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class="card-full-title"> Frailty: what鈥檚 it all about? </div> </h1> <span property="dc:title" content="Frailty: what鈥檚 it all about?" class="rdf-meta element-hidden"></span><span property="sioc:num_replies" content="0" datatype="xsd:integer" class="rdf-meta element-hidden"></span> <div class="resource-header-details"> <div class="card-resource-type-i"> <div class="card-resource-type"> Good practice guide </div> <div class="resource-type-i-icon">i</div> <div class="resource-type-info-arrow"></div> </div> <div class="resource-type-info"><div class="resource-type-info-text">Good practices guides focus on providing information on a clinical topic.</div></div> </div> <div class="node-header-details"> <div class="card-authors-wrapper"><div class="label">Authors:</div><div class="author-details">British Geriatrics Society</div></div> <div class="card-topics-wrapper"><div class="label">Topics:</div><a href="/taxonomy/term/2632">Comprehensive Geriatric Assessment (CGA) in acute settings</a>, <a href="/taxonomy/term/2935">Comprehensive Geriatric Assessment (CGA) in community settings</a>, <a href="/taxonomy/term/856">Frailty indexes</a>, <a href="/taxonomy/term/2955">Frailty</a></div> <div class="node-header-dates"> <div class="card-date-wrapper"><div class="label">Date Published:</div><div class="card-date"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2018-05-23T00:00:00+01:00">23 May 2018</span> </div> </div> <div class="card-date-updated"> <div class="label">Last updated: </div> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2018-05-23T11:33:00+01:00">23 May 2018</span> </div> </div> </div> </div> <div class="view view-sections view-id-sections view-display-id-main view-dom-id-941f73d657d20fa0b71aeff6881c3d41"> <div class="view-content view-content-main"> <div class="views-row views-row-1 views-row-odd views-row-first section-row palette-default "> <div class="section-inner"> <div class="card-body"> <h2>What is frailty?</h2> <ol> <li>An inevitable consequence of ageing</li> <li>A state due to multiple long term conditions</li> <li>A condition in which the person becomes fragile</li> <li>A state associated with low energy, slow walking speed, poor strength</li> <li>A condition for which nothing can be done</li> </ol> <p>Answer: 4 - low energy, slow walking speed, reduced strength</p> <p>So the other are untrue-</p> <ul> <li>not inevitable,</li> <li>associated with multiple LTC, but can occur in the absence of these</li> <li>amenable to treatment</li> <li>unlike “fragility” frailty is a specific syndrome with characteristic features, and a rapidly expanding research base</li> </ul> <h2 class="sidebar-nav">Frailty: why is it important</h2> <p>Definition: a state of increased vulnerability to poor resolution of homoeostasis after a stressor event</p> <p>Condition associated with increased risk of deterioration:</p> <ul> <li>“acute frailty syndromes” – falls, delirium (or acute confusion), “off</li> <li>legs” may result from a relatively minor insult</li> <li>Higher risk of acute hospital admission</li> <li>Care home admission</li> <li>Death</li> </ul> <p> </p> </div> <div class="card-view-4"> <div class="view view-attachment view-id-attachment view-display-id-main view-dom-id-78127d03b3fe5819a8bb8e272802265a"> </div> </div> </div> </div> <div class="views-row views-row-2 views-row-even section-row palette-default img-centre "> <div class="section-inner"> <div class="card-original"> <picture title="Response to an adverse event in a non- frail vs frail older person (Clegg et al, Lancet 2013)">  <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-wide/public/content/paragraphs/text/images/2018-05-23/Picture1.png?itok=JknTOpJ3&timestamp=1527076941 1x" media="(min-width: 