How are palliative care needs being identified and assessed in frail older people? A Mixed Methods Systematic Review

Introduction 

People are living longer with more complex multimorbidity across the globe. Those living with multimorbidity are at higher risk of becoming frail. Frail people have significant palliative care needs but as with other non-malignant conditions, access to palliative care support for frail patients is challenging. This is in part to a lack of recognition of these patient cohorts being able to benefit from palliative care. The aim of this review is to identify the evidence on how palliative care needs are being identified and assessed in frail older people and any evidence on implementation of identification and assessment approaches into practice. 

 Methods

A mixed methods systematic review was undertaken. Inclusion criteria were adults aged 65 and older, assessed as frail either through recognition of frailty phenotype or through a cumulative deficit model or a recognised clinical score. If the frail and non-frail population are not analysed separately, there must be a majority of 75% and over who are frail to be included. Full texts were then retrieved and independently assessed for eligibility by two review authors. 

Results 

There were 24 papers included in total.  The main exclusion reasons were due to lack of frailty measure or use of a frailty definition that didn’t meet criteria. The oldest paper was published in 2015 showing recognition of palliative care needs in frail older people is still a developing concept. The summary of needs identified were emergency hospital admission / emergency department attendance, palliative care symptoms, advanced care planning and specialist palliative care referral. In studies which compared frail and non-frail populations, the majority provided evidence that frail older adults had higher palliative care needs than those who were non-frail. 

Conclusion

This review provides evidence that palliative care needs are being identified in frail older people but there are few interventions at addressing the needs identified. Moving forwards, we need a consensus on the definition of frailty and the use of appropriate palliative care assessment tools and awareness to improve access to palliative care for this vulnerable, at need population.