In daily life, aging is often not regarded as an illness, so the end-of-life needs of weak and frail elderly people have not been taken seriously. Starting from June 2022, the terminally debilitated elderly have officially been included in the indications for health insurance and hospice palliative care benefits. Medical and nursing teams are also closely following the needs and policies, developing and improving relevant assessment and professional care knowledge.
In the initial stage of training for hospice specialists, the focus is on cancer, and then it is expanded to patients with organ failure. Whether it is cancer or organ failure, doctors can often grasp the course of the disease based on their expertise and experience, allowing palliative care to be initiated at the appropriate time. However, unlike cancer and organ failure, frailty is a disease that is slow and prolonged, and is integrated into daily life. Therefore, it has always been a difficult problem to determine when palliative care should intervene.
With the increasing elderly population in Taiwan, it is foreseeable that terminal aging will be one of the focus areas of elderly care in the future. Not only has the policy already recognized the need for the frail elderly, but the medical community is also stepping up efforts to enhance the care of healthcare practitioners through assessment tools, training courses, and etc., with the aim of providing assistance through timely professional intervention."
Imperceptible Weakness in an Once-neglected Area
"Frailty can become severe and life-threatening, but this concept has not yet been established in the mindset of the general public or the sub-specialists," said Hsien-Cheng Chang, Director of the Department of Family Medicine at Lotung Poh-Ai Hospital, and who has devoted himself to hospice and palliative care for many years. When it comes to the frail elderly people, he speaks with a slight regret in his voice, "Patients with better economic or nursing conditions may be able to obtain relatively more medical care through single or multi-disciplinary medical treatment. Even so, when they become increasingly frail or transitioning to the terminal stage, there are still many needs that cannot be met by multidisciplinary care.”
The frailty of the elderly is easily overlooked, and the issue of aging and decline cannot be solved simply by seeing a doctor, taking medicine, or being hospitalized once. Judging from the current aging rate in Taiwan, the imminent problem of the large number of old, aging, and dying patients cannot be solved by simply opening more hospice wards.
Hsien-Cheng Chang further explained that physical frailty is a process and that professional assistance is needed in the early stages of frailty. This may not necessarily involve taking medication, but may also involve proper diet and exercise to slow down the process. If handled properly, it may even result in a better quality of life.
According to research, serious problems commonly occurring in frail people include decreased mobility, disability, and dependence caused by falls, which make them more likely to require long-term care in institutions compared to their non-frail elderly counterparts. In addition, frail individuals have a higher risk of mortality than many patients, who have a single disease.
Hsien-Cheng Chang used a life curve chart to explain that the life curve of the frail elderly is not like that of patients with organ failure, which shows large fluctuations; but rather, has small waves and a continuous decline overall. He explains, "After the frail elderly face every medical incident, the curve will drop a little bit, but it's not easily noticeable, and it's hard to predict."
On the other hand, most of the existing national awareness or medical care system still tends to view diseases from an organ-centric perspective. Hsien-Cheng Chang believes that every so-called discomfort of the frail elderly may be relatively mild in terms of symptoms and severity. For example, the heart may not deteriorate to the point of requiring medical attention, and the kidney may not deteriorate to the point of requiring dialysis. He says, "Therefore, frailty is not only often overlooked by family members, but also may be overlooked in Taiwan's medical system, which has meticulous divisions of labor and sub-specializations."
“Treat the head when the head aches; treat the foot when the foot hurts.” Having seen doctors of various specialties and taken more and more medication, the elderly is still gradually declining in health. It is not only the patients who become discouraged, but also their family members who worry about if they are neglecting taking their medication or being lazy about exercise. All kinds of doubts and misunderstandings become entangled in the homes of frail elderly people, which make the family feel helpless.
Three-step Assessment to Help the Frontline Workers Determine Needs
Is it really the case that nothing can be done but to accept the status quo in the medical field? Hsien-Cheng Chang does not think so, and he affirms that many years ago, Taiwan's medical community had already recognized the needs and existence of the frail elderly patients, and actively learned from abroad and made repeated adjustments to build a localized evaluation and care model for the frail elderly in Taiwan.
