Frailty and Sarcopenia: Identifying the right care for older patients
By Miles Witham, Avan Sayer, Richard Dodds, Gill Turner
With the ever-increasing numbers of people living to old age, both in developed and developing countries, healthcare services must adapt to the illnesses and needs of this rapidly growing segment of the population. In this article, we take a look at two conditions that are attracting a lot of attention from researchers, clinicians and service planners – frailty and sarcopenia. Both are central to understanding and caring for vulnerable older people throughout the healthcare pathway.
What are frailty and sarcopenia?
Frailty is the loss of the body’s ability to withstand a stress – whether illness, trauma, or medication. Frailty is why an older person can lose independence and thus can be unable to get out of bed, confused, dehydrated with kidney failure after only a mild infection, whereas a person who is not frail would be able to withstand the infection and carry on with their daily life.
One of the main components of frailty is Sarcopenia – the loss of muscle size and strength that accompanies ageing. It’s a concept that is as old as medicine itself – Hippocrates recognised it – but recent research has made significant progress in both defining ways to diagnose the condition and in understanding what causes it. It is not merely caused by getting old, but a complex mixture of other illnesses, changes in hormonal levels, inflammation, and a reduced ability of older muscle to regenerate itself all play a part.
Both sarcopenia and frailty are common; 5 to 8% of people in the UK aged over 65 have sarcopenia, but it is much more common in certain groups such as those in care homes, where 30% or more of residents will have sarcopenia. Frailty follows a similar pattern, and becomes increasingly common with increasing age so that 25–40 % of people aged over 75 are affected by frailty. It is likely that large numbers of older people contacting ambulance services have sarcopenia and frailty. Not only are this group more likely to fall and injure themselves (see below), they are also likely to have multiple other illnesses such as cardiovascular disease or lung disease, that in turn can trigger the need for prehospital care.
How are frailty and sarcopenia recognised?
Sarcopenia is diagnosed by measuring muscle strength (usually handgrip strength and walking speed) and measuring muscle size (usually using CT scanning or DEXA scanning similar to that used to diagnose osteoporosis). As such, it is not a diagnosis that can be made at the prehospital stage of care.
Although the ’gold standard’ method for diagnosis of frailty is a comprehensive geriatric assessment, there are a variety of simple screening tools that can be used. One simple way to highlight people who are likely to be frail is to look out for patients presenting with one of the five frailty syndromes – falls, immobility, delirium (acute confusion), incontinence, and medication side-effects. Not everyone who presents to prehospital care in these ways will have frailty, but a high percentage will. These are a group of patients for whom further comprehensive assessment is beneficial, as we discuss later in the article. A simple tool that aligns reasonably well with gold- standard assessments is the Clinical Frailty Scale (box), which also allows users to gauge the severity of frailty.This scale relies on a global impression of a patients function, taking into account what the patients and their relatives say about their usual level of function – not just how they are when acutely unwell. It is simple and quick to use, and can be used in the prehospital setting as well as in hospital inpatients, clinics and GP surgeries. In England and Wales, GP surgeries are now able to calculate an electronic Frailty Index (eFI) which highlights those people who are likely to have frailty.
Most people with sarcopenia are frail, but not all those with frailty have sarcopenia. Care is needed to ensure that the two terms are not used interchangeably. Similarly, frailty is distinct from disability (which describes impairment of ability to perform activities of daily living) and is also different from multimorbidity, which refers to having several diseases or conditions. It is perfectly possible to have multiple disease diagnoses without being frail. Fig 1 makes the distinction between all of these states.
What are the consequences for older people?
People with sarcopenia and/or frailty are more likely to fall, are more likely to end up in hospital, than those who do not have frailty. People with frailty and sarcopenia are also more likely to need care from others, more likely to need to enter a care home, and have a much higher risk of dying than those without frailty. In the past, both muscle weakness seen with advancing age, and frailty, were thought of as the inevitable price of getting older. It is clear that this is not necessarily the case – not everyone who is old has sarcopenia or frailty – and as our understanding of these conditions improves, it is likely that we will be able to slow down the onset, or even reverse these conditions.
Clinical practitioners, as well as lay people, “know” when someone is frail. For both sarcopenia and frailty however, standardised criteria are important in making the diagnosis, so that misdiagnosis does not occur and people are not denied access
to appropriate care. For frailty in particular, there is a tendency for the word ‘frail’ to substitute for ‘old’ in healthcare discussions – a form of ageism by stealth.
Why are they important in prehospital care?
Older people with frailty and sarcopenia are particularly vulnerable when admitted to hospital – they are more likely to have long lengths of stay, are more likely to suffer from adverse effects from being in hospital such as delirium (confusion), loss of independence or even death. Being confined to a hospital bed can accelerate the loss of muscle mass and strength seen in sarcopenia. However avoiding hospital admission can only really be effective when there is a viable alternative which manages the associated risks. Exciting models which work across the interface between the ambulance service and other community providers have the potential to do this.
In the New Forest in Hampshire, a new model of care is being developed for people with frailty who suffer a crisis – such as a fall, becoming immobile or developing acute confusion. Combining the skills of an ambulance technician in assessing for illness with the skills of a therapist looking at the impact of the crisis on independence, a rapid triage team helps medical staff to prioritise those patients who could and should be managed at home without delaying admission for those who really need it.
For some specific conditions the assessment of older people by prehospital care services has the potential to avoid hospital admission – and assessing for frailty is a key part of this. In Lanarkshire, Scotland, paramedic practitioners now form part of the Hospital at Home team, working alongside doctors, nurses and therapists to assess, signpost and treat older patients at home with a range of acute conditions including exacerbations of COPD, heart failure, infections and falls.
Addressing frailty and sarcopenia takes time – they are not conditions that are amenable to rapid prehospital care. However, prehospital practitioners are ideally placed to signpost those with frailty and sarcopenia to services that best meet their needs – which may involve assessment by community geriatric medicine or primary care services, rather than defaulting to the emergency room.
What are the treatments for frailty and sarcopenia?
The treatment that is proven to work for sarcopenia is resistance exercise training – using weights, elastic bands, or working against one’s own body weight. The challenge for health services now is making sure that all those with sarcopenia, or those at risk of sarcopenia, can access such training. Other approaches being tested at present include nutritional supplements (such as protein supplements and leucine). Medications are also being tested in clinical trials – some new (such as myostatin inhibitors) and some familiar drugs which might help in sarcopenia (such as ACE inhibitors and allopurinol).
A similar approach – exercise training – also looks promising for frailty, and in clinical practice, rehabilitation services can make a great deal of difference to those who are frail.This doesn’t have to mean an admission to hospital though; more and more rehabilitation services for older people are moving out into the community and even into people’s own homes, reaching those who might be reluctant to attend hospital or clinic for rehabilitation and reducing competition for beds in hospitals. The important point is that the presence of frailty marks the point at which the priorities for care need to change from disease-based guidelines to a person-centred approach which meets the individual’s own goals and aspirations. In practice this usually means they need a comprehensive or holistic assessment which includes a drug review – Comprehensive Geriatric Assessment.
Frailty and sarcopenia are important conditions that are having an increasing impact on how we care for older people.
Identifying those who are living with frailty has the potential to guide triaging decisions around where to transfer patients from the prehospital setting, what services they may benefit from being signposted to, and gives practitioners in all areas of health and social care valuable information that can modify how we deliver care to our older patients. New systems of care and new treatments are starting to come into use, and practitioners will need an awareness of these new treatments as they are introduced to this rapidly developing field.
The British Geriatrics Society Guidance on frailty
Fit for Frailty Part 1 Recognition and management of older people with frailty in community and outpatient settings. British Geriatrics Society 2014. http://www.bgs.org.uk/ campaigns/fff/fff_full.pdf
Fit for Frailty Part 2 Designing, commissioning and managing services for Older people with frailty. British Geriatrics Society 2015. http:// www.bgs.org.uk/campaigns/fff/fff2_full.pdf
Biography: Dr Miles Witham
Dr Miles Witham is Clinical Reader in Ageing and Health at the University of Dundee. He works as a consultant geriatrician in the community, and also runs clinical trials of therapies for sarcopenia. He is co-chair of the British Geriatrics Society Sarcopenia and Frailty Research group.
Biography: Professor Avan Sayer
Professor Avan Sayer is Director of the NIHR Newcastle Biomedical Research Centre and Professor of Geriatric Medicine at Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust. She leads translational research on ageing syndromes such as sarcopenia, frailty and multimorbidity. She is co-chair of the British Geriatrics Society Sarcopenia and Frailty Research Group.
Biography:Dr Richard Dodds
Dr Richard Dodds is an NIHR Clinical Lecturer in Geriatric Medicine at University of Southampton and also a Visiting Clinical Lecturer at Newcastle University. He combines hospital work in acute geriatrics with research into the development of sarcopenia across the life course.
Biography: Dr Gill Turner
Dr Gill Turner is a Community Geriatrician in the New Forest where she is involved in work to develop a new workforce for acute frailty management. She has held several roles within the British Geriatrics Society, with a longstanding interest in frailty management, including the development of the Fit for Frailty guidelines.