Managing frailty

Holistic medical review

Once a person has been identified as frail, a holistic review by a GP will allow for optimisation of the person’s health and for considered forward care planning. It may involve onward referral for a more Comprehensive Geriatric Assessment by an interdisciplinary team. An appropriate period of time should be put aside to allow for this holistic review (it is likely to take at least 45 – 60 minutes - depending on how well the individual is known to the GP or specialist nurse doing the assessment). It may be appropriate to invite relatives and carers to be present at the assessment as well as any care workers involved with the individual. The setting of the review can be agreed with the patient; however the physical examination needed as part of this assessment will limit choice.

Underlying diagnoses and reversible causes for these problems must be considered and addressed as part of the assessment.

In looking for cognitive impairment, it is helpful to use a standardised cognitive assessment such as the 6-CIT cognitive test (which has been validated in primary care) (www.patient.co.uk) or the Montreal Cognitive Assessment (http://www.mocatest.org/).

New medical problems, which can present atypically, should be enquired about in the structure of a systems review. Previous diagnoses and long term conditions and their management should be reviewed. As patients with frailty commonly have other long term conditions, it is important to assess the impact of these as a whole and consider if national and local guidance is appropriate for the individual. A medication review is also important in this context (see below). A complete physical examination including eyes, ears and a neurological examination is vital.

The assessor (whether the patient’s GP or another) must ensure that there is a diagnosis or explanation for all newly discovered symptoms and signs. It is vital to look for reversible medical problems and to ensure that the agreed care plan (see next section) includes the appropriate investigations needed to look for treatable disease - as agreed with the patient.

In some situations, it might be helpful to consider an assessment structured under the domains used in Easycare (ref https://www.easycarehealth.co.uk/) which are;

• Seeing hearing and communication
• Getting around
• Looking after yourself
• Housing and finances
• Safety and relationships
• Mental wellbeing
• Staying healthy.

However this less medical centred approach does not remove the obligation on the person doing the assessment to look for reversible medical problems and underlying diagnoses.

Assessment of Capacity. If there are concerns about cognitive function, it is important to consider mental capacity which might influence subsequent care and support planning.  The principles of the Adults with Incapacity (Scotland) 2000 and Mental Capacity Act (England and Wales) 2005 are:

• Assume Capacity
• Help people to have capacity in all practical ways before deciding they do not have   capacity
• People are entitled to make unwise decisions
• Decisions for people without capacity should be in their best interest and the least restrictive possible.

The 4 point capacity test is:

• Can they understand the information given?
• Can they retain the information given?
• Can they balance, weigh up or use the information?
• Can the person communicate their decision?

If the answer to any of these is ‘no’ then the person does not have capacity. 

However it is also important to remember that capacity may fluctuate and that it is time and decision specific. All health and social care professionals must recognise their responsibilities with respect to mental capacity and be prepared to reassess capacity if the situation changes.

Drugs and medicines review.

Medication reviews are important – many drugs are particularly associated with adverse outcomes in frailty such as:

• Antimuscarinics in cognitive impairment.
• Long acting benzodiazepines and some sulphonylureas, other sedatives and hypnotics increase falls risk.
• Some opiate based analgesics increase risk of confusion or delirium.
• NSAID can cause severe symptomatic renal impairment in frailty.

Conversely, some drugs which would offer symptomatic benefit are omitted because of concerns about frailty, when with careful monitoring they would be safe to use (such as ACE inhibitors in heart failure). 

With ageing the metabolism of drugs changes and this needs to be taken into account when prescribing as it may affect dosage.

The use of multiple medications by older people with frailty is likely to increase the risk of falls, adverse side effects and interactions, hence the need to individualise the interpretation of national guidelines for single long term conditions in the context of multimorbidity in general and frailty in particular.

A discussion about the stopping of preventative chronic disease medication such as statins and warfarin for atrial fibrillation and sedatives and antihypertensives should include the potential impact on the hoped for long term outcomes for the individual in question. It might be appropriate to consider using validated medication appropriateness checklists such as the STOPP and START Guidelines.

Care plans and referrals

At the end of the assessment, which should also have included a discussion about individual goals and aspirations, the person doing the assessment should help the individual and, if relevant, their carers should draw up an individualised care and support plan.  There is more information about this in the next section.

The plan may include referrals to other community services such as intermediate care, mental health, a geriatric service or a falls service. This plan may therefore feed into a larger review which would constitute full CGA.

It is also important to develop an escalation plan which helps individuals and their carers identify what they should look out for and when and who they should call for help and advice. It should include an urgent care plan which, at a time of future crisis, could guide the emergency or out of hours services as to the appropriate decisions to take around emergency department conveyance and hospital admission. 

It may be appropriate to start to explore, sensitively, issues around end of life planning. If there are advance directives, it would be important to review and record this in locally agreed systems for future reference.

Comprehensive Geriatric Assessment

CGA is a clinical management strategy which will give a framework for the delivery of interventions which address relevant and appropriate issues for an individual patient. After CGA it will be possible to use the Rockwood Clinical Frailty index to demonstrate the level of frailty of the individual. However, it is not a rapid process. The initial assessment and care planning for a full CGA is likely to take at least 1.5 hours of professional time, plus the necessary time for care plan negotiation and documentation (likely total of 2.5 hours, plus there is a need for ongoing review). Therefore it is simply not feasible for everyone with frailty (from mild up to severe life limiting frailty) to undergo a full multidisciplinary review with geriatrician involvement. Nevertheless, all patients with frailty will benefit from a holistic medical review (see detail below) based on the principles of CGA. Some people will need to be referred to a Geriatrician for support with diagnosis, intervention or care planning and others will also need to be referred to other specialists in the community such as an Old Age Psychiatrist, therapists, specialist nurses, dieticians and podiatrists.   

