Understanding the many aspects of frailty: a conversation with Dr. Zahra Goodarzi

"When we did work talking to patients and care partners and providers, a lot of patients and care partners weren't aware of frailty as an idea or concept. But once it was explained to them, they felt much better and understood what was happening. 

We all seek understanding and explanation in some way, and I think that can really help people really understand what's happening to their loved one, but also understand what's happening to themselves."

Doctor Zahra Goodarzi is an academic geriatrician and an Associate Professor in the Department of Medicine and Department of Community Health Sciences at the University of Calgary, where she is also the Division Head for geriatric medicine, the medical lead for specialized geriatric services and transition services, and the Program Director for Leaders in Medicine, Dr. Goodarzi's current work looks at the development of clinical pathways for mood disorders, dementia, and frailty across the care continuum in clinical care, emergency, and long-term care. 

Learn more about the Strengthening a Palliative Approach to Long-Term Care project at: https://spaltc.ca/

Transcript

SPEAKER_02 0:00

Welcome to the Strengthening a Palliative Approach in Long-Term Care Alliance podcast, exploring challenges and best practices and palliative care approaches for individuals in long-term care.

SPEAKER_00 0:15

Dr. Zara Ghadarzi is an academic geriatrician and an associate professor in the Department of Medicine and Department of Community Health Sciences at the University of Calgary, where she is also the Division Head for Geriatric Medicine, the Medical Lead for Specialized Geriatric Services and Transition Services, and the Program Director for Leaders in Medicine. Dr. Godarzi's current work looks at the development of clinical pathways for mood disorders, dementia, and frailty across the care continuum in clinical care, emergency, and long-term care. Welcome to the podcast, Dr. Godarzi. Thanks for having me. I'd like to begin by asking about your interest in gerontology and how you came to work in long-term care.

SPEAKER_01 1:01

We're internal medicine specialists who then specialize further in geriatric medicine. And throughout that training, we do some work across kind of the care continuum. So not just hospitals, but clinics, but long-term care as well. So right now I'm not like a primary provider in long-term care, but I certainly have patients who are seeing me in other settings from long-term care.

SPEAKER_00 1:20

So you are involved sort of on the front lines as well as conducting research?

SPEAKER_01 1:25

About half of my job is not research, it's other things. So clinical work and administrative work, and then the other half is research.

SPEAKER_00 1:33

Are you able then to practice what you are discovering and what you're exploring in the research forum?

SPEAKER_01 1:39

Yeah. I think that goes both ways. It's like what do you observe in your work day to day that could be improved, better, benefit from more research? And then how can you then use that research once you figure it out, hopefully, to make your practice and patients' lives better.

SPEAKER_00 1:54

I know that you've been studying frailty, and I wonder if we can talk a little bit about what frailty is.

SPEAKER_01 2:00

Yeah, so frailty is the idea that as a person is more frail, they're more vulnerable to stressors. Another way to think about that is, you know, when you're younger and you get a cold, you could probably work through your cold, right? As your person is more frail, they may become sicker when they get something like a virus. So they might not be able to function. They might end up in hospital, they might end up dehydrated. And so you're more vulnerable to these stressors on your body than you once were. To clarify, frailty and age are not synonymous. You can age and not be as frail. We certainly have younger persons who are experiencing frailty. I think what's important when we think about frailty in long-term care is not assuming that, right? Not assuming that everybody in long-term care is, you know, severely frail if we were to think about it as a spectrum, but that there is a range in people's function and vulnerability. What we're doing for each person to meet their needs, but also being realistic about what might help them versus not. And so when we think of common stressors medically, right? You know, maybe somebody might need a surgery. Well, a more frail person, it's not that they shouldn't have surgery. It's just that the risk might be different to the less frail person, right? And that would be similar out of long-term care. I think it's really important to think of each person in their individual state and tailor what we're doing to that. I think there's a lot of assumptions people have about long-term care and the people who both live and work there. And I think it's really important that we kind of try to start to address some of those biases so that we can do more personalized care for these persons.

