Keeping Up to Date with Frailty Related Issues

This is the last post in the Frailty Matters Coaching and Teaching programme which you have all been participating in. Frailty and the care of people with frailty, like all areas of health and social care is an area constantly being researched and best guidance on care as a result changes. It is important therefore to keep up to date with what is going on in Frailty care and management so that you and your team continue to deliver the best care possible. So this post is going to offer a few tips for keeping up to date.

The first resource to mention is one that we have used already within the programme, which is the British Geriatric Society Frailty Hub The Hub was created in June 2020 and will be the place where the BGS will hold its national guidelines and best practice relevant to frailty. The BGS also have their own Journal Age and Ageing and on their website they host a collection of articles from the Journal that looks at Frailty in older people. You can access their collection at

The Royal College of Nursing (RCN) also host a a page on frailty where you will find advice and resources on identifying frailty in older patients and choosing the right interventions to help manage their condition. See:

They also have a larger frailty resource held on their magazine website called the RCNi frailty resource collection. This is not open access however, you need to be subscriber to one of the RCNi Magazines listed here. to get access to their online materials.

NHS England has two specialist groups that deal with frailty issues. They are the Acute Frailty Network. Their ‘Guidance and Resources’ pages in particular are useful and worth keeping track of.

There is also the NHS Specialised Clinical Frailty Network. on this site you will find a range of tools and resources to support the improvement of NHS specialised services for older people living with frailty.

On the Royal College of GP’s website there is a toolkit that provides a collection of relevant tools and information to assist primary care teams to implement a six-step model of collaborative care and support planning which is very useful for supporting the care a number of patients groups including adults living with frailty. See:

It is also worth noting that Health Education England, NHS England and Skills for Health provides a single, consistent and comprehensive framework that sets out the skills, knowledge and behaviours expected of any person who is involved in the care and support for people living with frailty. which may prove useful when you are considering your own development and that of the members of your team.

Finally it is worth occasionally using the following terms in Google from time to time just to see what is produced by the Cochrane Library Database of Reviews. They don’t have a specific frailty collection yet but they do very frequently review topics of interest to health and social care professionals looking after people living with with frailty. Search Using “Cochrane Library Frailty” in Google and see what comes up.

Additional Teaching/Learning Resources

When planning the sessions coaching sessions for this project there were two ‘guests’ we were going to invite to discuss their work with you, Janis McDonald who is the Chief Officer of Deaf Scotland who was going to discuss frailty and hearing and sight loss and Alison Bunce, the Programme Lead for Compassionate Inverclyde who is a Queen’s Nursing Institute Nurse. See who was going to discuss Compassionate Inverclyde with you.

Since they were unable to speak to you in person online they decided to record what they were going to discuss for you to watch. Both videos are below.

The second video is below:

So far in the programme we have been using text and video resources but there are a number of resources that exist in podcast form that we have not utilised. Podcasts tend to be a bit longer than video resources but you can download and listen to them in your own time. So you can listed to them from your ‘phone, on a smart speaker, on a walk, in the car etc.. You can of course also listen to them and share them with your own team and as they tend to be published in series, then you and your team members can listen to those you/they want to hear or feel are most relevant at the time.

The first series we are going to point you to are a series of podcats from Eat Well Age Well is a national project tackling malnutrition in older people living at home in Scotland. Eat Well Age Well is brought to you by award winning Scottish Charity Food Train. The website for the project is at

To access the first blog press play below

Their podcasts are all about sharing and discussing how we can support older people in Scotland to eat well, age well and live well. See,age%20well%20and%20live%20well.

The Royal National Institute for the Blind also have a series of Podcasts to aid in supporting people with sight loss. There are three different podcast series, focusing on:

Each podcast is less than 15 minutes long. They are designed for older people living with sight loss as well as those family members, friends and carers who support them, as well as anyone who supports and helps adults with complex needs – both in a home or care setting.

Another larger podcast resource which has a wider remit than just frailty is a resource called MDT Education on Ageing: which has been designed for anyone working with older adults. They are part of a podcast family of site called the Hearing Aid Podcasts. You can access all of their podcasts (there are 9 series) at

A guide to all their podcasts can be found at

Covid-19 and Frailty

During this pandemic, older people living with frailty and long-term conditions will continue to experience episodes of ill-health, falls or other unforeseen events. While COVID-19 will be the main concern for the healthcare system as a whole, much of the care that community and social care teams provide will be the routine care that they always provided. Efforts will be made to provide more care at home or in community settings, keeping older people out of hospital until it becomes necessary.

