Chris Beech is a Nurse Consultant at NHS Forth Valley, Falkirk. She is member of the BGS Specialist Nurse and Allied Health Professionals Special Interest Group.
Frailty is all around us, especially when you take a quick peek at the recent literature on working with older people. It is important that nurses working with older people in all care settings are aware of what frailty is, what the implications are if someone is identified as living with frailty and what, if anything, can be done about it.
We all have a picture in our head of a frail person, the problem is that there is a big chance that this picture is a different image to the one the person sitting next to you is thinking of. It is important therefore to have the ability to put an objective view point into play.
So, what is frailty? Well, it basically means that the person is less able to cope with illness and may lose their functional ability quite quickly. They will have a reduced capacity within their physical and psychological reserves. This may well mean that something small such as a UTI may tip the balance and that the person with frailty can have a dramatic change in their health status and circumstances. Older people with frailty who need to undergo surgery can have less successful outcomes if the frailty has not been identified prior to the operation because of this lack of physical and cognitive reserve.
Frailty can be seen as a long term condition just like heart disease or asthma but because the symptoms are much more hidden it is often not picked up especially by a health service that tends to focus on diseases. So, is there anything that you can do about it?
Naturally the answer to this is a resonating yes and to help you in this the British Geriatrics Society (BGS) can have just published a consensus best practice guidance for the recognition and management of older people living with frailty. Does this apply to me I hear you asking, well yes of course, the guideline is intended to be used by anyone who may be providing support for older people in the community or out-patient setting. One of the advantages of this guideline is that it was produced by a multidisciplinary team and therefore takes into account the different disciplines.
The guideline is available in 2 versions. There is a long version which is very medically focused and the short version which is accessible to all professions including social care and is written in plain English. The guideline goes through the process of how to recognise people with frailty. It talks about the syndromes that might cause you to think about frailty such as falls, immobility, delirium/acute confusion, incontinence and susceptibility to medication side effects (these used to be known as the Geriatric Giants). There are a couple of screening tools that might be useful in identifying those people with frailty and these are recommended in the guideline. They are gait speed and the timed up and go. It is recognised that conducting these tests in the confined space of a person’s own home may cause difficulties and so PRISMA 7 has been recommended as an alternative. The BGS guidelines do not recommend whole sale population screening rather they focus on opportunistic screening. So when you come into contact with an older person, as part of your holistic assessment, start to put frailty in as an aspect to consider.
If you identify someone as potentially frail, then what should you do? The guidelines will point you in the direction of a Comprehensive Geriatric Assessment (CGA), this is an evidence based approach that has been proven to benefit older people. The guideline does acknowledge that this can be time consuming and therefore recommends that at the very minimum a holistic assessment is undertaken of the person’s needs with referral for CGA if it is identified that this is needed. A comprehensive care plan should then be devised in conjunction with the patient and/or carer, ensuring that as professionals we are very sure about what the person’s goals are.
I would recommend reading the BGS guidelines, they are easy to read and focus on an integrated approach as they are aimed at ambulance, social care, third sector and health professionals.