SPEAKER_00 3:43

You've done a lot of work in mood disorders and dementia as well. Yeah. Is there a tie between frailty and mood disorders or mental illness?

SPEAKER_01 3:52

Yeah, there's lots of different models or frameworks that people conceptualize frailty, and some of them relate to numbers of conditions or things that people have. Similar to how age is not synonymous with frailty, the amount of comorbidities a person has is not synonymous with frailty. You can have many comorbidities and still be quite fit. But those things don't help, right? As you start to have more and more challenges, a person may become more and more frail. Depression is a big one that is noted to be quite common in persons who are frail. And one of those things that might be, again, bi-directional, right? Are you depressed and that's leading to frailty? Are you frail and that's leading to depression? None of us are happy when we have changes in our day-to-day function. I mean, we can't do something we want to do. And that comes with a level of frustration and upset and anxiety and all these things, right? Like you can't separate them, right? I think anxiety is quite common. And I think we probably underestimate that in this population.

SPEAKER_00 4:56

I can imagine that it's very challenging for people in long-term care, particularly if they are frail, but also if it's a new space for them. So I imagine that really increases the anxiety.

SPEAKER_01 5:07

100%. It's not your home. It's an environment you don't control. There's other factors, other people, other things that just happen to disrupt or change or whatever. Many people who may have been in that environment their whole life, right? You may never have moved out of that one house. You were in living with other people. You might even be sharing a room. You might have workers that do change daily. Fair enough. But that can be confusing for people if your memory is maybe not as good. Food that you don't control, you know what I mean? Like schedules you don't control, like a lot of things that you no longer control. And those can really affect people. On the other side, I have people who thrive because they've been lonely, because they haven't had routine, because they haven't had support. And now they're in a place where they are safer. And there's people checking on them, and there's community, and there's these wonderful care workers that are coming in and getting them dressed. I've fully seen people's mood drastically improve from moving as well. And when you first night move, that anxiety or a bit of low mood, and then it improves as you build community, make friends, engage in activities. There's tons of activities they are often doing, you know, more like recreational or therapeutic activities.

SPEAKER_00 6:23

People think about long-term care as people being in beds, which I would think would probably add to frailty problems if you were stuck in a bed all day. Yeah. As opposed to getting up and being part of an activity.

SPEAKER_01 6:35

There's absolutely people who are in care facilities who are not able to be very mobile, but our amazing workers do their absolute darnest to get everybody up, dressed, and out. You know, it kind of comes back to a lot of assumptions people have about aging in general and kind of the idea around perhaps some ageist views that people have. People older in facilities are just laying in bed, right? Like, no, most people aren't. Most people are up or setting or, you know, trying to engage. So I think that it's important for all of us to challenge our own intrinsic bias too.

SPEAKER_00 7:06

Most long-term care homes have an amazing interprofessional team of workers. What are the different roles that come into play to ensure that we care for people with frailty and mood disorders?

SPEAKER_01 7:19

My view is that frailty is part of overall care for the patient and that each person has a different role to play in what we're doing as it pertains to frailty. From the perspective of a physician, to start there, I think it's important as a physician to not only document, assess, and document what we believe the frailty of the individual is based on a relevant scale, and use that as part of a conversation to inform them about their prognosis and overall risk to their health. If the person wants to hear that, of course. And I think that's really important. Just to pause on that, prognosis is hard, but important for people to be realistically aware of what their potential outcomes could be. Understanding, of course, we can be wrong, but that a lot of data informs these statements about prognosis as it relates to frailty. And we have a lot of data about it. And that can be really helpful for people. You know, if you know to some degree, based on this, we'd expect that you have a few years, right? That's different to we'd be really worried if you got sick that it would be the the last time. Families can help patients make sure people are wrapping around their community the way they want to be in the time that they have. Now, some people don't want to know that, and that's that's okay. But I think that's really important for the prescriber to help that person to understand the risk if they go to hospital if they're sick, or if there is a suggestion for a new treatment or surgery or something, this can help to inform the potential outcomes and keep people really grounded in that realistic outcome. But I think along with that is also making sure that the rest of the care team understands the risk for that individual if they are sick or if there is a thing that's happening. Like this person's high risk. When we did work talking to patients and care partners and providers, you know, a lot of patients and care partners, family or friend care partners, weren't aware of frailty as an idea or concept. But once it was explained to them and understood, they felt much better and understood what was happening. We all seek understanding and explanation in some way. And I think that can really help people really understand what's happening to their loved one, but also understand what's happening to themselves. That communication to families and patients about that nuance, I think, is really what struck me as quite important with this work, is that that helped them to understand it. I think all of those team members can help to improve the function and the quality of life of a person with frailty. What can I do to decrease my risk? You know, how can I work on strengthening what I can strengthen or working on mood or pain or medication burden or whatever it might be, right? So I think that's sort of to me a really important second message is not to sort of be nihilistic about frailty, but like, okay, I can do something to try and improve where I'm at. I might not get all the way back in all likelihood, but you hopefully could improve your circumstances.

