Finding frailty and responding in primary care

Defining Frail

Most people have an intuitive understanding of the descriptive term ‘frail’.  In the last few decades it has been increasingly used in a technical sense in Healthcare.  However, an agreed definition still eludes us. There are different ways of ‘measuring’ it and the most effort continues to be put into the severe (hospital) end of the spectrum because short to mid-term outcomes of hospital (re)admission are the cost drivers.  Other, less measurable outcomes include adverse changes to quality of life, functional status, morbidities, mortality and carer stress.

There are a few ways of conceptualising this black box of frailty such as a phenotype of characteristics (including weight loss and specific signs of low energy/activity) or a count of deficits/conditions (1).  A description of frailty which still works after 30 years involves decreased reserves with less resistance to stressors (2) - fragility and vulnerability.

It is most helpful to think of it as a dynamic continuum with a range of contributing factors.  The possibility exists for intervention (medically, functionally, socially) at any point on this continuum to reverse or slow progression and to assist a person’s independence.

General Practice Context

Issues of acute deterioration, diagnosing delirium and organising discharge are important for a hospital identification of frailty.  However, general practice is the ideal context in which to flag frailty risk.  Tools are often not accurate nor validated on community populations.  There is an intention to implement a risk stratification tool under the Health Care Homes funding but we don’t need to wait for this.  We can already identify many risk factors for adverse outcomes.  We have data about whether our patients have multiple conditions or medications, depression or cognitive impairment.  Health Assessments record recent falls and functional status decline.  Furthermore we know psycho-social factors interact with clinical factors and appropriate interventions depend on knowing the patient in his/her context.  

Next time you see a patient you think is becoming frail,  check any contributing factors and then address ways of re-balancing their situation toward robustness.  Ask how they rate their health.  Do they need a condition treated, a medication stopped, psychological help, advocacy for extra social care, appliances or respite for a carer?  We can make a difference in many ways.

References

1. The frailty phenotype and the frailty index: different instruments for different purposes.  Cesari, M et al Age Ageing (2014) 43 (1): 10-12. DOI: https://doi.org/10.1093/ageing/aft160
2. Campbell AJ, Buchner DM.  Unstable disability and the fluctuations of frailty. Age Ageing. 1997 Jul;26(4):315-8. 

Useful reading

A very useful UK  document from the British Geriatrics Society, RCGP and Age UK - Fit for Frailty

A short Australian summary - Frailty Syndrome