The population is ageing. It is recognised that those over the age of 60 years will nearly double from 12 – 22% between 2015 – 2050 around the world (World Health Organization (WHO), 2021). In the UK, it is predicted that, by 2050, one in four people will be over the age of 65 years (Office for National statistics (ONS), 2018). The ageing process is often associated with the decline of social, cognitive and physical functions, which affect quality of life, impacting costs and increasing the need to access healthcare services. The NHS Long Term Plan (2019) has highlighted the importance of investment in primary and community care services, to provide support and care to increasing numbers of people living with multiple long-term conditions, frailty and dementia within community settings. This article will critically discuss the role the district nurse plays in the screening and assessment of frailty, current practices, and how working in collaboration with both service users and the wider multidisciplinary team (MDT) can improve patient care.
There is no clear definition of frailty, but it is agreed that frailty is related to the ageing process, in which multi-body systems functions weaken, making the person vulnerable to small health changes, which can be triggered by minor events (WHO, 2016; British Geriatric Society (BGS), 2017). The risk of developing frailty increases in service users who have comorbidities, low socioeconomic position, poor diet, sedentary lifestyle, and polypharmacy (Hoogendijk et al, 2018). Frailty is a fluctuating syndrome where a service user can improve with support and intervention. Early detection of frailty can help prevent service users from acute crisis, presenting with falls and disability, which impact upon community caseload. In acute care, it is recognised that service users with frailty are at increased risk for prolonged hospital stays, extended discharge planning and transfer of care, with increases in mortality following discharge due to low system reserve (Turner and Clegg, 2014). Keeble et al (2019) found hospitalised older service users with frailty that had been discharged from hospital were at increased risk of mortality after 2 years than non-frail service users. The Queen's Nursing Institute (QNI) (2022) highlights the fact that nurses are having to develop their skills and understanding to meet the needs of increasingly complex workload.
Although there is no clear definition for frailty, two main models related to it exist. The Fried et al (2001) frailty phonotype model is the first and is based on three out of five observed characteristics being present: weight loss, weakness, poor endurance, slowness, and low physical ability. The model is limited, as it does not consider a person with fewer characteristics that can be present in a service user with pre-frailty. The second model is the cumulative deficit as described by Rockwood et al (2005), which identifies a person's frailty based upon a range of age-related health deficits that includes disability and disease. Both models identify that a patient's frailty is based upon the presence of muscle wastage, declining cardiopulmonary reserve, nerve's function and loss of executive functioning, which does not suddenly present but occurs over time. This means risk factors for these service users increase, requiring intervention to minimise the risk caused by their characteristics and underlying comorbidities.
Current practice
Working as a student district nurse, current practice is to use the Rockwood et al (2005) frailty screening tool as part of the initial assessment. Assessment is a key element in the nursing process and allows the process of information-gathering to assess service users' holistic needs, implement a plan and evaluate care, providing a clear structure (Chilton, 2018). District nurses are specialists at assessing patients within their own homes, removing patient barriers and promoting shared decision-making, ensuring that care is patient-centred. Referrals to the district nurse services can be via other professionals or directly, meaning that this face-to-face contact is the first the service user has had with a healthcare professional, making assessment key in identifying risk and interventions that may be required.
The use of clinical judgement and screening tools, such as Malnutrition Universal Screening Tool (MUST) (British Association for Parental and Enteral Nutrition (BAPEN), 2011), Waterlow/PURPOSE-T (Pressure Ulcer Risk Assessment Tool), falls assessment and the risk of pressure damage, are implemented to identify and minimise risk to service users with the benefit of clear guidance and policy. The use of policy and guidance within healthcare is based upon best available evidence to determine safe care of service users. The limitation to the use of frailty screening is a lack of education and guidance for staff. Britton (2017) found that staff described completing screening as a contractable obligation due to lack of confidence and understanding on how information gained can be used. Arguably, while including this intervention within the assessment allows district nurses to identify patients with frailty, a lack of understanding and confidence can limit how this information is used to benefit service users.
