Realigning training with need: A case for mandatory family medicine resident experience in community-based care of the frail elderly.

Frailty is a “multidimensional syndrome of loss of reserves (energy, physical ability, cognition, health) that gives rise to vulnerability.”1 Younger seniors, generally speaking, are not frail. In fact, Canadian seniors between 65 and 75 years of age report limitation in activities of daily living similar to those adults aged 45 to 64 years.2 However, one-quarter of seniors aged 85 years or older report moderate to severe functional limitation,2 and the overall weighted prevalence of frailty in older seniors is about 30%.3 By 2052, the proportion of seniors aged 85 years or older is expected to comprise 6% of Canada’s total population compared with 2% in 2011.2 This means a substantial increase in frail older adults living in our communities. We all know that use of health care services rises with age. At a national level, in 2009 to 2010, Canadian seniors aged 85 years or older had a 2-fold higher rate of visiting the emergency department and a 9-fold higher hospital admission rate compared with those younger than 65 years of age.2 What is more, the rate of seniors’ visits to hospital emergency departments is actually increasing over time.4 A substantial proportion of this increased use is by frail older adults with multiple comorbidities. Ironically, this group is least likely to benefit from what a hospital can offer.5,6 Research has documented the increased risk of pressure ulcers,7 deconditioning,8 delirium, and iatrogenesis9,10 associated with hospital admission of frail seniors. Health systems in virtually every province are focusing on better ways to support this population outside the hospital setting.11,12 Given this projected demographic change and the disproportionate use of health services by frail older adults, at least some effort to focus family physician training on community-based care of the frail elderly should be self-evident. Despite this, many new graduates have little or no experience in providing nursing home or housecall (or home-based) medical care by the time they complete their training. And although provincial health systems are increasingly investing in home-care nursing and home support,11,12 many family medicine graduates have only a vague idea of what home health teams for the frail elderly actually do, let alone any experience actually working alongside them. How has this come to be?