Screening and preventing risks of frailty in community-dwelling senior citizens: a global personalised approach to promote healthy ageing

摘要

Concept and theory : multi-domains prevention at early stage Frailty is defined today within two main paradigms. The traditional approach considers frailty as an exclusively physical condition. This frailty syndrome represents declines in physiologic reserves and functions as well as resistance to stressors, leading to increased vulnerability and adverse health events. A person is said frail if three or more of the following criteria are present: unintentional weight loss, self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity (Fried LP, 2001). The second paradigm includes the psychological and social domains of frailty, shifting from a vision of frailty as a phenotype to frailty as an accumulation of deficits in various domains: cognition, mood, motivation, motor skills, balance, capacity to carry out day-to-day activities, nutrition, social status and comorbidities (Rockwood K, 2005). A more recent model defines frailty as “a dynamic state affecting individuals with losses through one or more functional domains (physical, psychological and social), increasing overall the risk of adverse outcomes"(Gobbens RJ, 2010). Inspired by this multidimensional paradigm, the CARSAT concentrates its efforts on the risks of frailty, far preceding the state of acknowledged frailty (Noguès M, 2015). Through a global approach, we aim to improve frailty prevention by targeting individuals who, although still in good health, might be at risk of frailty. This implies transforming the traditional vision of primary, secondary and tertiary prevention (often leading to segmentation) into a more evolving and comprehensive process, based on the consideration of health from three dimensions: physiological, social and environmental. From this integration of social and health approaches at an early stage, individually-tailored responses are possible. Integrated care in practise: the concerted window service The Regional Institute of Ageing (IRV) was founded by the CARSAT. This community, gathering regional experts and institutional stakeholders of the field, implemented in 2014 an experimental territorial project to offer global support to insured retirees or pre-retirees at risk of frailty. Individuals at risk of frailty are identified through the IRV's Frailty Observatory (geographic information system) or through other various social security organisations, and are then invited to present themselves. The aim is to provide advice and facilitate the access to rights and to social or health services, in partnership with the care sector. This concept is the concerted window service. The innovation is the possibility of crossing data from the health and the social sectors, enabled by a national decree of April 2015. Seniors who are part of this follow-up are given a personalised and regular monitoring every six months. As the number of individuals followed keeps growing, we aim to transfer this competency to regional stakeholders (institutions, foundations, health and wellbeing associations) by enabling them to act as concerted window services. The CARSAT will continue to ensure the coordination, the training of professionals, the research and the evaluation. CARSAT LR has adopted this concept as a pilot project and will thus be requested to ensure its diffusion at a national level as from the beginning of 2016. The principle has already been validated by the national authorities. The dissemination of this concerted window approach to all French regions is expected to be carried out shortly. Our tool: the active and healthy ageing spider In order to identify the real needs of the person entering the concerted window service and guide them to the appropriate services, the prevention case manager conducts a 45 min interview with the help of a multidimensional assessment tool (42-questions grid) built upon the EIP-AHA questionnaire (Bousquet, 2015). Individuals who are part of this follow-up will benefit from a dynamic evaluation of their individual risks of frailty, according to a 4-items assessment tool named the ?frailty risks star? (5 questions per item). This grid may be utilised by a caregiver, case manager or even the senior himself. The results are transcribed every six months and the simple observation of the spider graph can establish links between the 4 items identified. The current observations made on 500 cases highlight the relevance of the instrument: it is user friendly and constitutes a valuable tool for professionals. It is designed to become an ICT tool (both the initial grid and the dynamic star), to be used by the regional stakeholders accompanying seniors, including in remote areas.