Multiple Morbidities and Frailty

Multiple Morbidities and Frailty July 2017 version

Please note that this is the archived version of this chapter. For the current version, please navigate to Multiple Morbidities and Frailty | Surrey-i ( . As this is an archived version, links within this chapter may be broken or point to old information.

Executive Summary

  1. Multimorbidity is defined as having two or more chronic conditions at one time while frailty is defined as a reduction of the built-in reserves of multiple bodily systems among elderly people that leads to increased vulnerability to minor insults. Frailty frequently deteriorates once it has developed and emphasis should therefore be placed on prevention of frailty.
  2. Multimorbidity and frailty can commonly coexist and contribute to one another. Both have been linked to increased mortality, health service use and cost, polypharmacy and mental illness.
  3. Multimorbidity and frailty both become more common with ageing and deprivation, whilst frailty particularly is more common in women and people in long-term care. Where multimorbidity is present, the kind of health service use is largely dictated by the first presenting long term condition (LTC).
  4. Weight loss is a key feature of frailty and is often caused by malnutrition. Malnutrition is believed to affect 30% of hospital admissions and increase treatment costs by 3 times. Pathways of nutritional support could generate savings to the health and social care services of more than £200 million annually.
  5. There is no local data on either multimorbidity or frailty in Surrey. However, using data available from elsewhere, it is estimated that there are around 90,000 residents aged 65 and over with multiple morbidity and 22,000 with frailty. It is further estimated that those with frailty will increase to more than 27,000 by 2030.
  6. We expect care home admissions also to increase by approximately 60% by 2030, representing very approximately 4000 of the people with frailty in Surrey.
  7. The 2011 census recorded in the region of 77,000 people over 65 in Surrey who have some limitation in performing their activities of daily living.
  8. Interventions which have been found to be effective include:
    • a. Proactive and targeted case finding.
    • b. Promoting prevention using exercise and nutrition interventions and reducing polypharmacy.
    • c. Integrated healthcare services to provide a person-centred single point of care.
    • d. Use of technology such as shared electronic notes and the use of telecare and telehealth.
    • e. Housing with extra care and support to improve people’s chances of remaining at home long term.
  9. Implementation of these evidence based interventions are not consistent or at scale across Surrey. Early identification of multimorbidity and frailty are still not commonplace. While there are initiatives to address polypharmacy through CCG medicines management teams and some nutrition programmes, there do not appear to be coordinated initiatives to prevent frailty in Surrey. CCGs in Surrey have developed a number of integrated health and social care hubs, though approaches differ between CCGs. There is a lack of integration of information technology systems and human resources to enable continuity of information and care across time and place. There is currently an expected deficit of 2100 nursing beds, 1360 residential beds and 750 Extra Care apartments in Surrey by 2025.
  10. Recommendations are made in the final section of the main report to prioritise addressing the gaps identified in service provision.


Tableau Preview

Visualisation of data used in this chapter

Open Tableau 

Summary: Multimorbidity and frailty can commonly coexist and contribute to one another. Both have been linked to increased mortality, health service use and cost, polypharmacy and mental illness.

In this chapter, the concepts of multimorbidity and frailty will be introduced and their consequences and risk factors summarised. Estimates will be made of the level of need in relation to current existing services in order to best address the most urgent needs in Surrey. Broad evidence-based recommendations will then be made to inform for the future evolution of services for the multimorbid and frail elderly in Surrey.


Multimorbidity is defined as having two or more long term conditions (LTC) at one time. We know that the presence of one LTC makes the presence of another more likely (1) and that with the demographic transition to an older population (2–4) there are predictions that the proportion of people with multimorbidities is set to rise.


Frailty is a reduction of the built-in reserves of multiple bodily systems, leading to increased vulnerability (5). A fall, new drugs or minor infections can result in disproportionate deterioration in physical, functional and mental health in frail compared to non-frail older people. Frailty is not a specific disease, but instead an interaction of physical, psychological and social deficits and is also associated with ageing (6).

The Course of Frailty

Frailty develops insidiously over five to ten years and ranges from the pre-frail (who are at risk of developing frailty), to the mildly frail (who may be able to self-care), to the moderately frail (who might benefit from case-management), to severe frailty (where care planning and end-of life care may be appropriate)(7). There are numerous means of defining frailty, which make grading severity a challenge and this is described further in the later section of this chapter “The Level of Need in the Population”.

The prognosis of frailty is poor. For any given stage of frailty, about 40% of individuals progress to a more frail stage, while only 25% recover to a less frail stage. Moreover, once an individual becomes frail, they have a less than 1% chance of ever becoming non frail again and this chance reduces over time (8). Hospital admission can be a key trigger to frailty amongst non-frail people and can seriously impede recovery and discharge in frail individuals (9).

