Dr Sunil Angris offers top tips on the identification, assessment, and management of frailty in people aged 65 years and over

Dr Sunil Angris

Dr Sunil Angris

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Read this article to learn more about:

  • validated tools that can be used in primary care to identify risk
  • carrying out a comprehensive geriatric assessment
  • the importance of managing co-morbidities that affect mental wellbeing.

Frailty is now a recognised long-term condition, as defined by NICE.1 Its incidence and prevalence are associated with a number of factors, most notably age and multimorbidity. Clegg et al demonstrated that increasing severity of frailty is also associated with increased risk of hospitalisation and length of stay, future nursing home admission, and mortality.2

Advice in this article is focused on dealing with frailty in those aged 65 years and over, since this cohort contains the significant majority of people living with this condition, and 65 is conventionally used as the baseline age for defining older people. The effective management and support of older people living with frailty will improve quality and experience of life for those individuals, as well as address issues of the cost of care for the NHS and local authorities.

1. Identify frailty in primary care using a validated tool

Use the electronic frailty index for population-level identification

The development of the electronic frailty index (eFI)2 has allowed for population-level use of a validated theoretical risk stratification tool, which uses the clinical coding system used in GP electronic patient records. It organises over 2000 clinical codes into 36 variables (deficits) and produces a numeric score between 0 and 1 to grade the severity of an individual’s frailty risk. Frailty is graded as no frailtymild frailtymoderate frailty, or severe frailty.

The eFI is currently the best population-level frailty risk tool available in general practice and enables proactive identification. It is also validated against frailty-related outcomes and other frailty tools such as the Rockwood clinical frailty scale;3 however, it should be noted that it is not a diagnostic tool—clinical validation to confirm the presence and severity of frailty is still required.

The accuracy of the eFI depends on the completeness and accuracy of recording in any patient’s record. In my clinical work, I have regularly found relevant patient data in other documents held in primary care (such as care home records) that isn’t reflected in the GP records. Examples include patient’s sensory impairments (deafness, loss of sight, etc), level of cognitive functioning, dental status, level of continence, and functional ability. Therefore, if there seems to be a discrepancy between a person’s theoretical eFI score and what is known about their level of functioning ability, I would advise that the completeness of coding of their GP-held record is cross-checked against other available records.

It is also worth remembering that the eFI is a theoretical score, so it is also possible to have a person whose functional ability and level of independence is greater than their eFI score would suggest.

Consider other validated tools for identification of probable frailty

Apart from the eFI, there are several other straightforward validated tools that primary care professionals can consider in order to identify frailty in a person, and two of these are briefly described in more detail here:

  • The Rockwood (or Dalhousie) clinical frailty score3—pioneered by Professor Ken Rockwood. This scale is based on the phenotype model of frailty, augmented by specific facts about an individual’s life and level of dependency. It has been used widely across the world to screen for frailty quickly and effectively on a 7- or 9-point scale, and can be used in a spectrum of settings from a person’s home to GP practices and A&E/urgent care centres (NB the 9-point scale can be found at: www.cgakit.com/fr-1-rockwood-clinical-frailty-scale)
  • The PRISMA-7 scale. This is a simple but effective self-evaluation questionnaire using seven questions. Each question scores 1 for a positive (‘yes’) answer and a score of 3 or more indicates probable frailty that requires deeper assessment (the toolkit can be accessed at: www.cgakit.com/fr-1-prisma-7).

NB Other useful screening tests for frailty include the Gait speed test and the Timed up and go test.

2. Take opportunities for frailty identification

One of the most common ways a person who has frailty will present in primary care (including acutely) is with one or more frailty syndromes (previously known as ‘the geriatric giants’). According to the publication Fit for frailty by the British Geriatrics Society (BGS) there are five frailty syndromes:5

  • falls
  • immobility
  • delirium
  • incontinence
  • susceptibility to side-effects of medication (e.g. adverse effects of polypharmacy).

Primary care professionals should have a very high index of suspicion of frailty in anyone presenting with any one of the above syndromes. It is very often the case that a person presents with more than one frailty syndrome; for example, falls caused by hypotensive episodes secondary to taking multiple antihypertensive drugs, or delirium secondary to electrolyte imbalance from diuretics.

3. Know when to carry out a comprehensive geriatric assessment

The BGS Fit for frailty publication recommends comprehensive geriatric assessment (CGA) as the gold standard for assessment of those diagnosed with frailty, and for planning their ongoing management.5 This is because the CGA is a holistic (and usually multidisciplinary) process that has been demonstrated to be associated with improved outcomes in a range of settings. The CGA takes into account far more than just a person’s health and mental wellbeing—it adopts a patient-centred focus, and examines their living, social, and working environments and networks. The intended output of a CGA is a person-centred, comprehensive care plan that maximises the person’s autonomy and functional potential.

My advice, however, is that it is unrealistic and unnecessary for all those identified as having frailty to undergo a CGA. Based on the four eFI categories of frailty, my recommendation is as follows:

  • No frailty ormild frailty—the care plan should focus on promoting a healthy lifestyle and evidence-based management of any disease and/or long-term conditions
  • Moderate frailty or severe frailty—consider a CGA. It is likely that many individuals identified with severe frailty will already be well known to primary care professionals as they are likely to be housebound, vulnerable, and/or on end of life care pathways. Their existing care plans may already be ‘comprehensive enough’ to address their wishes and needs (which are often about preserving dignity and effective pain management).

4. Conduct a CGA in primary care

Conducting an effective CGA in primary care, using appropriately trained professionals, is perfectly feasible, and necessary given the huge number of people aged ≥65 years who are likely to need one.

