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Ten top tips on frailty in general practice

Dr Qian Tan and colleagues present their top tips on managing frailty in primary care

1. Consider frailty in any older person presenting with falls, delirium or incontinence

Frailty is a distinctive health state related to ageing, in which multiple body systems gradually lose their built-in reserves, leaving older people with the condition at risk of significant deterioration in physical and mental health following even a minor stressor. Around 10% of over-65s have frailty, rising to between 25% and 50% of those aged over 85.

Consider frailty in any older person who presents with falls, immobility, delirium, incontinence or susceptibility to the side-effects of medications. Be aware that what may appear to be a straightforward symptom can sometimes mask a complex or serious underlying illness.

2. Remember that the GMS contract requires practices routinely to identify moderate and severe frailty in patients aged 65 years and over

While more patients are living with long-term health conditions and multimorbidity, they will not all be frail. Frailty is not an inevitable part of ageing. It is not a static condition and can improve over time. However, older people who are frail are at increased risk of disability, hospital and care home admission, and mortality, so it is important to identify and manage frailty. Screening for it among older adults will help identify high-risk or vulnerable groups of patients who may require personalised care plans to reduce the associated risks of living with frailty. For patients identified as living with severe frailty, practices are contractually required to deliver a clinical review, including an annual medication review, discussing whether there have been any falls in the past 12 months, providing any other clinically relevant interventions, and promoting the benefits of an enriched summary care record (SCR) to patients who do not have one. Informed patient consent is required to activate the enriched SCR.1

3. Use a simple tool to identify frailty in primary care

The electronic frailty index (eFI)2 can quickly stratify a general practice population into those who are robust or those who have mild, moderate or severe frailty, and identify those needing further assessment and management. To identify frailty, the British Geriatrics Society recommends the use of gait speed (taking more than five seconds to walk four metres independently using any usual walking aids) or the Timed Up and Go Test (longer than 10 seconds to get up from a chair, walk three metres, turn, walk back and sit down). The PRISMA-7 questionnaire (score >3 indicating frailty) is a useful brief self-assessment test that can be completed in the waiting room. The Rockwood Clinical Frailty Scale should only be used to assess severity of frailty after a comprehensive geriatric assessment.

4. Remember to carry out a comprehensive review of patients with frailty

A holistic and comprehensive review, including medical, functional, psychological and social needs, based on the Comprehensive Geriatric Assessment (CGA) principles3, should be carried out for those identified as living with frailty. This should involve the person with frailty and their carers. It is also important to explore the impact of illness and symptoms on their day-to-day life. This review will usually involve medical, nursing and therapy healthcare professionals and will focus on optimising the person’s health and considering forward care planning. Within a 10-minute appointment, the role of the GP could be to initiate a screening test for frailty and, where appropriate, start discussions with patients about a CGA review.

Subsequent consultations may include completion of the medical aspects of CGA, including lab and imaging investigations, medication review and referral to community or secondary care services. A nurse or allied health professional could carry out the patient’s functional, social and psychological assessments. Patient information should be available to be accessed on a shared system and multidisciplinary team meetings should be held to formulate a personalised care and implementation plan for the patient.

5. Make sure to consider any potentially reversible causes and underlying diagnoses

Following holistic assessment, any new conditions that come to light should be addressed and management of chronic conditions optimised. Problems such as constipation may appear minor but could cause a rapid decline in function for those living with frailty and so need to be addressed. An individualised approach should be taken to managing chronic conditions, decided in conjunction with the patient or their advocate. This may sometimes mean acknowledging that local or national guidance is no longer appropriate and considering any other ways that management of long-term conditions can be improved.

If underlying cognitive impairment is a concern, the patient can be assessed using the Six-item Cognitive Impairment Test or Montreal Cognitive Assessment test. It is important to assess mental capacity in those with cognitive impairment as this will have implications for subsequent care planning. Capacity is time and decision specific. People with cognitive impairment may retain capacity to participate in some, if not all, decisions relating to their care and support, and this ability may fluctuate over time.

6. Review medications for side-effects that could worsen frailty

People living with frailty are generally more susceptible to medication side-effects. Medications that can be problematic for those with frailty include antimuscarinics (which can increase the risk of cognitive decline), sedatives, hypnotics and sulphonylureas (increased risk of falls), and opiates (can lead to delirium). Identification of these medications should trigger consideration of their indication and potential for discontinuation.

For preventive medications, a discussion with the patient regarding potential long-term benefits versus burden of side-effects is important and may lead to agreed discontinuation. While deprescribing is a common strategy for those living with frailty, some medications continue to have efficacy (such as ACE inhibitors in the management of heart failure) and so frailty in itself should not be a reason to stop any medication in the absence of a specific concern. Rationalisation of medications for those living with frailty can be guided by tools such as the STOPP/START criteria.4

7. Where frailty is associated with high complexity or challenging symptoms, consider referral to secondary care

Some patients with frailty will have coexisting multimorbidity and care needs, which may be challenging to address within the usual structure of primary care. There may also be uncertainty regarding underlying diagnoses or symptoms prioritised by the individual. Referral to secondary care for multidisciplinary review can be beneficial, and may include referral to a geriatrician, frailty practitioner or virtual ward depending on local provision. If the main management concerns relate to coexisting psychiatric illness or dementia, input from older persons’ mental health services should be a priority.

