Education and training available for all, so that everyone in the health and care system, including people living with frailty themselves, is at least frailty aware.
Welcome to the Frailty Academy
Our ambition is for everyone in Guildford and Waverley to have awareness of what frailty is and to provide training in the use of resources, so that people who are living with frailty can be best supported to age well and live life to the full. We are committed to developing our staff to the highest standard through our development programmes. We very much hope you find the following information and resources helpful.
Who’s who at the Frailty Academy
The frailty academy was set up in 2021 by Dr James Adams, Consultant Geriatrician, Frailty Academy Chair and Chief of Service for Frailty and Community Services at Royal Surrey. He created a vision of making extensive education and training available for all, so that everyone in the health and care system, including people living with frailty themselves, is at least frailty aware. The work plan of the Academy is directed by a multi-professional steering group including staff from both the Royal Surrey and the University of Surrey’s Faculty of Medicine.
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: Those that require general awareness of frailty.
- Tier 2: Health and social care staff and others who regularly work with people living with frailty but who would seek support from others for complex management or decision-making.
- Tier 3: Health, social care and other professionals with a high degree of autonomy, able to provide care in complex situations and who may also lead services for people living with frailty.
The five frailty syndromes
There are five conditions often associated with an acute crisis in someone living with frailty, these are known as the frailty syndromes. These may be a first presentation of frailty. It is important to understand that early recognition and timely management of frailty syndromes enables interventions to improve independence and quality of life for people living with frailty. It is also important to identify frailty early and proactively manage these syndromes before a crisis event. Those living with frailty may already have memory impairment or a diagnosis of dementia, impaired mobility (using a mobility aid), have accidental falls, be dependent on carers to help them, live in a residential or nursing home, have multiple long- term conditions, suffer with continence problems and be receiving multiple medications at once.
The five frailty syndromes are:
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 (hypoalert/hyperalert).
Balance is a dynamic process and the ability to balance declines with age. Balance relies on: sensory input, central processing and motor response. Each year in the UK over 700,000 older people attend the Emergency Department following a fall, however, impaired balance is amenable to rehabilitation.
Risk factors to balance, think 'D.A.M.E.':
- Drugs – prescribed (sedatives, hypotensives), 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 – e.g consider footwear, 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.
- ‘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).
Frailty likely marks the point at which use of evidence based medicine for secondary prevention of long term conditions should cease. It is common for older people with frailty to present in crisis due to unwarranted side effects of new medications because they have increased susceptibility to these due to poor reserve. It is important for healthcare prescribers to develop knowledge of common medications that can lead to harm in older people and for them to have knowledge of the cumulative burden from anti-cholinergic drugs.
If the risk of harm from medications is thought to outweigh the benefits, or the use of medications are not evidence-based in the patient’s bespoke circumstances, then there is likely to be a negative impact on the patient’s quality of life. The concurrent use of multiple medications by one individual is called 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.
And 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:
- Assess patient
- Define context and overall goals
- Identify medicines with potential risks
- Assess risks and benefits in the context of the individual patient
- Agree actions to stop, reduce dose continue or start
- Communicate actions with all relevant parties
- 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 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.
Frailty awareness training in your service
If Frailty Awareness (tier 1) training is not yet available in your service, you can contact your Practice Development lead to ask for it to be made available.
A training package is available from the Frailty Academy which can be adopted, or staff could attend a workshop or take the frailty training on the Skills for Health e-learning platform.
The NHS Frailty Core Capabilities Framework states tier 1 Frailty Awareness is relevant to people living with frailty, as well as their family, friends and carers, to ensure they are making the most of the support on offer and can plan effectively for their own current and future care needs. This tier is also for all those working in health care, social care and other services who have contact with people with frailty including those who will go on to further training at tiers 2 and 3. This tier will be relevant if you:
- are an interested member of the public
- are living with frailty
- support someone living with frailty
- work in adult health, social care sector or other sectors
For more information about frailty training opportunities please email the Frailty Academy.
There are lots of resources and posters to support professionals in managing patients with frailty.
- Rockwood Clinical Frailty Scale (NHS England)
- End PJ Paralysis
- Deconditioning: Sit up, Get dressed, keep moving (University Hospitals of North Midlands - found under resources)
- 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: