Professor Martin Vernon, National Clinical Director for Older People and Integrated Care at NHS England discusses the importance and potential in diagnosing frailty.
‘All the world’s a stage…and one man in his time plays many parts, his acts being seven ages’.
Shakespeare elegantly captured life’s journey, describing human frailty in ways we can still resonate with today, depicting an optimistic journey from infantile vulnerability through querulous childhood, to adulthood with its excitements, obligations and challenges.
Jacques’ speech in As You Like It characterised frailty emerging beyond midlife, exposing human vulnerabilities the inevitability of which we may have not planned for, distracted as we are by busy lives. Many of us will reluctantly recognise mid- life ‘in fair round belly…full of wise saws, and modern instances’ shifting to the first tangible signs of frailty in the sixth age ‘with spectacles on nose… world too wide for shrunk shank’. Few however will embrace well the prospect of a final scene ending our ‘strange, eventful history, in second childishness and mere oblivion’.
In the 1500’s average life expectancy was 35 years. Shakespeare did well to survive beyond this in a rat-infested insanitary environment with plague, smallpox and syphilis running rampant. Survival to old age was largely through good fortune and for the majority by no means certain. Today most people enjoy the prospect of living to beyond 80 and within twenty years can expect to live to beyond 90.
Shakespeare’s model of human ageing and description of frailty remain highly relevant today despite dramatic demographic changes. English women now have an average life expectancy of 83, men 79. In Tudor times the population of England was roughly 3 million, in 2016 it exceeds 65 million with 16% women aged over 60 exhibiting frailty and 12% of men.
The Bard observed ageing leading to muscle loss and physiological failure. Today we know that frailty is a condition characterised by loss of biological reserves across multiple organ systems and increasing vulnerability to physiological decompensation after a stressor event. Put simply, this means a general slowing down and/or not bouncing back quickly from illness, accident or another stressful event. We also know that people living with frailty are at increased risk of adverse events including hospitalisation, nursing home admission and death.
Frailty remains an easy condition to recognise. Today however, there are far greater numbers of older people than ever before, and while frailty can develop throughout adult life the numbers of older people living with the condition has increased substantially. With a highly developed health care system supporting us to later life, we should not be surprised when frailty declares itself as a health or social care crisis. However we must also recognise that this is a long-term condition, which can predate crisis by a decade or more.
If we are to respond positively to frailty and the challenges it poses we must be prepared to care for people exhibiting the frailty state in just the same way as we care for other long-term conditions. Frailty can now be identified and diagnosed with comparative ease using the validated electronic frailty index. This can lead to targeted assessment and person centred care-plans developed as the condition progresses.
The electronic frailty index (eFI) uses routine data already collected and coded within general practice to identify people who are fit, living with mild, moderate or severe frailty. It can enable us to distinguish those with severe frailty from those who remain fit. We can find populations who are at greater risk of adverse events including hospital and nursing home admission.
In a large-scale English validation study of the eFI, for 65 to 95 year olds with mild frailty, the risk of hospital, nursing home admission and death almost doubled. However for those with severe frailty the one-year risk of these events more than quadrupled.
A meta-analysis of trials involving nearly 100,000 older people has previously demonstrated that complex interventions targeted at improving function for older people living at home reduced their risks of hospital admission and falls. For those already at greater risk of death these interventions also reduced the likelihood of care home admission. The study concluded that complex interventions can help older people to live safely and independently and can be tailored to meet the needs and preferences of individuals.
Routine identification for frailty now creates the opportunity to identify people in our local populations living with severe frailty, thereby opening the way for targeted assessment of need and better coordination and planning for delivery of interventions. This provides us with greater opportunity to reduce the likelihood and impact of significant future life events.
Through the Five Year Forward View and GP Forward View the NHS has created a clear vision centred on developing a more engaged relationship with patients, carers and citizens to promote wellbeing and prevent ill health. The proactive identification, diagnosis and management of frailty provide a realistic prospect of an improved seventh age as never before.