People who live extra years of life in good health can participate in, and therefore strengthen, societies. However, extra years of life dominated by poor health and frailty increase dependency and the need for care.
Without preventive action, frailty will become more prevalent as the population ages. Just over a half of people aged over 85 live with moderate or severe frailty and the number in that age group is expected to double between 2016 and 2041 (Chief Medical Officer Annual Report, 2023). Frailty will place increasing demands on health and care services, demands that services are already finding hard to meet.
This Collection brings together evidence from the NIHR and elsewhere to help commissioners and healthcare providers address the challenge. The evidence we present supports improvements in the quality of care for people with frailty in the community, and in hospital.
What is frailty?
Frailty is a state of health which is more common among older adults. People with frailty lose their in-built reserves and their health becomes increasingly vulnerable to events such as an infection or change in medication or environment. This group of older people is at risk of adverse outcomes such as disability, falls, hospital admission, and the need for long-term care.
The likelihood of severe frailty increases sharply with age, but more younger people are living with the condition. A 2023 analysis of over 2 million primary care records found that the average age of frailty onset was 69 years; however 19% of younger people (50-64 years) had mild to moderate frailty. Few in this younger age bracket (3%) had moderate or severe frailty, compared with many more (58%) of those aged over 85. Deprivation, Asian ethnicity, female sex and living in an urban area all increased the risk of living with frailty.
Analysis of population based survey and demographic data from 2020 found wide geographic variation in the prevalence of frailty. Some areas had 4 times more frailty than others. The Chief Medical Officer described in his 2023 annual report, the increasing concentrations of older people in rural, semi-rural and coastal areas of England. Data from the English Longitudinal study of ageing (2002-2017) found people from the most deprived areas were twice as likely to experience frailty. One study of homeless people found high rates of premature frailty, suggesting a needs-based rather than age-based approach is needed to reduce health inequalities.
“If we choose, ostrich-like, to ignore the growing concentration of older adults and their inevitable healthcare needs in these geographical areas, we are not undertaking proper responsible planning and will have a far harder landing as the population in those areas inexorably age.”
Chief Medical Officer Annual Report, 2023
Frailty increases someone's need for care and support. A 2024 analysis of over 2 million primary care records (2006-2017) found that people with severe frailty are nearly 6 times more likely to be admitted to hospital than those who do not have frailty; their average hospital costs are 9 times greater. Even people with mild frailty are twice as likely to be admitted to hospital than those who do not have frailty, and their average hospital costs are 3 times greater. At a population level, the large numbers of people with mild and moderate frailty means this group costs services most.
However, frailty is not an inevitable consequence of ageing. Emerging evidence suggests that physical activity and diet can delay the onset of frailty, and reduce its severity. A 2020 literature review pointed to the potential benefits of physical activity (including resistance training, aerobic exercise and balance-based exercise such as Tai Chi) and dietary changes (increased protein intake and a Mediterranean diet rich in vegetables, fruits, cereals, olive oil and fish). Similarly, a large randomised control trial (SPRINTT, 2022) found that regular physical activity combined with dietary advice, improved the mobility of people with frailty.
Care in the community for people with frailty
National policy encourages services to identify and actively manage frailty; GPs are required to identify frailty in people aged over 65. A range of community services have been developed to better support people with frailty in the community. They aim to avoid hospital admission and/or support earlier discharge, enabling people with frailty to stay independent and in their homes.
Key components of high quality frailty care in the community
Click on the headings below to read about research that could improve frailty care.
Comprehensive Geriatric Assessment (CGA) is a multidisciplinary assessment of someone’s medical, functional, psychological and social capability. It is carried out by a team including doctors, nurses, physiotherapists and occupational therapists, to ensure that people’s problems are identified and managed appropriately.
A 2022 Cochrane review concluded that comprehensive geriatric assessments (CGAs) for people living with frailty in the community had no impact on death or nursing home admissions but might reduce the risk of unplanned hospital admission. A 2023 umbrella review of systematic reviews found evidence that community-based CGA could:
- improve medication, patient functioning, and quality of care
- reduce hospital admissions.
The British Geriatric Society toolkit provides guidance for primary care practitioners on CGA in the community. This recommends falls risk assessment, for which the World Falls Guidelines provide international expert consensus advice.
Primary Care Medical Home (PCMH) brings together health and social care professionals in a team. The team provides enhanced personalised and preventive care for the local community; generally, a defined population of between 30,000 and 50,000.
An umbrella review of 29 systematic reviews (14 with meta-analysis) concluded that the evidence for holistic assessment-based interventions was inconsistent; it suggested that health and social care improvers need to carefully consider their own context when designing interventions.