Screening and assessment
Pre-frailty is the early identification that an individual may develop the onset of clinically identifiable frailty, recognising this possibility and implementing a plan can delay the onset (O'Caoimh et al, 2021). It is recommended that health and social care professionals use validated screening tools to identify individuals with frailty and direct patients and carers to services (BGS, 2017; Royal College of Nursing (RCN), 2021). The limitation to this is that there are several different frailty screening tools that can be used, with no gold standard existing, indicating a need for better understanding of screening tools and assessment processes based upon best available evidence.
The Clinical Frailty Scale, developed by Rockwood et al (2005), is currently the screening tool used within the acute setting to predict patient outcomes, and is now utilised in the community. It is a nine-point screening scale, ranging from 1 (very fit) to 9 (terminally ill) (Table 1). The benefit of the scale is that it is quick and simple to use and based on clinical assessment. However, a limitation identified by Ruiz (2020) is that, although commonly used in practice, there remains uncertainty on how to correctly classify the patient based on clinical judgement. This highlights the need for greater understanding and use of the scale in monitoring and classifying patients to maximise benefit to service users. The BGS (2017) recommends healthcare professionals should complete the Clinical Frailty Scale based on a patient's ability 2 weeks prior to the assessment. The scale is recommended to be used following comprehensive geriatric assessment (CGA) to monitor patients' level of frailty. Lack of understanding of the assessment and incompatible IT systems means ensuring that the MDT is aware if a full CGA has taken place is difficult, and is a barrier to selecting an appropriate screening tool for service users.
Table 1. Clinical Frailty Scale
| No | Category | Description |
|---|---|---|
| 1 | Very fit | These are people who are robust, active, energetic and motivated. They commonly exercise regularly and are among the fittest for their age. |
| 2 | Well | These are people who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active ocassionally, e.g. seasonally. |
| 3 | Managing well | These are people whose medical problems are well controlled but are not regularly active beyond routine walking. |
| 4 | Vulnerable | While these people are not dependent on others for daily help, their symptoms often limit activities. A common complaint is being ‘slowed up’ and/or being tired during the day. |
| 5 | Mildly frail | These people often have more evident slowing and need help in high order finance, transportation, heavy housework, medications (IADLs). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework. |
| 6 | Moderately frail | These people need help with all outside activites and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing. |
| 7 | Severely frail | These people are completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high rish of dying (within around 6 months). |
| 8 | Very severely frail | These people are completely dependent, approaching the end of life; typically, they could not recover even from a minor illness. |
| 9 | Terminally ill | These people are approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail. |
Scoring frailty in people with dementia The degree of frailty corresponds to the degree of dementia:
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A CGA is gold standard for the assessment of frailty for a patient identified as at risk (BGS, 2017). This multidimensional assessment is usually carried out by the patient's GP; for this to be effective, the service user's aspirations and goals should be encompassed, and referrals to community services made to ensure individualised care planning (Turner and Clegg, 2014). This assessment allows the service users to have a multidimensional, interdisciplinary diagnostic test to develop long-term plans and treatment, further benefitting as this is undertaken in their own home. It has been shown that the CGA can act to reduce hospital admissions (BGS, 2017). It encompasses the service user's cognition, emotions, motivations, activities of daily living, social engagement, medications, and control of life. Its limitations include the fact that it is time-consuming, with assessments taking 90 minutes in addition to care planning; therefore, it is not always feasible for all service users identified as requiring screening for frailty to undergo a full CGA with full MDT and geriatric physician involvement (Turner and Clegg, 2014). Due to the ageing population and the increase in complex care, some primary care commissioning services have developed complex care frailty nursing teams within the community, undertaking the CGA assessment and care planning, addressing the limited time available to GPs while recognising the ability of nursing staff to undertake assessment (BGS, 2017; White, 2021). This does still require service users to be identified as requiring assessment through screening and clinical judgement.
