Health professionals

Foreword

Identifying Frailty

Identifying frailty can be challenging. Not all older people have frailty and not all people living with frailty are old. Individuals with severe frailty are easily identifiable whereas those living with less advanced frailty can be much harder to distinguish. As well as working to identify those over the age of 65 with frailty it is just as important to try and identify it at an earlier stage in life and severity so measures can be taken to prevent it getting worse. Across North and Mid Hampshire, the following steps are encouraged for identifying Frailty:

1. Identify those potentially living frailty using available tools

• In Primary Care, the GPs General Medical Services (GMS) contract requires us to use the Electronic Frailty Index (eFI) to routinely screen people over 65 for Frailty. eFI is a starting point for preventative, proactive person-centered care planning.
• Rockwood Scale to be applied post assessment
  
  

  2. Apply your clinical judgment

• Use the individual's complete clinical picture
• Supplement with Gait Speed Test, Timed up & go test or a further measure relevant to the need of the individual.

Additional resources for identifying and managing frailty

• Edmonton Frailty Score
• eFI User Support Hubs: (SystmOne, EMIS and Vision)
• A presentation by Healthy Ageing Collaborative: Electronic Frailty Index, can be found here: https://www.kingsfund.org.uk/sites/default/files/media/Healthy-Ageing-Collaborative-Electronic-Frailty-Index_2.pdf
• NHS England published Safe, Compassionate Care for Frail Older People Using An Integrated Care Pathway that provided practical guidance on a best practice service (2014)
• David Oliver, Catherine Foot and Richard Humphries describe how to “make our health and care systems fit for an aging population” (2014) providing good practice examples which have been reviewed inform the pathway design
• A website from 'Moving Medicine' - mostly aimed at GPs, includes a toolkit to start important conversations (amongst others). Also includes information on COPD, diabetes, cancer, depression, dementia, IHD, IRD, MSK and primary prevention
• Edmonton Frailty Score

So once a patient is identified as living with frailty, what next? Across England we want everybody in the work force to begin to think F.R.A.I.L (Forward thinking, Resilient, Active and Informed in Later life). We can all be more ‘Forward thinking’ by contributing to the identification of frailty as early as possible.

Forward thinking can also be applied in the health care setting. Prevention and mitigation are at the centre of this. Being forward thinking can prevent hospitalisation and can help individuals to lead independent lives for as long as possible.

Have an action plan

Regardless of whether they have been identified as living with frailty or not, empower your patient; involve them, their family and carers in decision making and to talk to them about what to expect and what they can do going forward.

Fit – but at risk

These individuals may have a Rockwood score of 1-4. It is important to signpost these patients to information and advice on preventing frailty; the public facing pages of this website host an abundance of information on this.

Identified as Frail

If your patient is identified as living with frailty after initial assessment (Rockwood score 5-8) it is worth thinking over a few things:

• Has your patient got a care plan in place? Have you had a care planning or wellbeing conversation with them? Is it time to review?
• Do they have a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)? The ReSPECT process allows your patient to create a personalized plan for their clinical care in emergency situations if they are not able to make decisions or communicate their wishes. To find out more about the ReSPECT process click here.
• Is a Comprehensive Geriatric Assessment (CGA) required? A CGA is a multi-dimensional interdisciplinary diagnostic process focused on determining a person’s medical, psychological, social, environmental and functional capability to aid planning of treatment and long term care needs. A comprehensive, holistic approach to the care of older people has been proven to increase independence, improve wellbeing and prevent admission to hospital. Patients receiving comprehensive geriatric assessments upon hospital admission we more likely to be alive and living in their own homes at 3- to 12-month follow up and less likely to be admitted into an adult nursing home (Ellis et al, 2017)
• Has your patient activated their Enriched Summary Care Record? Explaining the importance of this to patients is key.
• Has your patient had a falls assessment completed with onwards signposting as required?
• Has your patient had a medication review?

If more specialist input or diagnostics are required patients can be referred for urgent or rapid assessment at hospital. In North and Mid Hampshire:

• Inpatient clinics are available offering CGA, within 48 hours, carried out by the Integrated Frailty Intervention Team (IFIT). This is allowing hospital admission to be avoided and shortening hospital stays when admission is required.
• Regular Rapid Assessment Clinics led by Consultant Geriatricians and Consultant Nurse for Frailty provide direct and rapid access from Primary Care to an expert CGA. This has the benefit of oversight from the hospital Consultant Geriatricians and diagnostics.

Understand the adverse effects of hospitalisation

There are an abundance of studies that highlight the negative effects of hospitalisation for the older patient. Some well-known statistics include:

• Every 10 days in hospitals leads to the equivalent of 10 years of muscle wastage in people over the age of 80 (Gill et al, 2004; Kortebein et al, 2008).
• In the first 24 hours of bed rest 2-5% of muscle power is lost (Fortney et al, 1996)
• In the first week of hospital admission 5-10% of muscle power is lost (Gill et al, 2004).
• 48% of people over the age of 85 die within 1 year of hospital admission (Clark et al, 2014).
• The older person requires proactive hospital discharge management to prevent unnecessarily extended lengths of stay leading to deconditioning.

