1. As a long-term condition
Framing frailty:
As a long-term condition
Deirdre Lang
Director of Nursing/National Lead Older Persons Services
@deirdrelanglang

2. How do we see Frailty?
Put up title only and ask students to take a minute in pairs to come up with works they would use to describe “frailty”
These are common words people use to describe frailty, but frailty is beyond what we see at first glance.

3. Frailty (Fit for Frailty , BGS 2015)
Though frailty results from ageing, it is not an inevitable part of ageing.
World’s oldest yoga teacher – 96 Tao Porchon Lynch (3.24minute clip)
National Clinical Programme for Older People. National Frailty Education Programme: November 2017

4. Defining Frailty can be challenging as there is no formal consensus…..
A distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves.
Around 10% of people aged over 65 years have frailty, rising to between 25% and 50% of those aged over 85 years.
A state of increased vulnerability, associated with a decline in physical and psychological reserves.
An apparently small event may trigger a dramatic change in the physical or mental wellbeing.
(Fit for Frailty , BGS 2014)
There is a range of literature about frailty – what is it? Why is it important? When and how frailty should be recognised? What do we do once we have identified it?
In 2014 the British Geriatrics Society published a short guidance document called “Fit For Frailty” which was presented as a consensus document and sought to answer these questions.
Several definitions of frailty have been proposed, but there is as yet no formal consensus within the international gerontology profession. The debate has centred on whether frailty should be defined purely in terms of biomedical factors or whether psychosocial factors should also be included.
Comprehensive Geriatric Assessment is recommended once we have identified frailty.
There is a consensus that the concept of frailty should be multi-dimensional, covering disease, function, cognition, and nutrition . This concept has been extended to include the broader environment, including factors such as poverty and isolation, in addition to individual factors. This definition avoids framing the problem of frailty as biomedical.
(Lally & Chrome 2007) Postgrad Med J 2007;83:16–20. doi: /pgmj

5. Biological V Chronological Aging
Not all old people are frail: not all people with frailty are old
Biological V Chronological Aging
Chronological Age ≠ Biological Age)

6. Decreased Physical Activity
Genetics
Cumulative Cellular Damage
Environmental Factors
Increased Vulnerability to Frailty
Decreased Physical Activity
Poor Nutrition
Decreased Reserve
Stressor event
Instability
Falls
Incontinence
Changes in cognition
Adapted from Clegg 2013

7. Frailty is the Most Problematic Expression of Population Ageing
So we need to think about it, understand and recognise it and plan for how we will support and care for those living with frailty in our community and in our hospital.
We need to future proof delivery of our health care services for the people who will be using it!
So we need to think about it, understand and recognise it and plan for how we will support and care for those in our community and in our hospital. We need to try and future proof delivery of our health care services dfor the people who will be using it!
“Frailty is the most problematic expression of population ageing”
Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves
We know it when we see it, but recognising it and doing something about it has got to become a core part of our business as
Over the last decade, some 40% of the increase in emergency admissions is
from over 65s
65-69 = 4%
70-74 = 7%
75-79 = 9%
80-84 = 16%
Over 85 = 26%
Over the last decade, some 40% of the increase in
emergency admissions is
from over 65s

8. Acopia Off Feet Frailty : What We know Pleasantly Confused Bed Blocker
A distinct health state, related to the aging process
A heterogeneous condition, people present differently
Characterised by decreased physiological capacity across multiple body systems
A risk factor for adverse health outcomes
A transition phase between healthy ageing and disability
(Clegg et al, 2013; Morley et al, 2012; Rockwood et al, 2007; Wlaston et al, 2006; Fried et al, 2001)
Bed Blocker
Mechanical Fall
Acopia
Off Feet

9. Frailty as a long term condition
If we consider frailty as a long-term condition we begin to apply internationally established models and implement evidence based care
Frailty shares the features of the typical long-term conditions
Common (25-50% of people over 80 years)
Costly at an individual and societal level
Typically progressive (but not always)
Potentially modifiable
Episodic crisis
Severe
INCREASING FRAILTY

10. CARE & SUPPORT PLANNING
Frailty as a Long Term Condition
A long term condition can be diagnosed, is not curable but can be managed
As resilience is lost, care and support planning assumes greater importance through to the end of life
CARE & SUPPORT PLANNING
END OF LIFE
PREVENTION
RESILIENCE
INCREASING FRAILTY

11. Frailty in the Community
TILDA participants aged 65 years and older (n=3,422) categorised as: Robust (0-3 health problems), Pre-frail (4-7 health problems), Frail (8 or more health problems).
Roe et al., TILDA 2016