In 2019, with the support of the Health Promotion Administration of the Ministry of Health and Welfare, the Taiwan Academy of Hospice Palliative Medicine assembled frontline personnel covering physiology, psychology, sociology, and spirituality to jointly compile the Guidelines for Hospice and Palliative Medical Care for the Frail Elderly and developed corresponding online teaching materials for education, training, and promotion.
Regarding when the frail elderly people should begin to receive hospice and palliative care, it is suggested in the guidelines to make the decision based on a three-step assessment model.
The first step is to identify the frail elderly with reduced function in a clinical setting.
This can be done through screening with the Study of Osteoporotic Fractures (SOF) or Linda Fried Evaluation Scale. Among them, the frail elderly in the early stages can be provided with appropriate care, treatment, and functional training to improve or delay the progress of frailty.
The second step is to assess the prognosis and whether the expected survival time is less than one year.
Hsien-Cheng Chang stated frankly that the assessment of survival time has always been the most difficult part in the field of frail elderly. Nowadays, The Frailty Index, Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS), Supportive & Palliative Care Indicators Tool (SPICT), and other frailty assessment scales are useful for survival estimation references, and surprise questions can also be used.
The third step is to use the SPICT scale to assess the referral to palliative care.
The SPICT scale mentioned in step two can also be extended to this step. In cases where the frail elderly cannot be met, their primary care physician can provide enhanced care or seek assistance from the palliative care team.
Accelerate the pace for care to spread from hospitals to primary care units
Hsien-Cheng Chang believes that the United Kingdom is worth mentioning as it is currently the country with the most complete and comprehensive implementation in the field of care for the frail elderly. However, UK’s medical system has a clear network of family doctors, who can serve as the core caregivers and observers, and can refer to specialized teams in a timely manner when necessary. Unfortunately, it is difficult to directly replicate this care process in Taiwan.
"As treatments for cancer and organ failure become more and more advanced, people are less likely to die from a single cancer or single organ failure." However, hospice wards are limited, the frail elderly decline slowly, and the care process is often prolonged. According to Hsien-Cheng Chang, in addition to family medicine, physicians in geriatric medicine are actively involved, and other specialist physicians must also have basic knowledge. Moreover, the involvement of physicians in community clinics will also help Taiwan make great strides in the care of the frail elderly.
"For example, if an elderly person received home medical care, then when the illness progresses to debilitating, the ideal initial palliative care provider is this team. We can take care of his palliative medical needs first.” With the support of primary healthcare at the front end, once frailty intensifies, referral can be made to allow immediate intervention by a palliative care specialist team.
"This is no longer just an ideal, but has been gradually implemented and is making continuous progress," Hsien-Cheng Chang spoke with satisfaction. In recent years, the Department of Medical Affairs and the Health Promotion Administration of the Ministry of Health and Welfare have successively promoted palliative care in primary medical care with various plans. For example, some counties and cities try to have hospitals guide physicians in primary clinics, and medical staff in small regional hospitals or nursing institutions share the need for palliative care.
"With the increasing participation and experience of clinic doctors in these tasks, the ability to care for the frail elderly is also actively improving." With the outbreak of the COVID-19 pandemic, primary doctors have been engaged in the treatment of patients in home quarantine, which undoubtedly lays the foundation for a model of palliative care for the frail elderly.
Hsien-Cheng Chang further analyzed that the aging rate of Taiwan's population is rising sharply, faster than most countries. "Our speed from 7% to 14%, or from 14% to 20% is among the fastest in the world." Therefore, to meet the growing demand, more community-based and long-term care facilities are needed to meet the needs of the great number of frail elderly. Hsien-Cheng Chang concludes, "In this era of rapid aging, the integrated response of the medical and care systems must be accelerated, and there should be no delay."