“Frailty is the most problematic expression of population ageing”

Dr Diarmuid O’Shea is a Consultant Geriatrician at St Vincent’s University Hospital in Dublin, Ireland.  The aim of this article is to provide an overview of the clinical syndrome of frailty, how it can be considered and effectively managed as a long-term condition.

One of the greatest challenges posed by an ageing population is the ability of healthcare professionals to understand, recognise and manage vulnerable older adults at increased risk of adverse healthcare outcomes. This frailty syndrome is age associated and is most marked in among those over 75 years of age. The older person showing signs of frailty is at increased risk of long term institutional care, hospitalisation, prolonged length of hospital stay and mortality, and will require specific interventions that span several health and social care services to enable them to live well for their remaining years.

Frailty is a distinctive health state related to the ageing process – in which multiple body systems gradually lose their in-built reserve.

We need to understand it, recognise it, identify it, and be prepared for managing health and social care service delivery around it.  We should make it everybody’s core business in the health and social care sector.

Frail older people are at a higher risk of worsened health care outcomes and death than would be expected from age alone.

If we design and improve the quality and quantity of care available to the frail older person and build a service around that we will also improve the health and social care system for everyone.

We need to break down the silos of care based on single diseases, single organ failure, settings of care or clinical disciplines.

Addressing frailty requires a co-ordinated, multidisciplinary approach.  We need to move away from a person having multiple specialist appointments and replicating tests and assessments across different sites, and in effect have “one stop shops” that actually cater to the needs of the patient – not the providers.  Whether these are appropriately staffed Day Hospitals or Ambulatory Day Care Centres on or off acute hospital sites will in all likelihood be driven by needs in each local area.

It will require increasing understanding and flexibility from many people and the demonstration of real leadership from health care professionals.

As healthcare professionals, we will need to become more flexible in our work practices and better at working across community and hospital based MDT teams.  This will require more integrated understanding and action on the part of all those involved across the continuum of care a person experiences, with true collaboration and collaborative team work between primary and secondary care.

Society, politicians and budget holders will need to support and embrace this change in practice.  We also need a resetting of expectations of what can be supported financially and delivered.  We collectively need to accept that expectations need to be recalibrated.  This should include an understanding that not everyone survives an illness and sometimes people, in spite of everyone’s best efforts, do not have a good outcome and may survive an illness with a disability or die.

Prevalence of frailty rises with age. In Canada approximately 25 % of those over the age of 65 and 50% of those over the age of 85 are medically frail.  In Northern Ireland, 16% of people aged 60-64 are frail and 36% of those aged 80 and over. In the Republic of Ireland, 3% of 60-64 year olds and 15% of those aged 80 and over are frail (Scarlett et al., 2014).

Frailty and education around frailty, across the spectrum of education (from early school years to post graduate training and professional development) may be the key that enables and empowers us all to make this breakthrough.  Over the next series of blogs we will outline the areas we are focusing on to bring about this breakthrough in the context of care for the frail older person in Ireland.

We are, through the leadership and direction given by the clinical Programmes, the Royal College of Physicians of Ireland, and the Health Service Executive in Ireland, developing the road map for our country and it now needs support and implementation.

 References

• HSE. (2012). National Clinical Programme Older People. Specialist Geriatric Services Model of Care Part 1: Acute Service Provision.
• HSE. (2015). National Clinical Programme Older People. (2015) Specialist Geriatric Team Guidance on Comprehensive Geriatric Assessment.                                                    
• NHS. (2014) Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders.
• Scarlett S, King-Kallimanis BL, Young I, Kenny RA, O’Connell MD. 2014. Frailty and Disability. CARDI Research Brief.