Key messages

BGS key messages: Frailty

Published date
Last updated
Authors
British Geriatrics Society
James Adams
Topic tags
Frailty
Frailty indexes

BGS key messages have been developed to provide members and multidisciplinary colleagues with topline information about specific issues relating to older people's healthcare. We encourage discussion of these issues with decision-makers and other stakeholders.

Key messages

1. Frailty must be understood at every level of society.

Frailty is defined as a clinical state, more common with increasing age, and characterised by decreased physiological reserve, an increased vulnerability to stressors.1 However, in spite of agreed consensus on a definition of frailty, it remains a globally poorly understood condition by the general public, older people living with frailty themselves, the care sector, politicians, senior healthcare leaders and the wider NHS. There is a need for global understanding of what it means as a clinical condition, how it overlaps with other long- term conditions, how it may present differently, and how this can impact on multiple pathways and services.

Key points:

  • Older people living with frailty often live with multiple single organ diseases and other long- term conditions, including age related conditions such as dementia.
  • Key frailty syndromes include falls, impaired mobility, being dependent on care, living with a cognitive disorder (such as dementia), incontinence, mood disorders, sensory impairments and polypharmacy.
  • Frailty is not just a phenotype, with higher prevalence of musculoskeletal frailty including sarcopenia and degenerative joint disease; it can be the result of multiple deficits accumulated over a life course of illness and long-term conditions.
  • The presence of a stressor event leads to older people living with frailty presenting differently, with clinical conditions such as failure to thrive, new care needs, new incontinence, delirium, sudden changes in mobility and falls.2
  • Older people with dementia can have significant cognitive frailty, and complex needs, without physical frailty.
  • The majority of deaths occur in older people living with frailty, meaning provision of high-quality end of life care for this cohort is a national priority.
  • There is significant overlap between frailty, multimorbidity and disability, leading to complexity of needs.
  • Frailty is a very important long-term clinical condition in its own right but needs to be considered in the wider context of co-morbidities, complex health and care needs, disability and polypharmacy.
  • Effective health and care systems for older people living with frailty need to encompass all of these needs rather than a focus on single organ, disease-based models.
  • People living with frailty, their support networks and families, should all understand the condition, so that they can be empowered to live well, age well and die well.

2. Frailty is not an inevitable part of ageing.

The risk of developing frailty increases with longevity, but it is not an inevitable part of ageing. Frailty develops gradually as people accumulate health deficits across their lives, reflecting reduced resilience and increased vulnerability. These deficits can be offset with assets such as personal characteristics, community resources and systems of care. The development of frailty is shaped by lifelong influences including long-term conditions, functional changes, psychological and social factors, and the wider determinants of health.3 There is evidence that muscle strengthening and exercise, in conjunction with nutritional interventions can help prevent and even reverse frailty states.4,5 Social isolation and loneliness carry a high risk for poor outcomes. Opportunities exist to identify those vulnerable to developing frailty or those living with mild frailty to introduce healthy ageing initiatives. Many risks are modifiable even in later life, meaning prevention, early intervention and positive societal attitudes can delay or reduce frailty while supporting independence and wellbeing.

Key points:

  • Prevention must begin early and continue throughout life, focusing on physical activity, nutrition, social connection, mental wellbeing and management of long-term conditions.
  • Public health messaging and policies addressing inequality, the environment and the wider determinants of health are essential to reducing frailty across the population.6
  • Every system should have an ageing well strategy focussing on evidence- based interventions to help prevent and even reverse frailty, including tackling social isolation.
  • Every system should have a mechanism to identify early onset frailty, where social determinants of health may be more prevalent and to ensure prevention strategies are in place.
  • Positive, empowering language and intergenerational approaches can help reduce stigma and support people to age well.
  • A societal shift is required, from one that focusses on deficits for older people with frailty to one that frames living with frailty positively. This should enable older people to not feel unnecessary stigma, to be supported to live and age well and to maintain independence.
  • Most older people have a critical role to play in wider society, including as unpaid carers for family members living with frailty. It is important they are recognised and supported in their role.

3. Developing whole system frailty-attuned healthcare, including neighbourhood health, is the key priority for the NHS.

Demographic shifts mean that the proportion of older people will double by 2045. Current prevalence of frailty is 10% in over 65s, rising to up to 50% in over 85s.3,6 Frailty carries an increased risk of adverse outcomes such as falls, delirium, loss of function, hospitalisation, long-term care needs and premature mortality. The increasing prevalence of frailty will put pressure on healthcare systems to manage increasing demand, to maintain high quality care and to keep pace with the need for new frailty attuned services. Whole system frailty attuned care will be needed to prevent poor outcomes with an associated increased cost to the NHS and society.7

Frailty is one of the most common reasons older people need healthcare, yet systems and pathways often remain designed around single disease models rather than the realities of multimorbidity, functional change and complexity. As frailty advances and an individual is more likely to have several long-term conditions in addition to frailty, treatment of single diseases may be of limited benefit or even adversely affect a person’s coexisting illnesses. A frailty attuned system acknowledges frailty as a major driver of service use and outcomes and intentionally designs care, workforce, environments and community support around older people’s needs. Building such a system enables personalised, integrated and sustainable care that reflects the needs of the population now and in the future. Frailty-attuned care will need to become the cornerstone of emerging neighbourhood health teams (in England), out of hospital integrated care models, hospital-based elective and non-elective pathways, including surgery, and specialist services such as heart failure and cancer teams built on single organ disease models.

Key points:

  • A shared, universal definition of frailty must underpin all health and care planning.1
  • Every part of the NHS should have a whole system frailty strategy to embed frailty-attuned evidence- based care.
  • Wherever possible this should be co-produced with older people with frailty and their carers who have lived experience of using health and care services and systems.8
  • Integrated neighbourhood teams and whole system planning are essential to deliver coordinated, proactive care to older people living with frailty.9
  • In order to be frailty-attuned, neighbourhoods and healthcare systems need to recognise frailty co-exists with other co-morbidities, age-related long- term conditions, including dementia and other complex needs.
  • Frailty is a long-term condition, with exacerbations and uncertain trajectories. It requires continuity of care across systems and integrated co-ordinated care across traditional organisational boundaries.
  • Pathways must move away from single disease models toward personalised, function focused, holistic approaches.
  • Frailty attuned systems promote independence, continuity, and better long-term outcomes for older people.
  • All systems, pathways, new care models need to be viewed through the lens of frailty. As the largest user group of all healthcare systems, pathways and services, including those for dementia and end of life care, older people must have their needs considered in the design and delivery of services.
  • Capacity for frailty attuned clinical leadership at a service, local and system level, will need to be embedded and prioritised.

4. Early identification of frailty leads to better care and improved outcomes.

Recognising frailty early allows professionals to anticipate needs, prevent avoidable deterioration and deliver proactive, personalised support, ideally as part of an integrated neighbourhood team intervention.10 It is important to understand the distinction between those living with stable frailty syndromes in a population and those presenting in crisis due to a stressor event. Both offer opportunities for early identification. When in crisis, older people living with frailty often present atypically through functional decline, delirium, falls, reduced mobility or rising care needs, rather than symptoms of a single disease. Early identification enables earlier access to appropriate pathways, avoids unnecessary investigations and admissions, and reduces harm caused by reactive crisis-oriented care, creating a paradigm shift to one that is planned around the needs of the population.11

Key points:

  • Older people living with frailty often have associated complex needs, including frailty syndromes, multimorbidity, polypharmacy and disability, allowing for proactive detection at a population level.
  • Identification of older people living with frailty at a population level through population-level tools (e.g. electronic frailty index) supports risk stratification, enables healthcare systems to effectively plan for frailty attuned care across a system and enables strategic use of resources.12
  • Risk stratification enables identification of those living with severe frailty who may be in the last phases of life, offering opportunity to plan care in advance of deterioration.
  • Population health management makes older people living with frailty visible to the system, before crisis happens, in order to recognise their unmet medical, functional, psychological or social needs early, maintaining independence and minimising risk of deterioration.
  • Every contact with a health or care professional is an opportunity to identify someone living with frailty.
  • All health, care and voluntary sector professionals should be able to identify frailty using validated tools, the commonest being the Clinical Frailty Scale in the UK.13
  • Identification tools assessing for the level of frailty create a shared understanding and language for frailty, facilitating integrated care.
  • Early identification when an older person is in crisis reduces harms, prevents unnecessary admissions, and directs people to the right support, including community-based alternatives to hospital.

5. All older people with frailty should have access to gold standard multidisciplinary, multidimensional care (Comprehensive Geriatric Assessment).

Comprehensive Geriatric Assessment (CGA) is the most effective way to understand the complex and interlinked medical, psychological, functional and social needs of people with frailty.14 CGA leads to improved outcomes when used as the clinical construct for multidisciplinary care across a variety of healthcare settings, including in hospital geriatric units,15 front door frailty teams, community-based assessments, Hospital at Home models16,17 and peri-operative pathways.18 Older people are more likely to be living in their usual residence with a greater degree of independence and improved cognitive health if they receive CGA. CGA reduces expensive healthcare interventions (non-elective spells in acute hospitals and bed days) and premature avoidable costs of social care (higher care dependence and care home admission).

CGA ensures care is coordinated, person-centred and based on what matters most to the individual. It should be accessible in all settings - from primary care and community services to urgent care, inpatient wards and elective pathways - so that older people receive consistent and high quality assessment wherever they present.

Key points:

  • Timely access to CGA improves decision-making, supports personalised goals and reduces harm.19
  • CGA helps coordinate multidisciplinary input and ensures continuity of care.
  • There needs to be fidelity to CGA, so that it stays true to the definition and involves a multidisciplinary team and all domains are assessed. This includes ensuring it is led by clinical experts in frailty across the healthcare system.
  • Provision of CGA across the healthcare system will need to be planned for as part of policy implementation including the NHS 10 Year Health Plan, neighbourhood health guidance and associated operating guidance for all healthcare providers.
  • CGA should be embedded in all relevant care pathways within hospitals, including front door frailty provision, Same Day Emergency Care (SDEC), peri-operative pathways (POPS), cancer pathways and inpatient units.
  • Community based models (e.g. Integrated Neighbourhood Teams, Urgent Community Response and Hospital at Home) are in a position to extend the benefits of CGA outside hospital.20
  • Reimagining outpatient care for older people with frailty, ideally as part of neighbourhood health provision, should be built around CGA as a clinical model.

6. Partnerships are the foundation of high quality, integrated care for people living with frailty, including with social care.

High quality frailty care depends on strong, respectful partnerships between older people, their families, carers and the professionals involved in their care. Because frailty involves interconnected medical, psychological, functional and social needs, collaboration across sectors and disciplines is essential to avoid fragmentation and ensure continuity. Partnerships help deliver coordinated care, shared decision-making, crisis prevention and better long-term outcomes.21

Key points:

  • Partnerships must include older people, carers, advocates and families as equal contributors to decisions about their care.
  • Partnerships between healthcare professionals, older people living with frailty and their advocates should encompass high quality advance care planning supporting conversations about what matters most to the individual. This should inform end of life care planning in the preferred place of death.
  • Partnerships should be underpinned by clear communication, shared care records available across the system, including availability of advanced care plans.
  • Organisations involved in the care of older people living with frailty must work in partnership, at a strategic level as well in front line clinical care, in order to make integrated care work.
  • In order to deliver CGA across traditional boundaries, collaborative working between different disciplines with shared purpose will require strong relationships and partnerships.
  • Integrated neighbourhood health will only work if partnerships are formed by all health and social care providers working together.
  • Collaboration across primary, community, acute, mental health, voluntary and social care can improve outcomes for older people living with frailty and can lead to a healthier, happier interprofessional workforce.
  • Partnership working is a key enabler to a home first approach, minimising unnecessary hospital-acquired harms for those living with frailty and ensuring appropriate and timely early supported discharge with reablement and rehabilitation in the community.
  • The majority of deaths are in those living with frailty and other age-related long-term conditions, such as dementia.22 Partner organisations including specialist palliative care, will need to work together to deliver high quality end of life care across the healthcare system.23

7. For those living with moderate to severe frailty, sometimes less is more.

Older people with moderate or severe frailty are more likely to suffer from unintentional harms associated with medical care24 and least likely to benefit from secondary prevention strategies. Traditional evidence-based practice, founded on robust research and national guidance, is often based around disease processes and based on evidence from trial data that has probably excluded older people living with frailty.

Older people with frailty are highly vulnerable to harms from invasive tests, aggressive treatments, hospital environments, polypharmacy and over‑medicalisation, which can lead to poor outcomes from inducing frailty crisis, delirium25 or deconditioning.26,27 Personalised, proportionate care, guided by the person’s priorities and tolerance for intervention, often leads to better outcomes and fewer complications. A “less is more” approach requires skilled clinical judgement, respectful open and honest communication and awareness of the person’s goals, values and remaining reserve.28

Key points:

  • When assessing someone living with frailty, always focus on the frailty first. This should include identification of the level of frailty, degree of impaired mobility, cognitive frailty and care dependence 2 weeks prior to presentation. This can help when gauging the degree of reserve and pragmatism required.
  • Traditional evidence- based protocols and guidance should be viewed through the lens of moderate and severe frailty, if appropriate.
  • Care should prioritise what matters most to the individual and avoid unnecessary healthcare burden. This could include taking fewer medications, a preference for treatment at home or to not have invasive interventions.
  • Pragmatic prescribing is a very important skill needed as part of structured medication reviews for older people living with frailty.29,30,31
  • Early recognition of poor reserve supports timely advance care planning and end of life discussions.32,33
  • Community first frailty-attuned approaches can reduce unnecessary hospital admissions without limiting access to appropriate high-quality care.34,35
  • Disease specific guidelines for conditions common in older age should include advice on the management of the condition in people living with frailty.
  • Pre-operative and pre-cancer therapy CGA allows for shared decision making, often reducing the need for unnecessary interventions that may cause harm.

8. Everyone should have the knowledge, skills and attributes to deliver comprehensive frailty attuned care.

Frailty is widespread, yet many professionals across health and social care have limited training in recognising or managing it. In order to deliver whole system frailty-attuned care, a frailty attuned workforce is required. This encompasses shared knowledge, confidence, and values, supported through structured education, core capabilities, competency frameworks and systemwide workforce planning. Embedding frailty skills at every tier — from the general public to specialists — is central to improving safety, reducing preventable harm and meeting the needs of an ageing population.

Key points:

  • Frailty competencies, aligned to the core capabilities framework, should be embedded across all health and social care sectors.36
  • Every individual, including unregistered staff, older people living with frailty and their carers, should have tier 1 frailty awareness training as a minimum. This will ensure everyone understands what frailty is, can identify it and knows what to do next when they encounter it.
  • Everyone caring for older people with frailty should be tier 2 trained as a minimum, equipping the wider workforce with frailty-attuned knowledge and skills. They should all understand their role in delivering CGA at scale.
  • We will need an appropriately trained Tier 3 workforce37 to oversee multidisciplinary teams delivering CGA as well as leading and shaping services for older people with frailty.
  • In order for neighbourhood health to have workforce readiness, existing staff will need to work differently. They may need to develop new frailty-attuned knowledge, skills and attributes.
  • Frailty-attuned integrated care requires a workforce that can bridge care across primary, secondary, community, social and mental health services, allowing seamless care transitions and minimising hospital acquired harms.38
  • Every healthcare system should have a strategic workforce plan aligned to needs of their population and demographic growth. This is needed to ensure the right amount of trained health and care staff alongside the right amount of frailty specialists and frailty skilled generalists.
  • A compassionate, value based workforce supports dignity, shared decision making and independence.