12. Frailty in the Community: What we know
Prevalence of frailty varies from 17% to 29% CHO regions
57% of Public Health Nursing service users aged 65 years and older are frail.
•Less than 1/3 frail older people access the PHN service
THE IMPACT OF FRAILTY ON PUBLIC HEALTH NURSE SERVICE UTILISATION Findings from The Irish Longitudinal Study on Ageing (TILDA)

13. Frailty Syndromes: How people with frailty present acutely
Non Specific: e.g. fatigue, weight loss, recurrent infection
Falls/Collapse
Immobility/worsening mobility
Delirium (“acute confusion”)
Incontinence (new or worsening)
Fluctuating disability
Increased susceptibility to medication side effects
e.g. Hypotension, Delirium

14. Falls
Incontinence
Cognitive Impairment
Social Isolation
Susceptibility to side effects of medications
Multiple chronic disease processes
Poor Nutrition – unintentional weight loss
Hospital admissions
Delirium
Immobility
FRAILTY
Syndromes
Frailty syndromes
1] Falls (e.g. collapse, legs gave way, ‘found lying on floor’).
2] Immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’).
3] Delirium (e.g. acute confusion, ’muddledness’, sudden worsening of confusion in someone with previous dementia or known memory loss).
4] Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence).
5] Susceptibility to side effects of medication (e.g. confusion with codeine, hypotension with antidepressants).
The frail older adult has diminished homeostatic reserve and reduced resistance to stressors consequent to cumulative decline across multiple physiological systems, thus being vulnerable to several adverse events, including functional decline and disability, falls, and mortality, independent of age (Gill et al., 2010). The conceptual model of frailty has been expanded to include the psychological and social domains for a holistic view of an older individual (Chong et al., 2015).
Frailty is a result of multisystem declines in physiologic reserve of the older adult, rendering them vulnerable to increased risk of hospitalisation, and dying when exposed to stress (Pin Ng et al., 2015). The Cardio Health Study offers a clinical definition of frailty phenotype consisting of a combination of weight loss, weakness, slowness, exhaustion and reduced physical activity (Fried et al., 2001).
Social factors are now recognized as relevant to understand frailty. However, research into the prevalence of frailty and its correlates, particularly social influences, is still limited - Luis Miguel Gutiérrez Robledo January 19-20, 2011, Athens, Greece IAGG/WHO/SFGG Workshop n°3 “Promoting access to innovation and clinical research for frail old persons”
“Frailty, while a very important clinical paradigm, largely remains a diagnosis or descriptor most suited to community dwelling older persons, as its application and utility within the acute setting still remain unclear” McCabe,J.J., Kennelly, S Acute care of older patients in the emergency department: strategies to improve patient outcomes. Open Access Emergency Medicine. 7,
Frailty is strongly linked to polypharmacy e.g. Esther Study will be discussed in future module on polypharmacy

15. Frailty in the Acute Hospital: What we know
Acute medical admissions
ED attendance over 65

16. Frailty in Residential Care: What we know
5-6% older population receive residential care
Approximately 22% of 85+ require nursing home care.
This group is forecast to increase by 46% to 2021

17. Recognising Frailty: Two Broad Models
Phenotype model (Fried et al. 2001)
Describes a group of patient characteristics:
Unintentional weight loss (4.5kg in last year)
Self reported exhaustion
Weakness (grip strength)
Slow walking speed (<0.8 metres/second)
Low physical activity
Generally individuals with three or more of the characteristics are said to have frailty.
Cumulative Deficit Model (Rockwood et al. 2005)
Assumes an accumulation of deficits ranging from:
symptoms e.g. loss of hearing or low mood
signs such as tremor,
diseases such as dementia
which can occur with ageing and which combine to increase the ‘frailty index’ which in turn will increase the risk of an adverse outcome.
Easily recognisable when advanced: ‘know it when you see it’
The first frailty model the phenotype model -firstly to define phenotype -it is a set of physical (observable) characteristic of an individual, resulting from the interaction of ones genes with the environment. Examples such as some ones height and weigh. It is defined as an organism's expressed physical traits.
1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype.
JGerontolA BiolSciMedSci 2001;56(3):M146–M156.
2. Kenneth Rockwood, Xiaowei Song, Chris MacKnight, Howard Bergman, David B. Hogan, Ian
McDowell, and Arnold Mitnitski. A global clinical measure of fitness and frailty in elderly people. CMAJ.
Aug 30, 2005; 173(5): 489–495.
The cumulative deficit approach to defining frailty is broader than the phenotype approach, encompassing co-morbidity and disability as well as cognitive, psychological and social factors. The potential causes are therefore wider and include the multiple risk factors which are implicated in the various diseases and conditions. (British Geriatrics Society 2014)

