Summary
This topic on the recognition and management of frailty in older people is a practical guide aimed at all members of the healthcare team including doctors, pharmacists, advanced nurse practitioners, physician associates, and paramedics.
Frailty is an issue that affects all specialties within medicine and surgery. Health professionals from multiple disciplines need to be involved to ensure it is managed well.[1] By having an awareness and understanding of frailty, healthcare professionals can provide person-centred care to individuals with frailty, and support to their families with the goal to improve outcomes.
What is frailty?
Frailty is a distinctive health state, that is related to the ageing process, in which multiple body systems gradually lose their in-built reserves.[2] It is characterised by a decline in functional state across multiple physiological systems.[3] This decline means more vulnerability to stressor events. Even a 'minor' change such as a new medication, or something more major like an infection or surgery, can result in a disproportionate change in state of health, taking a person from being independent to dependent.[3]
[Figure caption and citation for the preceding image starts]: Vulnerability of frail older people to a sudden change in health status following a minor illness. The green line represents a fit older person who, following a minor stress such as an infection, experiences a relatively small deterioration in function and then returns to homeostasis. The red line represents a frail older person who, following a similar stress, experiences a larger deterioration which may manifest as functional dependency and who does not return to baseline homeostasisClegg A et al. Lancet 2013 Mar 2;381(9868):752-62; used with permission [Citation ends].
Living with frailty increases the risk of multiple adverse outcomes including falls, admission to hospital, and death.[4]
Frailty is not an inevitable consequence of ageing. Many people can reach an advanced age without developing frailty.[3] Terms like multimorbidity, disability and frailty are sometimes used interchangeably but are distinct, albeit related, terms. Data from one large cohort study in community dwelling adults over the age of 65 looked at the overlap between disability, multimorbidity and frailty.[5] It looked at a total of 5317 subjects aged 65-101 who had comorbidity and/or disability and/or frailty. It found that there is overlap, but not concordance, in the co-occurrence of frailty, comorbidity, and disability. The study concluded that comorbidity is an aetiological risk factor for frailty and that disability is an outcome of frailty.[5] This pattern of data has been subsequently echoed in studies across Europe.[6][7] The following image represents the findings of one of these studies in 4414 participants from the population-based Age Gene/Environment Susceptibility Reykjavik study.
[Figure caption and citation for the preceding image starts]: Venn diagram displaying the overlap in prevalence (%) between frailty, multimorbidity and disabilityAdapted from Aarts S et al. J Frailty Aging 2015;4(3):131-8; used with permission [Citation ends].
This supports the hypothesis that frailty may cause disability, independent of clinical diseases. Indeed, frailty can be thought of as a state of pre-disability. This is important as frailty is therefore an independent predictor of adverse outcomes.[5]
Details
- Why do people become frail?
- Why is it important to recognise frailty?
- Impact of living with frailty
- Potential for improving outcomes
- Models of frailty
- Assessment in the emergency department
- Acute hospital setting: deciding on the most appropriate setting for care
- Acute hospital setting: assessment of common frailty syndromes
- Acute hospital setting: falls
- Acute hospital setting: delirium
- Acute hospital setting: ongoing care
- Acute hospital setting: deconditioning
- Acute hospital setting: preventing delirium
- Acute hospital setting: nutrition
- Acute hospital setting: perioperative care
- Acute hospital setting: medication optimisation
- Acute hospital setting: advance care planning and urgent care planning
- Community setting: identifying frailty
- Community setting: living with frailty/ageing well
- Community setting: Comprehensive Geriatric Assessment (CGA)
- Community setting: crisis intervention
- Community setting: assessment of common frailty syndromes
- Community setting: continence issues
- Community setting: falls/syncope
- Community setting: medication optimisation
- Community setting: advance care planning
Contributors
Authors
Dr Polly Brown, BSc MBBS MRCGP
GP, Practice Lead for Frailty
Sussex
UK
Disclosures
PB was the editor of some content in BMJ Best Practice.
Acknowledgements
PB would like to acknowledge Dr David Hunt for his contribution to the scope of this topic.
Peer reviewers
Professor Simon Paul Conroy, MB ChB PhD
Consultant Geriatrician
Central and North West London NHS Foundation Trust
London
UK
Disclosures
SPC is paid as clinical lead for the national frailty improvement collaboratives and in receipt of related research income, mainly from National Institute for Health and Care Research. SPC is the author of one or more references cited in this topic.
Professor Jay Banerjee, MBBS MSc FRCS FRCEM
Consultant in Geriatric Emergency Medicine
University Hospitals of Leicester NHST
Honorary Professor
University of Leicester
Leicester
UK
Disclosures
JB is co-editor of the 'Silver Book II' (British Geriatrics Society, 2021) and co-author 'Silver Book' (British Geriatrics Society, 2012). JB has undertaken research for: the Economic and social research council into frailty in older people from black and minority ethnic communities; Health Service Executive Ireland for research outcomes in older people; and PhD co-supervision on hospital acquired harm in older people. JB has lectured on Geriatric Emergency Medicine in national and international conferences. JB is a director of Jay Banerjee Consultancy Ltd. work includes commissioned delivery of LeicGEM courses in UK/Europe, clinical lead for NHS Elect, and patient safety courses for Loughborough University. JB is the author of one or more references cited in this topic.
Dr James Alexander Adams, BSc MBBS FRCP MSc
Consultant Geriatrician
Chief of Service for Frailty and Community Services
Royal Surrey County Hospital NHS Foundation Trust
Guildford
UK
Disclosures
JAA declares that he has no competing interests.
References
Key articles
Royal College of Physicians. Acute care toolkit 3: acute care for older people living with frailty. Jan 2021 [internet publication].Full text
Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56.Full text Abstract
British Geriatrics Society. Silver book II: quality care for older people with urgent care needs. Feb 2021 [internet publication].Full text
Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007 Jul;62(7):722-7.Full text Abstract
World Health Organization. Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity. Jan 2017 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available here.
Use of this content is subject to our disclaimer