What is frailty?

In simple terms, frail patients lack physiological reserves, and it takes more for them to bounce back after an insult. Contrary to common beliefs, frailty is not an inevitable part of ageing. It does not necessarily imply multiple comorbidities, although these often co-exist.

There is a growing body of evidence about the underlying pathophysiology of frailty. Sarcopenia (loss of muscle mass) and chronic inflammation seem to be central to the progression of frailty. Two main models of frailty are the phenotype model (frailty as a syndrome, with slowness of walk, weakness and fatigue as main symptoms) or a cumulative deficit model (hearing loss, visual deficit, etc.).

Why think about frailty when clerking? 
It is crucial that clerking of new patients focuses on identifying frailty. There are several reasons for this:

• Hospital admission of a frail person may lead to severe deconditioning. Knowing the baseline of a patient, and being able to establish how far off their baseline they currently are, may allow you to save them a hospital admission and hence further deterioration of their frailty.
• Recognising the level of the frailty of newly admitted patients will greatly help with rehabilitation (physiotherapy and occupational therapy) and speed up discharge planning, hence shortening their admission, and therefore avoiding deconditioning and nosocomial infections.
• Setting treatment goals is important in frail patients, and will be aided by recognising what their baseline is (as well as taking into account their wishes, advance decisions and/or discussions with relatives about their best interests).

A salient example of the last point is Do Not Resuscitate decisions. The frailer the patient, the less likely a patient is to be discharged home after an in-hospital cardiac arrest. This needs to be discussed with patients and their relatives, and decisions made in the light of this as well as their co-morbidities and current presentation.

How to diagnose and quantify frailty 
How you measure frailty depends on the setting – the Rockwood frailty scale is often used in hospital settings. This takes into account both existing comorbidities, as well as the level of dependence for activities of daily living (scale reproduced below).

Rockwood Clinical Frailty Scale

As a clerking FY1, you will thus need to take a detailed and thorough social and past medical history. Try to gain consent from the patient to contact other people to complement the history, such as:

• Relatives or friends who know the patient and their home environment
• Carers or nursing home staff
• GPs
• Community speech and language therapists
• Community dietitians
• Other specialists involved in the care of the patient (oncologists to get an idea of stage and prognosis of any malignancy, etc)

To guide your history taking, you can think of the Comprehensive Geriatric Assessment (CGA) framework. You would of course not be expected as an FY1 to carry out a full CGA, but incorporating aspects of it in your clerking is very helpful for the geriatricians and therapists who later come and assess the patient.

The different domains of the “multidimensional assessment”, as reproduced from the British Geriatrics Society website, are as follows:

• Physical Symptoms (which must include pain) and the underlying illnesses and diseases.
• Mental Health Symptoms (including memory, mood and poor organisation) and the underlying illnesses and diseases.
• Level of function in daily activity, both for personal care (washing, dressing, grooming continence and mobility) and for life functions (communication, cooking, shopping using the phone etc.).
• Social Support Networks currently available, both informal (family, friends and neighbours) and formal (social services carers, meals, daycare). It needs to include the social dynamic between the individual and his/her family and carers (whilst trying to avoid too much judgement).
• Living Environment – state of housing, facilities and comfort. Ability and tendency to use technology. Availability and ability to use local transport.
• Level of Participation and individual concerns, i.e. degree to which the person has active roles and things they have determined are of significance to them (possessions, people, activities, functions, memories). Will also include particular anxieties, for example, fear of ‘cancer’ or ‘dementia’. Knowledge of these will help frame the developing care and support plan.
• The compensatory mechanisms and resourcefulness which the individual uses to respond to having frailty. Knowing this will allow the care and support plan to incorporate strategies to enhance this resilience.

Common presentations in the frail
Common conditions, including infections, acute coronary syndrome, and electrolyte abnormalities may present differently in frail persons, for example as falls, delirium, or incontinence. Falls have been covered extensively in a different article.

Falls can be seen as the manifestation of a “frailty crisis”. As a clerking FY1, you must try to exclude an acute medical event leading to the fall:

• Infection
• Cardiac event
• Electrolyte abnormality
• Intracranial event
• Constipation/retention

Consider whether this fall could be iatrogenic (medication review, see below).

Then, use the history gathered to look at the trajectory of this patient in terms of their function – is this a patient who was previously frail but not acutely unwell, therefore not requiring healthcare resources? This fall may be an opportunity to set up adequate support to help them cope better in their environment.

