Frailty
“Frailty syndromes can mask serious underlying illness and the response to a crisis call from an older person with frailty should reflect the potential underlying illness and not the symptom itself. It is not acceptable for ‘just a fall’ to be regarded as a non urgent situation without reviewing the patient in person.”
What is Frailty?
Frailty develops as a consequence of age-related decline in multiple physiological systems, which collectively results in a vulnerability to sudden health status changes triggered by relatively minor stressor events [1]
Frailty can be considered as a long-term health condition characterised by loss of physical, emotional and cognitive resilience as a result of the accumulation of multiple health deficits. [2]
Frailty is a disorder of multiple inter-related physiological systems, it is a dynamic process, but decline to worsened state of frailty is more common than improvement [1]
Frailty is characterised by a decline in functioning across multiple physiological systems that increases susceptibility to stressors [3]. These stressors can range from infection, minor surgery or a new medication but can also, like in the context of dementia, include stressors such as a change in environment or social setting. The latter is of particular relevance in dementia patients.
Frailty is not age, disability or having multiple long term conditions. Frailty is a clinical syndrome whereby the person gradually loses the ability to maintain their homeostasis. Many definitions though neglect the cognitive and social elements which are so important, if you have good cognition and social support those deficits may not be so apparent.
Frailty leads on to a whole host of potential complications - many of which are covered in previous and future episodes of the MDTea podcast- e.g. Dehydration (ep8) Delirium(ep2), Inadequate nutrition (in series 2), Skin breakdown, pressure ulcers, Lowered resistance to infection, Falling (ep 5 and in series 2).
Prevalence
Frailty is statistically more prevalent in women (11 studies, 9.6%, 95% CI 9.2-10) than men (5.2%; 95% CI 4.9-5.5).
Frailty increased steadily with age: 65-69 years: 4% of the population estimated to be frail, 70-74 years: 7%; 80-84 years: 16%; and in the >85 years: 26%. Rates appear to be higher in studies that employed the graded frailty index, which would count as frail some people whose increased risk is captured in the pre-frail category of the phenotype model. In short, prevalence depends on how you score it, but rises significantly in the over 80s. [4]
“It is estimated that a quarter to a half of people over 85 years are frail, these people have a significantly increased risk of falls, disability”
Why is frailty important to recognise?
People living with frailty are more vulnerable to the effects of potential stressors and to deterioration than others of the same chronological age [6]. Frailty generally results in a spiral of decline- increased frailty, risk of worsened disability, falls, multiple admissions to hospital and death.
Frailty scoring helps us identify patients who may be at higher risk of living with frailty and benefit from interventions that aim to reduce the impact of frailty related harms.
Frailty is associated with:
Increased risk of falls
Increased admissions to hospital·- prevention possible by paramedics who don’t just transport to the hospital.
Longer lengths of stay
High risk of readmission
Increased dependency with activities of daily living
With the likelihood to require some form of care
Trajectory is towards institutional care (nursing home)
Excess risk of death
Physiological changes in ageing
Brain - reduction in volume and blood supply. Increasing frailty is associated with increased rate of cognitive decline
Endocrine - Decreased hormone production, decline OGF-1 assoc neuronal plasticity and increased skeletal muscle strength decline.
Immune system - decline in stem cells, reduced T-lymphocyte production, blunted B-cell led antibody response, reduced phagocytic activity of neutrophils, macrophages and natural killer cells, immune system can function at baseline state but may fail to respond appropriately to acute inflammation.
Sarcopenia- This is a key component of frailty and often a catalysing element of the cycle of frailty.
Sarcopenia is a progressive loss of skeletal muscle mass, strength and power, possibly accelerated by a decline in neurological/endocrine and immune components which may upset homeostasis and accelerate muscle loss.- combine reduced muscle mass, reduced strength, and reduced power with a reduced functional ability and you have a cyclical decline.
Associated with increased fall risk, impairment of performing ADLs, mobility disorders and among other things, increased risks and costs of care relating to hospitalisation.
Causes: - reduced activity in ageing, reduced appetite and anorexia, reduced ability to utilise protein to maintain muscle mass.
Frailty scoring
Rockwood or Clinical Frailty Scale:
Validated for =/>65’s
Observe mobility & ask about daily tasks and assistance at home.
1 to 9: very fit to very frail and including palliative, >5 is considered frail. Mild= CFS4-5, Mod=6 Severe =7-8, Score of 6 or above initiates CGA (ideally) ~OPALS
Used internationally, across settings (hospital, LTC, OPC, community) and use has been increasingly documented since 2005 onwards Church et al, 2020)
Pictorial and physically focused although wording does mention ADLs
Dementia mentioned but this is often hard to define as moderate or mild if don’t know the patient well or particularly familiar with dementia
Therefore cognition, mood, social elements not included.
Good correlation to FI
Easily implemented and followed with minimal need for training.
Complete based on two weeks prior- HCPs often see people at a time of functional decline, so it is important to remember we want to know a ‘baseline normal’
Don’t just pick the picture that matches the mobility aid used in the picture… READ THE DESCRIPTION
Dont just pick a middle ground/circle- will often see paper notes where clinician has circles 4-6? which are they?
Why paramedics/ambulance crews are particularly suited to score it well using Rockwood CFS
no data validating to Prehospital setting (but lots of other settings data eg community, hospital, care homes etc)
Paras see pt homes, so can see the ADLS, spend time collecting a holistic assessment eg ADL’s carers etc. We also see how people’s homes look so might get a feel for if they are giving ‘optimistic’ answers- in ED/hospital scoring is based entirely on paperwork and patient hx.
As well as the numerical score, is it useful to see how we have arrived at that? i.e. document it in SHx.
ADLs, Mobility Aids, Care package, Falls frequency / Shopping- alone? transport? driving? are they a care giver? / Mobility aids- from OT? or bought themselves? inside/outside home? furniture surfing, stairs, lift, house/flat/bungalow.
Take Away Points
Take Away Points
Frailty is a long term health condition, caused by the accumulation of multiple co-morbidities, both physical and psychological. It is a reduced ability to maintain homeostasis, resulting in increased susceptibility to stressor events.
Frailty is dynamic with improvements and deterioration possible. Often patients will deteriorate as frailty is a terminal event.
If we are seeing the so called, “geriatric giants” frailty, sarcopenia, and anorexia of aging, we should be ensuring patients have a holistic assessment, we should consider asking wider questions and consider what else could be ongoing with the patinet.
Use someone’s baseline over the last 2 weeks to frailty score them. Not how they are in front of us right now.
It is useful to demonstrate how we have arrived at our score with a detailed SHx in our notes.
Frailty scoring is an essential tool to flag up our patients to specialist teams in hospital, ensuring they receive the best care.
Pre-hospital crews are best placed to score frailty, as we spend a long time with patients and get to see them in their homes.
Take Away Points
Take Away Points
Remember, clinicians are responsible for their own practice. These podcasts are produced for informative purposes and should not be considered solely sufficient to adjust practice. We provide lots of learning resources, so don’t just take our word for it…navigate to these and reflect on this topic further. See "The Legal Bit" for more info.
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