment is relevant. Adverse effects of medications can inhibit functional mobility, increase the risk of falls, and level of cognitive impairment, thus, a medication management assessment is important for frail patients (BCPSHCWG, 2014). Assessment of nutrition and hydration management is key as frail older adults may receive all of their hospital meals in bed, contributing to the risk of poor nutritional intake, aspiration and immobility, which can lead to general functional decline (BCPSHCWG, 2014). Lastly, a thorough pain assessment is vital as older adults may not accurately articulate their level of pain, which may impair functional mobility (BCPSHCWG, 2014). This can contribute to functional decline, which is detrimental to frail older adults (Bakker & Olde Rikkert, 2015).  Note: Some of these key assessment areas such as cognition, which includes the identification, assessment and management delirium, dementia and depression, and pain warrant their own practice guidelines, not specific to frail older adults. Interventions Note: Frailty is a geriatric, multifactorial syndrome and it cannot be treated easily with a single intervention (Labella, Merel, & Phelan, 2011). Frailty requires a multifactorial approach to care with an interdisciplinary team (Labella et al., 2011). 1. A physiotherapist (for physical function assessment and intervention, including strength and walking), occupational therapist (to assess activities of daily living and recommend treatment and home modifications), dietician (to assess nutritional status and treatment), pharmacist (for medication review), and other members of the interdisciplinary team can be consulted by the nurse, geriatrician, or social worker if needed (State of Victoria: Department of Health, 2012).  27   2. A CGA includes care planning for the frail patient in hospital to improve patient outcomes (Ellis et al., 2011; Ellis et al., 2017). Therefore, interdisciplinary team members, including nurses and social workers, should develop a personalized plan of care for the frail patient based on patient-centred goals, CFS and CGA. Care planning should demonstrate involvement of patients and family members in decision-making, including incorporating their preferences and needs (Healthcare Improvement Scotland, 2015).  3. Patient care coordinators (PCCs) should organize regular, co-ordinated interdisciplinary team rounds to discuss the frail patient’s care and discharge plan (at least five times a week) (Parker et al., 2006). A key feature of CGA is coordinated interdisciplinary meetings (Ellis et al., 2017). Frail patients are at risk for adverse outcomes while in hospital and an increased LOS (Parker et al., 2006), therefore, team rounds ensure there is discussion and communication between the disciplines regarding the plan of care. In interdisciplinary team rounds, the patient’s physical, cognitive, and psychosocial function should be reviewed (Parker et al., 2006). Regular discussions of the frail patient’s status ensures each domain is discussed and the risk of further deterioration or adverse events is minimized. 4. The primary nurse should identify and prioritize specific interventions to avoid overtreatment and adverse events. Functional decline is common in frail older adults and mobility interventions should be prioritized for those who are at risk for deterioration.  5. Intervening for frailty goes beyond involvement of the interdisciplinary team, care planning and interdisciplinary team rounds. From a nursing perspective, it is important to intervene in a holistic way. Best practices for hospitalized older adults using the  28   document “Best care for older people everywhere: The toolkit” (State of Victoria: Department of Health, 2012) will be discussed. These interventions on their own are broad and generic for the care for frail patients in acute care. The interventions will be modified to account for the unique needs for frail older adults. Intervene to improve: 5.1 self-care and mobility: Ensuring older adults’ mobility and self-care is maintained is the responsibility of nurses, care aides, physiotherapists and occupational therapists. It is recommended by best practice guidelines that older adults should be encouraged to dress (consider the possibility of wearing their normal day clothes and footwear), get out of bed and move around the ward with supervision as required, sit out of bed as soon as it is considered safe to do so, walk to the bathroom with supervision as required, and eat meals out of bed in a communal dining room where available and appropriate (State of Victoria: Department of Health, 2012). Best practices also state maintaining mobility and participation in self-care during an older adult’s hospital stay can maintain their independence, reduce the occurrence of falls and fall-related injuries, and minimize loss of confidence due to fear of falling (State of Victoria: Department of Health, 2012). Furthermore, regular mobilization can improve muscle strength, stamina and reduce the risk of older adults experiencing adverse events such as pressure injuries (State of Victoria: Department of Health, 2012). However, for a frail older adult, this is not sufficient. Nurses and care aides should mobilize frail patients at least three times a day. Nurses and care aides should also encourage frail patients to do as much self-care as possible when assisting with ADLs, such as washing and dressing in the morning and at night. Frail older adults are at increased risk for mobility impairments and restricted mobility during hospitalization that may  29   further reduce muscle strength, bone density and mobility, possibly leading to deconditioning, falls and fractures, and/or increased dependency (Bakker & Olde Rikkert, 2015). 