In the modern age, people are living longer than they used to. Two of the issues which are more common in an older population are frailty and multimorbidity.
What is frailty?
In common language, frailty means being weak, delicate and vulnerable. This can be caused by health problems, and it can make people more likely to get health problems. NHS England describes frailty as: "a loss of resilience that means people do not bounce back quickly after a physical or mental illness, an accident or other stressful event." A guideline by the British Geriatrics Society in association with the Royal College of General Practitioners and Age UK defines frailty as a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. It recommends that health professionals consider frailty when caring for older people, and assess people to see if they qualify as frail. If they are considered frail, there should then be a plan of care specifically made for them and their individual needs. In particular, care plans should work out how to avoid crises, and how to best manage them when they occur.
In itself, frailty is now looked upon as a long-term health condition.
What is multimorbidity?
Multimorbidity means having more than one long-term medical condition. 'Multi' means several, and 'morbidity' means the condition of being diseased. All health conditions can contribute to multimorbidity, including:
- Physical illnesses such as diabetes, heart disease or rheumatoid arthritis.
- Mental health illnesses such as schizophrenia or anxiety.
- Learning disability.
- Hearing loss or poor vision.
- Conditions causing persisting pain.
- Misuse of alcohol or drugs.
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How is frailty assessed?
Health professionals may use a number of different methods to determine if a person has frailty and how severe this is. These methods include:
- Measuring or estimating walking speed.
- Questionnaires. There are various specifically designed questionnaires which produce a total frailty score. They include questions about falls, mobility, support network, age and health problems.
- Asking the person how they assess their own state of health.
- Electronic scores taking account of codes within patient records.
The sort of thing that suggests a person might be living with frailty includes:
- Older age.
- Difficulty getting about - slow walking, using a stick or frame, weaker muscles.
- A history of recent falls.
- Health problems which interfere with getting out and about, or which lead them to be unable to leave their house altogether.
- Being confused or having dementia.
- Being on lots of medicines.
- Needing help to do everyday tasks.
- Living in a care home or nursing home.
Frailty should not be assessed when somebody is acutely unwell, ie if they have an infection.
Who is most likely to be living with frailty and multimorbidity?
As we get older, frailty and multimorbidity become more common. Around one in ten people over the age of 65 are considered frail in medical terms. Up to half of those over the age of 85 are frail. Two thirds of people over the age of 65 have multimorbidity.
What is the impact of frailty and multimorbidity?
Why does it matter? It matters because people with multimorbidity and/or frailty have a greater health burden for themselves, their carers and society as a whole.
People with multimorbidity:
- Are likely to be on lots of different medicines. The more there are, the more the risk of interactions between the medicines, side-effects and possible ill effects. See the separate leaflet called Polypharmacy for more information.
- May have to attend lots of different hospital appointments. Often there will be little or no co-ordination between the various specialists. So for example, a heart clinic doctor might start a pill for the heart problem, which then affects a kidney problem so the kidney specialist doctor stops it. Transport to numerous appointments may be a problem, especially for a person who is not very mobile.
- May have a poorer quality of life.
- Are usually not included in research studies. A lot of research applies to people with just one health condition, and it isn't known if the guidelines which come from this research can be applied to people with multimorbidity.
- May be trying to take account of excessive or conflicting sets of lifestyle advice.
- Need more help in terms of medical appointments and care from either family or social services.
People with frailty:
- Are more at risk of falls.
- Are more at risk of being admitted to hospital, and to need to stay in hospital for longer.
- Are more likely to need care in a nursing home.
- Are more likely to have difficulty walking and getting around.
- Are more likely to be incontinent.
- Are more likely to be or become confused.
- Are more likely to have side-effects when new medicines are prescribed.
- Are more likely to have major fallout from a minor problem - eg, following a urine infection or a change to medication.
How are frailty and multimorbidity best managed?
It is important that the presence of frailty and/or multimorbidity is recognised. If carers and health professionals are aware of these conditions then, by careful planning, some of the outcomes in the section above can often be avoided. The sorts of measures which can be taken include:
- Regular review of medication. It may be appropriate to stop some medicines if they might be causing more problems than benefits.
- Regular assessment of physical and mental health and the specific needs for care and/or support.
- Looking at factors which might make a person more likely to have falls and addressing those that can be improved. (For example, changing pills which might increase the chances of falls, fitting grab rails around the house, physiotherapy to strengthen muscles, checking footwear.)
- Creating personalised care plans. Agree who will co-ordinate this.
- Planning for care in the event of falls or infections, avoiding hospital admission wherever possible.
- Supporting carers to help them manage.
- Co-ordinating care from specialists, GPs, nurses and carers as much as possible and sharing information between all those involved, as long as the person consents to this. Involving the person in all decisions about their care, as long as they are able to understand the information. Assessing whether they do have the ability to understand the information about their health, and the mental capacity to make important decisions. Taking into account each person's own preferences and priorities.
- Stopping hospital follow-up and appointments which don't have much benefit to the patient. Co-ordinating those that do have benefit where that is possible.
- Treating pain effectively - also mental health problems including depression and anxiety.
- Supporting people to eat well, regularly and healthily (by, for example, advice from a GP or dietician, arranging 'meals on wheels' (meals at home) or involving family or carers. Considering vitamin supplements - for example, vitamin D supplements for those who are not getting out of the house very much).
How can multimorbidity and frailty be prevented?
Of course we can't do anything to prevent getting many diseases or conditions. Or if there is a way to avoid them, it hasn't yet been discovered. However, there are many long-term conditions which can be avoided by living a healthy lifestyle. In particular, conditions such as coronary heart disease and strokes can be avoided by not smoking, taking regular exercise and eating a healthy diet. Many cancers can be avoided by not smoking. Obesity and its many complications can be avoided by eating a healthy diet and taking regular exercise. Type 2 diabetes can often be avoided by eating a healthy diet, taking regular exercise and keeping your weight within a healthy range. Many skin cancers can be avoided by a sensible approach to sun exposure. Although it is obvious that not all illness can be avoided by being healthy, at least if you can prevent those that are, you will have fewer medical conditions to contend with at the same time. This means you are less likely to have multimorbidity, less likely to be frail, less likely to be on numerous medicines and more likely to have a better quality of life.
Further reading and references
Multimorbidity: clinical assessment and management; NICE Guidance (September 2016)
Multimorbidity and Polypharmacy; NICE Key Therapeutic Topic (KTT18), January 2017 - updated February 2018
Fit For Frailty Part 1 - Consensus best practice guidance for the care of older people living in community and outpatient settings; British Geriatrics Society in association with the Royal College of General Practitioners (RCGP) and Age UK
Smith SM, Wallace E, O'Dowd T, et al; Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2016 Mar 143:CD006560. doi: 10.1002/14651858.CD006560.pub3.
Xue QL; The frailty syndrome: definition and natural history. Clin Geriatr Med. 2011 Feb27(1):1-15. doi: 10.1016/j.cger.2010.08.009.