9. There needs to be equitable inclusion of older people living with frailty in research and digital innovation.

People living with frailty are routinely underrepresented in research and can be excluded from digital transformation.39 This limits the relevance of evidence and can widen inequalities. Equitable inclusion ensures that research evidence and digital tools reflect the needs, priorities and outcomes important to older people. Thoughtfully designed digital innovation can reduce burden, support continuity and enhance workforce capacity when aligned to accessibility and person-centred principles.43

Key points:

  • Research participation should be available to older people living with frailty across all settings and is essential to improve the quality of evidence which informs prevention, effectiveness of healthcare models and overall care.40
  • There should be consideration for inclusion of older people with frailty in clinical trials involving adults, outreach to under-represented groups (e.g. care home populations), prioritisation of research funding for frailty and sufficient capacity for translational research and implementation science studies.41,42
  • Digital transformation must consider usability, accessibility and inclusion, to help support workforce capacity and free up hands to care.44
  • Technology should support, not replace, professional judgement in delivering frailty attuned care. Artificial intelligence could be harnessed as an enabler to support better data gathering and capacity for CGA.43,44
  • Digital solutions should be designed around the needs of older people living with frailty and can be applied at a system level including measurement and frailty dashboard development; identification of at-risk cohorts; CGA record assimilation; remote monitoring and connecting teams with experts; bedside diagnostics.

10. A sustainable NHS is underpinned by a frailty-attuned health and care system.

Frailty-attuned care contributes to a more sustainable health and care system by reducing high intensity, high carbon and avoidable crisis care. Older people living with frailty often experience preventable admissions, long hospital stays, over investigation and treatment burden — all of which carry environmental, financial and personal costs. A sustainable approach prioritises prevention, independence and community-based care, aligning the needs of older people with the NHS’s environmental and operational goals.45

Key points:

  • Preventative, proactive care reduces conveyances, admissions and length of stay.
  • Frailty-attuned, person-centred holistic care delivered through Neighbourhood health co-ordinates the overall care for older people with multimorbidity, polypharmacy and complex needs, minimising the need for multiple appointments in secondary care.
  • Digital connectivity for both frailty teams and carers and patients can minimise the need for carbon-intensive activity. Virtual consultations and remote monitoring reduce travel for patients and staff, but care should be taken to address the risk of digital exclusion of older people and that this does not replace the need for hands on care.
  • Frailty-attuned realistic and pragmatic medicine, in partnership with the person and their advocates, reduces polypharmacy, unnecessary tests and over investigation. This can improve safety and reduce waste.
  • Sustainable evidence-based continence care, reablement and rehabilitation approaches reduce reliance on high carbon products and equipment.

References

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Key messages in brief

  • Frailty must be understood at every level of society.
  • Frailty is not an inevitable part of ageing.
  • Developing whole system frailty-attuned healthcare, including neighbourhood health, is the key priority for the NHS.
  • Early identification of frailty leads to better care and improved outcomes.
  • All older people with frailty should have access to gold standard multidisciplinary multidimensional care (Comprehensive Geriatric Assessment).
  • Partnerships, including with social care, are the foundation of high-quality integrated care for older people living with frailty.
  • For those living with moderate to severe frailty, sometimes less is more.
  • Everyone should have the knowledge, skills and attributes to deliver comprehensive frailty attuned care.
  • There needs to be equitable inclusion of older people living with frailty in research and digital innovation.
  • A sustainable NHS is underpinned by a frailty-attuned health and care system.

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