Frailty matters to us all.
Older people aged over 75 tend to have three or more long-term conditions. Living with multiple co-morbidities is often responsible for the development of frailty. In this blog I will describe what frailty is, what the consequences are, and what can be done to manage it and reduce its impact.
What is frailty?
Frailty is not a disease itself. It is a constellation of symptoms and signs characterised by a loss of physical reserve. It can be a consequence of a combination of acute and or chronic ill health, poor mobility, weight loss and social isolation.
An older person with frailty often presents to doctors complaining of loss of balance or falls as well as weight loss and exhaustion. As first described by Fried in 2001, frailty is characterised by three or more of the following criteria:
- Unintentional weight loss (4.5kg in last year)
- Self reported exhaustion
- Weakness (grip strength)
- Slow walking speed (<0.8 metres/second)
- Low physical activity
This can mean that those of us who are frail are less able to carry out normal activities of personal and domestic daily life without help. An inability to cook, clean, wash clothes and shop makes life a challenge. As the condition progresses, an older person may experience difficulties with personal activities of daily living such as not being able to get on and off a chair and bed, wash, get in and out of the bath, get on and off the toilet, dress and maintain bowel and bladder care (Personal care).
Embarrassment will often make people hide their inability to look after themselves. A minor illness may precipitate a crisis landing an older frail person in hospital facing problems mobilising and thus being discharged home.
What can we do? Prevent, identify, manage and plan!
My message is that old age is a marathon and that you have to prepare and plan to prevent and manage frailty. Old age itself is not a disease. Causes of failing to thrive should always be sought. Physical inactivity will accelerate difficulty with walking and mobilising; any period of prolonged bed rest, even, when ill, is not good. Older age and multiple long term conditions are much easier to manage if people continue to go out, walk, attend exercise classes and maintain their independence.
I always recommend that people regularly check with their GP that their medications are still helping them and not causing side effects as well as making sure that all their medical conditions have been treated appropriately. Sometimes GPs are not happy about stopping drugs prescribed by hospital consultants. If so I would ask the GP to check with them. Stopping smoking and reducing alcohol intake are essential at any age and level of frailty. In addition vaccinations against the flu and pneumococcus are vital and I advise older people to take vitamin D, as our exposure to sunlight is not sufficient to prevent vitamin D deficiency. Treating depression and or pain appropriately in an older person however frail will improve their quality of life.
Preventing social isolation and encouraging participation in social activities is crucial as is identifying loss of hearing, vision, problems with continence and deteriorating memory. Making life as enjoyable as possible is essential and adding life to years as well as years to life is what matters. Underpinning this must be a healthy diet and preventing weight loss as well as living in a warm environment.
How should you plan with the older person with frailty? What is care and support planning? What is a comprehensive geriatric assessment?
Care and support planning ensures that carers, GPs, family members, voluntary workers and social workers sit down and talk to the person to establish what matters to them and to agree goals and objectives for their current and future care as well as action plans. Their progress will need to be monitored and it is fundamental that the individual and or next of kin are included in discussions.
An electronic frailty index is being introduced nationally to ensure that GPs are able to identify older people with frailty, plan and work with them to prevent crises, to treat reversible conditions, to improve their quality of life and enable them to regain more control over their lives.
Comprehensive geriatric assessment underpins the care of older people with frailty. This is defined as a multi-disciplinary diagnostic and treatment process that identifies medical, psychosocial and functional capabilities of an older adult in order to develop a coordinated plan to maximize overall health with aging.
A proactive multi-disciplinary approach to the care of older people with frailty will go a long way to improving their quality of life as well as reducing hospital admissions and crises. This is just an introduction to frailty, which is probably one of the most important long-term conditions faced by older people in the United Kingdom over the next two decades.
Fried et al. J Gerontol A Biol Sci Med Sci (2001) 56 (3): M146-M157.
Electronic Frailty Index.
Professor John Young: A primary care based model for frailty 2016.
British Geriatrics Society 2014 Fit for frailty.