By Peter Hanlon and Frances Mair
It is often said that many of the challenges faced in healthcare are due to ‘ageing populations’. It is clear, however, that health (and the need for health services) is not simply related to how old a person is. There are many other factors more closely linked to an individual’s need for care, many of which are related to age. These include multimorbidity – having two or more long-term health conditions – and frailty. Frailty is closely linked to multimorbidity, but the terms are not interchangeable.
Frailty describes a reduction in the body’s in-built reserves which is generally due to the cumulative effect of a range of individual deficits. People with frailty are therefore more at risk of developing significant illness, sometimes in response to relatively minor events or ‘stressors’. To provide high quality healthcare to people with frailty involves a holistic approach, considering the whole person and their wider context, rather than purely focusing on individual diseases in isolation. Managing frailty also takes considerable resource, as people may require additional support or services, and are more likely to require hospital admission.
Both frailty and multimorbidity are more common with increasing age, and therefore most research and interventions to improve care has focused on elderly people. It is also true, however, that the majority of people with multimorbidity are aged under 65 years. This is particularly true in areas of high socioeconomic deprivation. Despite this, the prevalence and effects of frailty at younger ages and in multimorbidity has not been investigated. Most studies, as well as most health services, that seek to target frailty have tended to exclude people aged less than 65 years, even though many people in this age group are affected by multimorbidity and may benefit from an approach to healthcare that reflects this.
Our recent study [1], published in The Lancet Public Health, seeks to address this research gap. It suggests that frailty affects ‘middle-aged’ as well as older people. We found that frailty, while strongly associated with multimorbidity, identifies middle aged people at increased risk of death, over-and-above known risk factors and number of long-term health conditions.
This study analyses frailty in a younger population than most previous research. We used data from the UK Biobank cohort – a large study of around 500,000 volunteers aged between 37 and 73 years. Participants in the study were considered ‘frail’ if they met three or more of the following criteria: weight loss, slow walking pace, low hand grip strength, low physical activity, and exhaustion. People with one or two of these features were considered ‘pre-frail’.
While frailty does get more common with increasing age, we found that people of all ages had the potential to be ‘frail’ using this definition. While only a small proportion of ‘middle-aged’ people were identified as frail by this definition – 3% overall – frailty was much more common in people with multimorbidity. Of people with 2 or more long-term conditions, 7% were frail. This increased to 18% among people with 4 or more long-term conditions. Frailty was also closely linked with socioeconomic deprivation and obesity.
Frailty was associated with more than double the risk of death in men of all ages included (37 to 73 years) and in females above the age of 45 years. This was after accounting for deprivation, lifestyle factors such as smoking, obesity and alcohol, and the number of long-term conditions. Frailty, therefore, appears to carry additional risk of premature death in younger people, over-and-above the recognised risk factors such as smoking and multimorbidity. People with ‘pre-frailty’ also had an increased risk of death in all of these age groups.
These findings highlight the challenges faced by primary care teams caring for patients with complex problems and multimorbidity, many of whom may be too young to be eligible for existing services focusing on frailty in the elderly. This is particularly true in areas of high socioeconomic deprivation, where both multimorbidity and frailty among younger people is much more common.
This study shows that frailty may be identifiable at an earlier stage than is traditionally understood. This may, therefore, represent an opportunity to explore ways of intervening earlier. If this is to happen, researchers and healthcare professions will need to broaden their focus on frailty to include a wider age range. Importantly, it also highlights the need for a move away from disease focused to more person centred care that provides a more holistic approach to patient care that is tailored to meet an individual’s specific requirements.
Identifying frailty in those with multimorbidity may have positive implications for care, planning interventions and a patient’s prognosis. We suggest integration of an assessment of frailty into the routine assessment of people with multimorbidity might help identification of those at greater risk and ensure more accurate targeting of the multidimensional, patient-centred reorganisation of care required to address complex multimorbidity.
There is a pressing need to understand frailty in younger people much more fully. When trying to provide services and care for people with frailty and multimorbidity it will be crucial to consider the needs of younger people (particularly those in areas of high socioeconomic deprivation). Our work demonstrates that frailty, like multimorbidity, is not just a problem that affects older people.
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[1] Peter Hanlon, Barbara I Nicholl, Bhautesh Dinesh Jani, Duncan Lee, Ross McQueenie, Frances S Mair. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. Lancet Public Health 2018. Published Online June 13, 2018. http://dx.doi.org/10.1016/S2468-2667(18)30091-4.