The Frailty Industry: Too Much Too Soon?

02 August 2017
Frailty

Steve Parry works in acute medicine and older people's medicine. He has a special interest in investigation and treatment of falls and blackouts in adult patients of all ages. He is BGS Vice President - Academic and Research.

Fashions come and go, in clothing, news and even movie genres. Medicine, including geriatric medicine, is no exception. When I was a trainee, falls and syncope was the next big thing, pursued with huge enthusiasm by a few who became the many. But when does a well-meaning medical fashion become a potentially destructive fad? Frailty, quite rightly, has developed from something geriatricians and allied professionals always did to become a buzz word even neurosurgeons bandy about. No bad thing for all professionals who see older people to have awareness of the recognition and management of this vulnerable and resource intensive patient group. But increasingly vast amounts of resource are being devoted to the creation of frailty related services for our older population in the absence of a sound evidence base. Indeed, recent New Horizons articles in Age and Ageing quite rightly state that the evidence base for frailty (and the related “intervention” Comprehensive Geriatric Assessment) REFS is at best sketchy, with little apart from exercise making much of a difference, never mind any evidence at all of cost effectiveness.

So how did we get to this position, where front door frailty units, frailty clinics, frailty services for non-medical specialties and the like are funded simply because they sound like a good idea? Partly an understanding of the pressing need to care for this patient group better, with many including a burgeoning number of trainees finding a cause to identify with; partly charismatic and passionate leadership; partly BGS sponsorship; and partly I suspect a bandwagon effect, particularly in the research arena, where frailty commands the older people’s medicine agenda spectacularly.

We have a threefold responsibility in relation to frailty (and indeed all other areas of practice): first, to care for those with frailty with expertise and compassion; second to develop the evidence base for frailty identification and management; and third to operate within our knowledge and evidence base to ensure rational resource use. We are not delivering on the third. We should. The evidence base for falls and syncope grew over time, but in an era when we had the luxury of trying new service models that made clinical sense without the financial pressures of the current NHS. While advocating passionately for our patients, we must be honest about what we can and can’t achieve, and refuse to deliver services that we do not have an evidence base to support. That is not to say that we should not serve frail patients expertly, within what we know. But we must not allow frailty to exclude other aspects of good patient care; by way of example, the prevention agenda is barely acknowledged currently within the BGS, the wider older people’s medicine professional community and the research arena related to older people, where frailty and that dreadful term “multimorbidity” hold sway.

A challenge for frailty aficionados – when did you ever make someone with moderately severe frailty less frail? Having asked many colleagues, from learned professors to jobbing geriatricans, juniors to seniors, BGS office bearers to allied professionals, the only one with a resounding affirmative response was a personal trainer running exercise classes for older people in the community. It is time for the frailty fad to own up to its fallibility and allow the fashion pendulum to swing in other directions, while not neglecting this vital component of geriatric medical care.

 

Category: 
Best Practice Falls and Bones Frailty

Comments

Submitted by David Oliver on Fri, 04/08/2017 - 10:56
No one is being chastised for promoting wellbeing. Every single commenter on here would agree that prevention, well being, active ageing and public health are crucial as is support to live well with long term conditions. This is largely an internal doctrinal dispute amongst geriatricians about where the speciality should put its emphasis, whether we are pushing frailty too much at the expense of more traditional definitions of geriatric medicine what role lengthily trained doctors with acute care skills can reasonably play in the public health agenda when we are a smallish workforce and largely hospital based, and what we mean by high quality research evidence. You wont find a single person on here disagrees that wellbeing, prevention etc are important. Its largely a friendly spat between professionals who all basically know each other and all basically do the same job and are all motivated by a desire to give high quality care to older people and have all devoted their professional lives to what has often been seen as a less glamorous area of medicine because they care deeply. But even within a professional grouping some spiky debate is healthy. I “did a Steve” a couple of years back on here when suggesting that traditional lengthy once or twice a week multidisciplinary meetings were not fit for purpose in todays high turnover hospitals and we needed something punchier and twice daily. Similar results ensued! Good!

