Frailty again – and again!

I have long believed that the enormous and growing problem of frailty in later life is the chief source of the woes and exorbitant costs of the NHS – and the disability of so many of our pensioners. Sadly this is usually ignored or down played by clinicians – ie those responsible for dealing with our health problems.

The causes of Frailty

I say yet again – frailty is, for the great majority, preventable. It is not inevitable –  it is not inflicted on us by some evil force or malign deity. For most sufferers, frailty is the result of decades of underactivity.

For a small minority which includes many younger people, frailty is the result of other illness, not related to level of physical activity but inevitably leading to a decrease of exercise taking. Ultimately this carries the penalties of being frail – decline in physical and cognitive reserves leading to reduction in ability to respond to illness or injury. A classic result is an increased risk of emergency admission to hospital and increase in length of inpatient stays.

This aspect of frailty was covered by an article in this month’s Lancet (a very important and much appreciated medical magazine). The rather lengthy title was “Association between Hospital Frailty Risk Score and length of hospital mortality, and hospital costs for all adults in England: a nationally representative, retrospective, observational cohort study”!

The most unusual aspect of this study was the inclusion of all age groups aged 18 or more – most studies of the effects of frailty are confined to the over 60s and use the usual criteria – slow walking speed, weak hand grip and other results of loss of muscle (sarcopenia) and physical fitness. It is more complicated to identify frailty in younger people because the usual physical characteristics of frailty are much less pronounced but that does not mean that they are exempt. For them the chief characteristics are the presence of diseases – mainly non-communicable disease – and cognitive decline both of which would be much more common later in life. These findings were the characteristics used in the scoring system in this study.

The study included a sample of 1,478,554 emergency hospital admissions for 653,294 patients throughout England, between 12011 and 2019.

Prevalence and results

As expected, the frequency of frailty increased with age – from 0.2% for those aged 18-24 to 42% for those aged 95 or more. The presence of a high frailty score increased length of hospital stay for all age groups but this increase also rose with age. For example, for the 18-24 group the average length of stay was 4.5 days longer and the costs was £1217 higher than for the those without frailty. For the over 95 group the increase hospital stay was 15.3 days and the increase in costs was £2557 than for those without frailty.

The influence on in-hospital mortality was less marked but was still significant, but only up to the age of 65.

What should we take from this study?

The authors conclude that standard measures of frailty should be extended to all people over the age of 18 – to allow “holistic, frailty attuned interventions for young people” to help to delay or prevent frailty and related outcomes.

What do I take from this study?

The sentiments are admirable but little enough attention is paid to the current prevention of frailty, aimed  entirely at older people. I cannot believe that extending this very inadequate service to a group in which frailty is so rare is a profitable use of the hard pressed resources of the NHS. Nonetheless, younger people identified as being frail or at risk of frailty do need every encouragement to keep their exercise levels as high as they can. It is much more difficult for them and they do need a lot of help, advice and guidance.

However I am greatly heartened to find that clinicians are taking more notice of frailty as a major contributor to ill health and to growing costs to the NHS – and arguing for more effort to prevent what is an eminently preventable condition.