A key reason for this is that frailty is a strong predictor of adverse outcomes for older people hospitalised because of COVID-19 infection. A study of an acute hospital ward in Greater Manchester has shown how risk of death from COVID-19 increases with age, frailty and comorbidity. The study which you can access here examined the outcomes of 215 patients with COVID according to age group and levels of frailty, 86 of which sadly died. Tragically, 16% of the patients who were younger than 65 years died, 37% of the patients aged 65 to 75 years died: 53% of the patients aged 75 to 85 years died , and 62% of the patients aged above 85 years died. Frailty was measured using the Rockwood Clinical Frailty Score which scores people from 1 (very fit) to 9 (terminally ill), 16% of patients with a score of less than 5 died, 42% of patients with a score of 5 died, 67 % of patients with a score of 6 died, 82% of patients with score of 7 and 8 died, and 100 % of patients with a score of 9 died early. There is no doubt that avoiding the illness if you are over 65 and frail is the most effective strategy until there is a widely available effective vaccine.

It is highly likely that some older people you are looking after will unfortunately die from this disease or will die with this disease from their underlying health conditions over the coming months. It is important to remember that while older people are the most likely to be seriously affected by COVID-19, many will recover from it. Treatment for the virus must be determined by clinical need and best evidence and not by age alone.

It is worth noting also that there is a growing body of evidence that indicates that COVID-19 can occur with atypical presentations, especially in older people. For example in Italy, 24% of COVID-19 patients who died during pandemic had no fever, 27% had no dyspnea, and 61% had no cough. There are also descriptions of older people with COVID-19 presenting with a history of falls or delirium suggesting that there is a need for an early assessment of frailty in the community and careful monitoring of physical and cognitive status during this current period of social restriction In addition, the lack of physical activity in those restricted or those sheilding may be contributing to muscle mass loss, weakness, and falls, as well as having an impact on their mental health status. Again early assessment of frailty can be extremely useful to identify frail people who at risk of deterioration due to these factors.

Finally, people recovering post-COVID-19 may still exhibit extra-pulmonary manifestations, including neurological, cardiovascular, and musculoskeletal disorders increasing their likelihood of frailty or worsening already existent frailty. Hence, most of the older people post virus may require functional, neuromotor, respiratory, and cardiac rehabilitation, which all warrant frailty assessment. 

The key message in all of this is that frailty assessment which is being encouraged by NICE for all older adults being admitted hospital is equally and perhaps more valuable for all people in the community at risk from the COVID-19 virus. It should perhaps be considered as a vital sign, at least until the current crisis is over.

On a practical note it also worth noting that the British Geriatric Society have compiled a page of resources for keeping older people safe at home. It is particularly relevant for shielding and isolated older people but also applies more generally to older people who live without assistance in their own homes and might be exposed to other risk factors or hazards. You can find it at:

They also have a page of wider advice designed for health and social care professionals which can be found at :

Guidance for providing care and support at home to people who have had COVID-19 was published by the Social Care Institute for Excellence (SCIE) this week (14th of November 2020).You can find it at:

Palliative Care in Frailty

Ask any community nurse and they will say that delivering care for patients who are considered palliative is one of the most satisfying parts of their job.   This is not surprising when the main aim of palliative care is to relieve suffering and to improve the quality of the person’s life.  Traditionally,  the focus of palliative care was on those with a terminal diagnosis of cancer where a clear trajectory is more predictable.  However, frailty is a complex long term condition with a less predictable end trajectory and as such, it becomes more difficult to identify when palliative care should be considered. 

The following diagram was created from stakeholder and focus group discussions in an attempt to develop a short term palliative support model for older people with frailty.  It illustrates the unpredictable illness trajectory associated with frailty  highlighting opportunities for a more integrated and palliative approach and a need to anticipate support and care across this journey.

from Bone et al (2016)

In earlier posts on this site, we have discussed the complex care and support needs for people across the frailty trajectory, but when should we consider palliative care?  If you are not clear about when this is, ask yourself; “Is the patient at risk of missing out on very important elements of their care as they head towards the end of their life?” When asking, you must also consider the patient’s family as they could also be deprived of the opportunity for improved support at this time.

