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Frailty and ageing well

A key priority for Guildford and Waverley Health and Care Alliance is how we work together to integrate health and care for our older population.

A number of older people are living with frailty, multiple long-term conditions and complexity and we need to ensure they can access consistent care.

Frailty is often identified when an older person is less able to live well and independently because their poor health causes them difficulties. The person might start having falls, have to use a walking aid, taking a lot of prescribed drugs or maybe they sometimes get confused. When a person has frailty, they are likely to find it difficult to recover from relatively small illnesses and injuries.

Frailty is a change in a person’s overall resilience which can lead to health and mobility issues as people get older. If a person becomes affected by frailty, relatively minor events can have a long term impact, lead to a deterioration in health and/or their ability to live independently. For example, older people with frailty may need mobility aids or be at greater risk of falling, they may experience a decline in their mental ability, and find they take much longer to recover from illnesses or injuries.

Frailty is a long-term condition and people with frailty often require support and care for physical, social, and emotional needs. When frailty is identified at an early stage, changes can be put in place with some patients to reduce or reverse the impact of frailty. A patient’s frailty can also increase or decrease in response to specific circumstances such as an infection, a change in environment, a bereavement etc. It is therefore very important for frailty to be identified early when interventions are likely to be most effective.

People with frailty also retain considerable strengths and it is imperative that goal-oriented frailty care is guided by their values, priorities, and preferences. 

Signs of frailty

Here are some of the things a healthcare professional might look for when deciding if a person has frailty:

  • They have had a ‘fall’
  • They have experienced a period of confusion (possibly undiagnosed cognitive impairment such as dementia or when it happens quickly is often called ‘delirium’)
  • They have started to find walking more difficult and might need to use a walker or walking sticks
  • They have begun to have toileting difficulties such as incontinence
  • They are having a poor reaction to the prescribed drugs they are taking

Frailty ambitions for Guildford and Waverley

If frailty is identified early, it can be reversible. However, a person’s degree of frailty may change over time depending on other factors. For older people with frailty, proactive screening and comprehensive geriatric training can help reduce the risk of progression.

We have reviewed vital evidence and analysed the system that we live and work in, benchmarking on best practice, we have drafted a strategy to outline our strategic ambition.

Have one integrated pathway for frailty with different services working together to deliver joined-up care for older people.

  • Encourage vulnerable people or those living with mild frailty to age well and ensure they are supported.
  • People living with moderate frailty are supported through community-based integrated multi-disciplinary teams to prevent further progression of their frailty.
  • People living with severe frailty, including those in care homes, receive individualised and personalised care, incorporating advanced care planning.
  • Everyone in frailty crisis has timely access to high-quality urgent crisis services.
  • Staff have the skills and knowledge in frailty to provide the best care for our older population.
  • Use digital solutions and technology to support the delivery of care and to inform the development of frailty services.
  • The experience of people living with frailty and their carers informs and improves how we provide care and support.

View our strategy to find out what we are doing in your area.

Ageing Well in Guildford and Waverley Frailty Strategy 2022 - 2026 [pdf] 5MB

Resources

Frailty basics

To learn more about frailty, please take a look at ‘Frailty Basics’ that will help you to understand frailty, how you might know when a person has frailty and how frailty can be identified:

External websites and guides