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Managing frailty

  • Carry out a comprehensive and holistic review of medical, functional, psychological and social needs based on comprehensive geriatric assessment principles in partnership with older people who have frailty and their carers.
  • Carry out a comprehensive and holistic review of medical, functional, psychological and social needs based on comprehensive geriatric assessment principles in partnership with older people who have frailty and their carers.
  • Ensure that reversible medical conditions are considered and addressed.
  • Consider referral  to geriatric medicine where frailty is associated with significant complexity, diagnostic uncertainty or challenging symptom control. Old age psychiatry should be considered for those with frailty and complex co-existing psychiatric problems including challenging behaviour in dementia.
  • Conduct personalised medication reviews for older people with frailty, taking into account number and type of medications, possibly using evidence based criteria (e.g. STOPP START criteria).
  • Use clinical judgement and personalised goals when deciding how to apply disease based clinical guidelines in the management of older people with frailty.
  • Generate a personalised shared care and support plan (CSP) which documents treatment goals, management plans, and plans for urgent care which have been determined in advance. It may also be appropriate for some  older people to include end of life care plans.
  • Establish systems to share the health record information (including the CSP) of older people with frailty between primary care, emergency services, secondary care and social services. 
  • Ensure that there are robust systems in place to track CSPs and the timetables for review.
  • Develop local protocols and pathways of care for older people with frailty, taking into account the common acute presentations of falls, delirium and sudden immobility. Ensure that the pathways build in a timely response to urgent need.
  • Recognise that many older people with frailty in crisis will manage better in the home environment but only with support systems which are suitable to fulfil all their health and care needs.

 

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