Last reviewed 10 June 2015
The British Geriatrics Society has been running a campaign on frailty, and a growing body of work has been produced on the topic. Jef Smith reports.
Frailty, thy name is woman, said Hamlet at a moment of particular pique with his girlfriend, Ophelia. The prince was not of course a very stable young man and he was under extreme family pressures one way or another, so perhaps he can be forgiven his sexism. Frailty indeed, is no respecter of gender. In a twentieth century context and referring to an age group rather older than Shakespeare’s doomed Dane, the British Geriatrics Society recently adopted frailty as a study and campaign theme, producing, in association with the Royal College of General Practitioners and Age UK, a growing body of work on the topic under the neatly ambiguous title Fit for Frailty.
The campaign opened with a 2014 publication dealing with the “Recognition and management of frailty in individuals in community and outpatient settings”. The term “community setting”, here as elsewhere, should emphatically be interpreted as including residential care homes, and indeed this document contains a good deal of useful material for social care practitioners.
First, it was necessary to set out what is meant by the much used — and often misused — word “frailty”. The authors offer as a definition “a clinically recognised state of increased vulnerability”, but from a social care perspective, I think we can ignore the exclusively medical emphasis of “clinically recognised” — is no-one allowed to be frail unless a doctor says so? — and focus simply on “increased vulnerability”.
In general terms, we all know and can easily recognise the signs of frailty, but it is useful to have them tabulated, particularly at the points where the medics take the trouble to express conditions in everyday terms — as, in fairness, these authors do most of the time. They identify five “syndromes”, the presence of one or more of which should trigger the suspicion of frailty, making the important point that these are easily overlooked, a dangerous gap since they may “mask more serious underlying disease”.
First up — or maybe one should say down? — are falls. Perhaps remembering how often when younger they fell without serious damage being done — the slightly hilarious slip off a chair at a party, the embarrassing but otherwise harmless trip on a pavement, the muddy slither in the garden — older people are often inclined to dismiss their falls as trivial. “My leg let me down”, “I wasn’t looking where I was going”, “just a moment of dizziness” they say half-disparagingly, as if such incidents are of no great significance and probably their own fault anyway.
Workers in homes may err in the other direction, to a point where their anxiety annoys their elderly resident as overdramatising a slight lapse, but their estimate is often a more prudent indicator that all might not be well. Finding someone lying on the floor alone, perhaps a while after they have fallen, is justifiably alarming even if the person who has tumbled insists that no fuss should be made.
The onset of frailty cannot easily be extracted from its social context, the vulnerable older person often inclined to make light of evidence that should be taken seriously, a concerned professional or relative perhaps going to the opposite extreme in demanding action in response to their own anxiety. A resident’s tendency to falling should always be the prompt for a thorough risk assessment, balancing the key values of safety and independence.
Change in mobility
Mobility, or rather an abrupt change to a person’s capacity to get around, is the second frailty syndrome. The same dynamics apply, the older person often trying to deny the potentially sinister sign that something is seriously wrong. Getting stuck on the lavatory can indeed be embarrassing, but the victim of such diminished agility may need to be helped to acknowledge that this could be a first sign of something more sinister.
The document recommends various quick and easily administered assessment processes for frailty. For example, the “Timed up-and-go test” requires the older person to rise from a chair, walk three metres, turn round and sit down again, the whole process to be achieved within ten seconds. Try it for yourself, but beware of awarding extra points for speeding up unnecessarily — too much haste in standing up and sitting down can also be dangerous even for the relatively youthful!
Delirium, the geriatricians’ third syndrome, is probably a term less familiar to social care practitioners. By delirium, the doctors mean an onset of acute confusion, the abrupt worsening of an existing pattern of confused thinking or behaviour, or perhaps a significant deterioration in short term memory loss. All of these will be familiar in residents, but they are not always given the status of danger signals which the authors of this report propose.