Submitted by Snow-Leavis on Wed, 02/08/2017 - 11:14
Dear Steve, Thank you for bravely and eloquently expressing concerns that I have had for some time about most well-meaning enthusiasm towards frailty. I expressed similar concerns about approaches to delirium. Both are complex issues which I recognise as needing most careful attention. My concern has been about medical reductionism – losing sight of the wide and complex backdrop to these states of being – that are not so simply and completely “medical”. I lost my nerve writing about this after a most senior UK healthcare professional personally attacked my character (in public and in writing) for sharing my philosophical considerations on “frailty”. I had already almost had my career ended by Healthcare Improvement Scotland for simply expressing ethical considerations on “national improvement’ work on delirium: https://holeousia.com/2014/07/23/correspondence-with-healthcare-improvement-scotland-his/ I would suggest the common “industry” behind these well-meaning “fads” may be “improvement science” which has become the “group think” of today. So thank You Steve for writing this. Thank you. aye Dr Peter J Gordon (NHS Scotland) Conflict of interest: I have given a critical talk about “improvement science”: https://holeousia.com/2016/11/24/reductionism-truly-madly-deeply/

Submitted by Penny on Wed, 02/08/2017 - 10:53
Yes, absolutely speaking as a blogger aged 71 (who once upon a time was a nurse but now interested in social policy and ageing) there is far too much emphasis on frailty and not enough on prevention and exercise and ageing healthily and getting people up and running – and I see from your article that means take that literally!

Submitted by Duncan Forsyth on Wed, 02/08/2017 - 10:53
Well said Steve! Frailty to my mind is simply a new composite term for all we as geriatricians do; it encompasses cognitive, physical, and social factors alone or in combination and so mirrors falls, delirium, Parkinson’s and other aspects of comprehensive geriatric services. Buzz words come and go but real geriatricians remain.

Submitted by Janet Thomas on Wed, 02/08/2017 - 13:52
A thought provoking read – thank you! I would also like to add my YES to having effective interventions for people who are frail. This is also via exercise but in a Day Hospital setting so not only are patients getting exercise interventions to address frailty and sarcopenia this is also in the context of CGA and MDT Input as well. Physiotherapists have key roles to play in this area and I’m looking forwards to presenting on this at the BGS autumn conference.

Submitted by David Oliver on Thu, 03/08/2017 - 12:01
to be honest, i don’t think its that important getting hung up on the F word. We know what we do. Specialist, holistic, skilled, multidisciplinary care to older people with frailty including related acute presentations like falls, delirium, with multiple long term conditions or with common age related conditions, with cognitive impairment. “Fraitly” or “Multimorbidity” are often used a short hand. But its what we do for people that counts most. If you look at numerous case reports, QI projects etc from nursing homes, from rapid ambulatory care, from acute medical units and emergency departments, from inpatient wards, from stroke units, from patients with hip fracture, from community rapid response teams its clear that what we do makes a difference. There is a spectrum,. an overlap between frailty, age, disability, acute illness, long term conditions (multiple or single) and we mustnt forget also that geriatricians in the UK are mostly lengthily trained and dually accredited in GIM and often do this and acute internal medicine better than most ologists. We have also been the protagonists in stroke services, in improvements to care home medicine, in intermediate care, and in combatting ageism and age discrimination and in banging the drum for older people to get a proper diagnosis and management plan and a fair deal. Arguing among ourselves over how much prominence to give to Frailty misses the point in the same way that political parties’ internal doctrinal disputes and factions are a distracting sideshow from getting elected and getting things done. Does anyone reading Steve’s blog seriously think its a BAD thing for us to identify people with the kinds of problems i have listed and put together decent services with strong geriatrician and MDT involvement to support them? As for prevention. its important but there are c 1450 geriatricians in the UK, 35,000 GPs not to mention community health and socail care teams, local government/public health/social care, welfare, pensions, housing (where most wider determinants of healtth sit). As highly trained specialist doctors with skills in acute and complex care, there is much to be said for putting most of our efforts into areas where we are best placed to add most value. We absolutely should bang the drum more for prevention but we are not best placed to deliver it and certainly not alone

Submitted by Steve on Fri, 04/08/2017 - 14:30
……but while we are making good use of our skills in managing the care of our frail patients, the focus on frailty assumes a homogeneity that isnt there, and distracts from other facets of good care; including prevention and amelioration at a much earlier stage. When people talk about “frailty” its really shorthand for the very frail – and we simply dont have good data to support the focus on this group. In no way did I argue that we shouldnt be caring for our frail patients, rather that a healthy dose of realism was needed………

Submitted by Anne Davies on Wed, 02/08/2017 - 17:23
Another thank you for putting your head above the parapet. The use of “frailty” is, in my opinion,a dumbing down of geriatric medicine. Patients meeting the criteria form a large subset of our patients and our job is to work out if there are treatable causes for their symptoms – not give them a label. Challenging, progressive and long term exercise is important for older peoples health, ideally started before significant impairment and disability is detectable. It’s of note that the excellent “Sod 70! A guide to living well”, published for the British Geriatrics Society’s (BGS) 70th anniversary, was written by Sir Muir Gray, a physician with a public health background, and not a geriatrician. It is time the BGS had a public health special interest group.

