Concepts of frailty and better care for older people from a GP perspective. Article 1 of 3
Written by Dr Chris Bollen MBBS MBA FRACGP FACHSM MAICD
The SNPHN and NSLHD Frailty Initiative is piloting a new project to introduce frailty screening for older people to support early identification and develop pathways to appropriate evidence-based management. The overall aim of the project is to optimize the wellness and longevity of older people in Northern Sydney.
The project will be trialled in a hospital inpatient setting, community health locations and general practice. This article is the first of a series of 3 to assist GPs, primary care nurses and other health professionals to understand some of the issues confronting healthy ageing and what they can do differently in their everyday consultations.
The Intergenerational Report released in 2015 highlighted something many GPs are very familiar with. People are living longer and there are rapidly increasing numbers older people in our practice populations. The NSW population has 16% of people aged 65+. In comparison, the care of community dwelling older patients comprises a larger proportion of the workload for GPs. Encounters with patients aged 65 years or more accounted for 30% of general practice encounters (BEACH study 2013). This group is complex, with the number of medications used per person climbing after the age of 75 with at least 50% taking 8+ medications, and 30% having Chronic Kidney Disease stage 3a or worse (eGFR less than 60mls/min). Think about the issues of delivering safe and effective care to this group in your practice if CKD is not coded and identified in your prescribing software!
Dr Norman Swan (Radio National Journalist) addressed a health aging festival recently with a very positive quote, “We are living younger longer.” However a major issue for about 10-15% of older people is the concept of “frailty”, a subset of functional decline, and reflects the inability to perform usual activities of daily living due to:
- reduced muscle strength, and
- reduced exercise capacity
Watch this promotional ad from France regarding frailty. What do you think if our local TV stations started playing this. Is your general practices ready for this? We should be making changes to what all do, if we are going to effectively help people age well and keep well at home.
What is frailty? There are many definitions and tools – clinical, research, simple and complex, functional only vs function/ cognition.
Frailty can be defined as “Functional and/or Cognitive Vulnerability”, and may have one or more of the following features:
- Cognitive decline
- Falls and low trauma fractures
- Deteriorating gait
- Chronic Urinary incontinence
- Multiple medical problems (especially people aged > 85)
- Polypharmacy and medication side effects
Yet another way to think about it is as a multidimensional deterioration of function in cognitive, physical, and social domains.
The chronic condition known as “Frailty” occurs due to a combination of deconditioning and acute illness on a background of existing functional decline and is often under recognised. Frailty and functional decline are core factors for attendance at Emergency Departments, admission to hospital and premature entry to residential aged care facilities after an acute illness.
A “wellness model” of primary care based rehabilitation/restoration for older people is possible when general practice and community aged care providers collaborate to improve outcomes for older people. The evidence now shows that such intervention results in:
- Improved quality of life for older people
- Reduced functional decline
- Reduced cognitive decline
- Reduced hospital admission
How do you recognise “Frailty”?
It is important to be familiar with new evidence-based frailty screening tools as it is no longer acceptable to respond by demeaning the older person with unhelpful comments such as “there’s nothing much to be done, it’s because you are getting older”. Evidence based responses now show:
- referrals for exercise (muscle building) programs,
- dietary supplementation (Vitamin D, sustagen and other high protein drinks)
- plus social and cognitive stimulation and support
can slow the rate of functional decline, and frequently reverse decline if people are detected at the early frail stage.
Best practice in the care of older people can be found well described in the excellent publication “Fit For Frailty”, which is a joint collaboration between the British Geriatric Society and the UK Royal College of General Practitioners. (http://www.bgs.org.uk/fit-for-frailty/resources/campaigns/fit-for-frailty/fff-headlines ) Two practice based tips which are worth adding to our consults/care plans/health assessments for anyone over 75 are the FRAIL screen, and to weigh older people at every consultation.
Remember to add these the simple questions for the FRAIL screen to your practice’s 75+ Health assessment template (from Professor John Morley (geriatrician, St Louis, Missouri http://www.frailty.net/) )which requires a yes/no response:
Fatigue-are you feeling tired or fatigued? (yes-score 1)
Resistance- can you walk up a flight of 10 stairs? (overcoming the resistance of body weight against gravity) (no-score 1)
Ambulation- can you walk around the block (400m)? (no-score 1)
Illnesses- 5 or more chronic conditions? (yes-score 1)
Loss of weight of 5% or more over past 6 months? (yes-score 1)
What do you do about Frailty?
If the older person scores 2, they are pre-frail, 3+ indicates they are frail and would benefit with immediate referral to:
- a community based restorative care program such as coordinated by “Just Better Care” or other providers (see Healthpathways Sydney healthpathways.org.au
And click on older person’s health-> Frail But Stable Older Person
- Myagedcare https://www.myagedcare.gov.au (noting the FRAIL score in the referral), 1800200422 fax: 1800 728 174
- the Sydney Local Health District Aged Chronic Care and Rehabilitation Service (ACCR) https://www.slhd.nsw.gov.au/acrs/
- Exercise physiology using medicare
And finally, what are you doing for your own self care and healthy ageing as a health professional? It does need to be considered because it does not happen by itself! This recent BBC/ABC program discusses the issues of how to reduce the effects of ageing. Recommended viewing, as there is no pill for this! https://www.youtube.com/watch?v=jREH3EFZBQc
- A useful podcast on the topic of improving systems of care for older people (links to slides and podcast) http://www.ihi.org/resources/Pages/AudioandVideo/WIHI-Creating-Age-Friendly-Health-Systems.aspx
- Video links to updates on 75+ Health assessments and identifying frailty in general practice https://armchairmedical.vhx.tv/chris-bollen
- Meat and livestock brochure available to give to patients about:
- protein and its importance when older
- Tips for living well after 65
More information in the next newsletter.(including a link to the FRAIL management tool check list)