Frailty: what’s it all about?

Good practice guide
Good practices guides focus on providing information on a clinical topic.
British Geriatrics Society
Date Published:
23 May 2018
Last updated: 
23 May 2018

What is frailty?

  1. An inevitable consequence of ageing
  2. A state due to multiple long term conditions
  3. A condition in which the person becomes fragile
  4. A state associated with low energy, slow walking speed, poor strength
  5. A condition for which nothing can be done

Answer: 4 - low energy, slow walking speed, reduced strength

So the other are untrue-

  • not inevitable,
  • associated with multiple LTC, but can occur in the absence of these
  • amenable to treatment
  • unlike “fragility” frailty is a specific syndrome with characteristic features, and a rapidly expanding research base

Definition: a state of increased vulnerability to poor resolution of homoeostasis after a stressor event

Condition associated with increased risk of deterioration:

  • “acute frailty syndromes” – falls, delirium (or acute confusion), “off
  • legs” may result from a relatively minor insult
  • Higher risk of acute hospital admission
  • Care home admission
  • Death


Response to an adverse event in a non- frail vs frail older person

Phenotype model:

  • Walking speed reduced, grip strength low, immune deficits, reduced
  • ability of withstand an “insult”
  • Useful in clinical trials, difficult to implement on large scale,
  • Walking speed
  • timed up and go test (TUGT) used
Primary care/community care/outpatients Acute care
Gait speed <0.8m/s Clinical frailty scale
Timed-up-and-go test <12s Reported Edmonton frail scale
Grip strength ISAR tool
PRISMA 7 questionnaire (Gait speed)
Clinical frailty scale  
Edmonton frail scale  

Proven to correlate with comprehensive geriatric assessment

Theoretical background to the development of the electronic frailty index (eFI); searches in the primary care record for 36 variables (diagnoses, symptoms, sensory impairments, disabilities)

Proven to identify risk of hospital admission, care home admission, death

Proven statistically to identify a cohort of people who are highly likely to be frail

Like any other statistical tool will identify false positives, hence clinical correlation is essential

Clinical knowledge of patient, TUGT or other frailty assessment


“healthy ageing” reduces the risk of developing frailty:

Good nutrition

Not too much alcohol

Staying physically active

Remaining engaged in local community/ avoiding loneliness

Patients can be signposted to the NHS England and Age UK publications

Adverse effects of frailty can be mitigated- for example:

Falls risk can be reduced

Timely medication review can reduce risk of ADR, drug interaction, non-compliance

...hence BGS delighted to see the new GP contract

Frailty prevalence at various ages
Telegram overload - centenarieans will continue to be the fasted growing age group

Turning around years of Medical Practice

The Past The Future
Single organ specialties Patient centred care
Disease focused goals Principles of Comprehensive Geriatric Assessment
Non- integrated services Proactive person centred care planning
Reactive care  

Identify and code for moderate and severe frailty

Ask for consent to share further information using the Summary Care Record

For severely frail patients:

  • Falls assessment
  • Medication review

Average practice list per GP:

  • 2,000 (significant variation around the country)
  • 7% of the population over 65 yrs are likely to be severely frail
  • In an average practice this is about 27 patients per GP
  • “Pulse” estimate 0.5% of practice population

Based on GP contract data as at 31 Mar 2018, there were 320,000 people aged 65 and over with a coded diagnosis of severe frailty (c. 3.2% of 65+ population).  This was an average of 46 patients per GP practice or 0.6% of the average practice list. [Source: Fusion48]

Multidisciplinary assessment of physical, psychosocial, functional and environmental factors

Multidisciplinary team come together to agree a plan with the patient (and where appropriate their family)

Plan enacted; team can ensure actions implemented

Review with agreement of any further actions

Patient receiving CGA 12 times more likely to be alive and living at home 6 months after intervention NNT 24

Evidence is for multidisciplinary assessment, commonly several factors identified:

Eg 87 yr lady with dementia, hypertension, ischaemic heart disease, diabetes (type II), osteoarthritis
3 falls in the last 4 months.
One known about by practice when fractured radius
Taking night sedation (long acting benzodiazepine), gliclazide, enalapril, isosorbide mononitrate, paracetamol, amlodipine, GTN spray
Urgency, frequency, nocturia- falling at night trying to get to the toilet
Painful OA, disuse wasting of quads
Wearing spectacles- no vision check for 2 yrs
HbA1C 52
L/S BP: postural drop- enalapril dosage reduced
HbA1C too tight- on gliclazide 80mg once daily- stop
Night sedation slowly weaned
Over active bladder symptoms identified and treated
Commode next to the bed supplied
Family arranged optician check- specs updated (no bi-focals)
Improve analgesic treatment of knees- encourage and support to attend local gentle exercise group
Extra rail on the stairs fitted

  • identification of falls history
  • assessment of gait, balance and mobility, and muscle weakness
  • assessment of osteoporosis risk
  • assessment of the older person's perceived functional ability and fear relating to falling
  • assessment of visual impairment
  • assessment of cognitive impairment and neurological examination
  • assessment of urinary incontinence
  • assessment of home hazards
  • cardiovascular examination and medication review
  • strength and balance training
  • home hazard assessment and intervention
  • vision assessment and referral
  • medication review with modification/withdrawal

One study (2016) found that 65% people admitted to hospital after a fall were taking at least one medication associated with falls

23% of all over 75 yr olds taking inappropriate medications

Recent paper analysing primary care patient safety incidents highlighted medication issues

High risk medications: warfarin, insulin/ sulphonyl ureas, opiates

Problematic combinations: NSAIDs and ACE inhib

NSAIDs and warfarin

O’Mahony et al STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014 October 16, 2014.

NICE. Managing medicines in care homes (SC1). London: NICE, 2014. ectiveness-matters-January-2015- frailty.pdf veness-matters-aug-2017-polypharmacy- pdf

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