The Frailty Industry: Too Much Too Soon?
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.