The Interaction Between Disability, Comorbidity and Frailty

Although conceived as separate conditions, frailty and multimorbidity commonly coexist in older populations, can mutually contribute to each other and are both predictors of disability. 27.2% of frail individuals report disability, 67.7% report multimorbidity and 21.5% report both frailty, disability and comorbidity (6,22). Any prediction of future disability care needs can therefore be informed by the current rates of multimorbidity and frailty.

Implications of Multimorbidity and Frailty

Death is more common among people with more than one LTC than with a single condition (10,11) and frailty increases the risk of death within five years by five to seven times compared to non-frail people. In fact, frailty has been shown to be the greatest predictor of death and institutionalisation in the elderly (12).

Health Service Use and Cost

Multimorbidity has an even more dramatic effect on health and social care costs than age – largely because it can drive up the costs of acute non-elective care (12,13). People with multimorbidity account for 78% of GP consultations (14) and as the number of long term conditions accumulates, so too does the number of doctors an individual may see (15). This can be duplicative, inefficient and in many cases unsafe, (6,16–20) particularly when it is not clear who is taking primary responsibility. Frailty has also been associated with increased health service use, most commonly for hospital admissions and care home admissions (21–24).

Hospital Admissions:

Unscheduled and avoidable hospital admissions are up to ninety times more common in the multimorbid elderly (1,25) and can result in delayed transfers of care, long term institutionalisation and ultimately – additional harm and cost.

Frailty is also associated with approximately double the number of first hospital admissions (6) compared to non-frail individuals.

Long Term Admission to Care Homes:

Frail individuals are more likely to be admitted to care homes and accordingly care home residents are more likely to be frail than community dwelling people. Huge variation exists and prevalence of frailty in nursing homes can reach 68% in some countries (21). Initiatives designed to address frailty must therefore also try to prevent progression of frailty states among residents in care homes and emphasise prevention of frailty to reduce care home admissions.


Polypharmacy, (taking more than 5 regular medications (26)) is associated with multimorbidity and frailty (27) and is increasing (28). Whilst it is sometimes necessary and appropriate, polypharmacy can be inappropriate when: medications are no longer indicated, patients experience or are at risk of adverse drug reactions or are not taking the prescribed medications. Whilst guidelines suggest the use of multiple drugs to prevent long term disease, most studies exclude patients with multimorbidity and polypharmacy and follow up is shorter than the period of drug use in reality. Consequently, the appropriateness of many drug combination is unclear (29,30). Reducing polypharmacy could reduce both costs and incidence of frailty in the elderly (31).

Mental Illness:

At least 40% of people with multimorbidity are estimated to have at least one mental health condition (32) and this is more common where there is deprivation (32) and increases with the number of LTCs (33,34). Depression is up to seven times more likely in people with multimorbidity and increases the cost of care for patients with long term conditions by at least 45%(35). In the US, total healthcare costs for patients with diabetes and depression are five times greater than the costs for their non-depressed counterparts (36,37) and these patients have poorer glycaemic control and end organ damage (38).

Dementia is common in frail older people (39) and usually equivalent in severity to frailty (40). Frailty shares many modifiable risk factors in common with dementia, suggesting that a prevention approach for one may impact both conditions. The estimated public cost of dementia alone is greater than the sum of costs for heart disease, stroke and cancer (41) and yet, integration and parity of esteem between physical and mental healthcare remains uncommon.


Frail and multimorbid people are also at greater risk of falls (6,42) and their adverse effects (43) such as fractures, long term dependence and death (44-46). More information about falls in Surrey can be found here.

Who’s at risk and why?

Summary: Multimorbidity and frailty both become more common with ageing and deprivation, whilst frailty particularly is more common in women and people in long-term care. Malnutrition, which presents commonly with frailty is under recorded and has serious detrimental effects. Where multimorbidity is present, health service use is dictated by the first LTC.


Both multimorbidity and frailty are associated with increasing age. Based on a Scottish population-based study of over a million people, we estimate that over half of over 65s and over three quarters of over 75s in Surrey are multimorbid. Between the ages of 70 and 79, more than 10% of people have three LTCs (47). However, most multimorbid patients are under 65 (48), so this is not just a condition of ageing. Frailty on the other hand, is a condition of ageing (6,49,50) and affects approximately 1 in 10 of the over 65s and between a quarter and a half of the over 85s (6).


Deprivation can double the risk of multimorbidity (4,32) and of frailty (51) (in over 65s) in comparison to affluence (48) in the UK. In Surrey, the proportion of those 60 and over living in poverty varies between 1% and 41% in Surrey lower super output areas (LSOAs). The range is typical of Surrey’s wide inequality gap and highlight the need to target more deprived elderly people.


Women have double the risk of developing frailty (9.6%) compared to men (5.2%) (49), which, coupled with a 40% loss of mobility in women between the ages of 75 and 85 makes older women particularly vulnerable to the effects of both frailty and disability (52).


