Dr Ruma Dutta explores British Geriatrics Society guidance on assessing and supporting people with frailty and explains why good frailty services are important

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Read this article to learn more about:

  • how to recognise and assess frailty
  • the importance of a comprehensive geriatric assessment
  • self management and care plans.

Key points

GP commissioning messages

Frailty is a long-term condition that affects around 10% of people aged over 65 years and between one-quarter and one-half of those aged over 85 years. 1 It is defined as a medical syndrome with multiple causes and contributors, characterised by diminished strength and endurance, and reduced physiologic function, increasing an individual's vulnerability for developing increased dependency and/or risk of death.2 When hospitalised, frail patients have poor outcomes and often have a negative experience of care.3 They suffer harm as a result and on discharge require further services to help them recover from any acute injury or insult.3,4


The Department of Health envisages that over 800,000 people will benefit from the recently introduced Proactive Care Programme, by which people with the most complex needs will receive from their GP a personalised programme of joined-up care and support, tailored to their needs and views.5 This group often includes very vulnerable 'older people', who are the main users of healthcare and social care services. There is some evidence that focusing community services on people with frailty rather than on those 'at highest risk of hospital admission' might improve quality of patient care and reduce hospital bed usage.1,6 The NHS's aims in Five-year forward view include providing support for frail older people living in care homes, and provision of proactive intensive care to these target groups.7 In order to support people with frailty, they need to be recognised and assessed, and have a suitable programme of care put in place.

Recognising and assessing frailty

Frailty is usually recognised phenotypically in patients who have three or more of the characteristics described by Fried et al:8

  • unintentional weight loss
  • weakness
  • poor endurance and energy
  • slowness
  • low physical activity level.

Patients with frailty syndromes are often admitted to secondary care and intermediate care. Frailty can be opportunistically discovered in patients presenting with geriatric syndromes (e.g. falls, incontinence, delirium, immobility, iatrogenic harm)1 and can be quantified and measured using various scales (see text under heading 'Screening for frailty', below). It is useful to distinguish between the different concepts of frailty, disability, and co-morbidity and also to recognise where these overlap.9

The importance of recognising frailty

Research suggests that only one half of older people with frailty syndromes receive effective healthcare interventions.1 It is also known that people with frailty can experience significant harm if health interventions (e.g. starting a new drug, conveying them to A&E, or elective joint replacement) are planned without recognising the individual's frailty. 1 Active management is required to reduce these harms and to minimise potential adverse outcomes of other illnesses or interventions.1 The blueprint for excellence in care for older people with frailty is exactly the same as for high-quality and safe care for all users of healthcare services.1

British Geriatrics Society guidance on frailty

In June 2014, the British Geriatrics Society, in association with the Royal College of General Practitioners and Age UK, issued guidance entitled Fit for Frailty.1 This provides advice and guidance on the care of older people living with frailty in community and outpatient settings. In January 2015, Fit for Frailty Part 2 followed; this includes recommendations on redeveloping, commissioning, and managing services for these older people living with frailty.10 This Guidelines in Practice article summarises the main aspects of care and service provision recommended in this guidance.

Screening for frailty

Older people should be screened for frailty during all encounters with healthcare and social care professionals, who should be trained to do this.1 Recommended sensitive but non-specific screening tools include:10

  • the PRISMA 7 questionnaire (to identify disability see here)—a score of >3 indicates frailty 11
  • gait speed and up-and-go tests—a gait speed of >5 seconds to walk 4 m, or a 3 m timed up-and-go of >10 seconds indicates frailty. An up-and-go test measures the time taken to stand up from a standard chair, walk a distance of 3 m, turn, walk back to the chair and sit down1
  • the Edmonton Frail Scale can be used in primary and community care, and is recommended to screen patients for elective surgery.12,13

Comprehensive geriatric assessment

Frailty recognition in primary care should trigger a holistic and comprehensive review; the gold standard is a comprehensive assessment of medical, functional, psychological, and social needs followed by care planning.1,14,15 This review could be conducted by community geriatricians, supporting GPs in the management of individual cases; it is likely to take 30–60 minutes.1,10

Underlying diagnoses or explanations for all newly discovered symptoms and signs must be considered and addressed in the comprehensive assessment, which would include: 1,16

  • identifying and addressing any reversible medical conditions
  • assessing new problems that may present atypically
  • reviewing previous diagnoses and management of long-term conditions
  • assessing the impact of long-term conditions on patient and carer
  • considering whether any national and local guidance may apply.