Change of practice
The PRISMA-7 questionnaire has been recommended for use in screening for frailty prior to formal assessment (BGS, 2017) (Box 1). This incorporates seven questions, to which a score of 0-1 is given, with a score greater than 3 indicating frailty.
Box 1.PRISMA-7 questionnaire
| 1. Are you older than 85 years? |
| 2. Are you male? |
| 3. In general, do you have any health provlems that require you to limit your activities? |
| 4. Do you need someone to help you on a regular basis? 5. In general, do you have any health provlems that require you to stay at home? |
| 5. In general, do you have any health provlems that require you to stay at home? |
| 6. If you need help, can you count on someone close to you? |
| 7. Do you regularly use a stick, walker or wheelchair to move about? |
A benefit of the PRISMA-7 screening tool is that it is specifically designed to identify frailty in a community setting; it also highlights a high sensitivity for frailty, which makes it a useful screening tool in identifying patients who have pre- or mild frailty in the community setting (Yaman and Unal, 2018; Hoffmann et al, 2020).
Although PRISMA-7 can be used as an initial screening tool, the use of the Clinical Frailty Scale following diagnosis would allow district nurses in practice to monitor and update the index during a visit, which is not currently done. Therefore, a change of practice and training is required in the use of the PRISMA-7 screening tool and its monitoring of frailty for service users. The ability of district nurses to lead teams and build good relationships with service users in the community supports the tool's capability to identify service users with pre- and mild frailty.
Patient-centred care
The ability for a district nurse to provide holistic, patient-centred care in the patient's own home is essential (QNI, 2015; Nursing and Midwifery Council (NMC), 2018). The utilisation of screening tools for continual monitoring, along with clinical judgement of older patients already on and new to a nurse's caseload, can assist in identifying and monitoring patients with pre-frailty and frailty. Screening tools for frailty should be viewed in practice as having the ability to improve patient outcomes, prevent deterioration, identify interventions and allow for patient preferences and fears to be discussed, and enable support given to patients and families. Nicholson et al (2018) found that frail patients reported a lack of engagement with healthcare professionals in decision-making and care planning as a barrier, describing that they often felt frailty was viewed with stigma. Improving frailty guidelines and training would allow district nurses to work in collaboration with patients and families and provide support and information in relation to care planning and frailty. The ability to utilise this should be viewed as a means of ensuring patients are cared for at home, preventing acute crisis being reached and patients feeling involved and able to discuss care needs openly.
Goalsetting is a key aspect in good patient care and management of long-term conditions, understanding the patient's own preferences and circumstances to work as a partnership (Oliver et al, 2014). Avgerinou et al (2019) found that service users identified as having mild frailty found goalsetting, using active listening and building a relationship with patients gave them the ability to set goals relating to mobility, physical activity, transport, socialising, mental health, diet and financing. This was viewed positively, especially in promoting the patient's ability to remain independent and increasing self-esteem. Corker et al (2019) found that, across specialities, it was recognised that older patients with frailty required holistic assessment; it was noted that different specialities focused upon various aspects of care, which indicates the importance of integrated care. The ability to utilise the skills of district nurses in coordinating care, working to refer and liaise with other multidisciplinary teams to meet patient goals, will enable patients to live well with or even reverse frailty.
In discussing care needs, it is important to recognise that differing frailty statuses of individual service users will require tailored interventions, and each will respond to the interventions differently (Kojima et al, 2019). Service users identified as having pre- and mild frailty have been found to benefit from self-management support. Physical exercise programmes, dietary advice, medication review and social support have been found to have positive outcomes for patients deemed to have pre-frailty (de Souto Barreto et al, 2018). These interventions enable weight maintenance, build muscle mass, reduce any risk caused by polypharmacy and promote social support to prevent loneliness and isolation. Recognising this will reduce impact on the district nurse caseload, as putting preventive measures in place earlier may prevent the deterioration of overall health that may require district nurse intervention.