Frail and multimorbid individuals often have difficulty with eating and absorbing nutrients and consequently can develop often unrecognised malnutrition (53,54). Malnutrition is a state in which a deficiency of nutrients causes measurable adverse effects on the bodily function (55). This can result in acute illness and prolonged recovery from medical problems. An estimated 30% of patients admitted to hospital and 35% admitted to care homes are at risk of malnutrition, which can increase treatment costs by three times (56). The clinical complications of malnutrition are severe and can in many cases be prevented with the introduction of a healthier diet. In severe cases, complications can be reduced by up to 70% with effective use of oral nutritional supplements (57) or programmes such as ‘Food First’. Indeed, appropriate pathways of nutritional support could generate savings to the health and social care services of more than £200 million annually (56) and better nutritional care is the 4th largest potential source of cost savings to the NHS (55). Most measures of frailty also include a measure of nutritional status (58), such as the Malnutrition Universal Screening Tool (MUST), yet, healthcare professionals frequently fail to pick it up because they are not trained or aware to look for it.

Multimorbidity and the associated patterns of disease:

The Kent Public Health Observatory has shown from primary care records that over 95% of people with heart failure have multimorbidity and nearly 30% have 5 or more LTCs. Whilst some disease combinations are expected because of shared pathology, for example chronic heart disease (CHD) and hypertension, other combinations are perhaps more surprising, such as comorbid asthma and hypertension. The number of conditions can be a greater determinant of the degree of health service use than the specific diseases (13).

Different LTCs lend themselves to particular care settings and thus distinctive patterns of disease can produce predictable patterns of health service use.

The level of need in the population

Summary: There is no local data on either multimorbidity or frailty in Surrey, but modelling data from Kent demonstrates increasing numbers of those with multimorbidity, particularly in NW Surrey and Surrey Downs CCGs. Frailty is also increasing and we estimate approximately 22,000 people with frailty in Surrey currently, which is expected to increase by nearly 30% by 2030. We expect care home admissions to also increase by nearly 20% by 2030, representing approximately 4000 people admitted to care homes in Surrey for frailty.


Although data is limited, population studies now estimate that in Scotland, nearly a quarter of the population have multimorbidity and approximately 15% have at least 3 LTCs; it is more common to have two or more LTC’s than only one (48). Whilst the number of people in the UK with one long term condition is projected to be relatively stable over the next ten years, the number of people with multimorbidity is set to rise to 2.9 million in 2018 from 1.9 million in 2008, amassing an additional cost to the NHS and social care of approximately £5 billion between 2011 and 2018 alone (47).


There are no local accurate measures of multimorbidity in Surrey. The Kent Public Health Observatory used GP records to measure multimorbidity and we have applied these proportions to estimates of the population in Surrey (59). The Kent and Surrey populations are similar in that about a quarter of both populations are predicted to be over 65 in the year 2030 (60) with similar proportions of men and women. Results show that by the age of 75, most people in Kent are expected to have multimorbidity. It is important to note that the study in Scotland looked at 40 LTCs, whereas Kent looked at only 19 and so the prevalence in Kent may be an underestimate. The proportion of people with no LTCs falls with increasing age whereas the proportion of people with one or more LTCs increases until the age of 80-84, when it starts to drop (see Tableau visualisation). This decrease may be related to increased death rates among multimorbid people over 80, resulting in a dilution effect of multimorbidity in the surviving population over this age. It is estimated that in 2023, NHS North West Surrey and NHS Surrey Downs Clinical Commissioning Groups (CCG) will each have the highest absolute numbers of people over 65 with multimorbidity, more than 27,000, whereas the highest numbers in the districts and boroughs are expected in Waverley and Reigate and Banstead – more than 12,000 – around 100,000 in total in Surrey. There are many more women expected to have multimorbidity than men for almost every CCG and district and borough in Surrey. There are limitations to applying data from Kent to Surrey: Kent has higher rates of deprivation amongst older people than Surrey as well as differences in ethnicity and cultural makeup. Consequently, these figures can really only be used as a guide in the absence of alternative data.

An alternative means of assessing multimorbidity is through the Right Care Approach, which documents comorbidities found in patients who constitute the top 2% of spend in each CCG and aims to elucidate patterns of multimorbidity amongst those patients. We have not assessed this data in detail here as it constitutes such a small proportion of the multimorbid population.


The estimated prevalence of frailty varies between studies from 4% to 59% in community dwelling adults (49). Two divergent models exist for measurement of frailty without clear consensus on which is better.

  • The Phenotype/Physical Model (6) classifies anyone with 3 or more of: “unintentional weight loss; reduced muscle strength; reduced gait speed; self-reported exhaustion and low energy expenditure” as frail and anyone with only 1 or 2 of these characteristics as pre-frail.
  • The Broad/Cumulative Deficit Model calculates a ‘frailty index’ score based on a range of different conditions. The most common index uses 92 baseline deficits including low mood, abnormal investigation results such as a low haemoglobin, disease states and disability (40).