However, it found that PCMH could:
- improve health-related quality of life and mental health
- reduce hospital admissions
- improve self-management
Hospital at home and virtual wards are alternatives to inpatient care. Hospital at home services provide face-to-face care at home through a multidisciplinary team based in the community. Virtual wards, led and managed by hospitals, deliver acute care at home. People are monitored and treated using a combination of remote and face-to-face care. Virtual wards rely on technology such as apps, technology platforms, wearables and devices such as pulse oximeters.
A 2023 rapid evidence synthesis found good evidence for Hospital at Home, but concluded that more robust evaluations of virtual wards are needed. The researchers called for better guidance on aspects of virtual wards provision such as team characteristics, outcome selection and data protection. Living systematic reviews that are continuously updated, could help capture an evolving evidence base.
The 2023 umbrella review of systematic reviews concluded that core components of successful community-based models include:
- holistic assessment
- multidisciplinary team consultations
- continuity of care
- care coordination tailored to complexity
- individualised treatment and self management support
- medication review.
The review called for better methods to identify people with frailty who need intervention, and more clearly-defined roles and responsibilities for multidisciplinary team members.
Barriers to implementation included: high workload, professional time constraints, perverse incentives of payment systems, and poorly-integrated computer systems.
Hospital care for people with frailty
The NHS Long Term Plan (2019) promoted acute frailty services with skilled multidisciplinary teams delivering Comprehensive Geriatric Assessments. NHS England developed a FRAIL strategy to support improvements in hospital care. This encourages rapid clinical frailty assessment; support from multidisciplinary acute frailty service if needed; a Comprehensive Geriatric Assessment; a patient-centred approach; rapid supported discharge.
In this section, we consider the current state of acute frailty services in hospitals. We look at evidence for services to address the needs of people with frailty and point the way to improvement in their quality of care. This includes Advanced Care Planning and Comprehensive Geriatric Assessment. People with frailty are at particular risk of falls, immobility, delirium, continence problems, inappropriate medication and surgery.
Key components of high quality frailty care in hospital
Click on the headings below to read about research that could improve frailty care.
Most trusts have an acute frailty team to assess and triage patients. But the Getting it Right First Time review (2021) found variation in teams’ working methods and effectiveness. Trusts did not routinely monitor or evaluate frailty assessments. A 2019 day of care survey found that two fifths of the 129 hospitals included did not have a routine frailty screening policy. Half did not have dedicated frailty units. Even those with screening policies had variable rates of assessment; most people at risk were not assessed.
The HoW-CGA study (2019) found that frailty or other risk stratification tools were used by some trusts only (30%). Multidisciplinary assessment and management was routine in wards specialising in older people’s care but less common elsewhere. Assessments tended to be informal. The HoW-CGA study piloted a CGA toolkit in oncology and surgery (an area not specialising in older people’s care) in three hospital sites. Pilot sites made limited progress in incorporating CGA during the study period, despite a good history of multidisciplinary collaboration. The researchers concluded that competing priorities and divergent views about professional responsibilities were barriers to the use of CGA clinical toolkits by non-geriatric teams. They suggested that an extended period of service development with geriatrician support could help. The Specialised Clinical Frailty Network, set up in 2018, combined learning from the HoW-CGA study with quality improvement methods to enhance the experience and outcomes of older people with frailty who have specialised healthcare needs. Research concluded that frailty assessments could be introduced, and more frailty-orientated services delivered, without reliance on geriatricians.
The Acute Frailty Network and NHS Elect have gone on to develop a range of tools including a frailty dashboard (see additional resources listed below).
A 2023 systematic review found that among older people admitted as an unplanned emergency to hospital, moderate to severe frailty increases their length of stay, their likelihood of being discharged to somewhere other than home, and the risk of death. People with severe frailty were at greatest risk. The authors concluded “the available evidence justifies more widespread screening for both the presence and severity of frailty with clinically administered tools, such as the Clinical Frailty Scale, to inform care and target Comprehensive Geriatric Assessment and interventions.”
A 2019 systematic review found that older patients who have a CGA on admission to hospital are more likely to survive and be in their own home at follow-up. The HoW-CGA large mixed methods study (2019) estimated that in a hospital admitting 1000 older people per month, around 200 would be classified as severely frail. The application of routine CGAs might result in 12 more people of this group being alive, and 40 fewer people being admitted to long-term care.
The CGA may lead to a small increase in costs, but the evidence on cost-effectiveness was of low certainty.
