1. Total care of older people with frailty Professor John Gladman University of Nottingham, Nottingham University Hospitals NHS Trust, East Midlands AHSN, CLAHRC East Midlands

2. Content Frailty Frailty care Challenges

3. Frailty Vulnerability Robustness, resilience “Biological age”

4. Conceptual models Phenotype Cumulative deficit

5. Phenotype model Physiological status 3 or more of - unintentional weight loss - reduced muscle strength - reduced gait speed - self-reported exhaustion - low energy expenditure

6. Deficit model Accumulation of deficits Almost infinite number Symptoms, signs, diseases, even social factors Frailty Indices: more deficits, more frail

7. What makes people frail / vulnerable? Variables in the multitude of measures: - nutrition - mobility - energy - strength - cognition - mood - social relations - social support

9. Frailty care: identification Geriatric conditions / presentations - falls - immobility - delirium - incontinence - susceptibility to drug side effects

10. Frailty in elective surgery British Geriatrics Society “Fit for Frailty” http://www.bgs.org.uk/campaigns/fff Edmonton Frail Scale

12. Frailty care Prevention: - choose parents well - life-course factors - smoking - exercise - diet and obesity Treatment of the phenotype - resistance exercise - dietary / hormonal – not yet clear

13. Frailty management Identify who is frail Assess all the domains of frailty Intervene across as many as possible Use assessment for prognosis & risk assessment Use assessment for care planning

14. Comprehensive Geriatric Assessment Multidimensional, interdisciplinary diagnostic process … of a frail elderly person … to develop a coordinated plan for treatment and follow-up Assessment, but more than assessment Process, not tool Trials and meta-analyses consistently show CGA: - saves lives - reduces institutionalization - reduces hospitalization - improves physical health - improve mental health

15. Frailty management in surgery Pre-operative CGA Surgical liaison: hip fracture care RCS Emergency Surgery Briefing Sept 2014: Emergency surgical care for older people should be improved through the use of Comprehensive Geriatric Assessments carried out by multi-disciplinary teams to ensure additional needs are fed into a person’s discharge planning. Joint care pathways shared between surgical teams and physicians specialising in care of the elderly can facilitate general medical care, rehabilitation and social care in the community.

16. Summary so far Concept of frailty Principles of frailty management Application to surgical settings

17. Challenges Frailty care is core business - organisations - individuals

18. Response to challenges Bravo! Royal College of Surgeons East Midlands Academic Health Sciences Network - implementation Health Education East Midlands - workforce East Midlands Clinical Senate - commissioners Patient and public engagement