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Use of proactive case management to address frailty in older people

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Early recognition, appropriate assessment and individual care plans all help improve outcomes for people living with frailty. This article comes with a self-assessment enabling you to test your knowledge after reading it, as well as a handout for a journal club discussion


Frailty is a common age-related condition that occurs when several physiological systems lose reserve and function. All health and social care professionals need to be able to recognise frailty in their older patients and clients, and put in place an appropriate assessment and care plan. This article highlights the characteristic syndromes and features that should raise suspicion of frailty in health and social care professionals. It describes several detection and assessment tools available to them, and stresses the importance of comprehensive geriatric assessments and person-centred care plans in improving outcomes for people with frailty, thereby helping them to live well for longer.

Citation: Yates L (2017) Use of proactive case management to address frailty in older people. Nursing Times [online]; 113: 6, 22-26.

Author: Lynne Yates is advanced nurse practitioner at Derbyshire Community Health Services.


In 2016 there were a total of 11.6 million people aged over 65 in the UK – approximately 17% of the total population; by 2040, it is estimated that this figure will have risen to 24% of the population (Age UK, 2017). As this age group has the highest number of unplanned admissions to hospital, this growth is predicted to lead to further pressures on acute hospitals (Age UK, 2017; Imison et al, 2012). 

Nurses in all specialties and settings will be increasingly confronted with older people living with frailty (British Geriatrics Society, 2015). As such, it is important that all nurses are capable of recognising frailty and planning appropriate care for this group. Proactive case management of older people living with frailty entails: 

  • Case finding;
  • Person-centred care planning;
  • Better use of resources in the community.

Case management can reduce hospital admissions by 20-30%, which in turn helps older people to live well for longer (BGS, 2015; Lyndon and Stevens, 2014). 

What is frailty? 

Frailty is a common, age-related condition that occurs when several physiological systems lose reserve and function (NHS England, 2014). It is characterised by a decline in health, cognition, physical strength and social functioning, and by the impact of decline on any long-term condition the person may have (BGS, 2015; Clegg and Young, 2011; Rockwood et al, 2005). 

The BGS considers frailty to be a clinical disorder with which the individual becomes vulnerable to subtle health changes that can lead to a rapid decline in wellbeing and function (BGS, 2014). It details five frailty syndromes that should alert health and social professionals to the fact that a patient could be frail (Box 1), and recommends that they consider frailty in older people who present with any of these. 

Box 1. The frailty syndromes

  • Falls (eg collapse, legs giving way, “found lying on floor”)
  • Immobility (eg sudden change in mobility, “gone off legs”, “stuck in toilet”)
  • Delirium (eg acute confusion, “muddledness”, sudden worsening of confusion in someone with previous dementia or known memory loss)
  • Incontinence (eg change in continence – new onset or worsening of urine or faecal incontinence)
  • Susceptibility to side-effects of medication (eg confusion with codeine, hypotension with antidepressants)

Source: British Geriatrics Society (2014)

Clegg and Young (2011) identified several features that should raise suspicion of frailty:

  • Sarcopenia (loss of muscle mass and strength);
  • Anorexia;
  • Osteoporosis;
  • Fatigue;
  • Risk of falls;
  • Poor physical health.

Later research emphasises that frailty is a complex syndrome that is not limited to the physical presentation of loss of function, but also includes psychological and social impairment. The psychosocial element of frailty is poorly researched and addressed by health professionals in general (BGS, 2015). 

Frailty can have a profound effect on mental health, leading, in the worst cases, to depression and social isolation (Fillit and Butler, 2009). The words ‘frail’ and ‘frailty’ themselves can have a psychological impact on older people and deter them from seeking early support and interventions. If they suspect frailty, health and social care professionals need to approach assessment and care planning in a sensitive way, and engage with their patients or clients to lift their health status, help them live well, and potentially reverse the effects of frailty (BGS, 2015; NHS England 2014; Lyndon and Stevens, 2014).

The need for early recognition

If frailty is recognised early its effects can be reduced; however, those affected are not always reliably identified by health and social care professionals, or are identified only when frailty is at an advanced stage. Often frailty is only recognised after an emergency situation, such as a fall. Any delay in detecting frailty can potentially lead to harm and poorer outcomes for the person (Age UK, 2016; BGS, 2015, 2014). 

Health and social care professionals should conduct a frailty assessment in individuals who present with at least one of the frailty syndromes or with any of the characteristics of frailty listed above. They should use every encounter with older people to check for frailty. In particular, health and social care professionals who are not specialists in the care of older people need to be aware of the importance of their role in identifying frailty (Age UK 2016; BGS, 2015, 2014). 

Tools to detect and assess frailty

A number of assessment tools can be used to identify frailty and assess its severity, including:

  • The PRISMA-7 questionnaire (Box 2); 
  • The gait speed test (Box 3);
  • The Timed Up and Go (TUG) test (Box 4);
  • The Edmonton Frail Scale (Table 1).

Box 2. PRISMA-7 questionnaire

The PRISMA-7 questionnaire comprises seven questions. If the individual gives a total of three or more positive answers, frailty is indicated.

The seven questions are:

  • Are you more than 85 years old?
  • Are you male?
  • In general, do you have any health problems that require you to limit your activities?
  • Do you need someone to help you on a regular basis?
  • In general, do you have any health problems that require you to stay at home?
  • In case of need, can you count on someone close to you?
  • Do you regularly use a stick, walker or wheelchair to get about?