5.2 continence: Best practices suggest helping older adults maintain continence in hospital is the responsibility of all clinicians, including nurses and care aides. When an older adult is admitted, it is recommended underlying causes or contributing factors (such as urinary tract infections, constipation, medications, delirium) be treated (State of Victoria: Department of Health, 2012). Furthermore, it is recommended to promote adequate oral hydration and food intake, and monitor the use of medications that may cause constipation, such as opiates. Older adults should be assisted in locating the call bell and bathroom, and adequate lighting and signage to bathrooms at night should be provided (State of Victoria: Department of Health, 2012). In addition, the use of indwelling catheters and restraints should be minimized where possible. Gait aids should be within reach at all times when the person is cognitively intact and independent with mobility (State of Victoria: Department of Health, 2012). It is also that recommended continence pad use, which may reduce an older adult’s ability to self-toilet, and bedpan or urinal use should be discouraged if possible. Best practice guidelines also state nurses and care aides should check disposable pads after each episode of incontinence (State of Victoria: Department of Health). However, for frail patients, nurses or care aides should provide adequate hydration, ensuring patient has water close by at all times, and allow an hour to eat their meals. Nurses should monitor frail patients taking opiates for constipation more closely and ensure a bowel protocol regimen is initiated as frail patients are at  30   increased risk of constipation due to mobility changes and deterioration. For frail patients, nurses or care aides should assist the patient to the bathroom every two hours or as needed. If a frail older adult is wearing disposable pads, nurses or care aides should check the pad every two hours. Frail older adults are at risk for developing incontinence as an adverse outcome in hospital (Bakker & Olde Rikkert, 2015). Furthermore, for a frail older adult, inability to maintain usual bowel and bladder function as well as use of urinary catheters can restrict ambulation and may increase prevalence of a UTI, as well as delirium (BCPSHCWG, 2014). 5.3 nutrition:  It is recommended that a nutrition risk screen should be undertaken on admission and at regular intervals. It is also recommended if an older adult consumes less than 50 per cent of their meals on three consecutive days, this should prompt staff to refer to a dietitian (State of Victoria: Department of Health, 2012). However, this is likely inadequate for an older adult with frailty. For a frail patient, nutrition risk screening should be done within 24 hours of admission and a dietician should be referred to promptly. Best practices also recommend that appropriate assistance and sufficient time to eat meals for older adults should be provided. However, for frail patients, nurses and care aides should provide one-to-one assistance when required and up to an hour to eat meals. Frail older adults are at risk for malnutrition (Bakker & Olde Rikkert, 2015) and poor nutritional status for frail older adults affects other domains of functioning, such as skin integrity, mobility, medications, and continence. Furthermore, nutrition plays an important role in maintaining muscle mass and function, especially for frail patients.  31   5.4 skin care: On admission to hospital, it is recommended that nurses should screen for the risk of skin damage in older adults. To assess pressure injury risk, nurses should use a validated tool such as the Braden Scale for Predicting Pressure Sore Risk (Bergstrom, Demuth, & Braden, 1987). Best practices suggest nurses should assess skin integrity, which can be done while assisting an older adult with personal hygiene (State of Victoria: Department of Health, 2012). It is also recommended for nurses to orient older adults to their environment and keep the environment free of clutter and easy to navigate to prevent injury. However, for a frail older adult, nurses should assess skin integrity within the first 24 hours as frail patients are at increased risk for skin breakdown, pressure sores, and infection (Bakker & Olde Rikkert, 2015). Changes in the integumentary system may cause altered thirst and nutrition, leading to a risk of dehydration and malnutrition for frail patients (Bakker & Olde Rikkert, 2015). 