How can I effectively assess and manage frailty in older patients in a primary care setting?

To effectively assess and manage frailty in older patients within a primary care setting, a systematic approach focusing on identification, comprehensive assessment, and tailored interventions is crucial.

• Identifying Frailty and Risk

  In primary care, the Electronic Frailty Index (eFI) can be used to identify individuals aged 65 years and over who may be living with moderate or severe frailty ⁴. Diagnosing frailty in primary care, while challenging, is crucial for guiding appropriate care (Somagutta et al., 2022). Healthcare professionals should routinely ask older people (aged 65 and over, or 50-64 with risk factors) about any falls in the past year, including frequency, context, and characteristics ¹,². This can be done opportunistically during routine appointments or annual health checks ². People who report a fall or are considered at risk of falling should be observed for balance and gait deficits ¹.

• Comprehensive Assessment

  A comprehensive falls assessment and management plan should be offered to people who have fallen in the last year and meet specific criteria, such as living with frailty, needing medical treatment for an injury, experiencing loss of consciousness, being unable to get up independently after a fall, or having two or more falls in the last year ². This multifactorial falls risk assessment should be performed by a healthcare professional with appropriate skills and experience, often in a specialist falls service ¹,⁴.

  The assessment may include:

  • Falls History: Identification of past falls ¹,⁴.
  • Gait, Balance, Mobility, and Muscle Weakness: Assessment of these areas ¹,²,⁴. Pragmatic tests like the Timed Up & Go test and the Turn 180° test are useful and require no special equipment ⁴.
  • Medication Review: A structured medication review should be considered to identify medicines that may increase falls risk, such as psychotropic medicines, and to adjust them as appropriate ¹,²,⁴. Discussion about the increased risk associated with psychotropic medicines and planning withdrawal should occur, potentially liaising with specialist mental health services ².
  • Osteoporosis Risk: Assessment for osteoporosis risk ¹,²,⁴. This includes considering fracture risk in all women aged 65 and over, men aged 75 and over, and younger individuals with specific risk factors like previous fragility fractures or corticosteroid use ⁵.
  • Functional Ability and Fear of Falling: Assessment of the person's perceived functional ability and any fear related to falling ¹,²,⁴.
  • Sensory Impairments: Assessment of visual and hearing impairments ¹,²,⁴.
  • Cognitive Impairment and Neurological Examination: Assessment for cognitive impairment (e.g., using a validated measure if suspected) and a neurological examination ¹,²,³,⁴. Be vigilant for changes indicating hypoactive delirium, such as withdrawal or slow responses ³.
  • Urinary Incontinence: Assessment of urinary continence ¹,²,⁴.
  • Home Hazards: Assessment of home hazards ¹,²,⁴.
  • Cardiovascular Examination: Including assessment for postural hypotension ¹,⁴.
  • Long-term Conditions: Consideration of conditions affecting daily life, such as arthritis, dementia, diabetes, or Parkinson's disease ².
• Management and Interventions

  Interventions to reduce falls risk should be tailored to the individual's identified risk factors ². A multifactorial intervention, often following a multifactorial assessment, can reduce the rate of falls ¹,⁴. Common components of successful multifactorial intervention programmes include:

  • Strength and Balance Training: Most beneficial for community-dwelling older people with a history of recurrent falls or gait/balance deficits ⁴.
  • Home Hazard Assessment and Intervention: Should be offered, especially to those treated in hospital after a fall ²,⁴.
  • Vision Assessment and Referral: As appropriate ⁴.
  • Medication Review: As detailed above, with consideration for adjusting or withdrawing high-risk medications ²,⁴.
  • Vitamin D Supplements: Encourage adherence to NHS advice on vitamin D for bone and muscle health, although there is insufficient evidence to support it specifically for falls prevention ².

  For people who do not require a multifactorial risk assessment, reassessment should occur at least annually, and verbal and written information on reducing falls risk should be provided ⁴. Frailty management often involves a multidisciplinary approach (McIsaac et al., 2020).