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The Study of Ageing: Understanding Frailty to Deliver Impactful Healthcare

The British Geriatrics Society (BGS) is an organisation for healthcare professionals involved in the care of older people, working to improve health in later life. Members include doctors, nurses, psychiatrists, physiotherapists and occupational therapists - as well as scientists working on the study of ageing. We talked to BGS President Dr Eileen Burns about the key ways in which geriatric medicine is advancing – and the role of frailty in understanding and delivering impactful healthcare.

How has geriatric medicine changed over the past few decades? Have there been any big advances in the way that we look at it?

Yes, there’ve been some massive advances – and probably the most important is the improvement in our understanding around why some older people remain fit, active and healthy and don’t become frail as they age - and other people do.

We use the term frail in general parlance and think we know what it means, but there’s a specific scientific definition, developed through research, which has led us to understand that some people, as they age become less able to withstand the impact of something like an infection.

A fit and active older person might get a chest infection and perhaps be in bed for a day or two, but then they’ll be back to normal with the right treatment.

A frail older person with a chest infection, however, might become muddled, perhaps have a fall, or lose their mobility and independence - and it will take them longer to recover. Sometimes, especially if they don’t get the right treatment and rehabilitation, they may never get back to the level of independence that they had before the illness.

Understanding why people may become frail, what we can do to reduce risks of becoming frail, what being frail means and how we can identify what level of frailty people are living with are all important things that have received attention in the last 10 years - and that’s really helped us to understand more about the science of ageing.

Is frailty a key marker for improving services and medicine for older people?

It is because it helps us to inform all sorts of decisions that we might make about future health care.

"One of the easiest ways [to identify frailty] is to measure someone’s walking speed. If someone takes quite a lot of time to walk a short distance that would indicate that they are likely to be living with frailty."

For example, if I, as a person living with frailty, need a hip replacement, my surgeon and I need to think carefully about whether that is definitely the right thing for me. If my hip’s not too bad, then actually the risks of the surgery for me may be greater than they would for someone who wasn’t living with frailty.

Frailty gives us a way of identifying people who have higher risks from procedures, interventions and processes that they might otherwise be routinely offered, and which they need to understand in this context so they can make a careful, informed decision.

On the positive side, some interventions will help people living with frailty. For people with moderate or severe frailty, this means an evidence-based approach, where their physical and mental health needs and their need for rehabilitation, aids and adaptations and care are assessed by a professional with expertise in the care of older people.

Then an action plan is produced to try and address those issues highlighted by the assessment that are potentially remediable.

There’s good evidence that you’re more likely to be living in your own home six months down the line if you’re living with frailty and have that intervention than if you just receive standard hospital care.

Are there challenges to people understanding and accommodating their own frailty?

There’s a big issue around terminology because ‘frailty’, like ‘geriatric’, is a word that has negative connotations. Understandably, older people are not keen to be labelled - and particularly not as frail.

"There’s a big issue around terminology because we know that ‘frailty’, like ‘geriatric’, is a word that has negative connotations. Understandably, older people are not keen to be labelled, and particularly not as frail."

We at the BGS commissioned Age UK to do some research with older people, and they told us clearly they don’t like the term frailty. They could just about cope with being described as “living with frailty,” but they didn’t want to be called frail.

There’s a difficulty, though, because the scientific literature uses that terminology and when we say to people, “Well okay, what else shall we call it then?” they come up with terms that don’t really describe it or give a sense of what we’re really talking about.

How do you identify frailty?

One of the easiest ways is to measure someone’s walking speed. If someone takes quite a lot of time to walk a short distance that would indicate that they are likely to be living with frailty.

However, this is just a screening tool, because obviously, if I fell over and broke my leg tomorrow, I’d have a slow walking speed - but I wouldn’t be frail.

Similarly, you can use something called the ‘get up and go’ test, where you ask someone to get up from a chair, walk a few yards, turn around and sit back down. Similarly, you can actually identify whether they’re at risk of frailty.

Should these types of tests be automatic for anyone over a certain age?

NHS England has taken this on board, and as of last summer GP contracts now include a requirement to identify patients in their practice who are living with moderate or severe frailty.

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GPs then have a requirement to ask those patients if they’ve had problems with falls, offer them a falls assessment and also to review those patients’ medication - because we know that as we age, and particularly as we become frailer, some medications that were effective when we were younger may have fewer benefits and potential side effects.

The other thing that GPs are recommended to do for patients with moderate or severe frailty is to ask them to agree to allow their data to be shared to something called the Enhanced Summary Care Record. What that means is, if you turn up at the hospital the doctors will be able to see key information in your GP record that will then help in managing your care.

There’s been antipathy to data sharing in some quarters because of concerns about people selling data, but this is actually an instance where it is absolutely in people’s best interests to agree to allow data to be shared.

If someone is delirious, or perhaps suffers a head injury and presents at the hospital, and the hospital has no information about that person, it makes their care much more problematic.

Sarcopenia has been highlighted as a key feature of frailty – what is it?

Sarcopenia is basically the loss of muscle mass and muscle strength, and it’s associated with a reduction in walking speed. There are other aspects of frailty such as the immune system not working quite so well, but sarcopenia is a really important factor, and there’s a lot of research going on to identify what, if anything, can be done to prevent or to reduce its progression.

A recent study, the FIT trial, demonstrated that sustained exercise taken with nutritional supplements did actually retard, and in fact reverse, some degree of sarcopenia. So there’s some encouraging evidence that there are things that we can do to actually reverse that loss of muscle strength.

And it’s never too late to start - I wouldn’t want to give the impression that if you’ve reached your 60s and you’ve not been terribly active, there’s no point in trying. That’s absolutely not the case - but undoubtedly, the earlier you start in your life, and the more active you keep, the better.

What other steps can you take to improve moderate frailty?

You can improve the impact of frailty. So thinking about, for example, the effect on your immune system, if you are poorly nourished, there’s evidence that an improvement in your nutrition can improve your ability to resist infections.

There’s also good evidence that a comprehensive geriatric assessment and the right intervention can improve your life and reduce your risk of having to be admitted to a care home, for example.

So there are positive messages there. On the other hand, we have to be realistic. If someone is living with severe frailty, it is sensible for them to think about what they would like for their future and how they want things to progress as they move towards the end of their life.

What, for you, is the most important research currently being done in terms of understanding frailty better?

There’s a lot of research going on, so it’s very difficult to pick out specific projects. However, two important areas are work led by Professor Avan Sayer, into sarcopenia, looking at exercise and nutrition and how we can understand more about the science of maintaining and promoting muscle functioning, and there’s also an important piece of work led by Dr Andrew Clegg and Professor John Young in Bradford, looking at preventative measures around frailty.

This work considers the impact of community-level interventions to help people to remain active, pursue healthy lifestyles and remain engaged with their communities as they age and not become socially isolated - and how effective those kinds of broad interventions might be in helping people not develop frailty in the first place.

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