Advance care planning involves a voluntary person-centred discussion between an individual and their care providers about their preferences and priorities for future care. When advance care planning is done well, treatment focuses on what matters most to an individual in a personalised, holistic way, and helps them to live as well as possible. For example, people living with frailty may prefer less aggressive treatment, but these preferences are often not known or respected. A 2020 systematic review found that although 74%–84% of older inpatients are receptive to advance care planning, only 0%–5% have plans in place. One randomised controlled trial found that advance care planning improved outcomes. The review concluded that better understanding could improve end-of-life care for older people living with frailty.
Delirium is a state of confusion, with disturbances in attention, consciousness, and the capacity to think and process information. It develops over hours to days. Delirium can be treated. Untreated, it is associated with considerable distress along with poorer outcomes including increased mortality and cognitive decline. Up to one in five adult patients in hospital have delirium, but only half have a diagnosis documented in their notes.
A large multicentre study (2023) based on 2019 data found that the risk of delirium increased with the severity of frailty, and that those with most severe frailty were least likely to have their delirium diagnosed. The researchers recommended risk stratification for all patients for delirium.
The 4 ‘A’s test (4AT: Arousal, Attention, Abbreviated Mental Test – 4, Acute change) is a short, easy-to-administer screening tool that can be used by non-specialists. A 2019 NIHR study (based on 2017 data) found that the 4AT can rule out delirium or identify those who need more detailed testing. It could improve the speed and accuracy of treatment. This would save money and improve outcomes.
Incontinence can cause distress and loss of dignity for older people living with frailty. It is often overlooked or poorly managed in hospital settings. A previous NIHR Evidence Collection looked at continence care for people with dementia. Many of the same lessons can be applied to people with frailty. These include:
- prioritisation of continence care in all settings; it needs to be seen as a key component of high quality care
- training for staff in all settings, encouraging them to promote personal dignity and safety including the use of appropriate language and delivery of personalised, sensitive care for incontinence including appropriate choice of products
- a proactive approach to continence problems among staff, meaning they raise issues and address them in care plans to promote people’s independence
- adaptation of care environments to help people safely use the toilet
- agreement on, and monitoring of key quality indicators for continence by organisations, including capturing the use of pads.
NICE provides guidance on managing faecal incontinence and recommends case finding for all at risk groups; this includes people with frailty.
Falling can cause distress, pain, injury, loss of confidence, loss of independence and mortality. Falls in hospitals are the most commonly reported patient safety incident, with more than 240,000 reported in acute hospitals and mental health trusts in England and Wales.
A 2022 systematic review of interventions concluded that patient and staff education can reduce falls in hospital. There was evidence to support multi-factorial interventions but not for chair alarms, bed alarms, wearable sensors or scored risk assessment tools. Guidelines to prevent falls are followed more closely by some hospitals than others. An NIHR study (2024) recommended that Trusts should:
- clarify roles and responsibilities in relation to falls prevention
- ensure processes and systems support a multidisciplinary approach
- reduce the bureaucratic burden associated with falls risk assessment and monitoring
- encourage staff to provide patients with individualised information on risks and falls prevention.
Frailty is associated with the regular use of at least 5 medications (polypharmacy), poor clinical outcomes and a risk of inappropriate prescribing. This includes over- and under-prescribing as well as misprescribing. Acute admissions are a valuable opportunity to optimise medications, and evaluate whether they provide a net benefit or net harm. NICE provides guidance on medicine optimisation.
A systematic review (2022) included studies of medicines optimisation of people with frailty aged 65 years and over in an acute hospital. While there was little evidence that it improved clinical outcomes or saved money, the evidence available suggested that it was safe and feasible. The researchers recommended systematic identification of people with frailty in hospital.
Up to 60 per cent of older people lose functional abilities including mobility during a stay in hospital; some prematurely move to a care home as a result. Keeping people active in hospital can reduce their decline, but in busy clinical settings, professional staff may struggle to encourage mobility. In 2012, the Royal College of Nursing reported that 59% of nurses felt that promoting mobility was one of the aspects of care most frequently neglected due to time pressure. In a 2022 analysis of patient and carer opinions, a quarter of carers observed a deterioration in their relatives’ condition after spending too long stationery and in bed.
In a small mixed methods study (2020), volunteers encouraged twice daily mobility and bedside exercises in people with an average age of 86. This study demonstrated the feasibility of the intervention, including the recruitment, training and retention of volunteers. The intervention was acceptable to healthcare professionals and patients. Controlled trials are needed to explore the impact of this volunteer-led physical activity intervention on patient outcomes and its cost-effectiveness in different healthcare settings.
The British Geriatrics Society produces resources for staff and patients to encourage more mobility.
People with frailty are at risk of complications after surgery. Prehabilitation is a programme of exercise, improved diet and psychological support in advance of admission to hospital, with the aim of reducing risk. A systematic review (2024) found prehabilitation reduced hospital stay by 1 day, and decreased severe complications in patients who were frail, older, and undergoing elective abdominal surgery. Prehabilitation was feasible, safe, and posed a minimal risk of complications.
