People with frailty have particular needs, as a result of which they have the most to gain from integrated and responsive systems of care which take a holistic and person-centred approach.
In order to make sure people with frailty receive the right care and support, at the right time and in the right place, we need to identify and assess people with frailty at the earliest opportunity in their journeys of care. The importance of this is highlighted in key guidance including the British Geriatrics Society Fit for Frailty and NICE guidance on multimorbidity, which recommends assessing people with multimorbidity for frailty.
Whilst there is no universally agreed model for frailty, and therefore no unified diagnostic framework or measurement approach for the condition, there are a wide range of tools that support the identification and assessment of frailty. The appropriateness of the tool depends on the approach taken. Broadly we can consider approaches to be focused on the individual or operated at the population level.
At an individual level the approach may be considered opportunistic as it will typically take place when the person is in contact with health and care staff for another reason, such as a routine appointment or an urgent care presentation. As such it may be limited to identifying and assessing only those people already ‘known’ to the health and care system.
One analogy for this reaction driven approach is the visible part of an iceberg, whereas a proactive population-based approach has the potential to uncover people with frailty who are not immediately ‘visible’ to health and care staff. This can be considered to be finding frailty before it finds us. Individuals identified in this way have important health and care needs, which if managed proactively can have a huge positive impact upon health and care systems.
There are four broad types of tools for identifying and assessing frailty these are:
- Simple instruments such as basic physical assessments like the walking (gait) speed test, the Timed Up and Go test or measurements of grip strength.
- Questionnaires and self-reporting. These may be simple one or two question responses or more detailed surveys. Opportunistic assessment tools include: PRISMA 7, FRAIL questionnaire, Self-reported health status, level of fatigue and levels of physical activity. Tilburg and Groningen Frailty Indicator questionnaires can also be used for population-based approaches.
- Clinical assessment. These tools require a trained individual to assess the person face to face through a clinical interaction. The depth of the assessment can vary considerably but will typically be multi-dimensional to some extent and therefore have the advantage of leading more directly to a set of actions or interventions. They include the Edmonton Frail Scale, Clinical Frailty Scale (Rockwood) and Comprehensive Geriatric Assessment.
- Using routinely collected data. These tools enable population-based approaches to identification and risk stratification. Examples include electronic Frailty Index which has been developed and rolled-out across the main primary care systems (SystmOne and EMIS) to calculate an eFI for each individual over 65 on a GP practice list. It is also possible to use primary care electronic health records to identify markers of potential frailty such as the number of regular medicines a person is prescribed.
The selection of the tool for identifying and assessing frailty will depend on both the approach and the setting.