5.5 use of medications: It is recommended that medication reconciliation should occur within 24 hours of admission. To avoid errors, nurses should check that all of the medications the older adults should be taking are what they are actually taking. It is also recommended that this process be repeat on transfers to other facilities or units and discharge. Nurses should refer to a pharmacist if there are signs of polypharmacy or any adverse effects are present of medications (State of Victoria: Department of Health, 2012). However, this is not adequate for frail patients. For frail patients, nurses and the interdisciplinary team should also assess the patient’s ability to manage their medications safely. At discharge, the frail patient (and family) should receive the correct medications and information to support taking them appropriately.  32   In addition, for frail patients, nurses and the interdisciplinary team should set up support and monitoring of medications for those who require it after discharge (Healthcare Improvement Scotland, 2015). This is important for frail patients because they may require assistance with taking medications. In addition, adverse outcomes of medications can inhibit functional mobility, and increase the risk of falls and level of cognitive impairment, especially for frail patients (BCPSHCWG, 2014). Education 1. Education for nurses. All nurses, Clinical Nurse Educators (CNEs), and Clinical Nurse Specialists (CNSs) should receive education and training on the frailty definition, screening, assessment and interventions. There should be a hospital or organization-wide education program that trains nurses to respond appropriately to the needs of frail patients. This includes both initial and refresher training and ensuring training is available for new staff. This education should begin with in-person education sessions and eventually be developed into an online education module. For ongoing sustainability, it is necessary to provide adequate training for staff and to effectively use and implement the education provided (State of Victoria: Department of Health, 2012).  2. Education for patients and families. Nurses and CNEs should provide patients and families with information and resources on frailty. Patients and their families should be educated about the factors associated with frailty and informed on how they can minimize the risk of increasing frailty while in hospital. Nurses should encourage patients to engage in activities designed to reduce social isolation and involve carers and family in this process (State of Victoria: Department of Health, 2012). Patients and their families should also be educated about strategies to optimize function and wellbeing at home.  33   Frailty is poorly understood and under-recognized by the public (CFN, 2013), therefore educating patients and families about frailty will increase awareness and understanding.  3. Education for interdisciplinary staff. All direct care interdisciplinary staff in acute care areas should have access to education and resource materials on frailty in the older adult, through CNEs, CNSs, Clinical Practice Leaders, and clinical policies. This includes education and resource materials on frailty, its definition, CFS, and CGA. This will increase the awareness of frailty in older adults for interdisciplinary staff. Evaluation 1. Compare baseline status to current status of the frail patient.  2. Evaluate effectiveness of interventions on the care plan and 24-hour documentation record. 3. If frailty is not managed, review CGA and older adult’s current status, note potential underlying/root cause(s), take appropriate actions and reassess. The frail patient may require further rehabilitation at a different facility outside the hospital.       34   Chapter 4: Discussion and Recommendations The purpose of this Scholarly Practice Advancement Research (SPAR) Project was to complete a literature review in order to develop a CPG for frailty in hospitalized older adults. From the literature that was reviewed, the findings indicate that frailty for older adults in acute care is a significant concept for nurses to understand and recognize. This chapter will summarize and discuss the findings within the broader literature of frailty and acute care, while also providing several recommendations in research, practice, education and leadership. Discussion Older adults tend to have more chronic illnesses that need medical management and use of healthcare services, including hospitalization (CIHI, 2011). Decline in multiple systems results in geriatric syndromes in older adults which are complex in nature and have a multifactorial etiology. Frailty is a key geriatric syndrome and frail older Canadians represent a large percentage of patients in various sections of the healthcare system (CIHI, 2011; CFN, 2013). In acute care, frail older adults represent up to 87.1% of all older adults, depending on the frailty measure used (Bieniek et al., 2016; Chong et al., 2017; Gregorevic et al., 2016; Juma et al., 2016; Oo et al., 2013; Perna et al., 2017). The literature in this paper has revealed that there are