Making the case for action
People with frailty are at risk of falls. They're also at risk of developing conditions such as anxiety and depression, and are more likely to have unplanned hospital admissions. Identifying people with frailty and improving their care and support are therefore priorities for the health and care system.
The NHS Long Term Plan includes an aim for all major A&E departments to set up an acute frailty service to ensure people with frailty receive the most appropriate care quickly. Three areas of the Five Year Forward View relate to frailty:
- urgent and emergency care – freeing up hospital beds, and reducing unnecessary hospital attendances and admissions
- prevention – helping frail older people stay healthy and independent
- efficiency– medicines optimisation.
NHS England describes frailty as a loss of resilience that means people don't bounce back quickly after a physical or mental illness, an accident or other stressful event. The National Clinical Director for Older People, Professor Martin Vernon, has based NHS England's advice on the British Geriatric Society’s Fit for Frailty model. This involves the following steps, which together spell FRAIL:
- Recognise frailty in a person.
- Assess – a multidisciplinary assessment involving a geriatrician, allied health professionals, specialist nurses, and mental health and social work teams. The aim is to identify and manage long-term health conditions, identify goals and develop a personalised care and support plan.
- Intervene – for example, a falls risk assessment and a multimorbidity review.
Finding the right information
Our guidelines on multimorbidity: clinical assessment and management and older people with social care needs and multiple long-term conditions are particularly relevant. They include recommendations covering the ‘Assess’ and ‘Intervene’ steps in the frailty model.
The main NICE Pathways for this area are:
The following video explains how to use NICE Pathways.
Using quality standards to make an impact on care and support
Care and support
The main focus for frailty is on improving care and support. Our quality standards help you identify areas to make high impact improvements for people with frailty or at risk of frailty, in line with the British Geriatric Society model. Quality standards contain a list of quality statements, each describing a priority area for quality improvement. They include metrics that can be a useful source of key performance indicators or performance metrics for system-wide performance dashboards. See how to use quality standards for more details.
For example, the quality standard on social care for older people with multiple long-term conditions highlights the importance of integrated health and social care plans. The development sources section of the quality standard shows the guidance underpinning it and the national policies that it fits with.
The main quality standards that help with improving care and support for people with frailty are:
- Social care for older people with multiple long-term conditions
- Falls in older people
- Pressure ulcers
- Delirium (includes risk assessment and prevention)
- Dementia: support in health and social care
- Medicines optimisation
- Nutrition support in adults
- Transition between in-patient hospital settings and community or care home settings for adults with social care needs (see quality statement 2 on comprehensive geriatric assessment)
- End-of-life care for adults.
Reducing the risk of increasing frailty
Risk factors that can be reduced include excessive alcohol use, dementia and mood disorders, falls, social isolation and polypharmacy. Interventions such as good foot care and preparing for winter and helping people keep warm can be targeted for people most at risk of becoming increasingly frail.
The quality standards listed above can help with this, and the following ones can help with specific risk factors:
- Mental wellbeing and independence for older people (addresses mood, physical activity and social isolation)
- Mental wellbeing of older people in care homes (physical and mental wellbeing, sensory impairment and sense of identity)
- Dementia: independence and wellbeing (includes home safety, physical activity, and physical, social and emotional wellbeing)
- Preventing excess winter deaths and illness associated with cold homes
- Diabetes in adults (see statements 5 and 6 on adults at right of diabetic foot problems)
- Alcohol-use disorders: diagnosis and management
- Smoking: supporting people to stop and Smoking: harm reduction
- Managing medicines in care homes (addresses polypharmacy).
Support for quality improvement
We publish a range of tools and resources to help with putting our guidance into practice.
You can find these on the ‘Tools and resources’ tab for any guidance (such as multimorbidity: clinical assessment and management).
We also list any tools produced by other organisations that we've endorsed as supporting our guidance. For example, we've endorsed several tools relevant to preventing falls. They include a toolkit produced by Keele University in collaboration with NHS Walsall Clinical Commissioning Group.
Shared learning case studies show how organisations have used our guidance and standards to improve the quality of services around the UK.
There are some useful examples relevant to frailty, including some on medicines optimisation for older people:
- Integrated care clinical pharmacist for frail older people: case management and enhanced rapid response
- Peer support meetings for pharmacists undertaking medication reviews for older people in care homes and domiciliary settings
- Medicines optimisation for older people in care homes and the intermediate care setting: developing and reproducing new models of care
- Neighbourhood integrated medicines optimisation team: improving medicines use at home
- Patient-led clinical medicines reviews.
Other case studies cover work to improve mental well being:
- The Alive! approach to providing meaningful activities for older people living in care, particularly those living with dementia
- Improving the mental and social wellbeing of the elderly in residential care – a case study from Mellifont Abbey Residential Care Home.
Organisations have also written about how they are preventing risk of falls:
- Patient information leaflets about preventing falls in hospital and the use of bedrails
- Multifactorial interventions can reduce harm from falls in acute hospital settings.
And other organisations have used our guidance to improve services for people with dementia: