What is frailty?
Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Around 10% of people aged over 65 years have frailty, rising to between a quarter and a half of those aged over 85 years 3.
Older people living with frailty are at risk of adverse outcomes such as dramatic changes in their physical and mental wellbeing after an apparently minor event which challenges their health, such as an infection or new medication. The purpose of this guidance is to advise about action which can be taken to prevent these adverse outcomes and help people live as well as possible with frailty.
It is important to understand the difference between frailty, long term conditions and disability. Many people with multiple long term conditions (so called multi-morbidity) will also have frailty which may be masked when the focus is on other disease based long term conditions. Likewise, some people whose only long term condition is frailty may be low consumers of health care resources and not regularly known to their GP (until they become bed bound, immobile or delirious as a result of an apparently minor illness). There may be overlap between the management approaches for people with multi-morbidity and those with frailty but these conditions are not identical and this guidance looks primarily at frailty. Similarly, there is overlap between frailty and physical disability – many people with frailty also have disability, but lots of people with a long term disability do not have frailty. Frailty may be the cause of disability in some patients and the consequence in others.
The language and management of frailty can act as barriers to engaging with older people who may not perceive themselves, or wish to be defined, by a term that is often associated with increased vulnerability and dependency. Older persons may not recognise themselves as living with frailty and there is evidence that older people do not want to be considered as ‘frail’, although happy to accept that they are an older person 4. For an older person, living with frailty can mean living with various ‘losses’ and it is easy, as a professional, inadvertently to collude with the loss of control over everyday life that results from an extensive care package, social isolation or the rapid fluctuation in mental state that sometimes accompany frailty. Research has demonstrated 5 that many older people living with frailty develop ways of coping and make other compensatory choices. As a group ‘frail older people’ encompasses a diversity of individual people each with different expectations, hopes, fears, strengths and abilities, as well as different types and levels of need and support. It is our job to ensure that these are, as far as is possible, accommodated, thus restoring control, preserving dignity and facilitating person-centred care to the older person living with frailty and those close to them.
Within these guidelines we look at the condition of frailty (Section 2) and then how to recognise it in the older people we encounter (Section 3). Recognition will mean understanding that people with frailty can appear to have a straightforward problem or need (where frailty might not be apparent unless actively sought) or can present with one of a number of so called frailty syndromes which should raise suspicions of the vulnerability of the individual. Section 4 details how frailty can be managed.