Prevalence based on the physical/phenotype model alone is an estimated 10% for frailty and 44% for pre frailty. The broad/cumulative deficit model estimates a prevalence of 14% for frailty and 34% for pre frailty (49). The total proportion of the population considered pre-frail and frail is similar between both these approaches with the phenotype model being more conservative in the number of patients considered frail.


By applying the phenotype model prevalence of frailty to estimated population of community dwelling adults (59) in Surrey, it is possible to estimate the local prevalence of frailty. To do this, we used the prevalence figures from the phenotype model to estimate that there are approximately 22,000 people with frailty and approximately 96,000 people with pre-frailty in Surrey and both are estimated to rise by approximately 28% by 2030 in line with population projections. Estimates of numbers of frailty at different ages and in different areas of Surrey is shown in the data visualisation. The largest number of patients with either frailty or pre frailty are estimated to be in NW Surrey CCG and Surrey Downs CCG, whereas the smallest number are expected in Surrey Heath CCG.

Long Term Admission to Care Homes:

About 1 in 25 people over the age of 65 in Surrey lived in care homes (8,118) in 2015 and we expect this to increase by approximately 60% (13,045) by 2030 (60). An audit carried out by BUPA on residents of all of their care homes across 4 countries in 2009, showed that about 30% of residents were admitted for frailty. We can therefore estimate that there will be approximately 4000 older people admitted to care homes in Surrey in 2030 for frailty. These residents usually have complex health and social care needs, disability, frailty, multimorbidity associated with multiple hospital admissions and often require ‘continuing healthcare’.

In Surrey, roughly 1 in 3 men over the age of 75 (14,960) and twice this proportion of women (37,271) live alone (60) and are therefore at greater risk of the physical, cognitive and social decline that often accompanies isolation.


Given the known overlap between disability, multimorbidity and frailty, we have also looked at the numbers of people with disability in Surrey. This was calculated using the 2011 census data about people who have any limitations with any activities of daily living, such as washing and dressing. We found that there were approximately 77,000 people in Surrey with a disability over 65 in 2011, accounting for 42% of the over 65 population. Whilst this is lower than the national average of 52%, it still represents a growing dependency in the community, 30% of which is found in NHS North West Surrey CCG. This compares to an estimated 22,000 people over 65 with frailty and 90,000 with multimorbidity in 2017.


More than three million people in the UK are either malnourished or at risk of malnutrition. Most live in the community, while 5% live in care homes and 2% are in hospital (61). 1 in 10 people over 65 and living in the community are estimated to be malnourished or at risk (62). We can therefore estimate that there are approximately 22,000 community dwelling people over the age of 65 in Surrey who are malnourished or at risk and we expect this number to be closer to 29,000 by 2030 with projected population demographics. However, data recording for malnutrition is frequently inadequate and is scarce in Primary Care. Table 1 shows Hospital Episode Statistics for Surrey between 2013 and 2016 that reveal only a small number of people admitted to hospital with recorded malnutrition. This may be because a number of malnourished people in the community may not be admitted to hospital. Malnutrition may also not be accordingly coded on their hospital records where it is not the primary reason for admission; some patients may be receiving (appropriate or otherwise) treatment but we are unable to say how many.
Table 1: Number of elective and emergency patients admitted for malnourishment in over 65s in 2013/14, 2014/15 and 2015/16 by CCG

  65 and over
CCG Name 2013/14 2014/15 2015/16*
East Surrey 15 14 21
Guildford and Waverley 8 16 32
North West Surrey 27 31 28
Surrey Heath 21 26 15
Surrey Downs 36 44 37
Total 107 131 133

Source: Hospital Episode Statistics
*Data for 2015/16 is provisional

Services in relation to need.


There are no systematic programmes in place that utilise evidence-based individual interventions like exercise and nutrition to minimise development of frailty in those at risk. Existing prevention services are summarised below.


The Surrey Prescribing Advisory Database (‘PAD’) is a website for healthcare professionals in Surrey that provides guidance and information on medicine use in Surrey and is linked to NICE guidance. Routine use of the STOPP and START tools are not known to be in wide use currently in Surrey by healthcare professionals. However, individual CCG Medicines Management teams do have a range of programmes to address polypharmacy including working in care homes.

Healthcare Services

The three Sustainable Transformation Plans in Surrey aim to ensure integrated and proactive support for people with multiple complex health and care needs. There are integrated pathways across Surrey, which act as single points of care for frail patients. There are a variety of programmes at different stages of development across Surrey that are addressing frailty, ranging from proactive care programmes in NW Surrey, Guildford and Waverley and Surrey Heath to a more reactive care programme in Surrey Downs and East Surrey. In view of the lack of historic coding for frailty and lack of consensus on a validated measure, systematic case-finding is a real challenge. An overarching review of the existing services in Surrey is summarised in the table below. Red indicates a programme that does not yet exist, amber indicates a project that has been considered and is in the stages of development or has only been partially implemented and green indicates that a CCG is able to provide the programme.

