Dr Shibley Rahman is currently an academic physician in dementia and frailty. His contribution on the diagnosis of behavioural frontal frontotemporal dementia, published while he was a M.B./Ph.D. student at Cambridge in 1999, is considered widely to be an important contribution to the field, even cited in the Oxford Textbook of Medicine. Here he responds to Steve Parry’s recent BGS blog, The Frailty Industry: Too Much Too Soon? He tweets at @dr_shibley.
In response to Steve Parry’s recent BGS blog, The Frailty Industry: Too Much Too Soon?, I would simply in this article like to set out some of the strengths and weaknesses in the conceptualisation of frailty, with some pointers about “where now?”
There is, actually, no international consensus definition of frailty (although there is one of a related term “cognitive frailty”).
In a world of fierce competition for commissioning, and equally intense political lobbying in health and social care, the danger is that a poorly formulated notion becomes merely a “Trojan Horse” for commissioning.
I must humbly depart from the views of some colleagues – for me, frailty is not just a word. I could likewise point to other single words which cause gross offence, which are unrepeatable in my blogpost here.
All credit here, I feel, must go to Caroline Nicholson, Adam Gordon and Anthea Tinker for their timely article at the end of last year entitled “Changing the way “we” view and talk about frailty…” published in Age & Ageing.
“Older people described frailty as something they could recognise in others but which they would never use to describe themselves.”
Some people have described to me positively “loathing” the term. One researcher advised me on Twitter, “the term compounds the stigma and ageism rife within acute hospitals. Researchers must challenge funding use of ‘frailty’.”
In the classic work by Howard S Becker “Outsiders” (1963), the following is poignantly raised.
“What, then, do people who have been labelled deviant have in common? At the least, they share the label and the experience of being labelled as outsiders.” (p. 9/10).
This labelling concern is important, I feel. You wouldn’t justify service development in an area (e.g. BAME) by calling it something offensive to actual people concerned (e.g. “Black units”).
All of this is of considerable relevance if you are genuinely interested in designing systems with them (“co-design”). We also know from the mental health literature that mental illness labels can be so potent as to put off people seeking health and social care help at all, self management or otherwise.
“Textbook” change management, even as far back as the classic work of Lewin (1947) or Schein (1984), emphasis the critical role of all stakeholders, including people who are frail in this context, in determining the success of “change”. And this must arguably include “quality improvement”, however so defined.
Many corporate models of change now exist. Here’s one, for example, from Strategy&
Even QI professionals surely need to have an accurate working definition of ‘frailty’?
Even if you define “frailty is a greater vulnerability to stressors such as infection or falls where a full recovery is not often possible due to poor adaptive capacity”, what is the medical justification of grouping different conditions such as mild cognitive impairment or sarcopenia?
The following scheme is viewed as a “ideal” framework for intervening in a biomedical model.
Steve Parry refers to the current “weak” evidence of “interventions”, and the precise wording of the way Simon Conroy and Sarah Turpin had phrased it in their 2016 “New Horizons” article in Age & Ageing is as follows (link here):
“A recent report noted: ‘although there is a large body of evidence on relevant [urgent care] interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled’.”
And the evidence for the comprehensive geriatric assessment (CGA) as an intervention in frailty continues to progress.
Please don’t get me wrong – an efficacious intervention for frailty or any of the 100 or so dementias would be wonderful and is possibly achievable (e.g. here).
In summary, the label “frailty”, even if great for putting ‘geriatrics on the map’ of national policy, engenders a sense of otherness. Is the drive for finding the “magic bullet” for frailty, at the expense of putting sufficient resources in enablement or rehabilitation?
Finally, a very big practical problem persists. You can’t half do ‘person-centred’ approaches – i.e. NOT defining people by diseases, “dementia communities” or “frailty collectives”. If the term ‘frailty’ is genuinely being used as a Trojan Horse for commissioning’ for other services (e.g. falls), this should be admitted. If you have one patient with eight different conditions such as frailty or dementia, are they simultaneously going to be pursued down eight different pathways?
A person is more the sum of his or her medical diagnoses.
Surely all this nonsense has now got to stop, please?