Frailty is a condition in which people become less resilient and more vulnerable – even little upsets which may seem quite trivial to someone who doesn’t have frailty, can have a big impact.

Health and care professionals tend to think first about this impact in terms of acute health events, such as people needing  to go to A&E or being admitted to hospital. However,  there are many other adverse outcomes associated with frailty that may not necessarily come to the attention of health and care services, such as a deterioration in people’s wider wellbeing or their ability to do things that are important to them in their daily lives.

Frailty is a result of the changes that occur in many different physiological systems during a person’s lifetime and so it is most common in older age, although it is important to remember that it is not an inevitable consequence of ageing.

It is a complex and multi-dimensional state, which is related to, but distinct from, ageing and other important concepts including multimorbidity (the presence of more than one long term health problem), co-morbidity (when two or more long-term conditions interact together), disability and dependency.

Frailty is also a dynamic condition, the course of which can be influenced, and has the capacity to improve as well as to progress.

Frailty and multimorbidity

The concept of frailty first emerged as a result  of the increasing recognition that there was a subset of older people particularly prone to adverse clinical outcomes following apparently minor stressors. As well as the impact of these poor outcomes upon individual older people and their carers, this group collectively had increased health and care needs, creating increased economic and capacity pressures in health and care systems.

However, the problems these older people experienced could not necessarily be defined in relation to specific diseases or disabilities.  Furthermore, they often did not respond well to the guideline driven disease management approach widely adopted in modern health and care services.  It became apparent that this group had changes in multiple physiological systems and that focusing clinical management solely upon their individual long-term conditions did not achieve the desired outcomes. This was because in the presence of multimorbidity, the effectiveness of evidence-based guidelines for single conditions becomes limited by the overall complexity of the person’s condition.  More recently, recognition of this has led to the publication of NICE guidance (NG56) Multimorbidity: clinical assessment and management.

Although the concept of frailty is now well established, there is still no universal agreement regarding a single model of frailty or some other key aspects of condition.

Perceptions of Frailty

‘Frailty’ remains a term that is widely used but which can mean different things to different people. Perceptions of the condition vary depending upon whether the perspective is that of individuals with frailty, their families and carers, health and care professionals, or wider society.

Compared to people living with frailty, families, professionals and carers often use different language when discussing or describing frailty and assign different priorities to the consequences of the condition. For example:

  • In medical literature frailty is described as ‘a state of vulnerability, resulting from a cumulative decline in many physiological systems over a lifetime, in which minor stressors are associated with an increased risk of adverse outcomes‘.
  • A qualitative study by Age UK Understanding the lives of older people living with frailty; a qualitative investigation described people with frailty as: ‘people over 65 years, and probably much older, who struggle to do everyday tasks themselves and are becoming increasingly vulnerable to setbacks and difficulties‘.

This variance partly reflects the difference between lay and professional perspectives, but it also illustrates the absence of common agreement regarding the nature of frailty.

However, in real terms the most important thing about frailty is that it is a big part of many people’s lives.

Why is the concept of frailty useful?

The usefulness of the concept of frailty depends upon it having meaningful applications that can help to improve individual experience and quality of life for people living with the condition. These applications can be considered in three main categories:

  • Individual case management.
  • Service planning and delivery.
  • Research and development.

On an individual level, recognising frailty can help to identify opportunities and approaches for intervention.  It can also inform clinical decision-making.  For example, people with frailty have altered pharmacokinetics and therefore the recognition of frailty has important implications for medicines management.  It can also support targeted interventions related to potentially modifiable features of frailty, such as sarcopenia and nutrition.  The recognition of frailty can also help to avoid interventions that might be inappropriate in the context of frailty, thus preventing or minimising complications or unintended consequences of healthcare interventions in this group of people.

Go to next post: What does Frailty look like

Further information:

http://www.thelancet.com/pb/assets/raw/Lancet/stories/audio/lancet/2013/08february.mp3

http://www.thelancet.com/cms/attachment/2018141618/2038311048/mmc1.mp4