75em)" /> <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-normal/public/content/paragraphs/text/images/2018-05-23/Picture1.png?itok=rgYlNXfx&timestamp=1527076941 1x" media="(min-width: 60em)" /> <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-narrow/public/content/paragraphs/text/images/2018-05-23/Picture1.png?itok=vRkDDKCV&timestamp=1527076941 1x" media="(min-width: 45em)" /> <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-mobile/public/content/paragraphs/text/images/2018-05-23/Picture1.png?itok=KzqB7M9n&timestamp=1527076941 1x" media="(min-width: 0em)" />  <img src="https://www.bgs.org.uk/sites/default/files/styles/nugget-mobile/public/content/paragraphs/text/images/2018-05-23/Picture1.png?itok=KzqB7M9n&timestamp=1527076941" alt="Response to an adverse event in a non- frail vs frail older person" title="Response to an adverse event in a non- frail vs frail older person (Clegg et al, Lancet 2013)" /> </picture> </div> <div class="card-body"> <h2 class="sidebar-nav">How is frailty diagnosed?</h2> <p>Phenotype model:</p> <ul> <li>Walking speed reduced, grip strength low, immune deficits, reduced</li> <li>ability of withstand an “insult”</li> <li>Useful in clinical trials, difficult to implement on large scale,</li> <li>Walking speed</li> <li>timed up and go test (TUGT) used</li> </ul> <h2 class="sidebar-nav">Frailty assessment tools</h2> <table> <tbody> <tr> <td>Primary care/community care/outpatients</td> <td>Acute care</td> </tr> <tr> <td>Gait speed <0.8m/s</td> <td>Clinical frailty scale</td> </tr> <tr> <td>Timed-up-and-go test <12s</td> <td>Reported Edmonton frail scale</td> </tr> <tr> <td>Grip strength</td> <td>ISAR tool</td> </tr> <tr> <td>PRISMA 7 questionnaire</td> <td>(Gait speed)</td> </tr> <tr> <td>Clinical frailty scale</td> <td> </td> </tr> <tr> <td>Edmonton frail scale</td> <td> </td> </tr> </tbody> </table> <h2 class="sidebar-nav">Cumulative deficits model</h2> <p>Proven to correlate with comprehensive geriatric assessment</p> <p>Theoretical background to the development of the electronic frailty index (eFI); searches in the primary care record for 36 variables (diagnoses, symptoms, sensory impairments, disabilities)</p> <p>Proven to identify risk of hospital admission, care home admission, death</p> <h2 class="sidebar-nav">Using the eFI</h2> <p>Proven statistically to identify a cohort of people who are highly likely to be frail</p> <p>Like any other statistical tool will identify false positives, hence clinical correlation is essential</p> <p>Clinical knowledge of patient, TUGT or other frailty assessment</p> <h2 class="sidebar-nav">Is frailty amenable to prevention and treatment?</h2> <p>Yes</p> <p>“healthy ageing” reduces the risk of developing frailty:</p> <p>Good nutrition</p> <p>Not too much alcohol</p> <p>Staying physically active</p> <p>Remaining engaged in local community/ avoiding loneliness</p> <p>Patients can be signposted to the NHS England and Age UK publications</p> <h2 class="sidebar-nav">What about established frailty?</h2> <p>Adverse effects of frailty can be mitigated- for example:</p> <p>Falls risk can be reduced</p> <p>Timely medication review can reduce risk of ADR, drug interaction, non-compliance</p> <p>...hence BGS delighted to see the new GP contract</p> <h2 class="sidebar-nav">Frailty prevalence at various ages</h2> </div> <div class="card-view-4"> <div class="view view-attachment view-id-attachment view-display-id-main view-dom-id-18c0c0af430e9b33ef4a4cb45df060e0"> </div> </div> </div> </div> <div class="views-row views-row-3 views-row-odd section-row palette-default img-centre "> <div class="section-inner"> <div class="card-original"> <a href="https://www.bgs.org.uk/sites/default/files/styles/gallery-ps/public/content/paragraphs/text/images/2018-05-23/Picture2.png?itok=bZtt44kx" class="photoswipe" data-size="974x620" data-overlay-title="Frailty prevalence at various ages"><img