Frailty and “common misunderstandings”

I recently submitted a response to a Healthcare Improvement Scotland blog titled “the right words are crucial to empower patients and the public”. Dr Graham Ellis, National Clinical Lead for Older People, Safety and Improvement, has since replied:

Dear Dr Gordon,
Thank you for your comment.

I think there are several important things to say here and a common misunderstanding.

Firstly, the misunderstanding is that frailty is seen as a label. It is not a label but a diagnosis and precision around this is vital. We have had a similar fight to get the language right for delirium and are now seeing the benefits.

Frailty represents a risk of acute dependence or death in the context of an acute illness. It therefore represents an opportunity to intervene and prevent harms.

Getting the diagnosis correct for frailty is important. A recent trial showed that if GPs were given a diagnosis of frailty for their patients, they were more likely to make appropriate tailored treatment plans for that patient. Evidence is overwhelming that correct treatment for frailty (comprehensive geriatric assessment) reduces long term dependence and institutionalisation and potential mortality. Identifying the right patients to target best care to is essential.

You are correct in suggesting that older people find a diagnosis of frailty difficult. Other diagnoses such as cancer and dementia are similarly difficult, but we cannot avoid an honest discussion with our patients. We owe that to them. Care does need to be taken to be accurate and careful with diagnosis, and in the ‘living well’ teams we are making every effort to get accurate and reliable tools into the hands of clinicians. In fact, we have taken a long time to ensure the rigorous evaluation in a Scottish context of tools such as the eFI.

We are now working with teams to test the response to the tool.

I hope this helps a little.

Graham Ellis
National Clinical Lead – Older People
Safety and Improvement

This response is most welcome but fails to address the central issues that I raised in my original blog. I therefore sent this clarification of the issues that I had raised:

Dear Dr Ellis,
I am most grateful for your response on behalf of Healthcare Improvement Scotland. It does indeed help for there to be an open sharing of views. It is clear that we both share the determination to see the older generation live as well as possible.

I am always concerned about national approaches which may be perceived as ‘top-down’ but particularly where the patient group has not been fully involved. There is now growing medical literature on frailty which examines the need to include considerations of assets as well as deficits.

I have been interested for a long time in considerations of the language used in relation to medical diagnoses particularly in relation to risks of reductionism and stigma. I do not think that we have always got this right and it is important to maintain open minds for potential unforeseen consequences.

We both, as NHS doctors, will use rating scales and other tools on a regular basis and so have an awareness of their strengths and limitations. My concern remains about the increasing reliance that Healthcare Improvement Scotland is putting on such tools or toolkits (perhaps at the expense of comprehensive geriatric assessment). The language in itself suggests that we are dealing with mechanical failures rather than with our fellow humans.

Thank you again for responding.

Kind wishes
Peter J Gordon

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