RELEVANT CHAPTERS

Preventing, Reducing or Delaying Needs

RELEVANT INFORMATION

Frailty in elderly people (Age UK)

Frailty and the NHS Long Term Plan (Age UK)

This chapter was added to the APPP in September 2021.

1. What is Frailty?

The term frailty or ‘being frail’ is often used to describe older people.

People who are frail often have reduced muscle strength and so get more tired easily (fatigue). They may find it much harder to quickly recover from health issues such as a urinary tract infection or leg ulcers.

Frailty describes a person’s overall stamina and how this relates to their chance of recovering from health problems quickly. Approximately 10% of people aged over 65 are frail. In those aged 85 and over, this increases to 25-50% (Age UK).

People living with frailty may or may not have other major health conditions. Being frail can be seen as a fairly ‘minor’ health problem, but in reality it can have a severe and long term impact on someone’s physical and mental health and wellbeing.

2. Frailty and General Health

Whilst frailty is not a major health illness itself, there are a number of conditions that are associated with being  frail. Where staff from different organisations work together with the person, their carers and family, the overall aim should be that their frailty does not result in poorer health outcomes for them (see Promoting Wellbeing and Preventing, Delaying or Reducing Needs chapters). It is important that they have well-planned, joined-up care to prevent problems arising in the first place and a rapid, specialist response if their situation changes.

The following are areas of health of a frail person which should be assessed and monitored on an ongoing basis as part of their care and support plan (see Care and Support Planning chapter):

  • general health;
  • malnutrition and dehydration;
  • bladder and bowel problems;
  • dementia;
  • delirium (confusion);
  • mental health;
  • risk of falls.

2.1 General health

As people age their health needs change, but there are practical steps people can take at any age to improve their health and reduce their risk of frailty.

All aspects of a person’s health should be addressed as part of their general health needs. These include:

  • looking after their eyes;
  • looking after their mouth and teeth;
  • keeping active;
  • getting the right medicines;
  • getting vaccinations;
  • preventing falls;
  • looking after their hearing;
  • eating and drinking well;
  • looking after their bladder and bowels;
  • keeping mentally healthy;
  • keeping their brain active.

There are other issues that affect someone’s general health, including:

  • keeping warm and well;
  • making sure their home environment is safe;
  • preparing for winter as well as for heatwaves;
  • caring and looking after themself.

Information about all of these issues can be found in A Practical Guide to Healthy Ageing (NHS and Age UK). 

2.2 Malnutrition and dehydration

Having a balanced diet and sufficient (non-alcoholic) fluids are essential for everyone in help to keep well. This is particularly important for someone living with frailty.

Malnutrition affects approximately 1 in 10 older people and is a risk factor for becoming frail. It is a serious condition where a person’s diet does not have the right amount of nutrients. This could be due to not getting enough nutrients (undernutrition) or getting more than is needed (overnutrition). Both these factors can contribute to health conditions. Nutrients are important to maintain physical health and promote healing after injury or illness.

People who are malnourished are more likely to visit their GP, have hospital admissions and take longer to recover from illness or operations. If an older person loses weight, whilst it could be due to health conditions, it may also be a result of being malnourished.

Older people are also more at risk of dehydration, where the body loses more fluid than it is taking in. Symptoms include:

  • feeling thirsty;
  • having dark yellow and strong-smelling urine;
  • feeling dizzy or lightheaded;
  • feeling tired;
  • having a dry mouth, lips and eyes;
  • not passing much urine – fewer than four times a day.

Dehydration is one of the most common reasons why an older person is admitted to hospital. It is also associated with increased risk of urinary tract infections, falls and pressure ulcers.

If it is suspected that a person who is frail  is malnourished or dehydrated, with their permission (or their relevant person) their GP should be informed as soon as possible.

If the person is likely to become malnourished or dehydrated, ensuring sufficient intake of nutrition and fluids should be included in their care and support plan including working with the person to ensure they have food and drink that they like and can tolerate.

2.3 Falls

Falls can be common in older people and can result in serious health issues. Once someone has experienced a fall, particularly if it has resulted in a significant injury, it can be a main cause of loss of independence and even eventually going into long-term care. After a person has had a fall, the fear of falling again can result in a loss of confidence and self-esteem which can  lead to them becoming increasingly inactive, which then leads to a loss of strength and a greater risk of further falls.

Working with someone to prevent them falling or from having further falls can include a number of simple practical measures such as:

  • making simple changes to their home;
  • ensuring they have the right medication;
  • ensuring they have the right prescription glasses; and
  • doing regular exercises to improve their strength and balance.

