Introduction to Frailty | British Geriatrics Society

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. HomeResourcesResources(menupositionrule) Share ShareonFacebook Tweet ShareonLinkedIn SharebyEmail IntroductiontoFrailty,FitforFrailtyPart1 Goodpracticeguide i Goodpracticesguidesfocusonprovidinginformationonaclinicaltopic. Authors:GillTurner Topics:CGAincommunitysettings,Frailty DatePublished: 11June2014 Lastupdated:  11June2014 Olderpeoplelivingwithfrailtyareatriskofadverseoutcomessuchasdramaticchangesintheirphysicalandmentalwellbeingafteranapparentlyminoreventwhichchallengestheirhealth,suchasaninfectionornewmedication. FitforFrailty ConsensusBestPracticeGuidanceforthecareofolderpeoplelivingwithfrailtyincommunityandoutpatientsettings-publishedbytheBritishGeriatricsSocietyandtheRoyalCollegeofNursinginassociationwiththeRoyalCollegeofGeneralPractitionersandAgeUK Part1:Recognitionandmanagementoffrailtyinindividualsincommunityandoutpatientsettings Whatisfrailty? Frailtyisadistinctivehealthstaterelatedtotheageingprocessinwhichmultiplebodysystemsgraduallylosetheirin-builtreserves.Around10percentofpeopleagedover65yearshavefrailty,risingtobetweenaquarterandahalfofthoseagedover85. Distinguishingbetweenfrailtyanddisability Itisimportanttounderstandthedifferencebetweenfrailty,longtermconditionsanddisability.Manypeoplewithmultiplelongtermconditions(socalledmulti-morbidity)willalsohavefrailtywhichmaybemaskedwhenthefocusisonotherdiseasebasedlongtermconditions.Likewise,somepeoplewhoseonlylongtermconditionisfrailtymaybelowconsumersofhealthcareresourcesandnotregularlyknowntotheirGP(untiltheybecomebedbound,immobileordeliriousasaresultofanapparentlyminorillness).Theremaybeoverlapbetweenthemanagementapproachesforpeoplewithmulti-morbidityandthosewithfrailtybuttheseconditionsarenotidenticalandthisguidancelooksprimarilyatfrailty.Similarly,thereisoverlapbetweenfrailtyandphysicaldisability–manypeoplewithfrailtyalsohavedisability,butlotsofpeoplewithalongtermdisabilitydonothavefrailty.Frailtymaybethecauseofdisabilityinsomepatientsandtheconsequenceinothers. Languagebarriers Thelanguageandmanagementoffrailtycanactasbarrierstoengagingwitholderpeoplewhomaynotperceivethemselves,orwishtobedefined,byatermthatisoftenassociatedwithincreasedvulnerabilityanddependency.Olderpeoplemaynotrecognisethemselvesaslivingwithfrailtyandthereisevidencethatolderpeopledonotwanttobeconsideredas‘frail,’althoughhappytoacceptthattheyareanolderperson.Foranolderperson,livingwithfrailtycanmeanlivingwithvarious‘losses’anditiseasy,asaprofessional,inadvertentlytocolludewiththelossofcontrolovereverydaylifethatresultsfromanextensivecarepackage,socialisolationortherapidfluctuationinmentalstatethatsometimesaccompanyfrailty.Researchhasdemonstratedthatmanyolderpeoplelivingwithfrailtydevelopwaysofcopingandmakeothercompensatorychoices.Asagroup‘frailolderpeople’encompassesadiversityofindividualpeopleeachwithdifferentexpectations,hopes,fears,strengthsandabilities,aswellasdifferenttypesandlevelsofneedandsupport.Itisourjobtoensurethattheseare,asfarasispossible,accommodated,thusrestoringcontrol,preservingdignityandfacilitatingperson-centredcaretotheolderpersonlivingwithfrailtyandthoseclosetothem.  Whylookforfrailty? Frailtyshouldbeidentifiedwithaviewtoimprovingoutcomesandavoidingunnecessaryharm.  Thecentralproblemwithfrailtyisthepotentialforseriousadverseoutcomesafteraseeminglyminorstressoreventorchange.Thiscouldmeananythingfromasimpleepisodeof‘flutoamajorinterventionlikeajointreplacement.Evenapparentlysimpleinterventionslikeamovetoashorttermresidentialplacementforrespite,atriptothelocalemergencydepartmentafterafallorthetrialofanewanalgesiccanhaveunforeseenandadverseoutcomes.Thusforanindividual,theknowledgethattheyhavefrailtycanhelphealthandsocialcareprofessionalstotakeactiontopreventthepooroutcomeforaparticularintervention(oreventoavoidtheintervention)andtostartapathwayofcaretoaddresstheissuescontributingtofrailty. Itisimportanttorememberhowever,that: Frailtyvariesinseverity(individualsshouldnotbelabelledasbeingfrailornotfrailbutsimplythattheyhavefrailty). Thefrailtystateforanindividualisnotstatic;itcanbemadebetterandworse. Frailtyisnotaninevitablepartofageing;itisalongtermconditioninthesamesensethatdiabetesorAlzheimer’sdiseaseis. Whenshouldyoulookforfrailty? Anyinteractionbetweenanolderpersonandahealthorsocialcareprofessionalshouldincludeanassessmentwhichhelpstoidentifyiftheindividualhasfrailty.Thisincludes(butisnotlimitedto)thefollowing: Routineoutpatientappointmentsinalldepartments,includingsurgical(orthopaedic,GI,vascularandophthalmicdepartments),medicalandmentalhealth(memoryclinics). Socialservicesassessmentforcareandsupport. Reviewbythecommunitycareteamsafterreferralforcommunityintervention. Primarycarereviewofolderpeople(eithermedicalinterventionormedicinesrevieworanyotherinteractionsuchasoneofthelongtermconditionsclinics). Homecarersinthecommunity. Ambulancecrewswhencalledoutafterafallorotherurgentmatter. Itisself-evidentthatthetypeofassessmentwilldifferwhendealingwithanindividualwhoiscurrentlyunwell(andthereforeashortscreeningassessmentmaybeoflimitedbenefit)insteadofbeinginastablesituation.Professionaldiscretionwillneedtodrivethenatureoftheassessment.Howeverplanninganyintervention(e.g.startinganewdrug,conveyingtotheemergencydepartmentoranelectivejointreplacement)inanindividualwhohasfrailty,withoutrecognisingthepresenceoftheconditionandbalancingtherisksandbenefits,mayresultinsignificantharmtothepatient. Causesoffrailty Therearetwobroadmodelsoffrailty.Thefirst,knownasthePhenotypemodel,describesagroupofpatientcharacteristics(unintentionalweightloss,reducedmusclestrength,reducedgaitspeed,self-reportedexhaustionandlowenergyexpenditure)which,ifpresent,canpredictpooreroutcomes.Generallyindividualswiththreeormoreofthecharacteristicsaresaidtohavefrailty(althoughthismodelalsoallowsforthepossibilityoffewercharacteristicsbeingpresentandthuspre-frailtyispossible).ThesecondmodeloffrailtyisknownastheCumulativeDeficitmodel.DescribedbyRockwoodinCanada,itassumesanaccumulationofdeficits(rangingfromsymptomse.g.lossofhearingorlowmood,throughsignssuchastremor,throughtovariousdiseasessuchasdementia)whichcanoccurwithageingandwhichcombinetoincreasethe‘frailtyindex’whichinturnwillincreasetheriskofanadverseoutcome.Rockwoodalsoproposedaclinicalfrailtyscaleforuseafteracomprehensiveassessmentofanolderperson;thisimpliesanincreasingleveloffrailtywhichismoreinkeepingwithexperienceofclinicalpractice.  Acentralfeatureofphysicalfrailty,asdefinedbythephenotypemodelislossofskeletalmusclefunction(sarcopenia)andthereisagrowingbodyofevidencedocumentingthemajorcausesofthisprocess.Thestrongestriskfactorisageandprevalenceclearlyriseswithage.Thereisalsoaneffectofgenderwheretheprevalenceincommunitydwellingolderpeopleisusuallyhigherinwomen.ForexampleaUKstudyfrom2010usingthephenotypeapproachtodefiningfrailtyfoundaprevalenceof8.5percentinwomenand4.1percentinmenaged65–74. Prevention Intermsofmodifiableinfluences,themoststudiedisphysicalactivity,particularlyresistanceexercise,whichisbeneficialbothintermsofpreventingandtreatingthephysicalperformancecomponentoffrailty.Theevidencefordietislessextensivebutasuboptimalprotein/totalcalorieintakeandvitaminDinsufficiencyhavebothbeenimplicated.Thereisemergingevidencethatfrailtyincreasesinthepresenceofobesityparticularlyinthecontextofotherunhealthybehaviourssuchasinactivity,apoordietandsmoking. Otherareasofinterestincludetheroleoftheimmune-endocrineaxisinfrailty.Forexampleahigherwhitecellcountandanincreasedcortisol:androgenratiopredicted10yearfrailtyandmortalityinonerecentstudy. Howevertheinter-relationshipbetweenprescribedmedicationandfrailtyindependentofco-morbidityisarelativelyunder-exploitedarea.Thereissomeevidencethatasidefrommyopathy,somedrugsmayhavemoresubtleadverseeffectsonmusclefunction. Thecumulativedeficitapproachtodefiningfrailtyisbroaderthanthephenotypeapproach,encompassingco-morbidityanddisabilityaswellascognitive,psychologicalandsocialfactors.Thepotentialcausesarethereforewiderandincludethemultipleriskfactorswhichareimplicatedinthevariousdiseasesandconditions. Populationscreeningforfrailty