There is an argument that palliative care should commence on diagnosis of any life limiting condition.  This is to allow individualised care and support planning and optimal symptom management as well as the opportunity for early anticipatory care planning discussions.  Add frailty to this and consideration should also be given to the person’s physical, psychological  and possible cognitive decline as well as their expected inability to bounce back from episodes of acute illness.

Does the surprise question apply in this situation?  There is some evidence to suggest that the ‘surprise question’ is useful in identifying when the patient would be considered palliative or would  benefit from palliative care support (White et al 2017). The surprise question involves any healthcare professional asking themselves “ …would you be surprised if this person were to die (within a specified time period) such as within the next 6 months or within a year”.   This type of question has now been incorporated into a number of clinical guidelines as well as the Gold Standards Framework

If this is the case then you should be considering comfort measures for the patient including de-prescribing of unhelpful medications, a focus on symptom management within the context of a comprehensive geriatric and palliative care assessment, good communications and family support.  Please check out the excellent BGS resources highlighted in the end of life blog.

Bone, A.E., Morgan, M., Maddocks, M., Sleeman, K.E., Wright, J., Taherzadeh, S., Ellis-Smith, C., Higginson, I.J., Evans, C.J. (2016)  Age and Ageing, 45, (6), pp. 863–873,

Hamaker, M.E., van den Bos, F., Rostoft, S. (2020) Frailty and Palliative Care. BMJ Supportive and Palliative Care, 10: pp. 262-264. doi:10.1136/bmjspcare-2020-002253

White, N., Kupeli, N., Vickerstaff, V., Stone, P. (2017) How accurate is the ‘surprise question’ at identifying patients at end of life? A systematic review and meta-analysis.  BMC Medicine, 15:139

End of Life Care in Frailty

There is little need for us within this project to write about end of life care in frailty because an extensive, near comprehensive and free to access resource on this topic prepared by the British Geriatrics Society (BGS) already exits.

Rather than condense what this resource says we will just introduce it to you. The aim of the BGS guidance is to support clinicians and others in considering the needs of and providing high quality care for frail older people as they move towards the end of their lives.  It sets out to prompt and support timely discussions about preferences for care, ideally at a time which facilitates the input of the older person themselves. They hope their guidance will provide practical advice to help staff working with frail older patients so they can provide them with the best opportunity to live and die well. 

You can access this resource at:

It is worth noting that in the BGS End of Life Care in Frailty resource, where it discusses Advanced Care Planning refers you to the Advance Care Planning Resource for England and Wales at

Scotland has its own Anticipatory Care Planning Resource which has an earlier focus designed to give control to people with long term conditions control over their management plans at an earlier stage than end of life. You can find the Scottish Resource at

There is also an Anticipatory Care Planning Toolkit available at Healthcare Improvements iHub. See

They have also produced a number of videos about Anticipatory Care Planning of which this one, Anticipatory Care Plans (ACP’s) in a Care Home may have the most resonance when you consider ACP’s for the frail people that you encounter.

You can watch it here.

Frailty and Falls

This post will look at falls which is one of the most written about topics in relation to the care of older people and people living with frailty.

The reason for this are quite clear. With an ageing population and more people living longer with complex health needs falls present an important challenge. In Scotland in 2017–2018, over 37,000 people – 22,400 of whom were over the age of 65 – were admitted to hospital because of a fall.

The Scottish Government have stated that we all need to do more and offer opportunities earlier in the lifespan to help older people age healthily to avoid or postpone the time at which they may fall or sustain a fracture.

Frailty can contribute to falls and result in a person making a slower or poorer recovery following a fall. Conversely, a fall can trigger or accelerate the progression of frailty. Some actions and approaches to prevent falls will also help prevent or slow the progression of frailty. These include being physically active and less sedentary, improving muscle strength and balance, promoting continence, and ensuring good medicines management and adequate nutrition.

The following SWAY presentation looks at the issues involved in managing frailty and falls in the community we hope you find it useful


It is worth noting that the Scottish Government was consulting on a new ‘National falls and fracture prevention strategy for 2019-2024.’ which has not been published yet. The consultation document is at

Promoting Frail Adults Nutritional Intake

The recognition of nutritional problems in older people is important as these are associated with poor prognosis but are potentially treatable. Any assessment of frailty has to include some key questions about diet, appetite and weight, as these can indicate specific problems related to nutrition as well as being markers of other underlying medical conditions.