Delirium is another common presentation of frail people which may be an expression of the same underlying pathologies as falls (also, consider pain as a possible trigger). Again, delirium has been extensively covered in a different article.

Patients may have “dementia” or “cognitive impairment” listed in their past medical history from previous clerkings and discharge summaries. It is crucial to clarify whether a formal diagnosis of dementia was made (through a community dementia service, aka ‘memory clinic’), the exact type of dementia, and when the diagnosis was made. A patient with a very recent diagnosis of vascular dementia will need to be managed differently to a patient with advanced Alzheimer’s disease diagnosed ten years ago.

If you suspect cognitive impairment and you want to screen for dementia, you can take a collateral from a person who knows the patient well using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

In addition to an AMTS, it is useful to undertake a Montreal Cognitive Assessment (MOCA) or other more extensive cognitive scores. Having a baseline MOCA (from before admission) is also very useful, to track deviations from baseline.

To screen specifically for delirium, other tools must also be used (4AT or CAM score): these focus on attention, consciousness levels and fluctuations in cognition.

Incontinence is another presenting complaint commonly seen in frail patients. It should be actively screened for sensitively, as many may feel embarrassed or scared by new incontinence symptoms.

Complaints of new incontinence (faecal or urinary) should be addressed as they would in any patient, including making attempts to rule out sinister pathology such as cauda equina syndrome. Similarly to delirium, incontinence can be an expression of a wide array of pathologies (infections, electrolyte imbalance). Do a thorough medication review.

Decreased mobility is a direct result of increased frailty is a common cause of incontinence.

Polypharmacy is a common occurrence in frail patients. Hospital admission of frail people is an opportunity to review their medications and rationalise them to reduce risks of adverse effects, such as falls.

Many tools exist to help clinicians decide which medications have risks that outweigh benefits and vice versa. One of these (recommended by NICE) is STOPPFrail (or STOPP/START). In addition to the risk/benefit ratio, it also takes into account how difficult medication administration is and compliance of patients with treatment.

Involving patients in decisions to stop medications is important – some may have been on certain drugs for years and may feel confused as to why they are suddenly being stopped.

Take-home message
Overall, the key take-home message for FY1s is to remember to think very broadly when clerking a patient who appears frail. Contact relatives, carers, and GPs. Establish if any advanced care planning already exists. Get support from your seniors to discuss ceilings of care and treatment goals. When planning for discharge of frail patients, work with the rest of the multidisciplinary team towards the aim (as stated by NICE) to develop “a coordinated, integrated plan for treatment and long-term support”.

Summary of key resources

• More information about frailty and the NHS’s strategy to tackle it
• About the 4AT
• 4AT & CAM-ICU scores
• MOCA
• Collateral for cognitive decline: IQCODE
• Geriatric support tools
• Urinary incontinence NICE guidance
• Faecal incontinence NICE guidance

Bibliography

• “Introduction To Frailty | British Geriatrics Society”. Bgs.Org.Uk, 2020, https://www.bgs.org.uk/resources/introduction-to-frailty. Accessed 13 Apr 2020.
• Leng, Sean et al. “Frailty Syndrome: An Overview”. Clinical Interventions In Aging, 2014, p. 433. Informa UK Limited, doi:10.2147/cia.s45300. Accessed 13 Apr 2020.
• “Deconditioning Awareness | British Geriatrics Society”. Bgs.Org.Uk, 2020, . Accessed 13 Apr 2020.
• Walthall, Helen et al. “Trapped In Care: Recognising And Responding To Frailty As A Cause Of Delayed Transfers Of Care”. Journal Of Clinical Nursing, vol 28, no. 1-2, 2018, pp. 5-6. Wiley, doi:10.1111/jocn.14356. Accessed 13 Apr 2020.
• Smith, Roger J. et al. “Frailty Is Associated With Reduced Prospect Of Discharge Home After In‐Hospital Cardiac Arrest”. Internal Medicine Journal, vol 49, no. 8, 2019, pp. 978-985. Wiley, doi:10.1111/imj.14159. Accessed 13 Apr 2020.
• “Managing Frailty | British Geriatrics Society”. Bgs.Org.Uk, 2020, . Accessed 13 Apr 2020.
• “Overview | Multimorbidity: Clinical Assessment And Management | Guidance | NICE”. Nice.Org.Uk, 2020, https://www.nice.org.uk/guidance/ng56. Accessed 13 Apr 2020.