Frailty in older people: what it is, why it matters and what helps

NHS England describes frailty as a medical condition where people lose their in-built reserves and become increasingly susceptible to illness. Its clinical definition is a state characterised by decreased physiological reserve, increased vulnerability to stressors and an increased risk of adverse outcomes such as falls, delirium, loss of function or independence, hospitalisation, long-term care needs and premature mortality.

Frailty is not the same thing as having several long-term conditions or a disability, although they overlap. BGS says many people with multiple long-term conditions also have frailty, which may be masked when the focus is on the individual diseases, and that many people with long-term disability do not have frailty.

BGS also points out that many older people do not perceive themselves as frail and may not want to be defined by the term, so professionals aim to use language that preserves dignity and control.

The central problem with frailty, BGS says, is the potential for serious adverse outcomes after a seemingly minor stressor, anything from a simple episode of flu to a major intervention such as a joint replacement. Apparently simple events, such as a trip to the emergency department after a fall, a move to short-term residential care or a trial of a new painkiller, can have unforeseen and adverse outcomes.

NHS England says frailty, rather than age alone, is an effective way of identifying people at greater risk of sudden deterioration, falls, confusion, disability, hospital admission and the need for long-term care. Recognising it early makes it possible to take steps to maintain health, reduce vulnerability and delay loss of independence.

BGS describes two broad models. The phenotype model lists unintentional weight loss, reduced muscle strength, reduced walking speed, self-reported exhaustion and low energy expenditure, with three or more characteristics suggesting frailty and fewer suggesting pre-frailty. The cumulative deficit model counts accumulating problems, from loss of hearing or low mood through tremor to diseases such as dementia, and a clinical frailty scale can be used after a comprehensive assessment.

BGS advises that any interaction between an older person and a health or social care professional should include an assessment to identify frailty, including outpatient appointments, social care assessments, primary care reviews, home carers and ambulance crews attending after a fall. It also says individuals should not be labelled simply as frail or not frail, since frailty varies in severity.

BGS says a central feature of physical frailty is loss of skeletal muscle function (sarcopenia), that age is the strongest risk factor, and that prevalence is usually higher in women among community-dwelling older people. It cites a UK study from 2010 that found a prevalence of 8.5 per cent in women and 4.1 per cent in men aged 65 to 74.

It adds that, among modifiable influences, physical activity is the most studied. Evidence for diet is less extensive, but suboptimal protein and total calorie intake and vitamin D insufficiency have both been implicated, and there is emerging evidence that frailty increases with obesity in the context of other unhealthy behaviours.

BGS says that knowing someone has frailty can help professionals prevent a poor outcome from a particular intervention, or even avoid the intervention, and start a pathway of care to address the issues contributing to frailty. Planning any intervention, such as starting a new drug, conveying to the emergency department or an elective joint replacement, without recognising frailty and balancing the risks and benefits, may result in significant harm.

For individuals, the practical steps follow from the risk factors BGS lists: regular physical activity including resistance exercise, adequate protein and calorie intake, and attention to vitamin D. NHS England says frailty can make recovery from illness or injury take longer or be more difficult, so planning ahead for illness and asking for help early matters.

BGS emphasises that older people living with frailty are a diverse group, each with different expectations, hopes, fears, strengths and abilities, and that many develop their own ways of coping. Care should restore control, preserve dignity and be person-centred, including the people close to them.

NHS England says a relatively minor problem such as an infection can have a long-term impact on someone with frailty, so families and carers are encouraged to raise concerns early with the GP or NHS 111.

On the NHS, frailty is identified in primary care, hospitals and community teams, with NHS England publishing a best practice guide for frailty pathways. Care may involve the GP, community nursing, physiotherapy, occupational therapy and geriatric medicine, and social care assessment.

Private geriatric assessment is available for people who wish to have a comprehensive review. It is worth asking how the findings will be shared with your GP and how any recommendations, for example about medicines, will be followed up.