If frailty is viewed by some as a “commissioning Trojan Horse” this should be admitted

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?

2 thoughts on “If frailty is viewed by some as a “commissioning Trojan Horse” this should be admitted

  1. The justification for including diverse conditions under the umbrella “frailty” is the definition: multiply determined increased risk. When a person has one illness, the metaphor of that illness likely works well enough to inform care. It works much less well when it’s the eighth illness in.
    Far from obliging the person with eight illnesses to go down eight pathways, what is motivating frailty research is to see what frail patients have in common, regardless of their specific diagnoses and to start with that. Each diagnosis must be considered but they will not each be trumping, as they are in the hands (one pair at a time) of the disease “ologists”. I get ologist outrage. Many lack not just the ctraining but the requisite attitude to look after people with multiple, interacting medical and social problems. Not for them the joy of geriatrics. Fair enough. But I am baffled when geriatricians become upset by techniques that allow us to embrace the complex needs of our patients.
    I am (mercifully is my guess) insufficiently aware of the nuances of commissioning to understand what is the threat in commissioning for frailty. I suspect that the concern is inferior care and if so, I share it. We must build the evidence base to make care better. Even so, we are not starting from scratch: an original motivation back in the late 1980s to understand the heterogeneity of older adults was to see who most benefited from care by geriatricians. That case now seems obvious: those most at risk do, which is why I argue for frailty as our mandate, and the complexity of frailty as motivating and animating our approach to care. The considerable nuances of how this all works need to be better understood. How is that concerning? What’s the case against sorting out how best to meet the complex needs of frail older adults?

  2. Prof Ken Rockwood’s comment helped me a lot. Thank you very much.

    1. “The justification for including diverse conditions under the umbrella “frailty” is the definition: multiply determined increased risk.”

    For me, an increased risk certainly comes from the accumulation of deficits. How these arise over time, and whether the number of these deficits can go down again under the right circumstances, is hugely of interest. It’s possible that not all deficits are equal, so it might be that one deficit within the domain of movement may have a quantitatively different effect from a deficit in cognition. Working out how these numerous conditions build up a picture of a person who is vulnerable and less resilient in frailty will be a huge and worthwhile challenge, I think. And this is relevant to the risk stratification within the heterogeneity of frailty.

    2. “Far from obliging the person with eight illnesses to go down eight pathways, what is motivating frailty research is to see what frail patients have in common, regardless of their specific diagnoses and to start with that. Each diagnosis must be considered but they will not each be trumping, as they are in the hands (one pair at a time) of the disease “ologists”. I get ologist outrage.”

    I think the badging of frailty as “frailty hubs” or “frailty units” in terms of ethos is very different to viewing the person not the disease, the essence of personhood and person-centred care. Some people might want to view themselves as “frailogists”. But I understood geriatricians to be especially proud (in a good way) of their credentials of thinking holistically about the person. This is why I think geriatricians are wonderful.

    Ken’s comment here, for me, ties in with a previous comment made in the comments thread of Steve Parry’s blogpost. A potential danger with rebadging a geriatrician as a ‘frailogist’ might be wanting to be seen to have a powerful intervention. The Lancet neurology editorial on the FINGER initative in prevention of dementia, rightly in my view, gave credit to the impetus behind future development of multi-modal interventions. Here, I would hope that a drive to research interventions in frailty would be worthwhile (and I agree that we should value all information about frailty, not just EBM.)

    Finally, I have been asked why I found the term ‘frailty unit’ more objectionable than ‘coronary care unit’. I suppose the answer for me has been the stigmatising effect of the term ‘frail elders’ and the robustness of the interventions (compare stenting in angioplasty by an interventional cardiologist to an exercise intervention from a frailologist.) The stigma point was originally raised by people who are frail themselves; it has not been synthetically applied by me to start an argument.

    3. “Many lack not just the training but the requisite attitude to look after people with multiple, interacting medical and social problems. Not for them the joy of geriatrics. Fair enough. But I am baffled when geriatricians become upset by techniques that allow us to embrace the complex needs of our patients.”

    I think this comment is spot on.

    I have a huge regard for geriatricians. But it is clear to me that part of the complexity surrounding frailty is not just within a person from the medical point of view (for example how and why various comorbidities might interact physiologically), but how various assets in the community (e.g. social connectedness, sense of community cohesion) have a clear modulating – or stronger – effect.

    4. “I am (mercifully is my guess) insufficiently aware of the nuances of commissioning to understand what is the threat in commissioning for frailty. I suspect that the concern is inferior care and if so, I share it. We must build the evidence base to make care better. Even so, we are not starting from scratch: an original motivation back in the late 1980s to understand the heterogeneity of older adults was to see who most benefited from care by geriatricians. That case now seems obvious: those most at risk do, which is why I argue for frailty as our mandate, and the complexity of frailty as motivating and animating our approach to care. The considerable nuances of how this all works need to be better understood. How is that concerning? What’s the case against sorting out how best to meet the complex needs of frail older adults?”

    Arguably, there has never been a better time if one is interested in the frailty syndromes. The growth of this field has the potential to become a ‘race to the top’. Working out those people who are the most vulnerable and least resilient is clearly important, but I should argue that an approach which better embraces health assets (as well as functional deficits) would also mitigate against the risk of people, described as frail, from getting worse. This is related to prevention (e.g. Ottowa Charter), but has different nuances of a salutogenic variety?

    I don’t want to get into an argument about health policy, training or resources about who would be interested in doing this. This might go to the heart of whether geriatricians only consider themselves as ‘fixing illness’, in which case deficits might matter more than assets. But one could likewise argue that it is the balance in assets v deficits which really matters, and that could be the jurisdiction of a holistic geriatrician. By better fleshing out the details of frailty, this level of detail might avoid an unintended ‘race to the bottom’.

    Thank you, once again, for very thought-provoking and important points.

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