How can I identify older people who may be frail?
Frailty is not an inevitable part of ageing, yet it is more common in older people.
While frailty is not an inevitable part of ageing it is more common in older people. Of people over the age of 65 years 10% have frailty, which rises to between 25 and 50% of those over 85 (Clegg et al 2013). The British Geriatrics Society (BGS) (2014) Fit for Frailty guideline recommends that older people should be assessed for frailty at all healthcare encounters.
The benefits of identifying frailty in practice include: early identification of an at-risk population; promoting proactive rather than reactive care; reducing the incidence of unplanned care; and supporting individuals and their families through informed decision making while balancing the risks and benefits of interventions.
'Evidence-based interventions for frailty include exercise’
In the first instance the frailty identification process should be simple, quick and easy to interpret. The tools spoken about most favourably (BGS 2014, National Institute for Health and Care Excellence 2016), which are accessible, simple and easy to use in all practice areas and environments, include the following:
- The phenotype indicators of frailty (Fried et al 2001) identify frailty based on five characteristics: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed and decreased physical activity. The presence of three of the five indicators identifies the presence of frailty. Monitoring these indicators during all encounters with older adults may help identify individuals who could benefit from interventions to prevent or delay the adverse outcomes associated with frailty.
- PRISMA 7 Questionnaire (BGS 2014) is based on the identification of risk factors for functional decline, using seven questions. Answering yes to three or more of the seven questions indicates the presence of frailty. Individuals can complete the questionnaire themselves or with support from a family member, carer, healthcare or social care worker. The benefit of this tool in practice is that it promotes a shared conversation and understanding relating to the concept of frailty.
- The gait speed test (Studenski et al 2011) is a valid predictor of frailty, falls disability and mortality, which is confirmed by an individual taking more than five seconds to walk four metres. It is a simple test that can be used to support carers, relatives, volunteers and professionals from across the health and social care system to identify frailty in a variety of settings. Gait speed can also be assessed informally by walking with and/or observing individuals walking.
- Self-reported health status (BGS 2014) involves asking the individual to rate their overall health status on a scale of 0-10. A score of six or less may indicate the presence of frailty. In practice it should prompt further discussion and/or the application of another frailty identification tool such as the PRISMA 7 Questionnaire or gait speed test.
The diagnosis of frailty is progressive over five to 15 years (Harrison et al 2015), meaning that early detection can potentially prevent or slow down the syndrome leading to a healthier lifespan. When an older person is identified as having frailty it is important to consider evidence-based interventions including comprehensive multidisciplinary team assessments and exercise-based interventions.
Nurses and allied health professionals are ideally placed to identify older adults living with frailty in their area of practice, using validated screening assessment tools to direct individuals and their families/carers to supportive services and interventions.
- British Geriatrics Society (2014) Fit For Frailty Part 1 Consensus Best Practice Guidance for the Care of Older People Living in Community and Outpatient Settings.
- Clegg A, Young J, Iliffe S et al (2013) Frailty in elderly people. Lancet. 381, 9868, 752-762.
- Fried LP, Tangen CM, Walston J et al (2001) Frailty in older adults: evidence for a phenotype. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 56, 3, M146-156.
- Harrison J, Clegg A, Conroy S et al (2015) Managing frailty as a long-term condition. Age and Ageing. 44, 5, 732-735.
- National Institute for Health and Care Excellence (2016) Multi-morbidity: Clinical Assessment and Management. NICE guideline 56. NICE, London.
- Studenski S, Perera S, Patel K et al (2011) Gait speed and survival in older adults. JAMA. 350, 1, 50-58.
Claire Nelson (@ClaireNelson22) is a consultant practitioner trainee specialising in frailty, Berkshire Healthcare NHS Foundation Trust