typeof="foaf:Image" src="https://www.bgs.org.uk/sites/default/files/styles/nugget-wide/public/content/paragraphs/text/images/2018-05-23/Picture2.png?itok=Q22mqki2&c=26e4cd9454bae4060110669b9a4a7729" alt="Frailty prevalence at various ages" title="Frailty prevalence at various ages" /></a> </div> <div class="card-view-4"> <div class="view view-attachment view-id-attachment view-display-id-main view-dom-id-0347f536115ad57eacfcbc4718d9f8dd"> </div> </div> </div> </div> <div class="views-row views-row-4 views-row-even views-row-last section-row palette-default img-centre "> <div class="section-inner"> <div class="card-original"> <picture title="Telegram overload - centenarieans will continue to be the fasted growing age group">  <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-wide/public/content/paragraphs/text/images/2018-05-23/Picture3.png?itok=DyWYdffM&timestamp=1527076941 1x" media="(min-width: 75em)" /> <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-normal/public/content/paragraphs/text/images/2018-05-23/Picture3.png?itok=dcP2gJPR&timestamp=1527076941 1x" media="(min-width: 60em)" /> <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-narrow/public/content/paragraphs/text/images/2018-05-23/Picture3.png?itok=AKYe-UWl&timestamp=1527076941 1x" media="(min-width: 45em)" /> <source srcset="https://www.bgs.org.uk/sites/default/files/styles/nugget-mobile/public/content/paragraphs/text/images/2018-05-23/Picture3.png?itok=q4STd01q&timestamp=1527076941 1x" media="(min-width: 0em)" />  <img src="https://www.bgs.org.uk/sites/default/files/styles/nugget-mobile/public/content/paragraphs/text/images/2018-05-23/Picture3.png?itok=q4STd01q&timestamp=1527076941" alt="Telegram overload - centenarieans will continue to be the fasted growing age group" title="Telegram overload - centenarieans will continue to be the fasted growing age group" /> </picture> </div> <div class="card-body"> <p>Turning around years of Medical Practice</p> <table> <thead> <tr> <th>The Past</th> <th>The Future</th> </tr> </thead> <tbody> <tr> <td>Single organ specialties</td> <td>Patient centred care</td> </tr> <tr> <td>Disease focused goals</td> <td>Principles of Comprehensive Geriatric Assessment</td> </tr> <tr> <td>Non- integrated services</td> <td>Proactive person centred care planning</td> </tr> <tr> <td>Reactive care</td> <td> </td> </tr> </tbody> </table> <h2 class="sidebar-nav">New GP contract</h2> <p>Identify and code for moderate and severe frailty</p> <p>Ask for consent to share further information using the Summary Care Record</p> <p>For severely frail patients:</p> <ul> <li>Falls assessment</li> <li>Medication review</li> </ul> <h2 class="sidebar-nav">Severe frailty:</h2> <p>Average practice list per GP:</p> <ul> <li>2,000 (significant variation around the country)</li> <li>7% of the population over 65 yrs are likely to be severely frail</li> <li>In an average practice this is about 27 patients per GP</li> <li>“Pulse” estimate 0.5% of practice population</li> </ul> <p>Based on GP contract data as at 31 Mar 2018, there were 320,000 people aged 65 and over with a coded diagnosis of severe frailty (c. 3.2% of 65+ population).  This was an average of 46 patients per GP practice or 0.6% of the average practice list. [Source: <a href="http://fusion48.net/frailty/frailty-contract-analysis" rel="nofollow">Fusion48</a>]</p> <h2 class="sidebar-nav">Comprehensive Geriatric Assessment</h2> <p>Multidisciplinary assessment of physical, psychosocial, functional and environmental factors</p> <p>Multidisciplinary team come together to agree a plan with the patient (and where appropriate their family)</p> <p>Plan enacted; team can ensure actions implemented</p> <p>Review with agreement of any further actions</p> <p>Patient receiving CGA 12 times more likely to be alive and living at home 6 months after intervention NNT 24</p> <h2 class="sidebar-nav">Falls assessment</h2> <p>Evidence is for multidisciplinary assessment, commonly several factors identified:</p> <p style="margin-left:40px">Eg 87 yr lady with dementia, hypertension, ischaemic heart disease, diabetes (type II), osteoarthritis<br /> 3 falls in the last 4 months.