Whatever level of input is needed for an individual, the resulting process of assessment, individual care and support planning (see detail below) and regular review is vital to provide an evidence based management plan for frailty.

Multidimensional assessment

Comprehensive Geriatric Assessment (CGA), also known in some countries as Geriatric Evaluation and Management (GEM), involves a holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health.

CGA typically results in the formulation of a list of needs and issues to tackle, together with an individualised care and support plan, tailored to an individual’s needs, wants and priorities.

It is usual to describe the domains which comprise ‘multidimensional assessment’ as follows:

• Physical Symptoms ( which must include pain) and the underlying illnesses and diseases.
• Mental Health Symptoms (including memory, mood and poor organisation) and the underlying illnesses and diseases.
• Level of function in daily activity, both for personal care (washing, dressing, grooming continence and mobility) and for life functions (communication, cooking, shopping using the phone etc.).
• Social Support Networks currently available, both informal (family, friends and neighbours) and formal ( social services carers, meals, day care). It needs to include the social dynamic between the individual and his/her family and carers (whilst trying to avoid too much judgement).
• Living Environment – state of housing, facilities and comfort. Ability and tendency to use technology. Availability and ability to use local transport.
• Level of Participation and individual concerns, i.e. degree to which the person has active roles and things they have determined are of significance to them (possessions, people, activities, functions, memories). Will also include particular anxieties, for example fear of ‘cancer’ or ‘dementia’. Knowledge of these will help frame the developing care and support plan.
• The compensatory mechanisms and resourcefulness which the individual uses to respond to having frailty. Knowing this will allow the care and support plan to incorporate strategies to enhance this resilience.

Extensive research has shown that CGA in hospital increases independence (individuals are more likely to go home after this process compared to standard medical care) and reduces mortality. A recent Cochrane review showed that those who underwent CGA on a ward had a 30 pre cent higher chance (OR 1.31 CI 1.15 – 1.49) of being alive and being in their own home at six months. This equates to a Number needed to treat of 13.16 

However, despite considerable evidence for CGA in community settings in the US, there is less evidence to support CGA in community settings in the UK because the research has not been done. Nonetheless a recent review showed that CGA in the community which focussed on older people identified with frailty could reduce hospital admissions. 

The BGS believes that it is highly likely that CGA in any setting will be an effective intervention for an older person identified as having frailty. In the community there may need to be local flexibility in terms of what constitutes an interdisciplinary team and how the medical input is provided – nevertheless, the principle stands. The resulting individualised care and support plan must  include information for older people and their carers about how and when to seek further advice and possibly information which defines  advance planning for end of life care.  

Readers who would like to learn more about Comprehensive Geriatric Assessment are advised to read ‘Comprehensive Geriatric Assessment- a guide for the non specialist’. Welsh TJ.;Gordon AL.; and Gladman JR. Int J Clin Pract2013 doi: 10.1111/ijcp. 12313.

Summary: managing frailty

• Carry out a comprehensive and holistic review of medical, functional, psychological and social needs based on comprehensive geriatric assessment principles in partnership with older people who have frailty and their carers.
• Carry out a comprehensive and holistic review of medical, functional, psychological and social needs based on comprehensive geriatric assessment principles in partnership with older people who have frailty and their carers.
• Ensure that reversible medical conditions are considered and addressed.
• Consider referral  to geriatric medicine where frailty is associated with significant complexity, diagnostic uncertainty or challenging symptom control. Old age psychiatry should be considered for those with frailty and complex co-existing psychiatric problems including challenging behaviour in dementia.
• Conduct personalised medication reviews for older people with frailty, taking into account number and type of medications, possibly using evidence based criteria (e.g. STOPP START criteria).
• Use clinical judgement and personalised goals when deciding how to apply disease based clinical guidelines in the management of older people with frailty.
• Generate a personalised shared care and support plan (CSP) which documents treatment goals, management plans, and plans for urgent care which have been determined in advance. It may also be appropriate for some  older people to include end of life care plans.
• Establish systems to share the health record information (including the CSP) of older people with frailty between primary care, emergency services, secondary care and social services.
• Ensure that there are robust systems in place to track CSPs and the timetables for review.
• Develop local protocols and pathways of care for older people with frailty, taking into account the common acute presentations of falls, delirium and sudden immobility. Ensure that the pathways build in a timely response to urgent need.
• Recognise that many older people with frailty in crisis will manage better in the home environment but only with support systems which are suitable to fulfil all their health and care needs.

Can frailty be reversed?

A central feature of physical frailty, as defined by the phenotype model, is loss of skeletal muscle mass and function (sarcopenia). There is a growing body of evidence for beneficial interventions to address this aspect of frailty and this has been reviewed recently. The benefits of exercise in older people with frailty shows that home-based and group-based interventions result in improvement in both mobility and functional ability. Strength and balance training is a key component although a wide range of approaches have been employed and the optimal exercise regimen remains uncertain. 

The place of nutritional interventions also needs to be considered although evidence remains limited. Recommendations currently include optimising protein intake and correcting vitamin D insufficiency. A number of drug interventions have been proposed to improve muscle mass and function. Testosterone improves muscle strength but is also associated with adverse effects, particularly on the cardiovascular system. Growth hormone probably improves mass more than function. There is also interest in the idea of ‘new tricks for old drugs’ such as the angiotensin-converting enzyme inhibitors which appear to improve the structure and function of skeletal muscle. Currently there is not sufficient evidence for this to be translated into clinical practice.