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.
Frailty identification and assessment
Level 1
Supporting older people living with frailty requires early intervention and personalised care
What frailty identification and assessment looks like as:
- Involves watchful waiting and the ability to identify and respond to changes over time
- Enables the use of tools and processes that can capture what matters most to the older person living with frailty over time (e.g., Comprehensive Geriatric Assessment (CGG) and Patient Reported Outcome Measures (PROMs)
- Enables the use of standardised tools to determine the level of frailty and trigger appropriate care pathways
- Enables cross-sector engagement in watchful waiting
- Communities that have access to learning about living with frailty and how to live and age well
- Build an evidence base on innovative practice in:
— Using coordination hubs to navigate services
— Caregiver given emergency medicine - Centre for Ageing The State of Ageing 2025
- Happy healthy lives
Examples of Staff training and education to support holding risk and complexity:
- Royal Surrey NHS Frailty Academy
- Skills for health
- British Geriatrics Society Frailty Hub: Education and training
Examples of National Resources and guidelines:
- British Geriatrics Society Frailty – What is it all about
- NHS England Frailty resource
- Hospice UK Frailty: identification and assessment
- Hospice UK Measuring what matters
- Specialised Clinical Frailty Network
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