Integrated care
Integrated care is defined as an organisational approach, coordinating care based upon a patient's need. To ensure patient care in practice is person-centred, it is important, as district nurses, to work in collaboration with the wider primary health care services to respond to older people and provide access to high-quality, long-term care (WHO, 2021). Cocker et al (2019) found that there is no clear understanding of frailty across specialities. By addressing the lack of interdisciplinary training about frailty, the dynamic nature and differences of the frailty tools cited, MDT meetings and a lack of standardised guidelines, we could facilitate a shared understanding of frailty across teams. It is recognised that, to respond to patients' needs, other disciplines and professionals are required, such as GPs and other allied health professionals, to ensure high-quality care. These professionals all require the ability to share information that is fit for purpose and accurate, which can be passed between discipline areas easily. This indicates the need to look at how we communicate and streamline screening processes to identify and communicate patient care needs, with increasing preference to remain at home (Roy et al, 2018).
Implication for practice
Frailty is an important aspect of current complex community care, and there is the need to streamline community services to provide early and continuous support for those living with frailty. Britton (2017) found that district nurses undertaking frailty screening discussed certain limitations, such as time constraints to visits, and highlighted that staff were uncertain about particular aspects of frailty, indicating gaps in knowledge and the need for training. Screening tools can be used as part of initial care assessment to plan and implement care and put preventative measures in place based on risk. At a local level, there must be the ability to address staff training, understand screening and implement interventions that are promoted to provide older patients on the caseload with an improved quality of care.
To disseminate and improve staff knowledge on frailty screening and assessment, it should be based upon best available evidence, to ensure that this is reflected in practice. It is important that information which addresses the need for standardisation of frailty screening is shared (NICE, 2018), further ensuring that service user care is streamlined, providing coordinated, integrated care, and that information is shared to improve patient outcomes. The information gained from the literature (Yaman and Unal, 2018; Hoffmann et al, 2020) indicates the need for change in practice in terms of staff education on use of assessment tools and screening for frailty, as utilising clinical judgement, along with screening tools, can identify service users with pre- or mild frailty. A move away from only using the Clinical Frailty Index scale to document the severity, with no follow-up or communication for the wider MDT, is needed. It is important to recognise barriers, which can include the motivations of both teams as a whole and the individuals within them, the skills to make the change and the ability to communicate both the quality of current practice and the need for change in practice (Chilton, 2018). Change in practice requires monitoring and auditing. The use of assessment and screening in implementing and signposting older patients to services will allow to the monitoring of the benefits or constraints in practice.
Conclusion
In conclusion, district nurses have a key role in ensuring older patients are holistically assessed. Working in partnership with patients ensures that care is patient-centred and shared decisions are made. It is recognised that there is no gold standard screening tool for frailty. Rockwood et al's (2005) Clinical Frailty Index is currently used in practice with limited knowledge and guidelines. With consideration, the PRISMA-7 screening tool could allow district nurses to identify service users that have pre- or mild frailty, allowing for early intervention, which assists in delaying onset and preventing further deterioration. Working in collaboration with the wider MDT and improving communication methods will streamline services and improve patient outcomes, empowering patients to live as independently as possible within the community and prevent crisis points from being reached. The development of education and guidance will improve staff confidence in identifying patients with frailty, with the overall benefit of reduced patients on the average caseload.
Key points
- Frailty is a fluctuating syndrome that, with correct support and intervention, can improve
- District and community nurses are key in holistically assessing service users
- Early identification of frailty can delay onset, with interventions to support and empower patients to self-manage
- The use of screening and clinical judgement can identify and minimise patient risk
- Without a standard frailty screening tool, staff require training on how to transpose the information gained into a format that can be used across all teams
- Changing the initial screening tool from the Clinical Frailty Index to PRISMA-7 will provide a greater sensitivity when identifying service users with pre-/mild frailty
- Collaboration with both service users and the wider multidisciplinary team is needed to ensure interventions are patient-centred and work towards positive patient outcomes
CPD reflective questions
- What is your perception of frailty, and do you discuss this condition openly with service users?
- What is your current practice in screening for frailty?
- Are you aware of the need for comprehensive geriatric assessment following frailty screening?