Re: The challenge of ageing populations and patient frailty: can primary care adapt?
Frailty: Turning the Titanic?
We note with interest the recent article by Reeves and colleagues  regarding frailty in primary care in light of recent policy developments in the UK requiring GPs to identify and treat older people with moderate to severe frailty. The authors suggest that the ultimate success of this initiative will likely hinge on two contingencies: 1) reducing the workload of GPs while also simultaneously 2) improving outcomes for older frail patients.
We would like to suggest that properly addressing frailty within health systems will require no less than a complete reorientation of the health system away from a disease focus towards person-centred, coordinated and integrated care as advocated by the World Health Organisation and others [2–4]. To this end, the task ahead invokes the metaphor of “Turning the Titanic” in terms of its scope and complexity.
Because frailty is not currently well quantified, we do not know how many older people are currently falling through the gaps as a consequence of the failings of health systems worldwide. But it is likely this number is high, signifying many undiscovered cases of frailty, and that as populations age this number will be even higher in the future.
Consequently, it seems highly unlikely that better identification and management of frail people will in any way result in a reduction in workload for health service providers – at least not in the short term - because there is so much lost ground to make up. Our work to date [5–7] suggests that the outlook from Australia (where we are so many years behind the UK and Europe with respect to frailty identification and management), is even more dire, although research is slowly gaining momentum.
However, the alternative – to turn a blind eye to frailty – is unquestionably so much more serious. We know that frailty significantly increases the risk of a range of adverse outcomes including mortality, falls and fractures, hospitalisation and physical limitation , and a number of studies have indicated that being frail inflates health care costs [9–11]. The better outcomes for older people are thus likely to come with a time lag, as with much primary prevention.
While (as the authors note) the suggested policy response to frailty (implementing Comprehensive Geriatric Assessment) is as yet unproven, we do know that frailty has been shown to be treatable and even potentially reversible through appropriate and well-timed intervention [12–16]. Beyond this aim, the benefits of adopting a person-centred approach to supporting older people’s health and well-being should be obvious.
In conclusion, meaningfully addressing frailty will require a massive cultural (perhaps generational) shift in the way that world health systems are organised. GPs and health service providers will need to be supported to work in new ways through the provision of policy and funding, tools and resources, education and training and public awareness campaigns that raise consumer health literacy about frailty on a grand scale. Admittedly, there may be numerous ways to work smarter, not harder – as the authors acknowledge - with the implementation of eFIs being just one example . But turning the ship around on frailty will require no less than a massive effort from all of those involved in ensuring older people’s health and well-being, and it seems probable - at least in the short term - that GPs and their teams will need to invest additional effort in bringing about that change. From our perspective, we think the investment will be worth it.
06 September 2018
Rachel Ambagtsheer1,2, Justin Beilby1,2 and Elsa Dent1,3
1. Torrens University Australia, 220 Victoria Square, Adelaide, Australia
2. National Health and Medical Research Council Centre of Research Excellence in Trans-Disciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia
3. Baker Heart and Diabetes Institute, Melbourne, Australia
1 Reeves D, Pye S, Ashcroft DM, et al. The challenge of ageing populations and patient frailty: can primary care adapt? Bmj 2018;362:k3349. doi:10.1136/BMJ.K3349
2 Woo J. Designing fit for purpose health and social services for ageing populations. Int J Environ Res Public Health 2017;14. doi:10.3390/ijerph14050457
3 Lim WS, Wong SF, Leong I, et al. Forging a frailty-ready healthcare system to meet population ageing. Int J Environ Res Public Health 2017;14. doi:10.3390/ijerph14121448
4 Turner G, Clegg A. Best practice guidelines for the management of frailty: A British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing 2014;43:744–7. doi:10.1093/ageing/afu138
5 Dent E, Lien C, Lim WS, et al. The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. J Am Med Dir Assoc 2017;18:564–75. doi:10.1016/j.jamda.2017.04.018
6 Ambagtsheer R, Visvanathan R, Cesari M, et al. Feasibility, acceptability and diagnostic test accuracy of frailty screening instruments in community-dwelling older people within the Australian general practice setting: A study protocol for a cross-sectional study. BMJ Open 2017;7:e016663. doi:10.1136/bmjopen-2017-016663
7 Ambagtsheer RC, Beilby J, Dabravolskaj J, et al. Application of an electronic Frailty Index in Australian primary care: data quality and feasibility assessment. Aging Clin Exp Res 2018;0:0. doi:10.1007/s40520-018-1023-9
8 Vermeiren S, Vella-Azzopardi R, Beckwée D, et al. Frailty and the Prediction of Negative Health Outcomes: A Meta-Analysis. J Am Med Dir Assoc 2016;17:1163.e1-1163.e17. doi:10.1016/j.jamda.2016.09.010
9 Sirven N, Rapp T. The cost of frailty in France. Eur J Heal Econ HEPAC Heal Econ Prev care 2017;18:243–53. doi:10.1007/s10198-016-0772-7
10 Bock JO, König HH, Brenner H, et al. Associations of frailty with health care costs - Results of the ESTHER cohort study. BMC Health Serv Res 2016;16:1–11. doi:10.1186/s12913-016-1360-3
11 Hajek A, Bock JO, Saum KU, et al. Frailty and healthcare costs-longitudinal results of a prospective cohort study. Age Ageing 2018;47:233–41. doi:10.1093/ageing/afx157
12 Cameron ID, Fairhall N, Langron C, et al. A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Med 2013;11:65. doi:10.1186/1741-7015-11-65
13 Kim H, Suzuki T, Kim M, et al. Effects of exercise and milk fat globule membrane (MFGM) supplementation on body composition, physical function, and hematological parameters in community-dwelling frail Japanese women: A randomized double blind, placebo-controlled, follow-up trial. PLoS One 2015;10:1–20. doi:10.1371/journal.pone.0116256
14 Li C-M, Chen C-Y, Li C-Y, et al. The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized, controlled trial. Arch Gerontol Geriatr 2010;50:S39–42. doi:10.1016/S0167-4943(10)70011-X
15 Ng TP, Ling LHA, Feng L, et al. Cognitive Effects of Multi-Domain Interventions Among Pre-Frail and Frail Community-Living Older Persons: Randomized Controlled Trial. Journals Gerontol Ser A 2017;0:1–7. doi:10.1093/gerona/glx207
16 Tarazona-Santabalbina FJ, Gómez-Cabrera MC, Pérez-Ros P, et al. A Multicomponent Exercise Intervention that Reverses Frailty and Improves Cognition, Emotion, and Social Networking in the Community-Dwelling Frail Elderly: A Randomized Clinical Trial. J Am Med Dir Assoc 2016;17:426–33. doi:10.1016/j.jamda.2016.01.019
17 Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016;45:353–60. doi:10.1093/ageing/afw039
Competing interests: No competing interests