However first and foremost, it’s important to identify the signs of malnutrition, which include the following:

  • Tiredness and low energy
  • Loss of appetite
  • Unintentional weight loss
  • Clothes, jewellery or dentures becoming loose over time

Malnutrition can affect every system in the body and results in increased vulnerability to illness and complications which can lead to an increase in the need for community services, more visits to the doctor, prolonged hospital
stays and in some cases, death. The main consequences of malnutrition are:

  • Fatigue and lethargy
  • Falls
  • Difficulty coughing, which increases the risk of chest infection
  • Heart failure
  • Anxiety and depression
  • Reduced ability to fight infection

Malnutrition is also associated with several psychological issues. Mental health problems such as depression and anxiety or a change in the cognitive status of a frail older person can result in a loss of interest in eating. If insufficient nutrients are consumed as a result of loss of appetite, a change in mood and energy levels will occur and a negative cycle of reduced calorific and nutrient intake may ensue. 

Given the current coronavirus pandemic, social isolation is also more prevalent than ever among older people particularly those who are frail and have been encouraged to sheild. Immobility can significantly reduce appetite in frail older people and eating alone can also lead to lower than required nutritional intake. This can also lead to a reduction in the nutritional quality of the food consumed. Less thought is also given to selecting the right food when we shop alone, as convenience and haste are deemed more important than a nutritionally balanced diet. Dietetic research also suggests that eating the right food in the right setting positively improves both mental and physical well-being.

Equally important is the additional element of dining with dignity and the visual appearance of food. For those that live with dysphagia, this can be extremely challenging, as the ability to enjoy eating communally can often prove problematic. The potential embarrassment and social awkwardness which can accompany the feeling of eating something completely different to everyone else can be hugely debilitating for some. Again this contributes to an increased risk of developing malnutrition due to a drop in  nutritional intake often accompanied by a reduction in the nutritional quality of the food consumed. 

Some frail older people also choose to add liquid to meals and foods when they are home-blending. Whilst this may help achieve the correct texture, it also increases the volume and, depending on the type of liquid used, potentially decreases the nutritional content. Access to ready-prepared texture modified meals can provide a solution. Not only is nutritional content carefully controlled in such meals great care is also taken to ensure the meals look appetising. When texture modified meals resemble the appearance of regular food as far as possible, it makes it easier for the person with dysphagia to enjoy eating with others. 

Due to the complex nature of malnutrition there are no blanket measures to prevent its occurrence. However, once the causes for each frail older person are recognised, there are steps which can be taken to manage, treat and prevent it.

So, once you’ve identified the signs, what are effective dietary solutions for malnutrition? If someone suddenly loses their appetite, becomes thinner, or steadily loses weight unintentionally it is important to speak to a GP or a dietitian. For some time now, the treatment for malnutrition has often included the prescription of oral nutrition supplements. However, for dietitians, the preferred first step to treating malnutrition is to encourage a ‘food first approach’ where possible. This is likely to focus on encouraging people to eat higher calorie and protein foods more often. 

The food first approach seems straightforward but increasing food intake for frail people with a smaller appetite can be challenging. Adding things like a slice of cake, cheese and full fat milk to one’s diet can all be beneficial, as these are energy dense foods. Smaller and energy dense meals are crucial when cobatting a reduced appetite.

Malnutrition remains one of the most common nutritional challenges among frail older adults in the UK. Healthcare professionals have a key role to play in the recognition and prevention of this challenging disease, as they often have close and regular contact with older adults in the community. Anyone who comes into close or regular contact with an older person has the potential to spot the signs and symptoms of malnutrition and weight loss is not an inevitable part of ageing. It is always worth asking frail older adults some gentle questions about their dietary intake because reduced appetite often marks a decline in their health. There are also screening tools that can be completed, the most commonly used one being the Malnutrition Universal Screening Tool (MUST). The MUST tool is often used to guide appropriate referral to a dietitian.

