Introduction to Frailty, Fit for Frailty Part 1
Older people living with frailty are at risk of adverse outcomes such as dramatic changes in their physical and mental wellbeing after an apparently minor event which challenges their health, such as an infection or new medication.
Fit for Frailty
Consensus Best Practice Guidance for the care of older people living with frailty in community and outpatient settings - published by the British Geriatrics Society and the Royal College of Nursing in association with the Royal College of General Practitioners and Age UK
Part 1: Recognition and management of frailty in individuals in community and outpatient settings
What is frailty?
Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Around 10 per cent of people aged over 65 years have frailty, rising to between a quarter and a half of those aged over 85.
Distinguishing between frailty and disability
It is important to understand the difference between frailty, long term conditions and disability. Many people with multiple long term conditions (so called multi-morbidity) will also have frailty which may be masked when the focus is on other disease based long term conditions. Likewise, some people whose only long term condition is frailty may be low consumers of health care resources and not regularly known to their GP (until they become bed bound, immobile or delirious as a result of an apparently minor illness). There may be overlap between the management approaches for people with multi-morbidity and those with frailty but these conditions are not identical and this guidance looks primarily at frailty. Similarly, there is overlap between frailty and physical disability – many people with frailty also have disability, but lots of people with a long term disability do not have frailty. Frailty may be the cause of disability in some patients and the consequence in others.
The language and management of frailty can act as barriers to engaging with older people who may not perceive themselves, or wish to be defined, by a term that is often associated with increased vulnerability and dependency. Older people may not recognise themselves as living with frailty and there is evidence that older people do not want to be considered as ‘frail,’ although happy to accept that they are an older person. For an older person, living with frailty can mean living with various ‘losses’ and it is easy, as a professional, inadvertently to collude with the loss of control over everyday life that results from an extensive care package, social isolation or the rapid fluctuation in mental state that sometimes accompany frailty. Research has demonstrated that many older people living with frailty develop ways of coping and make other compensatory choices. As a group ‘frail older people’ encompasses a diversity of individual people each with different expectations, hopes, fears, strengths and abilities, as well as different types and levels of need and support. It is our job to ensure that these are, as far as is possible, accommodated, thus restoring control, preserving dignity and facilitating person-centred care to the older person living with frailty and those close to them.
Why look for frailty?
Frailty should be identified with a view to improving outcomes and avoiding unnecessary harm.
The central problem with frailty is the potential for serious adverse outcomes after a seemingly minor stressor event or change. This could mean anything from a simple episode of ‘flu to a major intervention like a joint replacement. Even apparently simple interventions like a move to a short term residential placement for respite, a trip to the local emergency department after a fall or the trial of a new analgesic can have unforeseen and adverse outcomes. Thus for an individual, the knowledge that they have frailty can help health and social care professionals to take action to prevent the poor outcome for a particular intervention (or even to avoid the intervention) and to start a pathway of care to address the issues contributing to frailty.
It is important to remember however, that:
- Frailty varies in severity (individuals should not be labelled as being frail or not frail but simply that they have frailty).
- The frailty state for an individual is not static; it can be made better and worse.
- Frailty is not an inevitable part of ageing; it is a long term condition in the same sense that diabetes or Alzheimer’s disease is.
When should you look for frailty?
Any interaction between an older person and a health or social care professional should include an assessment which helps to identify if the individual has frailty. This includes (but is not limited to) the following:
- Routine outpatient appointments in all departments, including surgical (orthopaedic, GI, vascular and ophthalmic departments), medical and mental health (memory clinics).
- Social services assessment for care and support.
- Review by the community care teams after referral for community intervention.
- Primary care review of older people (either medical intervention or medicines review or any other interaction such as one of the long term conditions clinics).
- Home carers in the community.
- Ambulance crews when called out after a fall or other urgent matter.
It is self-evident that the type of assessment will differ when dealing with an individual who is currently unwell (and therefore a short screening assessment may be of limited benefit) instead of being in a stable situation. Professional discretion will need to drive the nature of the assessment. However planning any intervention (e.g. starting a new drug, conveying to the emergency department or an elective joint replacement) in an individual who has frailty, without recognising the presence of the condition and balancing the risks and benefits, may result in significant harm to the patient.