See Falls Prevention (NHS)

2.4 Bladder and bowel problems

Urinary and bowel incontinence and constipation are very common, particularly in older people. However, embarrassment and stigma about these issues mean people often delay seeking help and support. These conditions in older people are often poorly managed and can cause them a lot of distress. Not enough of an appropriate diet and fluids can also impact on a person’s bowel and urinary problems.

If there are concerns that a person who is frail  is suffering incontinence or constipation, they – or their relevant person – should be supported to speak to their GP.

For further information about these issues, visit the websites below:

Urinary incontinence – NHS

Bowel incontinence – NHS

Constipation – NHS

2.5 Dementia

There are approximately 850,000 people estimated to be living with dementia in the UK and this number is set to rise in the coming decades. People who are living with frailty and who also have dementia are at increased risk of poor health as a result of not being able to care for themselves adequately, particularly if they are living alone.

For further information see Dementia: Practice Guidance chapter.

2.6 Delirium

Delirium is an episode of acute confusion. It can often be mistaken for dementia, but it is often preventable and treatable. Older people are more at risk of developing delirium and it can be quite common (particularly for those who have cognitive impairment, severe illness or have broken their hip or have a urinary tract infection for example).

Older people with delirium may have longer stays in hospital, have an increased risk of complications such as falls, accidents or pressure ulcers and be more likely to be admitted into long-term care. There is also a high mortality rate associated with delirium. It is therefore very important to recognise and treat delirium as early as possible, to avoid these complications.

For further information please see these websites:

Confusion (NHS) Sudden confusion (delirium)

Delirium – confusion (Dementia UK)

2.7 Mental health problems

Mental health problems such as depression and anxiety can be quite common for older people, which can have a major impact on their quality of life. Mental health problems in older adults may not be reported and so often go undetected and are therefore under-treated.

Where an adult who is living with frailty is suspected of having mental ill health issues, they may be supported to speak to their GP or other relevant agencies.

See also Your mind matters: Elderly Mental Health (Age UK)

 3. Related Issues

3.1 Loneliness and social isolation

Many elderly people suffer from loneliness in England. This can have a serious effect on their mental and physical health and wellbeing.

Loneliness and social isolation can have additional negative impact on someone who is already living with frailty. There are different ways that loneliness can be addressed, depending on the needs, wishes and interests of the person. Discussions should take place with them to see what local options they may be interested in to support them to feel less lonely and isolated.

For further information see Combating Elderly Loneliness (Age UK)

3.2 Physical activity

The benefits of physical activity for older adults is well evidenced, with multiple health benefits including promoting general health, improving cognitive function, lowering the risk of falls and reducing the likelihood of developing some long-term conditions and diseases.

Depending on the needs, wishes, interests and physical ability of the person living with frailty, there will be different options and organisations for them if they want to get involved in activities in their local area.

See also Being Active as you get Older (Age UK)

3.3 Safeguarding

People who are frail may experience, or be at risk of, abuse or neglect. This may be a result of their frailty or in combination with other mental or physical health conditions. They may be directly targeted by perpetrators who perceive them to be vulnerable or suffer unintentional abuse. Abuse may be committed by people they know such as family, friends or carers or by strangers.

People living with frailty may experience health and social care services that are not suited to their individual needs. They can also be vulnerable to being given poor quality healthcare and services. In such circumstances they or their relevant person should be supported to make a complaint, as appropriate, to ensure that they receive the care and support to which they are entitled. This may need to involve the local authority and / or the Care Quality Commission if there are safeguarding concerns related to a service provider. For further information see Safeguarding Adults Procedures Section.

3.4 Supporting people at the end of their life

Advanced care planning is key to ensuring a person who is frail receives personalised care at the end of their life. People should be encouraged to have proactive discussions about their wishes for care at the end of life as early as possible and their wishes recorded. These discussions should include advance decisions to refuse treatment and do not attempt resuscitation decisions.

See Making Advance Decisions chapter

4. Living with Frailty

People living with frailty can be supported to live as full a life as they wish and are able, although this may mean they need to adapt how they live their life and find new ways to manage daily tasks and activities. This may apply to their family and friends too.

If someone is living with frailty, it does not mean they lack mental capacity (see Mental Capacity chapter) or cannot lead a full and independent life. Just because a person is frail does not mean that they cannot make decisions about their daily life or wider issues such as finances and where they live for example. They may need some practical support to put those decisions into practice however, where they may have physical difficulties for example in achieving those goals.

Frailty can deeply challenge someone’s sense of themself as well as change how they are perceived and treated by others, including healthcare professionals. Ensuring they receive person centred care and their wishes and desires are listened to and acted upon wherever possible therefore, is key to their sense of self-esteem and ongoing enjoyment of life.