By Professor John Young, National Clinical Director for the Frail Elderly and Integration, NHS England
Frailty is related to the ageing process, that is, simply getting older. It describes how our bodies gradually lose their in-built reserves, leaving us vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in medication or environment. In medicine, frailty defines the group of older people who are at highest risk of adverse outcomes such as falls, disability, admission to hospital, or the need for long-term care.
Older people with moderate to severe frailty are often well known to local health and social care professionals. They usually have weak muscles and also usually have other conditions like arthritis, poor eyesight, deafness and memory problems. This means older people with frailty will walk slowly, get exhausted easily and struggle to get out of a chair or climb stairs. Typically therefore they are housebound, or only able to leave their home with help. This can be a simple practical way to identify people who are frail.
Older people with frailty are particularly vulnerable over the winter months so here are five simple tips that can help those with frailty cope and keep well.
“Rest is rust”
Frailty makes us tired. Even small amounts of activity can be exhausting so it’s easy to retreat into the comfort of an armchair, particularly during the colder months when other parts of the home may be chilly and unwelcoming.
But this can accelerate the frailty process and result in more muscle loss, especially the leg, chest and heart muscles.
For most people with frailty, simple advice to keep active in the home is all that is required. Promoting the use of stairs, it’s a good source of exercise, but make sure that it is safe – is an additional hand rail needed?
If the person cannot easily get up out of their chair, or move from room to room, alarm bells should ring. These people need a mobility assessment to develop personalised mobility plans that might include an exercise programme (for strength and balance), mobility aids, supportive footwear and home adaptations. Your local GP should be able to help organise this.
Weight loss is a characteristic feature of frailty as muscles become thinner and weaker, which in medicine we call the sarcopenia aspect of frailty.
Many older people with frailty report a diminished appetite and although research in this area remains inconclusive, it seems sensible to check that at least one substantial hot meal is available each day, along with snacks and hot drinks.
A slice of Christmas cake and a glass of milk, which can be supplemented with a spoonful of powdered milk, is roughly equivalent to the calorie content of a bottle of Ensure, and tastes a lot better!
Be brave! Stop those drugs!
Older people with frailty are very sensitive to medicines because the body has trouble getting rid of them. This can mean a normal dose of medicine can build-up in the body can cause an adverse reaction.
Adverse Drug Reactions (ADRs) account for 6.5 per cent of hospital admissions for older people and it is estimated that about 70 per cent of these might be avoidable.
There are common culprit drugs for falls (nitrates; calcium channel blockers; ACE-inhibitors; angiotensin receptor antagonists; diuretics), and for delirium (opiate analgesia; benzodiazepines).
Benzodiazepines are particularly nasty drugs in older people (Number Needed to Harm = 6 people) with increased risk for falls and delirium, and they contribute the fatigue state of frailty.
NHS Cumbria has used the STOP- START criteria to produce an evidenced based guide to medications management in older people. Your GP or Nurse Practitioner can help review your drugs with you.
But one extra drug!
Supplementation with Vitamin D, commonly as a combination tablet with calcium, is associated with a reduced rate of falling for housebound older people.
Ask the loneliness question
What’s this? The single and most obvious question is “do you feel lonely?”
This reminds us that being housebound is a risk factor for loneliness, and that loneliness is itself a risk factor for depression, poor sleep, impaired thinking skills, higher use of health care with more GP visits, higher use of medication, and higher incidence of falls.
It also reminds us of the limitations of “standard” health and social care responses for older people living with frailty and the special place for the voluntary sector in tackling these misery making situations. There are some excellent befriending services up and down the country, such as the Cockermouth Centre for the Third Age, Leeds Older People’s Forum, or the NHS Winter Friends campaign, supported by the Royal Voluntary Service.
These five simple things, which if done routinely, can help keep people with frailty well, especially over the winter months.
John Young has worked in Bradford as a consultant geriatrician since 1986. He is Head of the Academic Unit of Elderly Care & Rehabilitation, University of Leeds and has led health service research studies in the areas of community elderly care services, stroke care and dementia. He is currently seconded to NHS England as National Clinical Director for the Frail Elderly and Integration.