Submitted by Tom Hutchinson on Thu, 03/08/2017 - 07:32
A disappointing blog from BGS Vice President – I understand the message but I think the point is missed. Quality Improvement work embedded in Frailty developments; we don’t know the final outcomes but QI based in common sense improvement. Go and make the evidence don’t wait for it. Compare and contrast Zoe Wyrko’s TV programme Old People’s Home for 4 year olds with this blog. Keep ‘frailty’ in the spotlight, ride the wave, it will lead to much needed improvements in Frailty care #endpjparalysis – this is not a time for folk to get precious about being a ‘proper’ Geriatrician

Submitted by David Oliver on Thu, 03/08/2017 - 06:29
Readers might be interested in this extended, densely referenced essay I wrote when still BGS President along with Current President Eileen Burns about the full range of roles Geriatricians currently play in delivering clinical services, if not in prevention. I don’t think we would ever claim that frailty was the only thing that defined our caseload. I would also say that its the nature of our work that much of the evidence base should derive from quality improvement, health services research, realistic evaluation of service changes etc or from big data driven by iniatiatives such as the hip fracture database. RCTs and Meta-Analyses aren’t always fit for purpose for the patient groups we care for and the service models and intervetions we use and we are often in the business of balancing risks and benefits and goals of treatment in an ethical, legal and biospsychosocial context. BUt if you do want RCTs, it does seem that Comprehensive Geriatric Assessment for people with complex needs works quite well in a variety of settings. Here is the link to the essay http://www.bgs.org.uk/pdfs/2016_rcp_future_hospitals.pdf

Submitted by Snow-Leavis on Thu, 03/08/2017 - 17:27
Frailty is a word. One word. I would suggest that should be cautious in applying this word to our elders.

Submitted by Chris Dyer on Thu, 03/08/2017 - 21:20
While I agree that there are research gaps that we should strive to fill, frailty has allowed me to discuss the issues affecting older patients with other colleagues and also has allowed major service development. Getting a neurosurgeon discussing this is great news! . The biggest impact of the frailty “fad” has been to expand Geriatric Medical services and it is not true to say we haven’t evaluated these. The QI work inspired by the Sheffield “Improving Flow” programme has found major benefits (Los, bed occupancy, readmissions) in front door services which have been published using non-RCT design but nevertheless highly robust statistics – and we have replicated this during a PDSA of new frailty services in Bath. Read the science behind it at “Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources Kate M. Silvester; Mohammed A. Mohammed; Paul Harriman; Anna Girolami; Tom W. Downes Age and Ageing 2013; doi: 10.1093/ageing/aft170 ” and http://www.pasq.eu/DesktopModules/EventManager/Files/171/Paul_Harriman_NHS_UK_Presentation_Dublin_Sheffield.pdf Also the May Age Ageing issue (Jay et al) highlighted the impact of CGA at the front door in (presumably) frail patients and the impact seems to be on los which is really important. Simon Conroy’s work is central to this. While benefits for the patient themselves requires more research it is really important that frailty is high on the service development agenda as it really describes what we Geriatricians do far better than we have ever been able to enunciate it before. Call it something else if you like, but frailty sums it up for me. PS I’m happy that you have raised the issues for debate here though, so lets have more controversial blogs like this

Submitted by Snow-Leavis on Fri, 04/08/2017 - 05:39
Dr Oliver makes a valid point. I share the understanding that we are all just trying to make lives better. I hope that I am not just ‘pointless’ and ‘contrary’. I see there was a typo in my reply. Apologies. Forgive me if I have been an ‘unreasonable man’. I agree with Dr Oliver and others that it is healthy to have debate. It would be great if older adults themselves could contribute. kindly Peter Gordon

Submitted by Kate Swaffer on Fri, 04/08/2017 - 07:53
I remain shocked, as a person living with younger onset dementia, that frailty, rehabilitation, and a host of other positive interventions are not being discussed here. It is incredible that doctors promoting well being would be chastised, even bullied for engaging in this conversation!

Submitted by Steve on Fri, 04/08/2017 - 16:28
Thanks so much for the thoughtful and very helpful comments above, very similar voiced on twitter. A long way to go – as ever. As David notes, our goals are all the same…..

Submitted by Dr Shibley Rahm... on Fri, 04/08/2017 - 16:57
This is an excellent article. Understanding stigma, labelling and otherness is vital to proceed, given that people who are frail themselves dislike the label. Why? All corporate change models – including QI – urge the need for detailed stakeholder buy-in. Secondly, you need motivation from stakeholders themselves for sustained behavioural change. If a person dislikes a label, he or she is much less likely to engage in self-care. We know this from the mental illness literature. Therefore calling Frailty just another word is a completely inadequate professional response.

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