Routine measurement and recording of frailty in the community using any one of the validated tools (See below) S S S S S
Enable easy referral into the pathway for older people with frailty syndromes S S S S S
Allow frail patients in crisis to be cared for at home during or after a crisis using for example the CGA or discharge to assess models S S S S S
Shared information and care plans across GP’s, social services, ambulance services, Community Mental Health Team, Community Geriatricians etc. S S S S S
Include the provision of personal care staff to support older frail people as they recover and possibly provision of intermediate care facilities S S S S S
A discharge to assess model that facilitates early hospital discharge of frail older people once their acute care needs have been met. This requires records and IT to be shared and accessible to ambulances, social workers, emergency departments and hospitals S S S S S
Enable fast and frequent assessment and review of Continuing Health Care needs that are clearly documented in advance of any admissions and do not impede discharge S S S S S
Develop and sustain a workforce that can work flexibly across hospitals and community services with different employers but as part of the same frailty pathway as suggested by the Future Hospitals Commission from the RCP S S S S S

In East Surrey, frailty is still predominantly managed in the acute setting, through the development of a frailty unit run by a daily geriatrician and allied professionals. The purpose of the unit is predominantly to manage frailty syndromes and to prevent unnecessary admissions. The unit uses EMIS so that all records are shared with GP’s. A CQUIN has also been introduced in East Surrey that requires Rockwood frailty scoring in accident and emergency and triage to the frailty unit based on a score of 5-7.

So far, the locality care models have received positive feedback from service users, and are an important part of the local sustainability and transformation plans. It is too early to tell if they have been successful compared to their stated aims and objectives, and a continuous process of rigorous monitoring and evaluation is required. This process has begun.

Guildford and Waverley have two hubs at present. The Waverley proactive care hub had 203 referrals between August 2016 and November 2016.

The pathway for frailty in Surrey Heath shares very similar principles of integration and a ‘single point of access’ (SPA) for care that includes both health and social care professionals and the voluntary sector. In its first 11 days of going live the SPA received 158 referrals suggesting a welcome reception and ease of use. The pathway was built from the bottom up, incorporating the patient voice in its design and focuses on prevention. Services are incorporated across disciplines and sectors to identify patients at risk of multiple admissions and use simple solutions such as internet training and online shopping to enable them to function better at home for longer and in better health. In this video, health professionals involved in the SPA report improved efficiency and satisfaction of this integrated way of working.

In Surrey Downs, for example, the East Elmbridge locality reported that non-elective hospital admissions in the over 75s were 4% lower in the period December 2015 to December 2016 compared to the previous years’ data, while neighbouring areas saw a 5% rise in admissions.

The Bedser Hub in Woking, North West Surrey, has built a caseload of more than 1000 patients and has adopted a proactive approach. In their first annual report a 1.3% reduction in non-elective admissions for the over 75 population in Woking is reported, compared with an increase in admissions for the same age group in the other two North West Surrey localities (+0.3% and +5.8%).

Whilst CCG’s nationally often use avoided unplanned hospital admissions as a primary outcome indicator (86), this is problematic. The British Geriatric Society Guidance: Fit for Frailty states that changes in unplanned hospital admissions are unlikely to be seen for considerable time and at least until working practices have changed at scale and instead favours process measures, user experience and objective measures such as length of hospital stay and primary care consultations.

Several CCGs, including NW Surrey, Guildford and Waverley CCG and Surrey Downs CCG have also allocated resources to determining how care homes need to be supported. In particular, East Surrey have appointed a team to support care homes that includes medicines management, dietetics to review malnutrition and nurses. They report a £1.3 million saving from hospital admissions in this population in one year. Surrey Downs also sponsored a systems resilience grant to provide flu vaccinations for staff in care homes based on evidence that it may reduce influenza related hospital admissions among frail residents.

Social Care:

At present there are approximately 54 nursing beds and 40 residential beds per 1000 people over the age of 75 in Surrey. The availability of Extra Care apartments has been recommended at a ratio of 25 per 1000 people, and yet the national average remains a disappointing 11. In Surrey, we have on average 7 Extra Care apartments per 1000 people over the age of 75 (820), of which nearly 70% are funded by SCC. Geographical distribution is highly variable, with rates as high as 14 apartments per 1000 people over 75 in Guildford and as low as 5 apartments per 1000 people in Waverley. Evaluations in Surrey show that Extra Care can provide an appropriate alternative for people with complex medical and social needs, the socially isolated and people with unsuitable (or no) accommodation. Cost comparisons of Extra Care in Surrey also demonstrate potential gross savings from reduced ongoing care package costs, residential placements and unplanned admissions to hospital. This can be seen for cases A to V in the graph displayed. There is demonstrable need for more Extra Care apartments with a more equal distribution across Surrey.