Whilst a ‘food first’ approach, often with additional use of oral nutritional supplements, is the cornerstone of treatment for malnutrition, there are several key social aspects to consider as well. Simple strategies like attending a local lunch club, encouraging eating with friends or family members or a visit from volunteers from services such as Age UK’s Befriending Service, can all have a positive impact on the amount an older person eats at mealtimes.

When it comes to preventing and treating malnutrition, we should all be thinking of both the clinical and social interventions that can help.

This piece has been based on an article on the British Dietetic Association (BDA) website by Emily Stuart, a Dietitian fo Apetito & Wiltshire Farm Foods.

Other resources from the BDA that you may find useful

There is a Managing Adult Malnutrition in the Community malnutrition pathway which also includes a pathway for the appropriate use of Oral Nutritional Supplements. See:

The BDA earlier this year drew up an A4 leaflet listing a useful store of basic foods for older people who can’t easily get to the shops. Their ‘Older Peoples’ Store Cupboard Flyer’is available at the link given below.

The full BDA guidance for managing malnourished adults in the community, including their Policy statement can be found at:

This guidance website also has 4 sections worth exploring near the top. Click on the links to Introduction, Discussion, Examples, Conclusion and References while you are there.

The British Geriatrics Society also have a brief chapter from their resource ‘End of life care in Frailty’ on Nutrition which you may find useful.

The role of nutrition in the cycle of frailty diagram you will see on the page is interesting and worth considering.

Mental Well-being in Later Life

Much of the literature on Frailty has focused on physical health, however mental health including cognition, sleep, social interactions and positive aspects like well-being are just as important.

In 2014 in the UK general population about 300 in every 1,000 people experienced mental health problems. Of those 300 people, 230 visited a GP and 102 were diagnosed as having a mental health problem. For people with frailty who are at higher risk of mental ill-health, these figures will to be higher. National Surveys of NHS patients indicate that approximately 91 per cent of people with a mental health problem are treated within the primary care system, meaning that very few are referred to specialist mental health services. Figures also suggest that at least 25% of individuals with symptoms of mental health conditions such as depression and anxiety do not report them to their GP. People living with frailty will behave similarly. There is also an assumption by some that mental health problems are a ‘normal’ aspect of ageing, but most older people don’t develop mental health problems, and they can be helped if they do.

Healthcare professionals in the community are ideally positioned to make a difference. Age UK has identified key steps that every healthcare professional can take:  

  • Remember that mental health is just as important as physical.
  • Try to get into the habit of asking about the emotional well-being of the people you see. 
  • Look out for signs that your patients are struggling with their mental health. 
  • Start the conversation. It can seem awkward bringing up mental health but older people do say that they want to be asked and find talking useful.    
  • Think about language. Older people can be put off by terms such as mental health and depression. Try to use more informal language. 
  • Remember mental health problems are not inevitable. With the right support older people can recover. 

We have looked at two of the biggest causes of mental illness in frail older people already. See the earlier post on Loneliness which is at and our post about Dementia which is at

One of the main issues we have not examined relating to mental health is DEPRESSION. It has been estimated that 1 in 4 older people have symptoms of depression that require treatment, but fewer than 1 in 6 older people will seek help. Care home residents are also at an increased risk of depression. Depression in later life can be a major cause of ill-health and can have a severe effect on physical and mental well-being. Older people are particularly vulnerable to factors that lead to depression such as bereavement, physical disability, illness and loneliness. Depression in older people can be treated effectively through talking therapies and antidepressants. See the NICE Clinical Knowledge Summary on Depression mentioned below. Effective interventions to prevent depression in older people include reducing loneliness and isolation through encouraging learning, physical activity and any form social interaction including volunteering. Many of these are difficult at this time but a useful guide to ‘Keeping Well at Home’ which was devised for all older people whose interactions are restricted currently because of COVID-19 has been produced by the Healthy Ageing Research Group at Manchester University. You can download the booklet at

There is limited guidance from the Royal Colleges for those in primary care on what to do to maintain older people’s mental well-being but there is NICE guidance that you can refer to. NICE Guideline 32 is all about mental well being and independence in older people and there is also a NICE Quality Standard 137 which is on the same topic. You can look at the NICE flowchart and download both documents at

NICE (2020) Mental wellbeing and independence in older people overview: Interactive Flow Chart

You might also find the following NICE Clinical Knowledge summary on Depression useful.