Systematicscreeningforfrailtywouldbeanexpensiveventureandthereiscurrentlynoevidenceforimprovedoutcomesdespiteitbeingarecommendationinearlierinternationalguidance.Likesystematicscreeningfordementia,therewouldbeadegreeof“publicunacceptability”(forexample;peoplemaybefearfulofbeingdiagnosedwithdementiaandthereforebereluctanttosubmittoatestfordementiaunlessitwasspecificallyindicatedbytheirlifecircumstances).AgeUKresearchhasshownthatinaseriesoffilmedcasestudiesof‘frailty’noneoftheparticipantsclassifiedthemselvesas“frail”.Someofthemmentionedfiniteperiodswherethey“hadbeenfrail”buttheydidnotseeitasalifetimeconditionorasdefiningthem.  Acurrentapproachseekstobreakdownapracticepopulationaccordingtoriskofusingfuturehealthcareresourcesincludinghospitaladmission.Itusescomputerbasedtools,forexampleAdvancedClinicalGroupings(ACG),PredictionofindividualsAtRiskofReadmission(PARR)orScottishPreventionofAdmissionandReadmission(SPARRA).Thesetoolsinterrogateaprimarycare practicecomputertoidentifyhighriskindividualsbasedonpastuseofresources,drugprescriptionsorparticulardiagnoses.Unfortunatelythereisnoevidencethatfocussingresourcesontheseindividualsimprovesoutcomes.Additionally,thesetools,whichwerenotdesignedtolookforfrailty,oftenhighlightindividualswhohavehighcostconditionsnotamenabletomodification(suchasimmunosuppressionafterorgantransplant). Someareasandpracticeshaveadoptedalocalisedapproachtoidentifyfrailty,e.g.inWarwickshire,AgeUKhastrainedvolunteerstoadministertheEasycaretoolwhichstartstheprocessofidentifyingneedsanddevelopinganindividualisedcareplan.ThisissimilartoanapproachinGnosall,Staffordshire(winnerofanNHSinnovationaward)whereeveryonereceivesaquestionnaireontheir75thbirthday,seekingtoidentifythosewhomighthave,orbedeveloping,frailty.Theyhaveachievedaresponserateofover85percentandthosewhorespondarethenvisitedathomebyaneldercarefacilitatorbeforeundergoingacomprehensivegeriatricassessmentatthesurgerybyaGP. Conclusion TheBGSdoesnotcurrentlysupportroutinepopulationscreeningforfrailtybecauseofthelikelyconsiderablecostofcompletingassessmentsandthelowspecificityofavailabletools.Asuitablyvalidatedelectronicfrailtyindexconstructedusingexistingprimarycarehealthrecorddatamayenablefutureroutineidentificationandseveritygradingoffrailty,butrequiresadditionalresearch. Feedbackonthisresource? Email Ifyou’dlikeustocontactyou,pleaseleaveyouremail Yourfeedback* CAPTCHAThisquestionisfortestingwhetherornotyouareahumanvisitorandtopreventautomatedspamsubmissions. Download FitforFrailty(Summary)Part1pdf81.48KB Downloaddocumentsfromthecompleteseries FitForFrailtyPart1-FullGuidepdf278.58KB Otherresourcesinthisseries Recognisingfrailty 11Jun2014 Frailtymeanspatientswithwhatappeartobestraightforwardsymptomsmaybemaskingamoreseriousunderlyingproblem.Howtorecognisefrailtyinaroutinesituation,emergencysituation,orinanoutpatientsurgicalsetting,includingarangeofestablishedtestsyoucanuse.  Inaseries Goodpracticeguide Managingfrailty 11Jun2014 Onceyou'veidentifiedthatanolderpersonhasfrailty,whatstepsyoucantaketoundertakeaholisticreview,orComprehensiveGeriatricAssessment,inordertomanagefrailty.Andcanfrailtybereversed? Inaseries Goodpracticeguide Commissioningservicesforfrailty 18Dec2014 Focusingcommunityservicesonthosewithfrailtycanimprovequalityofcareandreducehospitalbedusage.Thisguide providesadviceonthecommissioningandmanagementofservicesforpeoplelivingwithfrailtyandincludesthedownloadablereportFitforFrailtyPart2. Inaseries Goodpracticeguide Seeallresourcesinthisseries Youmayalsobeinterestedin Thefrailtysyndromeinthe“frail”healthcaresystems 25Nov2013 Frailsafe:Anewchecklistfortheacutecareoffrailolderpeople. 18Nov2013 Identifyingfrailtyanditsoutcomes 20Jan2014 TheRelationshipBetweenWealthandFrailty 18Mar2013