multiple definitions, screening and assessment tools, and interventions for frailty. This extensive amount of literature on frailty can make it challenging for nurses to collate this information and clearly define, screen, assess, and intervene for frailty in acute care. Furthermore, there is no current and accessible CPG on frailty in acute care in the literature. The CPG presented in this paper provides a simple and holistic description of frailty as well as a screening and assessment tool, and interventions that can be utilized in acute care. Guidelines that have low complexity, strong presentation and simple  35   formats have higher adherence in practice (Ebben et al., 2015; Sinuff, Cook, Giacomini, Heyland, & Dodek, 2007). In this paper, multiple definitions were narrowed down to two that provide a holistic, broader view of frailty. The CFS was chosen as the most appropriate and well-validated screening tool for frail older adults in acute care (Rockwood et al., 2005). Then, completing a CGA, which includes a comprehensive assessment of a frail older adult and care planning, was chosen as the most appropriate next step (Ellis et al., 2017). However, there is still a need for a nursing perspective on the definition of frailty.  From the literature review, it was also apparent that interventions for frailty are multifactorial in nature, just as its etiology. Due to this complexity, there is a scarce amount of literature on interventions explicit to frail older adults. Therefore, best practices and interventions for hospitalized older adults were customized to frail older adults specifically in this CPG. There is a need for a broader consensus on the concept of frailty from various disciplines, including nursing, in order to develop more practice-based tools, including tools for the management of frailty in numerous areas of the healthcare system. The literature review and CPG in this paper can contribute in the improvement of care for frail hospitalized older adults. Labella et al. (2011) state one of the ways to improve care is to avoid iatrogenic complications during hospitalization for frail older adults. The lack of awareness of frailty as a geriatric syndrome has implications for older adults and the care they receive. Providing effective and timely inpatient care for these frail older adults should be a key priority. Practitioners use CPGs to assist with making decisions about appropriate healthcare for patients. The ‘Frailty in Acute Care’ CPG provides nurses and other healthcare professionals with a common knowledge base and a potential framework within which to practice. Evidence- 36   informed practice guidelines are developed to meet a practice need or gap by using the most recent evidence (Polit & Beck, 2017). Research utilization is the process of transforming research knowledge into practice and is a key aspect of evidence-based practice (Stetler, 2001). According to Cesari et al. (2017), the integration of such knowledge of older adults should be promoted for better addressing unmet clinical needs of frail individuals. With the amount of frailty literature present, nurses do not always have the time and resources to transform new knowledge into practice. CPG use in practice settings allows for nurses to use the best available evidence and expedite the application of new knowledge into clinical practice. Further CPGs of frailty in other parts of the healthcare system, including primary care, community and long-term residential care, also need to be developed. Nurses are positioned ideally in caring for frail older adults, being part of an interdisciplinary team in hospital settings (Parke et al., 2014). Nurses also develop and lead quality improvement programs and can foster an environment that is sensitive to the care older adults receive. There are multiple factors and potential challenges to consider for the CPG in this paper to be applicable for nurses in acute care. CPGs, like this one, do not always acknowledge context. This CPG may be appropriate in an ideal acute care environment that is well resourced and funded. However, acute care settings are not adequately resourced or structured. These areas are fast-paced environments that are not always suitable for older adults, especially frail older adults. Parke and Chappell (2009) found four areas that cause a poor fit for older adults in acute care environments: architectural features, bureaucratic conditions, chaotic atmosphere and hospital employee attitude. Furthermore, they conclude that acute care areas utilize a one-size fits all approach to care (Parke & Chappell, 2009). The unique needs of older patients, physical  37   environment, staffing structure, and organizational culture combined create an acute care environment that is not sufficient to meet the needs of older adults (Baumbusch, Leblanc, Shaw, & Kjorven, 2016). The challenges in acute care environments make it difficult for nurses to care for older adults in these settings. Baumbusch et al. (2016), in their research, found multiple factors that affect nurses’ readiness to care for older adults and their families in hospitals. These factors were at the point-of-care level, the organizational level, and in broader societal attitudes and include high workloads, patient complexity, high patient-to-nurse ratios, and a lack of interest in shifting the organizational culture to meet needs of older adults (Baumbusch et al., 2016). Despite the challenges present, Dahlke, Phinney, Hall, Rodney, and Baumbusch (2015) found nurses assess their environments and their older adult patients, leverage the assistance of others and stretch resources to provide what they define as good care.  