SPEAKER_00 10:12

I love that you brought in the family as well, because the team is caring for a resident in long-term care, but in many ways they're also caring for the family, right?

SPEAKER_01 10:21

100%. You know, I always talk about patients when I'm seeing them with their families as a team. And it's so crucial. And I think in long-term care, like the family members are your other team members, right? And the more we can help them to contribute and do so in a structured way sometimes can be really helpful. And also remembering, like, family and friend care partners have often been caring for this person for a very long time, often before they've moved. And they've done things every, you know, day, all day, a certain way, right? And I think it can be very difficult for them too when their loved ones move to also relinquish control. Is this a person you've cared for? It's your partner, wife, whoever, right? Like you have a way of doing it, and that loss can be very challenging. It's the worst when you have to separate a partner from their loved one, right?

SPEAKER_00 11:08

Yes. They're used to doing things together, they have their own routines.

SPEAKER_01 11:12

Might have been married for 70 years, and the first time they're living apart.

SPEAKER_00 11:20

I'd like to talk a little bit about your research and how maybe it's been translated into treatments or approaches in long-term care.

SPEAKER_01 11:29

Yeah, so it's a large group of persons involved in the work and really trying to understand how frailty is both viewed and impacts what we are doing in long-term care, how it impacts an understanding of prognosis, and how we can integrate frailty as part of our care that we're providing. So we did a lot of that frontline work through a few different grant projects. And so, what that looks like is we take that care pathway and we're working with care facilities to say, okay, how do we build in these steps? And often when we're thinking about care pathways, like it sounds fancy, but it's just a series of steps to make sure we're doing what we need to be doing to align with evidence, a recipe, if you will. And so focusing on first and foremost, we have to be diagnosing, detecting, and communicating that people have ex frailty, and then of course making sure it's documented and communicated to team members. So, step one, we got to make sure that's working. So, how do we do that? And which team member is gonna do it, who can build that into their workflow? How do we build these things so that once we've done that, how do we build in the resources and education and training for the persons needed to do the conversations about prognosis and make sure family and patients are aware and you know, where are we documenting that? And so at each step is sort of understanding what the barriers are and then what the facilitators are to making those things happen, and then how can we improve on any barriers or optimize our facilitators so that we can have the practice integrated into work. This is really important because when we generate evidence in medicine, it can take more than a decade for evidence to get into practice if it's not more directly implemented. So getting people to change behavior is really important and not straightforward because you're addressing human behavior and often coming up against barriers from the perspective of time and resources. We really have excellent team members on the front lines in long-term care who see the value and are trying to pull this in and try to make it happen more regularly. One of the really interesting things that heights come out of some of the implementation works in a perspective that I hadn't particularly thought of initially when we were talking with physicians was they saw this as a big way to advocate for their patients. Because in long-term care, you are observing this person every day. You are going to be the most accurate judge of their royalty and their function. But when that person might go to hospital, we don't know them as well. And yes, you know, documents are sent along, but what does that communicate? There's still assumptions, there's still bias, right? And so, how can I advocate for my patient when I'm not there? And it could be something like this. I could say, you know, yes, this person is only moderately frail. That puts their risk much lower than those who are severely frail. And so when they're going forward, you need to, you know, center our understanding of what we're doing for this person based on that. And so if somebody's sending you that information, it's so valuable to that conversation about, you know, there's still risk, but like that risk might be a bit lower. That risk-benefit ratio now shifts more to benefit. Like a really concrete example there is when we think about a frail person, maybe more severely frail, who might need a surgical procedure. Their risk of perhaps having confusion or an acute delirium after surgery is probably higher than somebody who's less frail. Okay, so then we might need to optimize medications, you know, optimize the environment, make sure we've got perfect lab work if we can. We're like, oh, what can we do to, you know, get this person to the optimal status as much as possible, right? So that going in and post-surgery, we're doing all the things we can to try and reduce that risk. And maybe we'll get that person to a stage where they're able to maybe not have as significant of an outcome.