18. Cumulative Deficit Model(Frailty Index)
32 Age-related Health Deficits
1. Difficulty Walking
17. Stroke/TIA
2. Difficulty rising from a chair
18. Irregular heart rhythm
3. Difficulty climbing one flight of stairs
19. CVD
4. Difficulty stooping, kneeling or crouching
20. Diabetes
5. Difficulty reaching above shoulder height
21. High cholesterol
6. Difficulty pushing/pulling large objects
22. Arthritis
7. Difficulty lifting/carrying weights >10lbs
23. Knee pain
8. Difficulty picking up a coin from table
24. Osteoporosis
9. Poor self-rated vision
25. Cancer
10.. Poor self-rated hearing
26. Varicose ulcer
11. Difficulty following a conversation
27. Urinary incontinence
12. Cataracts
28. Polypharmacy
13. Glaucoma/Age related macular degen
29. Poor self-rated physical health
14. Hypertension
30. Daytime sleepiness
15. Angina
31. Poor self-rated memory
16. Heart attack
32. Feeling lonely
Physical function deficits, Sensory deficits Cardiovascular deficits, Chronic or Acute illness, Other health deficits

19. Cumulative Deficit Model(Frailty Index) ( Rockwood et al. 2005)
The Frailty Index (FI) is a simple calculation of the presence of each health deficit as proportion of the total number of deficits
No of deficit
__________________ = Frailty Index Score
Total number of deficits
National Clinical Programme for Older People. National Frailty Education Programme: November 2017

20. Cumulative Deficit Model(Frailty Index) (Rockwood et al. 2005)
Robust
Pre-frail
Frail
(modified from O’Halloran et al. TILDA, 2018)

21. Simple instruments to identify frailty
Sensitivity
Specificity
Gait Speed <0.8m/s
99%
64%
Gait Speed <0.7m/s
93%
78%
TUGT >10s
62%
PRISMA 7
83%
83% (wide CIs)
Self-reported Health
72% (wide CIs)
Groningen Frailty Indicator
58%
72%
Polypharmacy (>5 meds)
67%
GP clinical assessment
Frailty instruments assessed against a reference standard: Clegg et al Age Ageing 2014
(Systematic Review)
National Clinical Programme for Older People. National Frailty Education Programme: November 2017

22. validated frailty assessment tools
Clinical Frailty Scale
3 of the following:
Unintentional weight loss
Muscle weakness (grip strength)
Slow walking speed
Feeling exhausted
Low physical activity
Biological markers
The Clinical Frailty Scale is in your pack and should be printed for participants
National Clinical Programme for Older People. National Frailty Education Programme: November 2017

23. Rockwood Frailty Scale
1 Very Fit – People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.
4 Vulnerable – While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.
7 Severely Frail – Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).
5 Mildly Frail – These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.
2 Well – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.
8.Very Severely Frail – Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
6 Moderately Frail – People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
9. Terminally Ill - Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail
3 Managing Well – People whose medical problems are well controlled, but are not regularly active beyond routine walking.
National Clinical Programme for Older People. National Frailty Education Programme: November 2017

24. National Clinical Programme For Older People: Acute model of care
Recommendation All identified older frail patients to have a timely Comprehensive Geriatric Assessment performed and documented in their permanent health record

25. Comprehensive Geriatric Assessment
CGA
Co-ordinated plan of care
Co-ordinated delivery of care
Organised approach to assessment
Identify treatable health problems

26. If Admitted to Hospital –
Positive correlation between age and admission rate from ED (75yr olds x 2 and 94 yr olds x 3) 
If Admitted to Hospital –
More Likely to Move
Wards
More Likely to Experience
a Longer Stay
a Delayed Discharge
More Likely to Suffer an Adverse Outcome
There is a strong correlation between excessively long PETs and in patient AVLOS
A stay of 4-8 hours increases inpatient length of stay by 1.3 days, while a stay of more than 12 hours increases length of stay by 2.35 days.
Every bed move adds two days to length of stay
10 days in hospital is equivalent of 10 years loss of muscle mass
48% of people over 85 die within one year of hospital admission

28. Frailty: What we know
By increasing the understanding of frailty, we can improve the detection, prevention, management and therefore outcomes for these older adults.

29. Frailty: What we know
The recognition of frailty is important and should form part of any interaction between an older person and a healthcare professional.
An individual’s degree of frailty is not static. It may be made better or worse, depending on the care received when an individual presents to a health professional.

30. Towards a New Paradigm

31. Thank You