1. Management of frailty: “we are not alone”
John Young
Professor of Elderly Care Medicine,
Academic Unit of Elderly Care & Rehabilitation,
Bradford & University of Leeds

3. So where does frailty fit in?
Some bad news
It’s not a disease
Some more bad news
It affects the whole body
Even more bad news
Every person is different
The worst of news
Several things wrong at once
A frailty focus is the potential key to unlock our current system failure

5. Populations are getting older
2015
2050

6. “We are not alone”
ADVANTAGE (managing frailty) European Union Joint Action Programme
Addresses common challenges where shared action at an EU level may facilitate national frailty prevention policies. (
European Innovation Partnership (EIP) on Active and Healthy Ageing
Yorkshire and Humber is a reference site. (
Canadian Frailty Network (

7. Healthy Ageing Strategy: New Zealand (2016)
Example ‘goals’:
Increase physical and mental resilience
Reduce inappropriate acute admissions
Support effective rehabilitation closer to the home
Explore the possibilities for a frailty identification tool
Better integrate services or people living in residential care
Improve medicines management

8. A little known fact about frailty………..

9. “Frailty is slippery when wet”
A little known fact about frailty………..
“Frailty is slippery when wet”

10. Cacophony of Frailty Definitions: Many, many definitions of frailty in the literature “We don’t know what frailty is”
It has indeed been difficult to nail frailty down
Is it a syndrome or an (abnormal) health state?

11. DEFINITIONS OF ‘COPD’
1997: “A slowly progressive disorder characterised by airways obstruction … which does not change markedly over several months”
2015: “… characterised by persistent airflow limitation that is usually progressive and is associated with an enhanced chronic inflammatory response in the airways…”

12. DEFINITIONS OF COMMON CHRONIC CONDITIONS WIGGLE AND WOBBLE OVER TIME
e.g. CHF DIABETES DEMENTIA DEPRESSION etc…
AND, DON’T GET ME STARTED ON LYMPHOMAS!
FRAILTY IS NO EXCEPTION
GET OVER IT!

13. “Slippery when wet!”

14. “Not so slippery when wet!”

15. Hugely similar; not actually much difference
Cacophony of Frailty Definitions: Many, many definitions of frailty in the literature “We don’t know what frailty is”
But …… but …… but…..
Hugely similar; not actually much difference

16. WHO Definition of frailty (2015):
“Frailty is a progressive age-related decline in physiological systems that results in decreased reserves of intrinsic capacity, which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcome.”

17. So, we have a definition, we also have over 20 years of research
Two international theoretical models for frailty:
(Fried) Phenotype model
(Rockwood) Cumulative deficit model (eFI)

18. Phenotype Frailty Model (Cardiovascular Health Study [n=5,210] Fried et al 2001)
Weight loss:
> 4.5kg or > 5% per year
Fatigue:
US Centre for Epidemiological Studies Depression Scale
Sedentary Life:
< 383 Kcal/week men
< 270Kcal/week women
Slow gait speed:
Standardised cut-off times to walk 4.57m stratified by sex & height
Weakness:
Dynamometer measurement stratified by sex & BMI
International research standard but difficult to implement in routine care (
262 different versions of Phenotype model (Theou et al., 2015)

19. Cumulative Deficit Model of Frailty: Frailty Index (Rockwood et al)
“The more things that are wrong with you, the more likely you are to be frail”
Frailty Index counts “deficits”
A deficit is a thing that is wrong with you (symptom, sign, disease or disability)
Frailty Index = the proportion of deficits accumulated over time
Simple calculation:
Zero deficits from list of 50: FI = 0/50 = 0
Ten deficits from list of 50: FI = 10/50 = 0.20
Frailty Indexes successfully replicated internationally (Mexico, China, Canada, Europe etc. …)

20. Diagnostic Test Accuracy (DTA) for simple frailty instruments (Systematic Review)
4 meters
More than 5 seconds
Sensitivity
Specificity
Gait Speed <0.8m/s
99%
64%
Gait Speed <0.7m/s
93%
78%
TUGT >10s
62%
PRISMA 7
83%
83% (wide CIs)
Self-reported Health
72% (wide CIs)
Groningen Frailty Indicator
58%
72%
Polypharmacy (>5 meds)
67%
GP clinical assessment
(Frailty instruments assessed against a reference standard)
(Clegg, Teale, Young. Age Ageing 2014)

21. Can these good practices be transferred to the community?
Comprehensive Geriatric Assessment (CGA) associated with improved outcomes for older people with frailty (Cochrane review 2017; 29 RCTs; 13,766 participants)
Can these good
practices be
transferred to
the community?
Comprehensive, multi-disciplinary assessment
Appropriate skills, training & attitudes
Prevention of complications (esp. loss of independence)
Promotion of independence
Person-centred care

22. Integrated Primary Care Models Review by Béland et al. (2011)
9 studies
7 studies reported reduced hospital bed days and/or reduced long-term care
Key care components identified

23. Key Care Components for Integrated Primary Care Models
Clear eligibility
Single entry point
Individual assessment & care plan
Electronic information tool
Case management & coordination of care
Clear policies
[Consistent with Integrated care for older people with complex needs (Review of 7 international case studies) Kings Fund 2017]

24. Frailty: conclusions Less slippery when wet than you might think!
Two reference standard theoretical models
Detection of frailty possible using simple tools
Potentially successful primary care systems for people with frailty are being developed

25. Thank you!