Another barrier for nurses caring for older adults effectively in acute care is not having specialized knowledge to meet the needs of this population (Baumbusch et al., 2017). However, Parke et al. (2014) found acute care nursing competence in gerontological nursing knowledge is a modifiable factor that contributes to safe quality care for hospitalized older adults. The potential challenges and barriers in acute care environments need to be acknowledged when moving this CPG forward into practice. My aim with this paper is to improve understanding and recognition of frailty among nurses, clinicians, patients, and families as the older adult population increases. Nurses are situated at the point-of-care and can provide education about frailty to older patients and families, which can increase awareness and facilitate understanding about frailty. This literature  38   review and CPG has illuminated several key findings, which are important to consider in the advancement of research, education, practice and leadership for frail older adults in acute care. Recommendations Research  In this paper, a variety of studies were reviewed, summarized, and critiqued. This literature review has shown that there are a number of definitions of frailty in older adults; however, it is necessary to critique these definitions and decide on a clear, all-encompassing definition of frailty. There were also multiple interventions in the literature for frail older adults. Although there have been some comprehensive literature reviews, systematic reviews, and meta-analyses completed, further research needs to be done that can provide standardized ways to intervene for frailty. As there are many challenges and factors to consider in implementing this CPG, further research is needed that addresses the unique needs of older adults in acute care. Baumbusch et al. (2016) indicate research is needed to investigate effective approaches that address system-level limitations that impact the care hospitalized older adults receive. Parke et al. (2014) state nurses can have a role in advocating for further research to identify and understand the modifiable factors that influence the care for older adults in hospitals. Use of the CPG in this paper cannot be fully determined unless it is implemented and the related processes and outcomes are evaluated. Implementation research evaluates the structures and processes associated with implementation of guidelines (Brownson, Colditz, & Proctor, 2018). Nurse researchers can make considerable contributions to nursing knowledge as they expand understanding about the structures and processes impacting nurses’ work. Furthermore,  39   research can be conducted on the use of the frailty CPG and its effect on the nurses’ autonomy and scope of practice. Practice It is pertinent to encourage nurses and other clinicians to follow elder-friendly principles (AONE, 2010; Healthcare Improvement Scotland, 2015; State of Victoria: Department of Health, 2012) and to teach about frailty. First, it is necessary to create a culture of an elder-friendly hospital environment, where all staff are conscious of key aspects of care in older adults, such as self-care, mobilization, polypharmacy, nutrition and hydration, cognition, and more (Parke et al., 2014). Baumbusch et al. (2016) found one factor for nurses’ readiness to provide effective care to older patients is accessing educators. Thus, in addition to creating this culture, nurse educators and specialists need to be accessible and facilitate more education in the moment and in orientations that provide an overview and demonstration of following these principles. Additionally, effective communication between nurses themselves is needed to encourage an elder-friendly environment in which interventions for frailty can be initiated in a timely manner.  