The use of adaptations and assistive technology is fast developing in Surrey and the current digital roadmap in Surrey aims to promote data sharing to promote person centred care; data pooling to allow development of rich data sets to assist commissioners in planning; intelligence platforms to improve data reporting, such as tableau, used in the JSNA and technologies to support data collection.

Assistive technologies have been adopted in districts and boroughs such as ‘care and repair’ programmes. Devices designed to detect extreme temperatures as well as pendant alarms, smoke alarms and key safes are being supplied free to individuals in need for 12 weeks. In some CCG’s such as NW Surrey and Surrey Downs, Telehealth has been used to enable remote monitoring of clinical observations to reduce hospital admissions or shorten their duration, alleviate caseloads of care workers and GP’s and to enable people to stay at home who might not be able to otherwise. Whilst evaluations have still not been completed, patients have so far reported positive satisfaction.


More detailed information on falls can be found here.


The level of need is still unknown due to scarce routine measurement of malnutrition. There are nutritionists working currently alongside pharmacists in some CCGs to support care homes to improve nutrition and PAD includes useful general guidance on managing malnutrition as well as guidance directed predominantly at care homes. Its Nourish Resource Pack is filled with tips, activities and recipes to help to prevent malnutrition amongst care home residents and improve the experience of eating amongst the frail elderly. NHS England have provided useful guidance on malnutrition and dehydration here.


Unmet needs and service gaps


We do not currently have a local accurate estimate of the prevalence of multimorbidity in Surrey or the patterns of disease that exist, though data from Kent suggest that there is likely to be a substantial proportion of people over the age of 75 with greater than 5 long term conditions and these individuals are at risk and without a service designed to target them.


In order to identify the unmet gap in provision of services for frailty there needs to be an identified unified measure to improve case finding and recording of cases of and progression of frailty. Current estimates are particularly rudimentary, but suggest that whilst the development of locality hubs represent a positive move in the right direction, we cannot demonstrate their effectiveness until more rigorous measures of evaluation have taken place. Nonetheless it remains the case that in CCG’s with a particularly high estimated prevalence of frailty, the caseloads of the hubs fall far short of the likely demands of frailty, particularly in NW Surrey and Surrey Downs that are likely to have large numbers of frail older people. The emphasis of most frailty pathways in Surrey have been largely reactive in the sense that they are driven to reduce hospital admissions. Gaps exist in prevention and the benefits of identifying and treating the pre frail with measures such as systematic exercise, nutrition and polypharmacy interventions. Whilst there are some interventions currently to suggest that interventions to support care homes do exist, there is also some local evidence that staff in care homes are keen to champion change in care homes and receive training to support themselves and their residents and this is outlined in the evaluation of the care home staff vaccination programme in Surrey Downs CCG.

Social Care:

After accounting for the expected growth in the elderly population, it has been calculated that:

  • We need another 2100 nursing beds with the most pressing needs in NW Surrey (823) and Surrey Downs (725) by 2025.
  • We also require another 1360 residential beds, with the greatest need in NW Surrey.
  • Finally, we need 750 Extra Care apartments in Surrey (600 to be funded by SCC) to bring the current ratio to 10 beds per 1000 people.

The burden of the frail elderly is more visible in NW Surrey and Surrey Downs and the low number of Extra Care schemes could represent a gap upon which we can capitalise to try to prevent further deterioration and development of frailty.


Whilst technology is playing a large part in the current landscape of transformation and integration, with the disappointing announcement that funding from NHS England would not be available for the Surrey Shared Care Record project, an integrated electronic health record that is visible securely to the entire team involved in integrated care remains elusive. Person-centred care delivered by integrated health and social care is challenging without shared care records. It is also extremely challenging to make estimates of needs in Surrey without person-level pseudonymised dataset with which to plan services.

What works


  • Proactive and targeted case finding of both multimorbidity and frailty and use of risk stratifying tools in routine settings is advised to identify frailty early.
  • Reducing polypharmacy, systematic exercise and nutrition interventions to promote prevention.
  • Integrated healthcare services to provide a single point of care with streamlined services to enable holistic, person centred and continuous care.
  • Technological advances such as shared electronic notes and the use of telecare and telehealth.
  • Initiatives such as Extra Care as a means to improve people’s chances of remaining at home and avoiding long term institutionalisation.

This section will establish the recommended approaches to case-finding for multimorbidity and frailty and will then look at evidence-based interventions and prevention. Finally, it will address the elements of integrated service design that are required to successfully manage healthcare services and social care for multimorbidity and delay progression of frailty.

Case finding:

Multi morbidity:

NICE Guidance on Multimorbidity: Clinical Assessment and Management (NG56)(63) recommend a combination of:

  • Routine assessment for multimorbidity during appointments
  • Proactive case-finding (by identifying people taking more than 10 regular medicines) and
  • The use of electronic assessment tools to identify people with multimorbidity.

