Frailty identification and assessment
Supporting older people living with frailty requires early intervention and personalised care
5M of geriatric care
A holistic framework used in geriatric care: Mind, Mobility, Medication, Multicomplexity, Matters Most.
Advancing Frailty
Used to refer to older people whose frailty has progressed to a moderate or severe stage.
Compassionate communities
Defined as communities that actively work together to provide social, emotional and practical support.
Family
Defined as a wider social network around the older person. This can be close relatives, but also friends, neighbours and community connections.
Home
Defined as a space, not a place.
Interdependency
Defined as a state of interconnection with others, based on connectedness, mutuality and reciprocity.
Parallel planning
Defined as the possibility of multiple different outcomes.
Watchful waiting
Defined as an approach to care that engages assessment over time, but does not always require changes to intervention.
Identification and assessment of need with the context of uncertainty
Level 1
Supporting older people living with frailty requires being able to identify, hold and respond to fluctuating needs
What the Identification and assessment of need with
the context of uncertainty looks like:
- Involves parallel planning
- Involves communicating what uncertainty might look like with the older person and family
- Involves early and ongoing conversations about different phases of life, where health goals may change
- Enables early identification of palliative care needs across the system
- Enables flexible, integrated care that can respond to uncertainty
- Enables a clear understanding of care pathways and criteria
- Enables access to advanced knowledge and skills to support complexity
- Supported by shared policies
- Supported by earlier access to palliative care
- Supported by the evidence building at a regional, national and global level
- Leadership that supports staff wellbeing
- Build an evidence base on innovative practice: Examples
— Caregivers given end-of-life medication
— Out of hours/crisis teams - Engagement in the use of multidisciplinary care plans and reviews
- Use of liaison workers across teams
- Use of planned decision-making throughout care
Resources and guidelines
- British Geriatrics Society End of life care in frailty identification and prognostication
- Hospice UK Co-ordinated care for people living with frailty
- Hospice UK Extending Frailty Care
- The King’s Fund Making our health and care systems fit for an ageing population
- The Gold Standards Framework
- Supportive & Palliative Care Indicators Tool
Identification and assessment of need with the context of uncertainty
Supporting older people living with frailty requires being able to identify, hold and respond to fluctuating needs
Current and future wishes and goals of care
Supporting older people living with frailty requires engagement in conversations about values, preferences and goals of care
Key clinical considerations in severe frailty
Supporting older people living with frailty requires the consideration of the multidimensional needs of the individual
The identification and support of family
Supporting older people living with frailty requires the consideration of the family and wider social networks around the older person