Nurses also must have active roles to influence their presence across organizations, shift established cultures, and advocate for high-quality care and appropriate physical environments that meet the needs of hospitalized older adults (Baumbusch et al., 2016). Clinical practice guidelines are developed to meet a practice need or gap (Polit & Beck, 2017). Practicing point of care nurses have the responsibility to make clinical decisions related to patient care based on the best available evidence, patient preferences and their own clinical experiences. In today’s busy hospital environments, increasing nurse-to-patient ratios and multiple roles and responsibilities can place excessive demands on nurses’ time (Weston, 2009). CPGs are tools to facilitate decision-making that fosters evidence-based practice within existing  40   time constraints. The CPG in this paper provides a potentially succinct and implementable guideline for frailty to be addressed in a timely manner in older adults. However, further review and research still need to be done, and more guidelines like this need to be developed for use in practice settings. Education Clinical practice guidelines can be a valuable teaching tool in clinical settings. Guidelines can be used to teach basic nursing content, nursing processes and can also be used to demonstrate how research evidence is applied to practice. In terms of nursing content, CPGs may provide the most up-to-date information on a variety of clinical conditions (Polit & Beck, 2017). The CPG in this paper can teach nurses the definition of frailty as well as provide a screening tool, and assessment and intervention guidelines that are appropriate for use in acute care. All nurses working in various acute care environments need to be educated about this CPG as well as other elder-friendly care principles. Baumbusch et al. (2017) highlights the importance of workplace continuing education in improving quality of care for hospitalized older adults.  In addition, nurses prefer learning opportunities that are accessible at work and diverse in delivering educational elder-focused content (Baumbusch et al., 2017). The frailty CPG for nurses education should begin with in-person education sessions and eventually be developed into an online education module. The education should include both initial and refresher training to ensure training is available for existing and new staff. The education should also include the identification of some of the challenges of complex healthcare contexts (Dahlke et al., 2015). It is essential to have nurse educators that can mentor nurses and be actively involved in the care planning of frail older patients to ensure that the CPG is being applied and used effectively. Finally, unit managers need to be proactive about assuring that all essential education  41   and training is available to nurses on the unit to promote timely assessments and implementation of interventions of frailty (Fleiszer, Semenic, Ritchie, Richer, & Denis, 2015). Additionally, organizations need to prioritize opportunities for professional development in older people nursing for nurses working in hospitalized settings (Baumbusch et al., 2016). Leadership  Administrative leaders play a major role in ensuring nurses have the staffing structure, resources, and tools they need in order to provide effective and timely care. Administrative leaders are in charge of staffing levels and mixes, equipment, resource allocation, and more. Nurses can face barriers following practice guidelines (Jun, Kovner & Stimpfel, 2016) and participating in continuing education at work (Baumbusch et al., 2017). This includes organizational barriers such as manager support and inability to get time off work (Baumbusch et al., 2017). Administrative leaders need to consider strategies that minimize these potential barriers in order for CPGs like this to be successful. They can also advocate for a stronger nurses’ voice in workplace committees and in forums which can help improve patient outcomes (Dahlke et al., 2015) and help adopt an elder-friendly care environment (Parke et al., 2014). Kang (2014) recommends administrators and nurse managers of hospitals need to empower Registered Nurses in order to facilitate research utilization. Fleiszer et al. (2015) indicate that the longer-term sustainability of practice guidelines requires support of committed leaders. Conclusion Frailty is a key syndrome in older adults that needs attention in acute care settings. Acute care nurses who are frontline professionals need to understand the importance of frailty, and assess and intervene for frailty in older adults. Given the increasing amount of older adults and frailty, this paper provides a timely literature review and practice guideline that can potentially  42   be implemented in acute care areas. Nurses need adequate resources and education in order to provide older adults with efficient inpatient care. Instantly accessible and easily implemented guidelines are a trusted resource for educators, administrators, and practitioners. The ‘Frailty in Acute Care’ CPG in this paper can provide nurses and other healthcare professionals a common knowledge base and framework within which to care for frail older adults. With the assistance of the information presented in the literature review, accompanying clinical practice guideline, and organizational support, nurses should have the tools necessary to provide appropriate and comprehensive care to frail patients in acute care settings.     43   References AONE (American Organization of Nurse Executives). (2010). AONE guiding principles: For the  elder-friendly hospital/facility and the role of the nurse leader. Retrieved from  www.aone.org/resources/elder-friendly-hospitals.pdf Ahmed, N., Mandel, R., Fain, M. J. (2007). 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