Recent studies have explored the needs of people with frailty when they are in hospital; they conclude that communication with patients and carers could be improved. An analysis of feedback from 609 patients across 12 hospitals, found that current communication, particularly on admission, first assessment, and at discharge, could leave people with frailty feeling distressed.
Noisy and busy emergency departments are challenging for older people living with frailty, according to a study on emergency care (2022). It found that this group prefers to receive care in a calm and quiet setting, where they are comfortable and have basic physical needs met. For example, they need access to food and drink while waiting. Older people with frailty were concerned that staff could be unresponsive when they called for attention, especially those who needed assistance with toileting.
The number of patients in acute hospitals who were ready to leave but were delayed increased by 43% from June 2021 (an average of 8,545 patients per day) to June 2024 (12,223 patients per day). Older people living with any level of frailty are more likely to have delayed transfers of care.
NHS England provides comprehensive guidance on discharge, and recommends “the default pathway for people with frailty should be home first, with recovery support at home to regain functional ability after discharge.”
An evaluation (2022) of the Discharge to Assess (Home First) model suggested the need for:
- a shared understanding of local processes (an operation policy)
- high standards of communication between teams and with patients and carers
- operational oversight of the pathway
- measurement of outcomes for service users and carers to facilitate continuous improvement.
Conclusion
In our ageing population, the numbers of people living with frailty are growing rapidly, with some areas disproportionately affected. Yet frailty is not an inevitable consequence of ageing. There is growing evidence that physical activity and a good diet could help delay the onset of frailty and reduce its severity. Prevention strategies could contain demand and control expenditure.
People with frailty, particularly severe frailty, are at risk of some of the poorest outcomes from hospital care; their care also consumes the highest resource. Systematically screening and assessing patients for frailty, particularly in hospital, will save lives and help people to retain their independence. Research suggests ways to mitigate their heightened risks from falls, immobility, delirium, continence problems, inappropriate medication and surgery.
Studies show unwarranted variations in hospital and community care. Issues to be addressed include poor communication both between professionals and with patients; lack of clarity about roles and responsibilities; failure to monitor outcomes that are important to patients; workforce pressures.
Unanswered questions remain about the best models of prevention and care, particularly in the community, as well as the implications for the health and social care workforce. Ongoing studies from the NIHR (see below) should help provide answers.
Chief Investigator: Professor Andrew Clegg End date: May 2023
Chief investigator: Dr Lesley Brown End date: March 2025
Main output will be a Pain and Frailty Service Commissioning Pack to support commissioning of services aligned with the needs of older people with frailty and pain.
Personalised care planning to improve quality of life for older people with frailty
Chief investigator: Professor Andrew Clegg End date: August 2025
This study aims to investigate whether Personalised Care Planning for older people with frailty can improve quality of life and reduce use of health and social care services.
Chief Investigator: Dr Bronagh Walsh End date: October 2025
Research Question: What is the present, and expected, size and composition of the health and social care workforce required to provide care for the frail older population? The primary objective of this study is the creation of a simulation model that will inform service and workforce planning to meet health and social care needs associated with frailty.
NICE
Improving care and support for people with frailty: How NICE resources can support local priorities
Frailty resources on NHSE website
To support health and care professionals and commissioners in the development of patient-centred services that enable people to age well there is a range of material available to improve understanding of frailty as a long term condition
British Geriatric Society
Acute Frailty Network (AFN)
The AFN provides guidance and resources
Quality indicators for geriatric emergency care
Specialised clinical frailty network (SCFN)
The Specialised Clinical Frailty Network supports specialised healthcare teams to improve the way specialised care and treatment is tailored to the needs and preferences of individuals living with frailty. The Network is a clinically led quality improvement collaborative. Resources include Specialised Clinical Frailty Toolkit.
Skills for Health
Skills for Health, NHS England and Health Education England Frailty Framework of Core Capabilities
Pathway
In addition to other impacts on health, being homeless accelerates ageing. Pathway’s work in the area to date includes contributions to research, with particular reference to the experience of frailty in hostel settings.
Previous NIHR Evidence review (2017)
Author: Candace Imison, Deputy Director of Dissemination and Knowledge Mobilisation, NIHR
How to cite this Collection: NIHR Evidence; Frailty: research shows how to improve care; October 2024; doi: 10.3310/nihrevidence_64717
Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
NIHR Evidence is covered by the creative commons, CC-BY licence. Written content and infographics may be freely reproduced provided that suitable acknowledgement is made. Note, this licence excludes comments and images made by third parties, audiovisual content, and linked content on other websites.
