Scott Wylie is a 3rd year medical student at the University of Glasgow.
Paul McNamara is a GP in Glasgow and honorary clinical lecturer at the University of Glasgow. He has an interest in research and medical education.
‘Frailty is the most problematic expression of population ageing’1 and in a country where the number of over 85 year-olds is expected to almost double by 2045, this is a fairly concerning proclamation.2
Frailty occurs due to gradual loss of function as age increases and puts patients at far higher risk of severe consequences, such as disability or cognitive decline, following minor health insults.3 GPs must be able to recognise and diagnose frailty in order treat and potentially reverse the condition. Scoring systems have been developed to aid in its identification.3 However, many of these methods have been criticised; with healthcare professionals raising concerns over their specificities, sensitivities and evidence-bases. Calls for more research into better scoring systems are not uncommon.4
…we simply do not have the resources and services to manage all the patients who we recognise as frail.
This begs the question; in such a multifactorial condition with complex causes, presentations and severities with no set worldwide consensus on definition and diagnosis – are quantitative scoring systems really the best way to recognise frailty?
As part of a Student Selected Component focussing on frailty in primary care, supervised by Paul McNamara, Scott Wylie had the chance ponder this quandary by learning directly from GPs and attending local frailty services. As part of the project, he also carried out an informal questionnaire of 172 primary care professionals via email and GP social media groups to gain opinions regarding the recognition and management of frailty in primary care.*
NICE Guidelines for recognising frailty are based on the British Geriatric Society’s (BGS) ‘Fit for Frailty’ document.3 This states that frailty can be recognised in two main ways; firstly, by the five frailty syndrome presentations (falls, delirium, incontinence, immobility and susceptibility to medication side-effects) and by the use of scoring systems.3
The BGS recommends the following systems for recognising frailty: The PRISMA 7 Questionnaire, Gait Speed, Timed up-and-go Test and The Groningen Frailty Indicator questionnaire.3
The Rockwood Clinical Frailty Scale is a widely used scoring system in frailty but has been designed for grading the severity of frailty, and it should not be used for recognition and diagnosis.3.
Scoring systems can be useful, but we wondered whether GPs felt they were needed and whether they had sufficient time to utilise them in a standard appointment.
Our informal questionnaire revealed that 79% agreed that they were ‘confident in recognising and diagnosing frailty’. Only 23% used scoring systems such as PRISMA7, Gait Speed and the Timed-up-and-go test. 18% of respondents used at least one of the frailty scoring systems to diagnose frailty, with 82% relying on clinical judgement alone to diagnose frailty.
21% did not feel confident in diagnosing frailty, and of these, none reported using any of the scoring systems outlined above.
Furthermore, the scoring systems’ impracticality was alluded to. Only 19% of respondents who use them reported that they have enough time to utilise them in a typical consultation.
After completing the project, we found that the majority of GPs who responded to our questionnaire ‘believe clinical judgement alone is sufficient in diagnosing frailty’.
Scott Wylie reflects: My Patient has Frailty, What Next?
As a third-year medical student trying to master the art of taking histories and diagnosing older patients with a myriad of symptoms, and complex medical and drug histories, I felt fortunate to shadow members of the local frailty services. This included a geriatrician-led Frailty Clinic where a geriatrician, frailty Advanced Nurse Practitioner (ANP) and clinical pharmacist conducted comprehensive geriatric assessments (CGA) on patients referred by their GP. The primary objective of the clinic: prevent hospital admission by getting appropriate social, pharmacological and medical support in place.
I also shadowed the frailty ANP on house visits to conduct Comprehensive Geriatric Assessments on patients referred by their GP. To establish the service, the ANP had travelled around the country to gain information on other health boards’ protocols. She reflected on how every single area had a different setup for managing patients with frailty.
The services I observed were well established in the area, however, on discussion with the GPs, I found that few were aware of them and, if they were, it was unclear how to refer and what the services provided.
These experiences highlighted two main points: effective management of most patients’ frailty can, in theory, be achieved by nurse-led community teams and secondly, there are no nationwide standardised pathways or services for managing frailty.
I gathered similar viewpoints from the questionnaire. A key idea was that the challenges in dealing with frailty in primary care stem not from recognising and defining frailty but from management and referring patients to secondary care services.
Should more time and resources be spent researching and developing scoring systems, or should efforts be made to improve standardised, national pathways for managing frailty once it has been recognised?
Only 36% were aware of a recognised frailty clinic or pathway which they could refer patients to in their area.
Scott Wylie reflects: What does this mean?
As the prevalence of frailty is set to rise, recognition and management of the condition is set to put added pressure on an already over stretched primary care service.
After completing my project, I found that most GPs are confident in recognising frailty on clinical judgement alone. This begs the question, ‘Should more time and resources be spent researching and developing scoring systems, or should efforts be made to improve standardised, national pathways for managing frailty once it has been recognised?’
One theme is very clear: we simply do not have the resources and services to manage all the patients who we recognise as frail.
*Deputy editor’s note: The survey results should not be regarded or cited as research, and we would discourage the submission of surveys to BJGPLife/Life and Times unless they are a meaningful part of an account of a student or trainee experience. What the learner did and learned is important here rather than the statistical data. See also https://bjgplife.com/fibromyalgia-and-chronic-pain-are-we-asking-about-psychological-trauma-or-traumatic-events/
- Clegg A, Young J, Iliffe S, Rockwood K. Frailty in elderly people. The Lancet. 2013; 381(9868): 752-762. https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(12)62167-9/fulltext
- Office for National Statistics. National population projections: 2020-based interim. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2020basedinterim[Accessed 24th August 2023]
- Turner G, Clegg A, Youde J. Fit for Frailty. British Geriatric Society. 2014
- Lee L, Patel T, Hillier L, Maulkhan N, Slonim K, Costa A. Identifying frailty in primary care: A systematic review. Geriatrics and Gerontology International. 2017; 17(10): 1358-1377. https://doi.org/10.1111/ggi.12955