Between 2016–2017, I was employed on a GP Access Fund initiative in Shropshire and conducted CGAs on all the care home residents registered with three different GP practices. Working alongside the GPs in each practice, I carried out CGAs on over 100 residents in 6 months. An evaluation of the project outcomes and results carried out by the Shropshire Doctors Co-operative (SHROPDOC) in 2017 showed that:

  • it was highly valued by GPs, care home staff, and the residents, and demonstrated a measurable positive impact on residents’ quality of life
  • CGAs performed in primary care are a cost-effective alternative to secondary care based CGA services.

Evidence-based medicines management was also carried out as part of the initiative, as recommended in NICE Guideline 56 on Multimorbidity: clinical assessment and management.1

5. Recognise the important role of carers

The importance of the role of carers and identifying their own support needs cannot be overestimated. Most older people with frailty live in their own home and are cared for by ‘informal carers’ for most of the time (i.e. family, friends, and their wider social network rather than paid healthcare or social care professionals). Informal carers play a critical and irreplaceable role, which must be recognised in any assessment and considered in a management plan, provided the patient agrees, as recommended in NICE NG56.1

Increasingly, such individuals have a more formal guardianship or power of attorney role, especially if the person being cared for has any measurable cognitive impairment. The excellent and free NHS publication, A practical guide to healthy caring, is a valuable resource for signposting both the assessor and carer towards a range of support services and benefits.

6. Ensure integrated care pathways are in place

Integrated care pathways are essential for successfully managing the needs of people with frailty as these individuals are especially at risk of the consequences of ‘siloed’ care. Without integrated care, patients with frailty are more likely to be inappropriately admitted as an emergency and to spend longer in hospital once they are medically fit for discharge.

It is incumbent on healthcare professionals to ensure that important information is shared in a timely fashion in the best interests of the individual across all the organisations involved in their care. The role of the third sector, voluntary sector, and public services is significant and a positive asset to be harnessed. Other emergency services such as the fire service are also often a source of information and practical help (for example, in assessing fire risk, installing alarms and other items of equipment).

7. Carry out a comprehensive medication review

Comprehensive medicines management for people with frailty is vital, especially for those individuals who are at risk of polypharmacy. Using a validated tool—such as the STOPP START tool7—to carry out a comprehensive review of medications in those with frailty is highly recommended. Such individuals almost always take four or more regular medications and are therefore at increased risk of the adverse effects of polypharmacy. The STOPP START tool allows a simple but effective evidence-based evaluation of a person’s medications using a RAG (red, amber, green) rating system. This allows for safe de-prescribing, a reduction in the treatment burden, and the minimisation of medication-related side-effects (see tip 2 for more information on polypharmacy/frailty syndromes).

8. Identify and manage co-morbidities that affect mental wellbeing

The identification, assessment, and effective management of co-morbidities affecting mental wellbeing is crucial. The disproportionate impact of dementia and measurable cognitive impairment on a person’s resilience and autonomy is well established—for example, the Rockwood clinical frailty scale3 notes that the degree of frailty correlates directly with the degree of dementia. Similarly, it is accepted that those with frailty are at increased risk of other factors affecting mental wellbeing, such as loneliness, anxiety, and depression.

I would strongly advise using the 6-item cognitive impairmenttest (6CIT)8,9 to assess for dementia or cognitive impairment in anyone who doesn’t currently have a diagnosis. In my clinical work in Shropshire the pick-up rate using the test in care home residents was around 70%. The test itself is simple, quick, and validated for use in primary care. Similarly, a validated test for assessing depression and anxiety such as the Hospital anxiety and depression scale (HADS)10,11 is also strongly advised, especially for anyone requiring a CGA.

Dr Sunil Angris

GPwSI, Frailty and integrated care

References

1. NICE. Multimorbidity: clinical assessment and management. NICE Guideline 56. NICE, 2016. Available at: www.nice.org.uk/ng56

2. Clegg A, Bates C, Young J et al. Development and validation of an electronic frailty index using routine primary care electronic health record data.Age Ageing 2016; 45 (3): 353–360.

3. Rockwood K, Song X, MacKnight C et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173 (5): 489–495.

4. South Warwickshire General Practitioners (SWGP). Frailty specific tools—PRISMA-7 questionnaire. SWGP, 2016. Available at: frailty.swgp.info/files/Documents/Prisma7%20Frailty%20Questionnaire.pdf

5. British Geriatrics Society (BGS). Fit for frailty part 1—consensus best practice guidance for the care of older people living in community and outpatient settings. Available at: www.bgs.org.uk/campaigns/fff/fff_full.pdf

6. NHS England, Age UK, Carers Trust, Carers UK, Public Health England. A practical guide to healthy caring. NHS England, 2016. Available at: www.england.nhs.uk/wp-content/uploads/2016/04/nhs-practcl-guid-caring.pdf

7. North of England Commissioning Support unit (NECS), NHS Cumbria CCG. STOPP START toolkitsupporting medication review. NECS, 2016. Available at: medicines.necsu.nhs.uk/download/stopp-start-2-cumbria-screen-version/

8. NHS Wales. Six item cognitive impairment test (6CIT). Available at: www.wales.nhs.uk/sitesplus/documents/862/FOI-286g-13.pdf

9. Brooke P, Bullock R. Validation of a 6 item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry 1999; 14 (11): 936–940.

10. British Geriatrics Society (BGS) website.Hospital anxiety and depression scale(HADS). Available at: www.bgs.org.uk/pdfs/assessment/hads_mood.pdf

11. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67 (6): 361–370.