For cognitive assessment, the 6-CIT cognitive test (validated in primary care) 1,17 or the Montreal Cognitive Assessment could be used.1,18 A complete physical examination should include special senses (vision, hearing, smell, taste). This should be followed by a medication review that takes into account the number and type of medications the person is taking (e.g. STOPP [Screening Tool of Older Persons' Prescriptions] and START [Screening Tool to Alert Doctors to Right Treatment] criteria).19

Care and support plans

Frail, elderly patients require individualised interventions aimed at improving their physical, mental, and social functioning and reducing the risk of adverse events (e.g. injury, hospitalisation, institutionalisation).1,10 People with mild to moderate frailty benefit from exercise programmes and home-based and group-based interventions, which improve both mobility and functional ability;20 strength and balance training is a key component in these.21 Mild to moderate frailty can be reversed or reduced by nutritional interventions including optimising protein intake, correcting vitamin D insufficiency, and reducing polypharmacy. 22 Advance care planning and commencement of palliative care may be the most appropriate intervention for people with advanced frailty. 1,23,24

The underpinning aim of the assessment review is to improve self-management of the person and carers by enhancing their knowledge, skills, and confidence and so to optimise the person's health and wellbeing. 10 An individualised care and support plan should follow, to include:1,10

  • healthcare and social care summary—symptoms, all diagnoses, medications, and the person's social situation
  • optimisation and/or maintenance plan—the individual's goals, actions by the patient, their carers, relatives, doctor and other healthcare professionals, with timescales
  • escalation plan—what a patient and/or their carer might need to look out for, and who to call or what to do if it happens
  • urgent care plan—what the individual wants to happen if a crisis occurs in their own health or in the health of their carer (e.g. do they want to go to hospital, under what circumstances would they want to stay at home, is there is a DNACPR [do not attempt resuscitation] order in place?).

and often:

  • advance care plan or end of life care plan—the patient's wishes with respect to their preferred place of dying, and whether they have 'just-in-case' medications in place.

Person-centred primary care for frailty

Care for a frail person needs to identify personal goals and to be:10

  • timely
  • person-centred
  • compassionate
  • accessible
  • coordinated
  • easily navigated
  • based on their assets and strengths, not deficits.

A good frailty service needs to be integrated and holistic, in contrast to the disease-centred approach taken with some other long-term conditions. The individual needs to take an active role, and engagement with the family and/or carers, whose needs should also be considered, is important. Services need to be sustained over a long period and to continue through intervening crises and adverse events. An individual with frailty needs to have a healthcare or social care practitioner responsible for the organisation of their care services, and who acts as a single point of contact for support and help. General practices should aim to ensure that an individual with frailty is managed by the same GP.10

Commissioning frailty services

Frailty services are important to the patients with frailty and to the whole health economy. Where frailty is associated with significant complexity, diagnostic uncertainty, or challenging symptom control, patients can be referred to geriatric medicine. For those with frailty and complex co-existing psychiatric problems, including challenging behaviour in dementia, old-age psychiatry services may be required.10 Ideally, services should be designed to accommodate closer working or integration with older people's mental health teams, social services, and care of the elderly services, as well as specialist services (e.g. for Parkinson's disease, pain services). Many dementia services already have these strategies and links, and many frail patients have dementia so it is sensible to join forces.25

Staff training and expertise

Staff in all the teams, whether in mental health, intermediate, or primary care will need to be trained to assess frailty and deliver effective interventions, as well as work across organisations and teams to provide person-centred care.

Care home residents

Care home residents are the most frail and vulnerable group in our society. Multidisciplinary assessment, effective medication reviews, and advance care planning are all known to be effective in this population;26,27 implementing proactive care for these populations could be a sensible place to begin.

Primary care IT coding for frailty

The electronic frailty index is a validated tool using existing data to calculate a cumulative score that is useful for prognosis, based on 2000 read codes for 36 possible deficits and is now available as a practice-level report in SystemOne.28,29


Clinical pathways for frail patients could include: 10

  • rapid assessment of frailty syndromes
  • admission-alternative pathways
  • a pull-out-of-hospital pathway25
  • a continuing healthcare assessment pathway. 25

These can be implemented via different models, for example local enhanced services, commissioning for quality and innovations (CQUINs), community 'care navigators', integrated nursing teams/frailty managers, or community geriatricians with a multidisciplinary team (a particularly effective way of addressing frailty). Full information-sharing between healthcare and social services is needed, with common assessment frameworks and IT infrastructure. These initiatives would all contribute to a truly integrated approach to healthcare delivery.25


Systems would be needed to assess efficacy and measure outcomes; for example: 27

  • number of trained staff
  • waiting times for comprehensive geriatric assessment after an index event
  • audits of frailty
  • patient safety
  • function and pain
  • reduction in delayed transfers of care
  • outpatient visits
  • quality of life measures for patients and carers.

Reductions in emergency admissions and social and healthcare care costs should follow in the longer term.24,30,31


Frailty is a distinctive health state in which minor stressors, often caused by hospitalisation, can lead to a sudden decline. These eventualities should be planned for and can often be prevented by comprehensive geriatric assessment. The person-centred care planning for people with frailty requires integration by all healthcare and care sectors in terms of training, strategy, and infrastructure.

Key points

  • Frail patients are vulnerable to the effects of hospitalisation and are often hospitalised for unrecognised, preventable syndromes
  • Identification of frailty should trigger comprehensive geriatric assessment as well as care and support planning
  • Primary care systems should support the ethos of person-centred, proactive care to target populations:
    • this will require the integration of IT, clinical pathways, and multidisciplinary teams co-ordinated at a single point.

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GP commisioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • Patients who are identified as frail are at increased risk of hospital admission and will benefit from targeted interventions
  • Commissioners should explore the efficacy of such interventions and look to commission them to improve health in these patients but also to avoid expensive inappropriate hospital admissions
  • CCGs should explore the new models of care espoused in the NHS Five year forward view, in particular, enhanced care to residential homes and multi-specialty community providers as ways of addressing the challenges of effectively identifying and responding to frailty
  • Multi-professional community teams will be required and CCGs should look to commission an integrated service to provide this
  • Building community geriatricians into these community services could be achieved without the necessity of expensive Payments by Results tariff payments and make these services more affordable
  • CCGs should explore with NHS England ways of resourcing and incentivising general practices to identify and manage frailty better, possibly using local alternatives to QOF or the Unplanned Admission Directed Enhanced Service as is happening in some areas (e.g. Somerset).

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  1. British Geriatrics Society. Fit for frailty: consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. British Geriatrics Society. London: BGS, 2014. Available at: www.bgs.org. uk/campaigns/fff/fff_full.pdf
  2. Gordon A, Masud T, Gladman J. Now that we have a definition for physical frailty, what shape should frailty medicine take? Age and Ageing2014; 43 (1): 8–9.
  3. Ipsos MORI. Understanding the lives of older people living with frailty: a qualitative investigation. London: Age UK, 2014. Available at: http://www.ageuk.org.uk/professional-resources-home/research/social-research/living-with-frailty/
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  11. Hébert R, Raîche M, Dubois M et al. Impact of PRISMA: a coordination-type integrated service delivery system for frail older people in Quebec (Canada): A Quasi-experimental study. J Gerontol B Psychol Sci Soc Sci 2010; 65B (1): 107–118.
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  31. Nuffield Trust. Evaluating integrated care and community-based care: how do we know what works? London: Nuffield Trust, 2013. Available at: www.nuffieldtrust.org.uk/sites/files/nuffield/ publication/evaluation_summary_final.pdf