England (2014), writing for the Royal College of GP’s has stated that community practitioners need to take responsibility for coordinating and signposting to services beyond health care, in particular social care, housing and benefits to effectively tackle mental well-being in older people. The more collaborative form of working integrated care heralds will move community staff from gatekeepers to that of navigators. Community healthcare workers need to take responsibility for co-ordination and signposting to services beyond health care and builds bridges with many community services, patients’ families and their communities, if improving the mental welfare of our older people is the goal.

If you want to know more about this topic an intersting report to read is by Lee, M. (2006) Promoting mental health and well-being in later life: A first report from the UK Inquiry into Mental Health and Well-Being in Later Life. London, Age Concern & Mental Health Foundation. 

The report highlights discrimination; participation in meaningful activity; relationships; physical health and poverty; as important parts of promoting mental health and well-being that also need to be considered

Welcome Back!

We would never have believed in early April when we last posted a blog item that it would take until the 19th of October to resume our coaching and teaching programme. It’s been a very strange and unique year and one that we are never likely to forget. We hope that you have all stayed well throughout the pandemic and our hearts go out to any of you who have had your lives or the lives of your family members affected by COVID-19.

Last month you would all have been sent a copy of our new plans for the coaching and teaching programme and we look forward to seeing you all again on Microsoft Teams on Thursday the 22nd of October between 3-5pm. We hope we have picked a time when most of you can be available.

From the timetable you will be able to see that new materials on the Blog should appear every Friday for 6 consecutive weeks. Please be patient with us if they don’t appear early, the intention is to have them available and posted by the commencement of each new week. Alongside the Blog it is our intention to include a number of podcasts/videocasts in line with topics that we are covering that week or that we have previously covered. If possible they will appear within the Blog posts for that week but they may have to be posted as separate items.

In the meantime we hope you #staysafe


Looking After Yourself and Your Team during COVID-19

This may be the last Blogging piece for a while but the project and this Blog will resume in due course. In the meantime we thought we should leave you with some resources that you and your team can turn to and try out in the coming weeks as this unprecedented, once in a hundred years, health crisis continues.

The first thing that we would like to share is some timely advice from the Queen’s Nursing Institute, Scotland (QNIS) from Hilda Campbell, Chief Executive of COPE Scotland and QNIS Honorary Fellow has provided the following wee ideas of things that could help you look after yourself and create some ‘me time’. Even if it is just a few minutes. You can access Blog here

It also includes other links within it which are worth following up. It would also be a good idea to share this resource with all the staff that you are working with.

The next resource we are going to suggest is from the Kings Fund and it looks at compassionate leadership in this time of crisis. it discusses the idea of an ABC of compassion at work, suggesting that leaders need to help provide Autonomy and Control, a sense of Belonging and a promote feelings of Competence. working in a compassionate way will aid in supporting your whole team through this stressful time. For more about this see:

On a similar theme this is a paper recently published in the BMJ by Greenberg N., Docherty M., Gnanapragasam S., Simon W. (2020)  Managing mental health challenges faced by healthcare workers during covid-19 pandemic BMJ; 368 :m1211 You can access it here.

The paper looks at measures that healthcare managers need to put in place to protect the mental health of healthcare staff having to make morally challenging decisions. Its brief and well worth reading particularly about aftercare; what needs to happen once this crisis passes.

Currently NHS staff are also being granted free access to a number of mental health apps to support their health and wellbeing as they work around-the-clock to treat coronavirus patients.

The apps, which include platforms to proactively improve mental health as well as sleep improvement programmes, will be freely available until December 2020.They include Unmind, a platform that provides a range of tools to help with stress, sleep, connection and nutrition; Headspace, a mindfulness and meditation app aimed at reducing stress and building resilience; Big Health’s Sleepio, a clinically-evaluated sleep improvement programme, and Daylight, a cognitive behavioural technique to manage worry and anxiety. You can access them all via this page of the NHS Employers website

The final resource and perhaps the most important is to be found on the Scottish Association for Mental Health (SAMH) website. They have collected together all the resources that can help and protect everyone’s’ mental health and wellbeing as they cope with the stresses brought about this pandemic and the stresses caused by of social isolation. We would urge to make use of this site and please share it with all your staff and patients

That’s all for now folks and we hope to see you all safe and well when things start to get back to normal.