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
See also: Guideline of the month: End-of-life care
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