8. Have open conversations and remember to ask what is important to the patient and their family

To deliver person-centred care, it is important to have open conversations with patients and their family members on what matters most to them. Individualised care and support plans can be generated to outline treatment goals and management plans. A care plan that supports older people to live independently and to understand and manage their chronic conditions reduces the risk of a crisis requiring emergency hospital admission. Anticipatory care plans may help prepare for urgent or end-of-life care in older people with advanced frailty for whom hospital admission may be inappropriate or unwanted.

9. Remember to advise older people on exercise and diet

Exercise is an effective and inexpensive non-pharmacological intervention that can improve older people’s mobility and independence. Activities such as strength and balance training have been shown to improve muscle strength and functional abilities in older people with frailty. Inadequate nutritional intake is also a modifiable risk factor and older people with frailty may struggle with shopping and cooking.

Patients with low BMI or a history of weight loss should trigger further assessment of nutritional status with a validated tool such as the Malnutrition University Screening Tool, Mini Nutritional Assessment or Simplified Nutritional Appetite Questionnaire.5

10. Develop local protocols and care pathways for people with frailty, ensuring timely response and training for all staff

Integration of health and social care with clear pathways and communication between primary and secondary care are important in the care of older people living with frailty. Poor communication and coordination between organisations can compromise the quality of care provided. By developing protocols and care pathways, person-centred care can be delivered to older people in a timely fashion, helping to prevent them from falling through the gaps of these interdependent systems.

The King’s Fund and Nuffield Trust offer some examples of good practices of integrated care pathways.6

Dr Qian Tan is an academic clinical fellow, Dr Natalie Cox is a research fellow and Dr Steve Lim is a clinical lecturer. They are training in geriatric medicine and work with Professor Helen Roberts in academic geriatric medicine at the University of Southampton


  1. NHS Digital, 2019. GMS/PMS core contract data collection.
  2. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016;45(3):353-60
  3. British Geriatrics Society, 2019. Comprehensive Geriatric Assessment Toolkit for Primary Care Practitioners.
  4. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-8
  5. Roberts H, Lim S, Cox N, Ibrahim K. The Challenge of Managing Undernutrition in Older People with Frailty. Nutrients. 2019;10;11(4):808
  6. Goodwin N, Smith J. The Evidence Base for Integrated Care.

Further resources

  1. PRISMA-7 questionnaire.
  2. Rockwood Clinical Frailty Scale.
  3. Six-item Coginitive Impairment Test.
  4. Montreal Cognitive Assessment test.
  5. Malnutrition screening tools. 

Related images

  • ttt frailty 535x350

Readers' comments (7)

  • Benn Gooch

    I welcome these tips but has a GP read this before publication? Seems a bit ambitious for a GP to tackle these in 10 or 15 min consultation. a 45 min outpatient appointment might be more appropriate for this little lot?

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  • I understand that the previous Care Plan enhanced service was withdrawn because it increased use of health resources (including admissions) without any clear improvement in outcomes.

    Is there any evidence that frailty reviews will be different?

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  • The issue with the frail elderly is that it is an extremely volatile state.

    You can do the best proactive review possible of a patient, it still won't stop them being admitted a week or two later for an acute illness.

    We cannot predict or prevent the future

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  • Dylan - Frailty services need have ALL the elements in - if you dont you do increase health resource useage - however if done properly they do work. Data from local pilots supports that. A larger scheme will have a proper evaluation.
    AnotherGP - No but you can put in place care plans for such an occurance....what usually is missing is either a plan or social care.

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  • Thank you for writing this- there are some very useful tips here. The burden of frailty is arguably one of the biggest challenges facing the NHS and we need to put our collective heads together on how to manage it better. However, I feel this article is missing the perspective of a General Practitioner!

    Resources and time are particularly limited in General Practice- it's a different environment to secondary care. From the evidence I've read and from speaking to GP colleagues, there is still a need to establish best practice system(s) to pro-actively identify/manage older people living with frailty in primary care and that these positively change frailty trajectories. I.e. Evidence doing this stuff actually makes a difference to the lives of older people living with frailty! Furthermore, where examples of good practice local systems exist (including a set of interventions), they need to be scalable and be sustainably resourced (and equitably given the other pressures on General Practice). E.g. The opportunity cost of various interventions (e.g. CGA) can be quite high. See Travers et al 2019

    In light of the NHS Long Term Plan and PCNs, it will be very interesting to see how systems in primary care transition over the coming years to better meet the need of older people living with frailty and help older people more generally live well for longer.

    I would recommend reading for further information.

    COI- ACF in GP with a research interest in frailty. I've been interviewing GPs about the GMS frailty contractual as part of my research project. [A shameless plug too- If you'd like to hear more about frailty from a primary care perspective, I've put together a clinical article called 'Frailty- an overview' coming out in the Feb 2020 issue of the GP trainee journal InnovAiT.]

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  • Just glad to have left. Great advice about improving frailty but guess what, in a couple of years they will be even more frail, perhaps we can sort things then but in another couple of years.... This is the same as the government, media and public expecting that we will prevent strokes, CVD and cancer - it's rubbish, we can postpone only and then when it does occur it is often a complicated disaster. Just received news this morning that a 98yr old relative has died thank God because the inappropriate and unrealistic interfering that the medical profession have been doing with him in the last couple of years beggars belief.

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  • Thank you for this. Of course, we are only delaying the inevitable, but that is what we do.

    I thought for a moment you were writing about the frailty of General Practice itself!! and trying to delay the inevitable !!. I hope not and GP land will get better!!

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