Advice on identifying and managing frailty

Practices are required to identify and manage patients living with frailty according to the following guidance 

CREDIT: This is an edited version of an article that originally appeared on BMA

Recognition that a patient has a degree of frailty can prompt a GP to review the care offered to them. Care should be tailored to their needs, and take into account the risks of polypharmacy and inappropriate treatment. Recognising frailty can also help in the planning and delivery of services, particularly for older people.

In identifying frailty, there is sometimes confusion between three concepts; multi-morbidity, frailty and disability. This guidance refers to frailty only.

The British Geriatric Society refers to five ‘frailty syndromes’:

• Falls (eg. collapse, legs gave way, ‘found lying on floor’).
• Immobility (eg. sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’).
• Delirium (eg. acute confusion, ’muddledness’, sudden worsening of confusion in someone with previous dementia or known memory loss).
• Incontinence (eg. change in continence – new onset or worsening of urine or faecal incontinence).
• Susceptibility to side-effects of medication (eg. confusion with codeine, hypotension with antidepressants).

Identifying frailty

Practices are required to use an appropriate tool, such as the electronic frailty index, to identify patients over the age of 65 who are living with moderate and severe frailty.

These tools should be seen as guides only. The decision to code someone as moderately or severely frail should be made by an experienced clinician guided by the electronic score. It is likely that these patients will be seen on a regular basis and coding can take place over the course of the year.

Electronic frailty index

The electronic frailty index uses data that is available in the GP electronic health record to identify and severity-grade frailty; this enables the identification of older people who are fit, and those with mild, moderate and severe frailty.

It uses a ‘cumulative deficit’ model, which measures frailty on the basis of the accumulation of a range of deficits, which can be clinical signs (eg. tremor), symptoms (eg. vision problems), diseases, disabilities and abnormal test values, and is made up of 36 deficits comprising around 2,000 read codes.

Management of the severely frail

For patients identified as being severely frail, the practice will be required to deliver a clinical review providing an annual medication review and to discuss whether the patient has fallen in the last 12 months. Practices should also provide any other clinically relevant interventions and code them.

Where a patient does not already have an enriched summary care record, the practice should offer this to the patient. It is up to the clinician whether it is appropriate to code patients who are moderately frail.