Understanding frailty - a beginners' guide
Gill Turner is Vice President, Clinical Quality for the British Geriatrics Society and Project Lead on the Fit for Frailty campaign. This blog, outlining the concept of frailty and highlighting the recent release of Fit for Frailty Part 2, first appeared on the Age UK website.
It is hard to open a book, newspaper or listen to the news currently without hearing words like ‘the elderly’ , ‘dementia’ and ‘frail’. But what is meant by these words? Frailty, for example. Many journalists use ‘frail’ to depict older people as victims of a failing NHS and underfunded social services. Doctors, nurses and relatives sometimes use ‘frail’ to describe people at the very end of their life, reinforcing its negative connotations. And yet, work done by Age UK shows that older people see being ‘frail’ as akin to being weak, dependent and hopeless: they reject the idea of using it.
So, what if the word ‘frailty’ actually denoted a health condition which could be recognised, managed and even improved? What if the recognition of frailty opened the door to a range of health and social care services organised to address an older person’s wellbeing, independence and control over their own life?
Frailty in scientific terms describes a situation where the body’s reserves are wearing out, meaning individuals are at risk of doing badly after a minor illness or stressful event. Decisions about health and social care for individuals with frailty need to be tailored to recognise their frailty, and in doing so address the problem.
The British Geriatrics Society, the Royal College of General Practitioners and Age UK have just published Fit For Frailty: a set of best practice guidance for managing frailty. Part 1, published a few months ago, describes recognising and managing frailty for individuals. Part 2, published last week, makes recommendations for the organisation of services for frailty. You can download both documents for free from the BGS website.
The guidance shows that there are several methods to recognise frailty; for example taking more than 5 seconds to walk 4 metres. Gold standard for treatment is a process called Comprehensive Geriatric Assessment(CGA): it’s an unattractive name, but research has demonstrated its effectiveness. We need to embrace its value, regardless of title. CGA involves an holistic review to consider troublesome symptoms and problems which might not have been previously reported to the doctor, and a discussion with the patient about goals and aims for their life. This could sometimes mean reducing medications.
For example, research shows that reducing blood pressure can reduce stroke risk: however, if an older person’s blood pressure medication makes them feel faint and fall over, that threatens their ability to shop and choose their own food, and thus their independence. Keeping a high level of medication might be the wrong treatment for that individual. For another person who feels that being able to walk to church on Sunday is an important priority, it could mean changing the focus of their treatment from careful diabetes control onto an exercise programme. Of course, you could think of a million examples here: there will be as many different approaches as there are people. The point is that the treatment plans must be centred around what an individual older person needs for their life and wellbeing. Sometimes, several different professionals will be involved: perhaps a geriatrician, a therapist or a nurse. Each of these will need to work in a team around the patient, helping formulate their own well-being plan which will need to be revisited as things change and new priorities emerge. CGA covers this whole ongoing process.
Ensuring that older people with frailty have access to holistic medical review and CGA will require some reorganisation of services. Part 2 of the guidance gives advice about what is needed when it comes to the commissioning and design of health services. Our expectation is that services will support the concept of frailty as a condition with which people live well and hence are keen to be associated with, not from which they suffer and die. Find out more about the British Geriatrics Society Fit for Frailty campaign Watch Age UK's video of older people sharing their perspectives on frailty