<br /> One known about by practice when fractured radius<br /> Taking night sedation (long acting benzodiazepine), gliclazide, enalapril, isosorbide mononitrate, paracetamol, amlodipine, GTN spray<br /> Urgency, frequency, nocturia- falling at night trying to get to the toilet<br /> Painful OA, disuse wasting of quads<br /> Wearing spectacles- no vision check for 2 yrs<br /> HbA1C 52<br /> L/S BP: postural drop- enalapril dosage reduced<br /> HbA1C too tight- on gliclazide 80mg once daily- stop<br /> Night sedation slowly weaned<br /> Over active bladder symptoms identified and treated<br /> Commode next to the bed supplied<br /> Family arranged optician check- specs updated (no bi-focals)<br /> Improve analgesic treatment of knees- encourage and support to attend local gentle exercise group<br /> Extra rail on the stairs fitted</p> <h2 class="sidebar-nav">NICE guidance: multifactorial assessment (re falls)</h2> <ul> <li>identification of falls history</li> <li>assessment of gait, balance and mobility, and muscle weakness</li> <li>assessment of osteoporosis risk</li> <li>assessment of the older person's perceived functional ability and fear relating to falling</li> <li>assessment of visual impairment</li> <li>assessment of cognitive impairment and neurological examination</li> <li>assessment of urinary incontinence</li> <li>assessment of home hazards</li> <li>cardiovascular examination and medication review</li> </ul> <h2 class="sidebar-nav">NICE: multifactorial interventions</h2> <ul> <li>strength and balance training</li> <li>home hazard assessment and intervention</li> <li>vision assessment and referral</li> <li>medication review with modification/withdrawal</li> </ul> <p>One study (2016) found that 65% people admitted to hospital after a fall were taking at least one medication associated with falls</p> <h2 class="sidebar-nav">Medication review</h2> <p>23% of all over 75 yr olds taking inappropriate medications</p> <p>Recent paper analysing primary care patient safety incidents highlighted medication issues</p> <p>High risk medications: warfarin, insulin/ sulphonyl ureas, opiates</p> <p>Problematic combinations: NSAIDs and ACE inhib</p> <p>NSAIDs and warfarin</p> <h2 class="sidebar-nav">Guides to support deprescribing</h2> <p><a href="http://www.polypharmacy.scot.nhs.uk/" rel="nofollow">www.polypharmacy.scot.nhs.uk/</a></p> <p>O’Mahony et al STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014 October 16, 2014.</p> <p>NICE. Managing medicines in care homes (SC1). London: NICE, 2014.</p> <p><a href="https://www.york.ac.uk/inst//crd/pdf/eff ectiveness-matters-January-2015- frailty.pdf" rel="nofollow">https://www.york.ac.uk/inst//crd/pdf/eff ectiveness-matters-January-2015- frailty.pdf</a></p> <p><a href="https://www.york.ac.uk/media/crd/effecti veness-matters-aug-2017-polypharmacy- pdf" rel="nofollow">https://www.york.ac.uk/media/crd/effecti veness-matters-aug-2017-polypharmacy- pdf</a></p> <p><a href="https://www.nice.org.uk/guidance/ng56" rel="nofollow">https://www.nice.org.uk/guidance/ng56</a></p> </div> <div class="card-view-4"> <div class="view view-attachment view-id-attachment view-display-id-main view-dom-id-4a1906e25820e09ff0bfdb8ee911a766"> </div> </div> </div> </div> </div> </div> </article> </div> <div class="content-additional"> <div id="block-webform-client-block-227" class="block block-webform"> <h2 class="resource-feedback-toggle">Feedback on this resource?</h2> <div class="content"> <div id="webform-ajax-wrapper-227"><form 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