There is still little consensus on which LTCs should be included in the assessment of multimorbidity and whether or not to weight the result to outcome of interest (for instance hospital admission). The average number of conditions assessed is about 19, which is similar to the data that we have used (64).


NHS England recommend targeted case-finding, risk stratification and electronic assessment tools in primary care and the community to identify frailty (7). Due to the lack of consensus on the definition of frailty, multiple measurement tools exist. They can be viewed as subjective, objective or a mixture of both. Only about a quarter have been tested for how consistently their results are similar (reliability) and how likely they are to actually measure frailty (validity)(58). Further information about the range of tools and their attributes can be found in Appendix A.

When should we be assessing for frailty?

Routine screening has not been advised for frailty at present, particularly in light of low specificity of the available assessment tools and low cost-effectiveness. There may be an opportunity however, for GP’s to try to identify their patients most at risk of admission using risk stratification tools and frailty assessment tools in their most appropriate context (see Appendix A for further detail).

People presenting with frailty syndrome in crisis can also be safely assessed and managed at home in many cases where there are well trained, dedicated, well-led, multi-disciplinary community teams. This requires the development of teams with these attributes who are integrated into primary and secondary care (7).



There is evidence that rationalisation of medications, exercise and nutritional support can prevent development of further LTCs and delay onset of frailty by improving physical, mental and social functioning.

Multimorbidity – Polypharmacy:

In view of the adverse effects of multiple high risk medications, the benefits and risks of each drug that a patient takes should be carefully considered where multimorbidity exists. Tools such as STOPP (Screening Tool of Older Person’s Prescription) or START (Screening Tool to Alert the Doctor to Right Treatment)(29) are effective in rationalising medications according to person centred rather than guideline based priorities. NICE guidance on multimorbidity (63) also recommends the use of the database of treatment effects to determine the effectiveness of treatments, the duration of treatment trials and the populations included in the trials.

Frailty – Exercise:

Specialised exercise programmes help prevent or delay the progression of frailty and restore functional independence (8,65) by improving muscle wasting, cardiorespiratory function, cognitive function and mood (66–68). Programmes are more beneficial and cost-effective when they are structured, include 3 sessions a week of 30-45 minutes, last longer than 5 months (69) and take place in the earlier stages of frailty where there are greater reserves for improvement (68). The greatest potential benefits are in older females and those living in long term care (compared to community dwellers). Providing exercise resistance training benefits attention and memory and when combined with protein supplementation it can even improve information cognitive processing speed (70).

Frailty – Nutrition:

Caloric and protein supplementation can also enhance weight gain and grip strength and ultimately reduce mortality and complications amongst older frail people (6,71). Vitamin D is also known to reduce falls and mortality in frail older adults (72,73). Treatment pathways for malnutrition have also been summarised and detail best practice use of oral nutritional supplements in the community.

Healthcare Services

NICE guidance on multimorbidity (63) and British Geriatric Society (BGS) and Royal College of General Practitioners (RCGP) guidance on frailty share many principles. The BGS and RCPG (74) advocate integrated health systems that provide a single point of access for services and provide continuity of care in the form of shared information, management plans and ongoing relationships. This enables holistic assessment; person-centred care planning; promotion of self-care (described further in Appendix B) and telecare; and intermediate care and reablement. In order to be a realistic alternative to admission, this service must be accessible for at least 14 hours on 7 days of the week and able to deliver prompt assessments of frail patients.


Integrated models of care for patients with multimorbidity are more effective and efficient than singular ones (75). Guidance suggests that services for multimorbidity should integrate generalist and specialist care creating a role for the ‘expert generalist’(1,76). Integrated management of mental and physical health have also been shown to improve access to and satisfaction of care, health outcomes and cost-effectiveness (77–82).


Improving care coordination of frail older people promotes independence and reduces falls, nursing home admissions and hospital admissions (83). NHSE recommends a number of complex interventions for people with frailty including ‘comprehensive geriatric assessment’ (CGA), ‘frailty units’, and ‘discharge to assess’ (described in further detail in Appendix B). Integrated multidisciplinary interventions can also reduce the absolute prevalence of frailty by 15% if continued for 12 months and if patients adhere to the programme (84). These types of interventions also have a positive impact on residents in nursing homes, particularly where teams are well co-ordinated (85). This requires the creation of streamlined ‘pathways’ of care for frailty, aligned with all the above guidance which should enable:

  • Easy identification of multimorbidity, polypharmacy and frailty
  • Easy referral into the pathway for older people with frailty syndromes
  • Shared information and care plans across GP’s, social services, ambulance services, Community Mental Health Team, Community Geriatricians etc.
  • Frail patients in crisis to be cared for at home during or after a crisis using for example the Comprehensive Geriatric Assessment (CGA) or discharge to assess models
  • Provision of personal care staff / intermediate care facilities to support older frail people as they recover
  • A discharge to assess model that facilitates early hospital discharge of frail older people once their acute care needs have been met.
  • Fast and frequent assessment and review of Continuing Health Care needs that are clearly documented in advance of any admissions and do not impede discharge
  • Development of a workforce that can work flexibly across hospitals and community services with different employers but as part of the same frailty pathway as suggested by the Future Hospitals Commission from the RCP.

