Canary in the Coal Mine? Considering Frailty using the Social Ecological Model

Defining Frailty

There is no consensus definition of frailty. It is agreed that frailty can be conceptualized as an increased state of extreme vulnerability brought on by problems in multiple domains (Rodriguez-Mañas, et al., 2013). This accumulation of impairments leads to a decrease in physical reserves and susceptibility to even minor stresses (e.g. infection, poly-pharmacy) (Rodriguez-Mañas, et al., 2013). Individuals experience losses in one or more domains of human functioning (for example, physical, psychological, and social), thus resulting in limited physical resources to react or adapt to the daily and acute stressors of life. (Gobbens, et al., 2010).

One approach to frailty assessment uses the Frailty Index (FI) (Mitnitski, et al. 2001). It is a reliable and valid measure of frailty (Rockwood, et al, 2005; Theou, et al., 2018). The FI measures a person’s state of vulnerability and associated risk, by quantifying the number of deficits, as opposed to focusing on the nature of the health problems (Searle, et al. 2008; Gobbens, et al. 2010). The FI is calculated as a ratio of deficits present over the total number of deficits considered (Searle, et al., 2008). A high FI has been likened to the ‘canary in the coal mine’ as it is a strong predictor of mortality and poor health outcomes in the elderly (Wyatt, 2018).

Social Ecological Model

The Social Ecological Model is a conceptual framework that describes five spheres of influence that impact on an individual’s ability to maintain a fit state of health. The individual remains in the center of their environment and experiences, as outlined in Figure 1.

Figure 1. Social Ecological Model of Health. Unicef (n.d.)

Individual Sphere

The first sphere of influence describes the individual’s characteristics that influence their ability to maintain health. By the nature of its calculation, the FI accounts for the biophysical, emotional and cognitive contributors to health. As deficits within these domains accrue so does the FI.

Many determinants of health not considered in the calculation have also been found to negatively impact the FI. These include low education levels, smoking, poor nutrition, low physical activity, and sedentary lifestyles (Hoogendijk, et al., 2014; Brinkman, et al., 2018; Blodgett, et al., 2015; Woo, et al., 2005; Gabrovec, et al., 2018).

One can imagine that any condition, which causes deficits or losses (physical, cognitive, social) that are sustained over a long period of time, could eventually impact on one’s frailty level. Therefore, it may not be a stretch to suggest that lifestyle choices and individual characteristics influencing one’s ability to maintain health throughout their life – from birth onward, all play an important role in frailty. To extrapolate further, one could also suggest that by addressing these, we can positively impact frailty. To the right are links to my MHST 601 classmate’s blogs that further delve into the multilevel spheres of influence on other health conditions that could, conceivably, impact frailty.

Interpersonal Sphere

The interpersonal sphere of influence considers the social networks and supports that influence an individual.

Strong social connectivity is associated with better health, from a physical, psychological, emotional and behavioural perspective (Umbersom & Montez, 2010). There is also emerging evidence linking social vulnerability and shrinking social and community networks with an increase in FI among the elderly (Andrew & Keefe, 2014). Andrew and Keefe (2014) suggest several reasons for this, including the fact that as we age, our social networks also become frailer, and/or die, thus shrinking the social and personal supports available to the elderly. As mobility becomes poorer, the ability to access the community, and link with the supports becomes more difficult.

Working conditions and workplace connectivity, socioeconomic status and retirement age have all been shown to influence frailty in later life (Stenholm, et al., 2014, Lu, et al., 2017). Work place stress and the inability to maintain a work-life balance throughout a career have been found to be detrimental to healthy aging (Lu, et al., 2017). This further supports the argument that experiences and health problems across the life course can impact frailty.

Community Sphere

This sphere examines relationships between organizations and institutions, as well as the built environment and how these can impact on the health of an individual.

Given the high prevalence of social vulnerability in older adults living with frailty, the composition of a community becomes an important consideration. Safe spaces for older adults to be physically active, accessibility of affordable public transportation when one can no longer drive, and the accessibility of hospitals, doctor offices and grocery stores could all have significant impact on the ability of older adults with frailty to access their communities for daily needs.

