1. Frailty
Cara Hanley
November 2016

2. Not just an inevitable part of ageing
Frailty
”a clinically recognizable state of increased vulnerability resulting from age-associated decline in physiological reserve and function, such that the ability to cope with everyday or acute stressors is compromised” (Xue 2011)
From Clegg et al. 2013
Not just an inevitable part of ageing

3. Frailty
Chronic illness
Disability

4. Consequences of Frailty
Falls (1/3 >65y, ½ >80y annually; £2b/year; 4m bed days)
Injuries
Worsening disability
Acute Illness
Hospital admission
Care Home Admission
Mortality

5. Recognising Frailty Frailty phenotype (Fried et al, 2000)
Describes a group of patient characteristics which, if present, can predict poorer outcomes
Rockwood Model (Rockwood et al, 2005)
Deficit model which assumes an accumulation of deficits (ranging from symptoms/signs/disease) that can occur with ageing and which combine to increase the frailty index which correlates with risk of adverse outcomes
Geriatric Giants (falls, immobility, delirium, incontinence, infection)

6. “Clinical consensus phenotype”
Characteristics include
Muscle wasting/sarcopenia
Weight loss (unexplained)
Loss of endurance
Decreased balance and mobility (falls)
Slowed performance
Relative inactivity
Instability of chronic disease
>3 = “Frailty”

7. Common problems in frailty
Falls
Cognitive Impairment
Continence
Mobility
Weight loss and poor nutrition
Polypharmacy
Physical inactivity
Low mood
Alcohol excess
Smoking
Vision difficulties
Social isolation
loneliness

8. How do we look for frailty?
7 studies that identify frailty (British Geriatric Society)
Walking speed
Timed up & go test
PRISMA 7 questionnaire
self-reported health
GP assessment
Polypharmacy
Groningen frailty indicator questionnaire +
Clinical presentation of the individual

11. How do we manage frailty?
Comprehensive Geriatric Assessment
Gives a framework for instigation of intervention
Proven to increase the likelihood of a patient returning home and avoiding admission to care home or deterioration (Ellis et al 2011)

12. Comprehensive Geriatric Assessment
Medical
C0-morbidities, Medication Review, Nutritional status, Problem list
Mental Health
Cognition, Mood and Anxieties, Fears
Functional Capacity
Basic/Instrumental ADLs, Gait and Balance, Activity/Exercise status
Social Circ.
Informal Support, Social Network, Eligibility for care resources
Environment
Home comfort, facilities, safety, transport facilities, access to resources

13. Comprehensive Geriatric Assessment
Main Principles
Ensure patient centeredness
Assess patients capacity to participate voluntarily; if lacking there needs to be a system to address their needs ethically
Links between social care and healthcare should be established in a timely and efficient manner, proportionate to degree of need
Assessments should be standardised
Specific situations that warrant a complete assessment
Acute illness associated with significant change in functional ability
Transfers of care for rehabilitation, re-enablement or continuing care
Frail patient prior to surgery
Frail patients experiencing two or more “geriatric syndromes” (falls, delirium, incontinence, immobility)

14. Summary
Frailty is
a spectrum; varies in severity
a dynamic process; can be made better or worse
Not an inevitable part of ageing
Frailty syndromes can mask serious underlying illness
Falls should not be considered as a non-urgent situation
Need to assess the patient in a holistic manner to support recovery/rehabilitation and to minimise future risk of adverse outcomes

15. References
Clegg et al. Frailty in elderly people. The Lancet 2013;382:19-25.
Ellis G, Whitehead M, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 343d6553.
Fit for Frailty - consensus best practice guidance for the care of older people living in community and outpatient settings - a report from the British Geriatrics Society 2014
Fried et al. Frailty in older adults; evidence for a phenotype. Journal of Gerontology 2001;56(3):M
Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state in a dynamic process. Gerontology 2009;55(5):
Rockwood K, Song X, MacKnight C, Bergman H, Hogan D, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal 2005;173(5):
Xue Q. The Frailty Syndrome: Definition and Natural History. Clin Geriatr Med 2011;27:1-15