Fourth, they identify incontinence, which by contrast certainly does not require much interpretation for care in homes — being an all-too-familiar symptom among elderly service users. Again, however, the frail person’s embarrassment may be a hindrance to the new condition’s being discussed and recognised as prompting further investigation. Those who are providing intimate care may be in a privileged position gently to initiate such preemptive thinking.
Medication side effects
Fifth, there are the side effects of medication, a complex area with many variations and not a few unknowns even to experts. An older people may have come to accept that an otherwise effective medicine has some not very convenient side effects which, however, are worth putting up with as a lesser evil. If such symptoms are known to a medical practitioner, they may not occasion too much worry, but the onset of new side effects should always trigger a serious discussion and perhaps responsive action. Again, a care worker may be the first to spot the danger signal.
The precise form of appropriate action if any of these signs of frailty appear will of course vary from case to case, but the geriatricians’ document recommends that there should always be a Comprehensive Geriatric Assessment (GSA), which should be “holistic” and “interdisciplinary”. The fact that it will also in many instances be “time consuming” may, it admits, limit the range of disciplines contributing to the total picture, but old age psychiatrists, various therapists, and specialists nurses including those working in community mental health teams are singled out for mention.
Residential care homes should of course not be afraid of offering their input since they often have opportunities for informal observation denied to the more clinically based professions.
Though the initial focus in cases of frailty is quite properly on possible illness, it is left to homes to ensure that social as well as health factors are given due weight. It is after all very likely that much of the subsequent action, set out in a personalised Care and Support Plan (CSP), will fall to the staff of the home where the old person lives. As the document admits, “many older people with frailty in crisis will manage better in the home environment”, but it goes on to emphasise the need for “appropriate support systems”, which is exactly what a care home is in a position to provide.
The organisations which prepared the initial Fit for Frailty document have now carried the work forward with Part 2 of their project, a further document published in January covering “Developing, commissioning and managing services for people living with frailty in community settings”. This opens with a helpfully extended definition of frailty as “a distinctive health state related to the ageing process in which multiple body systems gradually lose their built-in reserves”. What might seem in themselves to be minor stressor events, it emphasises, can quickly lead to significant unpredictable health deterioration.
The objective of interventions prompted by frailty should be to improve functioning across the whole range of faculties, and for this, the document commends “a goal-oriented rather than a disease-focused approach” based around “personal assets, rather than deficits”. The fact that a group heavily biased towards doctors can come up with statements like these is a tribute to the progress of social thinking within the medical profession, for which social care professionals can take some credit. Similarly, developing care plans should routinely involve older people themselves and their families and carers. The days of “doctor always knows best” are emphatically behind us.
Pressures to keep older people out of hospital, if at all possible, have intensified over the last year. This new publication is frank about “the potential health risks of hospitalisation”, urging “real and safe alternatives to hospital admission” and “pathways to pull older people with frailty out of hospital and prevent unacceptable delayed transfers of care”. The dangers of delayed discharges have been well rehearsed for many years, but there is surely a new urgency in that word “pull”. The importance of residential care in the total system could hardly be more clearly expressed.
The picture is further complicated by the rising numbers of people with dementia, since the combination of dementia with frailty more than doubles the pressures involved in giving meaningful and appropriate support. Carrying out even very simple diagnostic tests becomes much more complicated when the person under investigation has cognitive and communication difficulties. There is also a danger that the presence of dementia becomes such a dominant factor in planning help that other conditions are overlooked, a phenomenon sometimes called diagnostic over-shadowing.
It is all the more important that workers from all disciplines persevere in comprehensively understanding older people’s health needs and achieving precisely the holistic picture the frailty campaign advocates. Some critics have argued that the concept of frailty is used by professionals almost exclusively in relation to physical deficits and risks, further underlining the importance of ensuring that cognitive deterioration is included in the total diagnostic picture.
Nor would any report on these issues be complete these days without a mention of end-of-life care and planning. Anyone with the sort of frailty discussed here is likely to be relatively close to dying, and that fact must be taken into account, without of course dominating, everything that is provided. The timely spotting of frailty, it can confidently be asserted, extends lives.