There are many ways to mitigate this:

• Take into account the care environment, and the risk factors relating to that
• Falls Prevention
• Increase nutrition and hydration awareness
• Remember support and care at home, or in the usual place of residence is always the preferred response, if and when assistance is required, to enable the older person with frailty to maintain their independence
• The older person with frailty is only admitted to an acute bed if their condition cannot be managed in a non-acute setting

The Forward thinking section of our website for the public hosts advice and information that patients can use to reduce their risk of hospital admission. Sometimes hospital admission is required and the only appropriate action to take. When someone living with, or at risk of, frailty needs treatment in hospital it is important to keep their stay as short as possible. All over the UK hospital teams are developing new ways of working to reach this goal. Take a look at this video from Hampshire Hospitals NHS Foundation Trust to see how they are helping patients get home as soon as they are well enough.

Bibliography

Clark D, Armstrong M, Allan A, Graham F, Carnon A, Isles C. Imminence of death among hospital inpatients: Prevalent cohort study. Palliative Medicine. 2014;28(6):474-479. doi:10.1177/0269216314526443. Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, Conroy SP, Kircher T, Somme D, Saltvedt I, Wald H, O'Neill D, Robinson D, Shepperd S. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD006211. DOI: 10.1002/14651858.CD006211.pub3. Fortney S.M, Schneider V.S, Greenleaf J.E, The Physiology of Bed Rest. Compr Physiol 2011, Supplement 14: Handbook of Physiology, Environmental Physiology: 889-939. First published in print 1996. doi: 10.1002/cphy.cp040239 Kortebein P, Symons TB, Ferrando A, Paddon-Jones D, Ronsen O, Protas E, Conger S, Lombeida J, Wolfe R, Evans WJ. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008; 63: 1076–1081.

Empowering our population to be more resilient, both in mind and body, can help to reduce the impact and effects of frailty. This resilience is also important for those that care for a family member or friend living with frailty.

Building up resilience in your patients

• Help to reduce the risk of falls and fragility fracture using risk assessment tools such as fracture risk assessment tool (FRAX) or QFracture and appropriately prescribe treatment such as bone strengthening medicines. Risk assessment followed by appropriate interventions for falls prevention can reduce the rate of falls by 24%
• Encourage patients to have a medication review annually, or as required.
• Promote and educate individuals on the importance of hydration and nutrition
• Take into account the factors affecting the individual’s mental health and well- being (hearing capability, sight etc)
• Encourage exercise and activity as this can help to maintain, and even improve bone and muscle strength as well as boosting mood.

Our public facing page on resilience can provide information for your patients on the following:

• Keeping their health in check
• Keeping their mind active
• Building up their body’s resilience

Resilience in carers and family units

Being a carer of a friend or family member living with frailty can have a profound effect on their physical, social and emotional wellbeing. Therefore, it is crucial to build their resilience as well as the frail individual. There is an abundance of information for carers and family members on where they can seek support and advice in our Carers and Volunteers section. Remember don’t be afraid to ask the unaskable, sometimes a simple question can encourage a patient to open up more about their situation, making frailty easier to identify and tackle.

 

As mentioned in our ‘Resilience’ section, staying physically and mentally active is important for your patients’ mind and body. There are a range of studies that suggest that exercise and remaining active can have a positive impact on individuals living with Frailty (Theou et al, 2011; Clegg et al, 2012). It was also highlighted that there were no adverse events in most of the studies reviewed (Theou et al, 2011).

There are many programmes and groups across Hampshire where you can refer your patient, to help increase their daily activity. Not only will this combat social isolation in these individuals but also decrease the risk of having a fall. Group exercise has been shown to decrease the rate of falls by 29% and the risk of falling by 15%. Some examples of programmes include:

• STEER
• Steady and Strong
• Healthy Bodies, Healthy Minds
• Cardiac Rehabilitation
• Southern Health NHS Foundation Trust balance classes

However, some individuals may prefer not to attend group exercise programmes. If clinically appropriate there are many simple exercises that your patient can complete at home with similar benefits. Home-based exercise has been shown to reduce the rate of falls by 32% and the risk of falling by 22%. This video from the Chartered Society of Physiotherapy demonstrates six simple exercises that can be performed at home. This can also be downloaded as a leaflet, containing further falls prevention information here. You can also direct your patient to the Active section of our website for more ideas on staying engaged with everyday life.

As health care professionals it is important to keep up-to-date on frailty including understanding the syndromes, triggers and mitigating its impact.

The Frailty Syndromes

1. Falls (eg, collapse, ‘legs gave way’ or ‘found lying on the floor’)
2. Immobility or sudden change in mobility
3. Acute confusion (delirium) or worsening of pre-existing confusion or short-term memory loss
4. New onset incontinence or worsening of urinary or faecal incontinence
5. Susceptibility to side effects of medication (eg, confusion with codeine, hypotension with antidepressants)

By working collaboratively with our partners and other organisations we can share skills, resources and expertise which are available in the wider health and care system. There are a variety of subjects covered on the NHS England website:

• Webinar recordings covering frailty identification, Summary Care Records, eFI, coding frailty and falls
• Healthy ageing and caring

The Hampshire Connect to Support website is a resource that can be used to navigate the clubs, hubs and support available across Hampshire. Helping your patients to stay informed is another great way to prevent and mitigate the effects of frailty.