Accessibility of buildings (public and private businesses, apartment buildings) also plays a role in how those with frailty access their communities. In fact, one Haligonian is challenging inaccessible environments as being against basic human rights (see video below).

Not only are accessible spaces important considerations within this sphere, so too are activities that are of interest to older adults with frailty that provide them with social networks and support. Coordinated adult day programs run by community groups and/or health care departments (such as low intensity exercise classes, supported coffee and knitting groups, etc.) could be of great benefit to frail elders, especially given the strong connection between social vulnerability and increased frailty (Andrew & Keefe, 2014).

Geraldine Young provides a nice outline of barriers and considerations on elderly accessing their environment in her blog found below (There's no place like home...What influences a person's ability to age in place?).

Organizational Sphere

This sphere considers the rules and regulations for operations of organizations that affect how services are provided to individuals or groups.

Our current healthcare system was designed to address the single-system disease model, which does not adapt well to the complex, multi-system care needs of frail elders. Currently, half of the health care budget is spent on seniors in Nova Scotia, with the highest proportion occurring during the last six months of life (NSHA, 2018). The Nova Scotia Health Authority (NSHA) has recognized the costs associated with frailty - not only as an economic burden to the healthcare system, the seniors who are frail, and their families who support them, but more importantly, there is a cost to the patient who is not able to receive the coordinated care they require. The Nova Scotia Frailty Strategy outlines this problem in the following diagram:

Figure 2. Nova Scotia Health Authority - Frailty Challenges in the Central Zone (2018).

In response to these challenges, the NSHA developed a Frailty Strategy (NSHA, 2016) that aims to provide improved and coordinated care across the spheres of influence, including organizational, community, and public sectors. This strategy is outlined in the figure below:

Figure 3. Nova Scotia Health Authority Frailty Strategy (2016)

Policy/Enabling Environment

Finally, to properly address frailty, one must consider the impacts of social and health policies on the health and wellness of older adults.

One such example is the ‘home first’ philosophy adopted by the NSHA. There is a growing belief that patients recover faster and can experience fewer adverse outcomes with early discharge (NHS, Kent Community Health, 2018). However, without accounting for a patient’s social vulnerability and socioeconomic status, this policy could fail without the proper provincial support programs in place.

Again, Dene Young reviews many of these required home supports in her blog, while Amanda Rose reviews falls risks from a multilevel perspective in her blog (Who is at "FALL"t for Falls?) found above right.

As we age and become frailer, out-of-pocket costs of health care can increase. This includes transportation costs (e.g. for medical appointments) and medication related expenses. Provincial drug plans may not be adequate for someone with multiple co-morbidities and frailty. Policies and programs that support the purchase of medical equipment are also of benefit to the health of our frail elders.

Policies only focusing on older adults with frailty will not have long lasting impacts on the population levels of frailty. To decrease frailty levels over time, other social policies impacting health outcomes should also be considered. For example, policies regarding retirement ages and maternity leave benefits, work policies allowing for part time and alternative work-hour options may also lead to reduced frailty later in life (Stenholm, et al., 2014, Lu, et al., 2017).

Conclusion

Frailty is a complex age-related syndrome (Rodriguez-Mañas, et al., 2013) that is affected by many health determinants as well as health and social policies. I would argue that the FI is a ‘canary in the coal mine’ on two fronts. First, as outlined in the introduction, it is an indicator of increasing risk of mortality. Secondly, it could be an indicator of how well our health care system, social policies, communities and all the spheres of influence are creating environments that support the healthy lives of its citizens. Higher prevalence of frailty within a population may be a by-product of healthcare systems that value keeping people alive rather than well, and may indicate a lack of coordination between the levels of health influences.

The good news? Frailty is preventable and reversible if identified early.

References

Andrew, M.K. & Keefe, J.M. (2014). Social vulnerability from a social ecology perspective: a cohort study of older adults from the National Population Health Survey of Canada. BMC Geriatrics, 14: 90. DOI:10.1186/1471-2318-14-90

Blodgett, J., Theou, Ol, Kirkland, S., Andreou, P. & Rockwood, K. (2015). The association between sedentary behaviour, moderate-vigorous physical activity and frailty in NHANES cohorts. Maturitas, 80: 187-191. https://doi.org/10.1016/j.maturitas.2014.11.010

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