Frailty Academy

The NHS has a published Frailty Framework of Core Capabilities (skillsforhealth.org.uk). This defines an approach to care that builds upon the strengths of individuals, families and communities, and helps make the most of every contact an older person has with health care, social care, or other services. It sets out competency levels for people who have frailty and staff working with them, in 3 levels (or tiers) as follows:

Tier 1: Designed for individuals who need a basic understanding of frailty

Example: Community volunteers or family members who want to support elderly relatives.

Accessing the training

If you are an employee at the following organisations, you can participate in the Tier 1 e-learning course available on your organisation's Learning Hub:

• Royal Surrey (acute and community)
• ProCare Community Nursing
• Surrey County Council Adult Social Care
• SECAMB

We run a regular programme of Tier 1 training online; if you would like to receive an invitation to this please contact the Frailty Academy by email at rsch.frailtyacademy@nhs.net

If your organisation is in Guildford and Waverley and you would like to discuss Tier 1 training for your staff, please contact the Frailty Academy by email at rsch.frailtyacademy@nhs.net

Tier 2: Aimed at health and social care workers who frequently interact with people living with frailty and may need to consult with others for complex cases

Example: Nursing staff, community teams, primary care teams, or social workers who provide daily care but refer to specialists for advanced medical decisions.

Accessing the training

If you wish to take part in Tier 2 Frailty Academy Champion Training then please complete a Frailty Academy Tier 2 Registration Form.

Tier 3: For health, social care, and other professionals with significant independence in their roles, capable of managing complex situations and potentially leading frailty services

Example: Geriatricians, senior nurses, or care managers who oversee treatment plans and coordinate comprehensive care for patients with frailty.

Accessing the training

To discuss whether this training is appropriate for your role please contact the Frailty Academy by email at rsch.frailtyacademy@nhs.net 

All our training is aligned to the Skills for Health Frailty Core Capabilities and you will receive a certificate of attendance. The programmes are free of cost thanks to support by United Surrey Talent.

 

There are five conditions often associated with an acute crisis in someone living with frailty, known as the frailty syndromes. These may be the first signs of frailty.

Early recognition and timely management of frailty syndromes are crucial to improve independence and quality of life for people living with frailty. Identifying frailty early and proactively managing these syndromes can prevent crisis events.

People living with frailty may already experience:

• Memory impairment or dementia
• Impaired mobility (using a mobility aid)
• Accidental falls
• Dependence on carers
• Residency in a residential or nursing home
• Multiple long-term conditions
• Continence problems
• Use of multiple medications

The five frailty syndromes

Delirium

Delirium is a type of sudden confusion that can have many different causes.

Features of delirium are:

• Acute onset and with a fluctuating course.
• Inattention (distractible, cannot communicate).
• Disorganised thinking (illogical, rambling), perception, motor activity and mood
• Altered consciousness (hypo alert/hyperalert).

Recurrent falls

Balance is a dynamic process that tends to decline with age. It relies on:

• Sensory input
• Central processing
• Motor response

When considering risk factors for balance, remember 'D.A.M.E':

• Drugs – prescribed (sedatives, hypotensive's), over the counter (OTC), alcohol.
• Age-related change – gait, balance, sensory and cognitive impairment.
• Medical causes – cardiovascular, postural hypotension, syncope, neurological for example, previous stroke, Parkinson’s, dementia.
• Environment – for example ill-fitting shoes, trip hazards, lighting.

For more information see the information on prevention of falls and maintaining independent mobility on ‘Let’s Get Steady’.

Sudden deterioration in mobility

Mobility can be affected by three conditions that make up musculoskeletal frailty:

• Osteoporosis – a term derived from osteo (bone) and porous (full of holes) meaning that the bone is fragile and at increased risk of fracture.
• Osteoarthritis – a group of overlapping disorders that may have different causes, but which result in joint failure subsequent to changes in articular cartilage, subchrondral bone, the synovium, and other joint structures (Cyrus Cooper BMJ 2011;342:d1407)
• Sarcopenia – a progressive and generalised loss of skeletal muscle that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality. Sarcopoenia is associated with impaired muscle strength and muscle quality leading to poor physical performance.

Musculoskeletal frailty has the following five features:

• Weakness – which can be evaluated by grip strength.
• Slowness – often evaluated by gait speed.
• Reduced attitude to physical activity.
• Reduced energy – self-reported.
• Involuntary body weight loss.

Incontinence (new or worsening)

Incontinence is an involuntary loss of urine or faeces in sufficient amounts/frequency to constitute a social or health problem. It is common, disruptive and disabling.