SPEAKER_00 15:09

I wonder if the evidence too would also sometimes lead to this person not going to benefit from going to hospital near the end of their life.

SPEAKER_01 15:17

Absolutely, and similarly so for a procedure or potentially a medication, right? So let's look at how we can optimize this quality of life, right? Because that's key. We need to center on that person's quality of life and absolutely informing whether or not they might want to be transferred is really important if it's something that we don't think that that person would necessarily improve from. And those can be hard conversations to have, these sort of end-of-life or more prognostic palliative conversations, especially in a circumstance when there isn't a disease to anchor on. When somebody has a cancer, and you can anchor that conversation about prognosis and maybe quality of life or moving towards more end of life or palliative conversations. In frailty or non-malignant conditions, it can be a little bit more nebulous. And I think that can be really hard for people, patients, and care partners to anchor on. But I think there's a lot of conditions where we don't consider them or the greater public don't realize that it will impact your prognosis. Things like dementia. I don't think people often think about how that impacts their trajectory in life. Severe dementia has a similar prognosis to like stage four breast cancer. And it can be really awful to hear and know, but on the same tone, helps people to anchor and understand concretely what that prognosis might look like. So a person might be frail. They might have several conditions, none of which are in and of themselves particularly severe, but all together layer, plus their intrinsic frailty and functional decline. That's a very hard conversation to help a person navigate through when you don't have a little bit more of that data.

SPEAKER_00 16:59

Do you find that the evidence from your research is well accepted in long-term care?

SPEAKER_01 17:05

I always enjoy working with my long-term care colleagues. I think that they are very willing and able and want better for their patients, their care partners. I see a lot of engagement and acceptance. Where I see the challenge is there's a lot of competing priorities. Everybody understands the importance and is very keen, but the challenge is when there's so many competing priorities, it can be difficult to get to the top of the list. Frailty is super important, but it can be hard to balance with a lot of competing priorities. And I think this is a challenge for frailty as a concept that we're integrating. Again, back to that idea of concreteness. It's not necessarily as concrete, like if I say somebody is severely frail, do X, Y, Z. Like there's a list of things we would do, and they're kind of tailored to the individual, but it's not like they're this, start aspirant, right? It's more nuanced. And that also adds to complexity.

SPEAKER_00 17:54

What's the favorite part of your work?

SPEAKER_01 17:57

I really enjoy working in teams, and I'm including patient and caregiver in that team. I think the teams that work within seniors care or geriatric medicine are like the best humans and are just wonderful to work with. I would say the second part to that is our patients and care partners. I truly enjoy working with our older adults and their care partners. I feel like we both share and teach each other and learn things every day. These older persons are our parents, our grandparents, they're the people who've fought wars for us and you know built all these things and made the world, you know, where we are. And it's so nice to be able to give back to people and support them in a time when they need help.

SPEAKER_00 18:38

Wonderful. Thank you so much for speaking with me today. It was a pleasure.

SPEAKER_02 18:43

You've been listening to the Strengthening a Palliative Approach in Long Term Care Podcast. For more information about our project, visit spawnltc.ca