Professor Simon Conroy is a geriatrician at University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal.
With the recent NICE COVID-19 rapid guideline on critical care in adults [NG159] recommending assessment of frailty as part of the critical care decision making process, there has been a lot of discussion on social media about frailty in general and the clinical frailty scale more specifically.
We’d like to try and dispel some of the myths surrounding the notion of frailty, to help provide clearer information about how this concept is used in healthcare.
What is meant by the term ‘frailty’?
In healthcare, frailty is a clinical term that refers to a loss of ‘biological reserve’ (biological reserve refers to the ability of our bodies to recover from illness or other stress events). An individual with increasing levels of frailty is more vulnerable to poorer health outcomes, even from a very minor illness or stress event. Frailty is often associated with the ageing process, but not exclusively – we all know very old people who are incredibly fit, and less aged people who are rather frail. Across healthcare, we now consider frailty to be a long-term condition to be prevented, identified and managed alongside other health conditions.
Perhaps unsurprisingly, the terms ‘frail’ and ‘frailty’ are often not something that individuals wish to be associated with; in part this is because of the stereotypical images that the notion conjures in our minds. But the whole purpose of identifying and measuring frailty is to recognise that people of the same age, even with the same health conditions, can have very different levels of resilience or capability. Frailty helps clinical teams tailor their care to the individual, irrespective of age – it is the antithesis of ageism! Health and care professionals use judgement and skill to bring up the subject with patients and carers. If done sensitively, this can help people manage their frailty and prepare for the future. Increasingly frailty is being used to identify people who might benefit from evidence- based interventions, such as Comprehensive Geriatric Assessment, offering holistic care that improves their outcomes.
What is the Clinical Frailty Scale?
The Clinical Frailty Scale was developed to support healthcare professionals to recognise frailty in an individual. It uses a scale because we know frailty covers a wide spectrum from mild through to more severe frailty. The scale allows a healthcare professional to recognise frailty by the extent to which it is affecting a person’s mobility and cognition in relation to practical day to day activities. It is an evidence-based approach, having been studied in many different countries and different settings.
Frailty is best assessed at the beginning of a care episode (e.g. in the emergency department), but importantly should be based upon how the person was two weeks ago – it is a measure of their ‘baseline’ that can guide goal setting. The degree of frailty is important to inform how an individual’s needs can best be met. However, the scale should not be used in isolation from other assessments of health need. It is useful in informing shared decisions between clinicians and individuals. The scale itself does not dictate which type of healthcare intervention is appropriate.
Why is recognising frailty important in healthcare?
For an individual, recognising frailty can help to identify opportunities and approaches for interventions that improve health and help inform decision-making for care and treatment.
The recognition of frailty can also help to avoid interventions that might be harmful or unlikely to provide benefit, thus preventing or minimising complications or unintended consequences of healthcare interventions.
Importantly, an assessment of frailty can help to ensure that decisions about healthcare are not made on the basis of a person’s age, but are individualised, based on a holistic assessment. This is relevant in the current COVID-19 epidemic when people’s experience of the virus may be very different. While older individuals are much more likely to be adversely affected with COVID-19 compared to younger individuals, the majority of older people with COVID-19 will recover.
When is use of this scale not appropriate?
The use of the scale has not been widely validated in younger populations (those below 65 years of age), or in those with learning disability. It may not identify risks or treatment goals as well in people with stable long term disability such as cerebral palsy.
Common misunderstandings about the Scale
The scale can be misunderstood by non-healthcare professionals as a measure of disability. Disability and frailty are two different but linked concepts. Equally, the scale can be misunderstood by some non-healthcare professionals as a measure of Quality of Life – the scale is never used as a judgement about someone’s Quality of Life. Finally, the scale is not used in isolation to dictate access to healthcare resources. It is used as one part of an assessment process to help ensure that decisions about healthcare interventions are appropriate in the context of an individual’s healthcare needs.