Gillian Turner: Recognising frailty in older people

gillian_turnerGiven the current emphasis on emergency admissions and older people, it is perhaps not surprising that the words “frail” and “frailty” are used almost interchangeably with “older people.” Yet more than 50% of people over the age of 85 will not have frailty. For the 40 to 50 % that do, we need to carefully consider how health and social care can best be of service.

But firstly, it is important to know what is meant by frailty. In short, it’s a loss of physical and psychological reserves, which means an increased vulnerability to minor stressor events. In other words, the outcome of an apparently small change in health—such as a minor infection or the introduction of a new drug—can be disproportionately poor. This could mean never getting back to a pre-existing state of health or independence, which then leads to a move to a care home or even death.

For those living with frailty, it is a long term condition, just like diabetes or heart disease. It can vary in its severity, and people’s individual problems can move up and down the scale. It needs active management to attenuate its effects, and to reduce the potential adverse outcomes of other illnesses or interventions. Frailty can occur on its own or alongside other long term conditions. While some people with frailty have disability to a greater or lesser degree, many do not.

One of the other problems is that frailty can often go unnoticed until the adverse effects are already happening. People with frailty are not necessarily known to their GPs as significant users of the health service, and may not have big care packages. Consequently, in the current NHS culture, which is very disease focused, many older people might also be having their other long term conditions actively managed in primary care, without it being recognised that they have frailty.

Indeed, these patients may only come to notice when they become immobile or bed bound after a bout of flu, or are admitted to hospital with acute confusion (delirium) because of a chest infection, or fail to recover according to plan after an elective joint replacement.

The British Geriatrics Society (BGS) has published guidance for the management of older people with frailty in community and outpatient settings. Called Fit for Frailty, part one of this guidance deals with the recognition and management of individuals with frailty.

In the guidance, which was produced in association with the Royal College of General Practitioners and Age UK, the BGS calls for all routine encounters between older people and health and social care professionals to include a search for frailty. The tools most likely to help in this regard are walking speed (taking more than five seconds to walk four metres), and the timed up and go test (taking more than 10 seconds to stand up from a standard chair, walk a distance of three metres, turn, walk back to the chair, and sit down).

Sometimes older people can present with one of the frailty syndromes: falls, a sudden change in mobility, sudden confusion, a change in continence level, or a significant adverse drug reaction—confusion with opiates or hypotension with antidepressants, for example. This could be in a crisis situation, or possibly in a more routine setting. Nonetheless, this should immediately raise suspicion that the person has frailty, and that the apparently simple presentation may mask a more serious, underlying pathology.

Knowledge that an older person has frailty should, in the opinion of the BGS, set off a pathway of activity. In the routine situation, a holistic medical review is needed along the lines of comprehensive geriatric assessment (although it doesn’t necessarily need to involve a geriatrician). Reversible medical conditions need to be diagnosed and tackled, a drug review undertaken, and the older person’s own goals considered. A care and support plan (CSP), which is personalised for the individual, needs to be developed. This will often mean moving away from disease based guidelines towards more symptom based treatment and support.

Besides older people themselves and their GP, the delivery of the CSP will often involve other agencies like social services, community teams, and the ambulance service.

In the emergency or crisis situation, hospital admission may not always be the best solution for an older person with frailty (providing the alternative is safe and fulfils all their needs). However, this does not remove the need for a full medical review, and appropriate diagnosis of the underlying cause for the crisis. Local pathways need to ensure that diagnostic and investigation facilities are accessible wherever an older person with frailty is managed. For example, timely access to a CT scan after a fall with increasing confusion should not necessitate admission to hospital if not otherwise needed.

However, all crises will be managed much better if the emergency staff, such as ambulance crews and out of hours GPs, are aware in advance that the older person has frailty. Armed with the knowledge of the CSP, they can make decisions that are appropriate for the individual, which is why local protocols must be developed to facilitate the sharing of individuals’ care and support plans.

To sum up: look for frailty, manage the person with frailty as an individual, and make plans with them for all eventualities. Share those plans with the people who are likely to be making the decisions as an emergency, and provide realistic alternatives to admission when this is appropriate. It’s all fairly simple really.

Gillian Turner is a consultant physician in geriatric medicine, Southern Health NHS Foundation Trust. She is also vice president for clinical quality at the British Geriatrics Society, and lead author of “Fit for Frailty.”

Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests, and I have no relevant, further interests to declare.

“Fit for Frailty” can be downloaded here.