Causes of frailty
There are two broad models of frailty. The first, known as the Phenotype model, describes a group of patient characteristics (unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion and low energy expenditure) which, if present, can predict poorer outcomes. Generally individuals with three or more of the characteristics are said to have frailty (although this model also allows for the possibility of fewer characteristics being present and thus pre-frailty is possible). The second model of frailty is known as the Cumulative Deficit model. Described by Rockwood in Canada, it assumes an accumulation of deficits (ranging from symptoms e.g. loss of hearing or low mood, through signs such as tremor, through to various diseases such as dementia) which can occur with ageing and which combine to increase the ‘frailty index’ which in turn will increase the risk of an adverse outcome. Rockwood also proposed a clinical frailty scale for use after a comprehensive assessment of an older person; this implies an increasing level of frailty which is more in keeping with experience of clinical practice.
A central feature of physical frailty, as defined by the phenotype model is loss of skeletal muscle function (sarcopenia) and there is a growing body of evidence documenting the major causes of this process. The strongest risk factor is age and prevalence clearly rises with age. There is also an effect of gender where the prevalence in community dwelling older people is usually higher in women. For example a UK study from 2010 using the phenotype approach to defining frailty found a prevalence of 8.5 per cent in women and 4.1 per cent in men aged 65 –74.
In terms of modifiable influences, the most studied is physical activity, particularly resistance exercise, which is beneficial both in terms of preventing and treating the physical performance component of frailty. The evidence for diet is less extensive but a suboptimal protein/total calorie intake and vitamin D insufficiency have both been implicated. There is emerging evidence that frailty increases in the presence of obesity particularly in the context of other unhealthy behaviours such as inactivity, a poor diet and smoking.
Other areas of interest include the role of the immune-endocrine axis in frailty. For example a higher white cell count and an increased cortisol: androgen ratio predicted 10 year frailty and mortality in one recent study.
However the inter-relationship between prescribed medication and frailty independent of co-morbidity is a relatively under-exploited area. There is some evidence that aside from myopathy, some drugs may have more subtle adverse effects on muscle function.
The cumulative deficit approach to defining frailty is broader than the phenotype approach, encompassing co-morbidity and disability as well as cognitive, psychological and social factors. The potential causes are therefore wider and include the multiple risk factors which are implicated in the various diseases and conditions.
Population screening for frailty
Systematic screening for frailty would be an expensive venture and there is currently no evidence for improved outcomes despite it being a recommendation in earlier international guidance. Like systematic screening for dementia, there would be a degree of “public unacceptability” (for example; people may be fearful of being diagnosed with dementia and therefore be reluctant to submit to a test for dementia unless it was specifically indicated by their life circumstances). Age UK research has shown that in a series of filmed case studies of ‘frailty’ none of the participants classified themselves as “frail”. Some of them mentioned finite periods where they “had been frail” but they did not see it as a lifetime condition or as defining them.
A current approach seeks to break down a practice population according to risk of using future health care resources including hospital admission. It uses computer based tools, for example Advanced Clinical Groupings (ACG), Prediction of individuals At Risk of Readmission (PARR) or Scottish Prevention of Admission and Readmission (SPARRA). These tools interrogate a primary care practice computer to identify high risk individuals based on past use of resources, drug prescriptions or particular diagnoses. Unfortunately there is no evidence that focussing resources on these individuals improves outcomes. Additionally, these tools, which were not designed to look for frailty, often highlight individuals who have high cost conditions not amenable to modification (such as immunosuppression after organ transplant).
Some areas and practices have adopted a localised approach to identify frailty, e.g. in Warwickshire, Age UK has trained volunteers to administer the Easy care tool which starts the process of identifying needs and developing an individualised care plan. This is similar to an approach in Gnosall, Staffordshire (winner of an NHS innovation award) where everyone receives a questionnaire on their 75th birthday, seeking to identify those who might have, or be developing, frailty. They have achieved a response rate of over 85 per cent and those who respond are then visited at home by an elder care facilitator before undergoing a comprehensive geriatric assessment at the surgery by a GP.
The BGS does not currently support routine population screening for frailty because of the likely considerable cost of completing assessments and the low specificity of available tools. A suitably validated electronic frailty index constructed using existing primary care health record data may enable future routine identification and severity grading of frailty, but requires additional research.