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.
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.