It affects 15-30% of older people in the community and 50% of nursing home residents. Urinary incontinence is sometimes easier to talk about to patients by referring to it as 'toileting difficulty'.

The different types of urinary incontinence are:

• Stress incontinence – where the dam is not large enough to hold back the reservoir force (50%).
• Urgency – where the reservoir contracts and overflows the dam (15%).
• Overflow – where the reservoir keeps growing until it constantly laps over the top of the dam.
• Mixed.
• ‘Functional’ – where there is no problem with the urogenital tract at all, but circumstances mean voiding of urine happens in a socially unacceptable way for the patient.

Faecal incontinence affects up to 17% of older adults. The following matters should be considered:

• Rectal compliance (smooth muscle stretch increases with ageing leading to faecal loading and incomplete emptying.
• Stool consistency depends on: transit time, solidity at caecum, mucosal absorption of water, ability of rectum to hold in fluid (leading to the ability to produce formed, bulked stool).
• Medications that increase risk include: metformin, laxatives, sorbitol (in food), magnesium supplements.
• Post-cholecystectomy diarrhoea (bile salts).

Medication side-effects

Frailty often signals when evidence-based medicine for secondary prevention of long-term conditions should stop. Older adults with frailty frequently face crises due to adverse side effects from new medications, as they are more susceptible due to reduced physiological reserve.

Healthcare prescribers must understand which medications commonly harm older patients and recognize the cumulative burden of anticholinergic drugs.

When the risks of medication outweigh the benefits or are not evidence-based for the patient's specific needs, it can negatively impact their quality of life. The simultaneous use of multiple medications by one person is known as polypharmacy.

Polypharmacy can be caused by:

• Multi co-morbidity – single disease guidelines being followed.
• Multiple prescribers – e.g. GPs, secondary care specialists.
• Transfer of care – poor communication between care settings.
• Prescribing cascade – due to unrecognised side effects of medicines.

It can have the following adverse consequences:

• Increase in adverse drug affects.
• Increase in hospital admissions.
• Increase in poor medicines adherence.
• Increase in healthcare costs.
• Increase in risk of adverse drug reactions.
• Reduction in patient’s independence.

A medication review can be undertaken using the following seven step approach:

1. Assess patient
2. Define context and overall goals
3. Identify medicines with potential risks
4. Assess risks and benefits in the context of the individual patient
5. Agree actions to stop, reduce dose continue or start
6. Communicate actions with all relevant parties
7. Monitor and adjust regularly

STOPP/START screening tool

Polypharmacy and inappropriate prescribing (including potential prescribing omissions) are risk factors for adverse drug reactions, which commonly cause adverse clinical outcomes in older people.(Atkin PA,1999) (Beers MH,1991). Adverse drug reactions account for 30% of all hospital admissions in the elderly. (Gallagher PF, 2011). The Comprehensive Geriatric Assessment Toolkit includes the STOPP/START screening tool.

STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are explicit criteria that facilitate medication review in multi-morbid older people in most clinical settings. For more information go to the CGA STOPP/START tool.

Anticholinergic burden

Anticholinergic medications are used to block the neurotransmitter Acetylcholine. They have systemic effects on smooth muscle function including the lungs, gastrointestinal system and urinary tract. Anticholinergic drugs are prescribed to treat a variety of medical conditions including Parkinson’s disease, allergies, COPD, depression and urinary incontinence. In patients over 65 years of age these can cause adverse events, such as confusion, dizziness and falls. These have been shown to increase patient mortality.

There is an online Anticholinergic Burden Calculator available to help staff work out the Anticholinergic Burden for patients; a score of 3+ is associated with an increased cognitive impairment and mortality.

There are lots of resources and posters to support professionals in managing patients with frailty.

• Rockwood Clinical Frailty Scale (NHS England)
• End PJ Paralysis
• Surrey Training Hub for health and care workforce - a local partnership supporting the development and transformation of the primary and community care workforce through education and training across Surrey.
• MDTea podcasts (The Hearing Aid podcasts) - free, open access podcasts for all healthcare professionals working with older adults. They present evidence based, recent advances and established best practice in healthcare for older adults. Each episode reviews an aspect of caring for older adults from the perspective of their MDT faculty. There are over 100 episodes now available.
  • Episodes specifically about supporting patients who are from the LGBTQ+ community and/or people from different cultural backgrounds:
    • Episode 7.8 Cultural Aspects of Ageing
    • Episode 10.5 LGBTQ+ Older Adults
    • Episode 10.9 Different Cultural and Religious Practices around Death and Dying
    • LGBTQ+: Living with dementia | Alzheimer's Society (alzheimers.org.uk)