The F word

Dr Gill Turner is Vice President – Clinical Quality for the BGS and project lead for Fit for Frailty –  guidance published today on the recognition and management of older patients with frailty in community and outpatient settings. 

Frailty, or the ‘F’ word, must score as the most talked about condition over this last year. It is hard to go to any scientific meeting, participate in any discussion about health service development or even read a newspaper without encountering the  ‘ F ‘ word.

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But what does it mean?  It is likely that frailty means different things to each audience ranging from a scientific phenotype with specific outcomes in the Framingham heart study to a social description of someone in the last months of their life.

However, the real meaning of frailty for the NHS and social care is the possibility of identifying a group of older people, for whom services need to be specifically focused to improve quality and safety. The expectation is that through increasing effectiveness in proactive care, increasing efficiency and value for money will follow.

The British Geriatrics Society which represents more than 2700 UK specialists in health care for older people (doctors, nurses and allied health professionals) has produced  Best Practice Guidance for Frailty in community and outpatient settings. Under the title ‘Fit for Frailty’, it is published in 2 parts. Part 1, launched today describes the recognition and management of individuals with frailty in community and outpatient settings. Part 2 to be launched later in the summer, will describe the development, management and commissioning of services for people with frailty.

Other sources have described the need to move the current health service away from hospitals which tend to address single diseases and illnesses towards a more community based, personalised and holistically orientated service which focuses on individuals with long term conditions in order to reduce the need for hospital care. Frailty is the most frequently encountered long term condition in community health and social care settings and occurs in as many as a half of all adults over the age of 85.

Whenever frailty is mentioned – several questions immediately spring to mind;

What is frailty? Is it entirely related to age? What does it imply? Why does it matter if we know if someone has frailty? Is frailty reversible?

The BGS best practice guidance has answers to all these questions.

There are several key messages:

  •  Frailty describes a condition where the body’s reserve capacity is limited, meaning that severe deterioration can occur with only minor illness or change to the status quo. In other words, older people with frailty are at significant risk of adverse outcomes after only small changes in their health and well- being (such as a minor infection or change in medication).
  • Frailty might not be apparent unless actively sought. Many people with multiple long term conditions will also have frailty which may be overlooked if the focus is on disease-based long term conditions such as diabetes or heart failure.
  • Frailty can be recognised in individuals in various ways.
    • Some older people may present with a crisis which fits one of the so called ‘Frailty Syndromes’. These are conditions which commonly occur in frailty (such as a fall, sudden loss of mobility, rapid deterioration of memory in a patient with pre-existing dementia) and can often mislead carers and emergency personnel because an apparently straightforward symptom could mask a serious underlying illness. Understanding that the patient has frailty can allow a more appropriate decision about diagnosis and may prevent an unnecessary visit to the emergency department.
    • In a more routine encounter, where there is no crisis, there are several methods for recognising frailty; the BGS recommends that walking speed is probably the most accurate: taking more than 5 seconds to walk 4 metres (with a walking aid if used) suggests that the individual has frailty.
  • The BGS recommends that all encounters between health and social care staff and older people should include a look for frailty as this will affect the way health care is managed for that person. However there is currently little evidence to support population screening for frailty.
  • The gold standard for the management of people with frailty is Comprehensive Geriatric Assessment (CGA) ; CGA implies a multidimensional assessment and treatment plan often delivered by input from many professions and specialists in older people. Importantly however it must involve an holistic medical review which will:
    • Diagnose medical illnesses which need to be treated and those which need to be optimised and organises a plan to do both
    • Rationalise medications so that the older person takes what they individually need taking account of the priorities for treatment.
    • Define the impact of illness and symptoms on the individual’s life through discussion.
    • Work with the older person to create an individualised comprehensive care and support plan to manage all of the above – which will summarise who is responsible for doing what. It will also ensure that the individual with frailty has the opportunity to say what is important to them and their family in terms of their future care.

The medical review does not need to be done by a geriatrician but by an individual with appropriate knowledge and time set aside (possibly the patient’s GP or a specialist nurse) who can then refer to a geriatrician(or other community based specialists such as old age psychiatrists, therapists and community nurses) for help if there is uncertainty over diagnoses or particular complexity.

  • Besides the comprehensive care planning outlined above, there is emerging evidence that appropriate exercise and nutrition can improve frailty and thus reduce the vulnerability which results.

It is to be hoped that the directly enhanced service which forms part of the new GP contracting arrangements this year, will facilitate the delivery of holistic medical assessment and comprehensive care planning which forms the ideal way of supporting older people with frailty.   In short, actively seeking and addressing frailty in individuals in community and outpatient settings could offer a simple focus for the NHS as it seeks to address its current priorities.

You can read more about Fit for Frailty and download the guidelines here.

2 thoughts on “The F word

  1. This is very welcome but having spent a great deal of time trying to get decent medical care (incl CGA) for care home residents what becomes clear is that there is a sense of futility in the minds of many (including some doctors) when confronted by frailty. This is paradoxical when one considers the welcome focus and energy brought to end of life care which clearly has a very limited prognosis. In a recent paper (JRSM 2014 Vol 107 No 3 March Formative Care; defining the purpose and clinical practice of care for the frail) I developed a definition for care of people who are not dying but who are frail/poorly responsive to various medical approaches etc etc.
    What is missing in Fit for Frailty is a concise definition of purpose of medical care. For as long as I have been engaged in the care of the frail elder it has always puzzled me why such a positive “craft/specialty” lacked value for example in commissioning. Poorly communicated purpose and inadequate branding of the offer and its capability are the nub of the problem………..

  2. Clive, i believe it isnt too late for you to run for BGS president elect and correct our apparent poor communication of our mission to the rest of the clinical community. Perhaps not even too late for a return to the public sector – there is always a shortage of NHS geriatricians

    David

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