Source: British Geriatrics Society (2014)

Box 3. Gait speed test 

An average gait speed of longer than five seconds to walk four metres is an indication of frailty. Using the guidelines below, the test can be performed with any patient able to walk that distance.

  • Accompany the patient to the designated area, which should be well lit, unobstructed and contain clearly indicated markings at the start (zero metres) and finish (four metres)
  • Position the patient with his/her feet behind and just touching the start line
  • Instruct the patient to “Walk at your comfortable pace” until a few steps past the four-metre mark (the patient should not start to slow down before this mark)
  • Begin each trial on the word “Go”
  • Start the timer with the first footfall after the start line
  • Stop the timer with the first footfall after the four-metre line
  • Repeat three times, allowing sufficient time for recuperation between trials

Source: Lyndon and Stevens (2014)

Box 4. Timed ’Up and Go’ test

  • Measures, in seconds, the time taken by the patient to stand up from a standard armchair, walk a distance of three metres, turn, walk back to the chair and sit back down
  • A time of >30 seconds is predictive of requiring aids for mobility and being dependent with activities of daily living

Source: Podsiadlo and Richardson (1991)

Table 1. The Edmonton Frail Scale

The PRISMA-7 questionnaire is a short questionnaire comprising seven questions (Illsley and Clegg, 2016); it is commonly used in primary care and, due to its simplicity, is becoming increasingly used in all other spheres of health and social care (NHS England, 2014). The gait speed test and TUG test can be used in conjunction with the PRISMA-7 questionnaire to identify frailty, as it is thought that frailty will reduce gait speed (BGS, 2014).

The Edmonton Frailty Scale examines several frailty characteristics to determine the presence and severity of frailty. Gordon et al (2011) suggested it is a useful tool in patients admitted for elective surgery, and NHS England recommends its use in primary care settings (Lyndon and Stevens, 2014). 

Comprehensive geriatric assessments

After frailty has been identified, a comprehensive geriatric assessment (CGA) needs to take place to improve outcomes for frail older people in all health and social care settings (Ellis et al, 2011; BGS, 2010). A CGA is a holistic, multidisciplinary assessment of an older person living with frailty, and it is used to formulate a person-centred advance care plan (BGS, 2014). It can be requested by any health or social care professional involved in the person’s care and is usually carried out by the professional who has identified that the person is frail (BGS, 2010). 

There is currently no standard CGA but, in 2014, NHS England reported that a CGA tool was being developed for use by all partnership organisations (Lyndon and Stevens, 2014). The BGS (2010) suggested the assessment is best performed as a multidisciplinary team (MDT) exercise and must encompass the following key areas:

  • Medical: a full medical assessment should be undertaken that considers comorbidities, includes a medication review and a nutritional assessment, looks for weight loss and considers appetite;
  • Mental health: cognition, mood and fears should be assessed, while clarification and further information is sought from family members about the person’s memory and function at home;
  • Functional ability: an occupational therapist and physiotherapist should assess the person’s ability to undertake activities of daily living, as well as gait and balance and current activity status;
  • Social: an assessment of social circumstances is required, exploring what support is available at home, potentially discussing a package of care and considering finances;
  • Environment: find out where the person lives, what their home environment is like and whether it is adapted to their abilities and level of functioning.

Case management and person-centred care planning

After a CGA has been completed, a case management approach to the care of an older person living with frailty is required (Lyndon and Stevens, 2014). This approach is believed to provide more responsive and efficient care; it enables people to be cared for in their preferred place, and allows their wishes and preferences to be considered (Clinical Solutions, 2009). 

Case management entails the assessment, coordination and ongoing review of patients’ care, with the aim of enhancing their quality of life (Hutt et al, 2004). Successful case management of frail older people who have complex long-term conditions hinges on interagency and partnership working (Department of Health, 2010; 2004).

A case manager can be a: 

  • Qualified nurse;
  • Social care worker;
  • Allied health professional. 

All of these professionals will work with people with complex long-term conditions requiring care coordination (DH, 2005a). The presence of a case manager means there is time for a therapeutic relationship to develop, and gives patients and their carers the opportunity to contribute to care planning (The Health Foundation, 2014).

Completion of a CGA also leads to the formulation of a person-centred care plan, tailored to individual preferences and responding to the person’s needs; this can improve the health outcomes of vulnerable older people most at risk of frailty (DH, 2005b). A successful person-centred care plan requires close partnership working (Ross et al, 2011), and the case manager needs to make – with the individual’s consent – appropriate referrals to allied health professionals and social care to ensure there is a coordinated approach to care. 

The case study in Box 5 demonstrates how a CGA can help to formulate a person-centred care plan and generate referrals to other services, ensuring the approach to care is holistic.

Box 5. Case study: comprehensive geriatric assessment and care plan


Frailty is an often poorly recognised age-related condition. The ageing population means that all specialties in nursing will increasingly encounter older people who are living with frailty. 

Nurses play an important role in the early detection of frailty, which can help improve wellbeing and avoid unplanned hospital admissions. The early identification of frailty allows health and social care professionals to implement person-centred care plans, thereby increasing the chance of reversing frailty and helping older people to live well for longer.

Key points

  • Frailty is a common age-related condition characterised by a decline in health, cognition, physical strength and social functioning
  • Its effects can be reduced or reversed, but frailty often goes unrecognised until it is advanced or a crisis occurs
  • A number of characteristic features can help health and social care professionals recognise frailty in older people
  • A comprehensive geriatric assessment and person-centred care plan can help older people with frailty live well for longer
  • Good care for frail older people requires close partnership working, appropriate referrals and a coordinated approach

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