It is according to these core criteria that the services in Surrey have been summarised.

Social Care:

More investment in age-friendly and desirable housing could improve people’s chances of remaining at home and avoiding long term institutionalisation according to the Anchor Trust and the All-Part Parliamentary Group on Housing and Care for Older People. One example of this is ‘Extra Care housing’; these are self-contained homes with design and support features to enable self-care and independent living. Extra Care promotes a two way community interface, in which individuals are encouraged to participate in the local community and engage in activities. It can vary from ‘very sheltered housing’ to something more akin to a retirement community. The Extra Care housing in East Sussex has been suggested to be on average half the gross cost of alternative placements ranging from domiciliary care to full nursing care. An estimated 63% of people in Extra Care schemes in East Sussex would have needed residential/EMI/nursing care had they not been in Extra Care. More specifically, 37% would have been in residential care, 4% would have needed EMI care and 15% would have required nursing care. The best impacts and financial returns were from clients at the high end of the medium dependency spectrum and capital invested by East Sussex Council was recovered between 1.5 and 3.3 years. Extra Care can also provide support to intermediate care and rehabilitation and help to improve the ailing relationship between housing, health and social care.


The NHS five year forward plan (76) suggests that informational technology should be an ‘electronic glue’, connecting health and social care and to support people living in their homes for longer. There is some evidence to suggest that telecare can help to prolong independent living, avoid hospital admissions and support safe discharge from hospital but it is inconsistent. However, telecare is more likely to work when integrated as part of a wider service redesign, where stakeholders are all involved and patient choice and preferred outcomes are central to each decision.

Recommendations for Commissioning

There is great potential to make multimorbid and frail older people less dependent, immobile, fearful – and, in turn, less reliant on care. This requires commitment to a whole system change, including skills, knowledge and careful co-ordination to deliver savings to health and social care systems. Key recommendations are:

  • Self-care could form a significant part of prevention plans for frailty.
  • CCGs should explore the use of structured preventative programmes like exercise and nutrition to maintain patients in pre-frail or moderately frail states.
  • CCGs should continue with efforts to promote medication rationalisation to address problems caused by polypharmacy in primary and secondary care.

Healthcare services

  • CCGs, Surrey County Council and clinicians should work together to agree on a tool to measure frailty to be used across health and social care so that consistent measurements are used to plan services.
  • Frailty and multimorbidity should be routinely identified in all healthcare settings and referred to an integrated team that treats patients holistically whilst enabling provision of specialist skills when necessary.
  • CCGs should continue to develop integrated models of care and hubs with an emphasis on a single point of information and ongoing evaluation as well as care.

Social Care

  • ASC and SCC should continue with implementation of Extra Care housing.


  • Better nutritional care should be a key part of the STPs. Public Health should gather more information about the current needs in Surrey.
  • CCGs/NHS England should promote training to encourage early identification of malnutrition in routine settings.
  • CCGs should seek to improve equal access to appropriate NICE-compliant nutrition programmes.

Intelligence and Data Systems:

  • CCGs should improve recording and sharing of data on multimorbidity to contribute to better understanding of health outcomes and costs of multimorbidity in Surrey.
  • Efforts to create a unified electronic system to provide continuity of patient care plans and information across institutions should continue to form a key priority in the STPs.


  • Providers of health and social care should provide training in frailty recognition & malnutrition to front-line health and social care staff and promote systematic and proactive case finding using consistent tools for frailty.

Monitoring and evaluation

  • Process evaluation of the key facilitators and barriers to successful implementation of the hubs is key to future development. This may include waiting time to be seen for comprehensive geriatric assessment, excess bed days, primary care consultations and delayed transfers of care from hospital. Evaluations should also include self-reported experience measures from service users including quality of life.

Key contacts

Selina Rajan – Specialist Public Heath Registrar:

Chapter References

  1. B. Guthrie, S. Wyke, J. Gunn, J. Van den Acker SM. “Multimorbidity: The Impact on Health Systems and Their Development”, in Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities. OECD Publishing; 2012. file:///content/chapter/9789264122314-9-en .
  2. Van den Akker M, Buntix F, Metsemakers JFM, Roos S, Knottnerus JA. Multimorbidity in general practice: Prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51(5):367-375. doi:10.1016/S0895-4356(97)00306-5.
  3. Walker AE. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn. 2007;3:202-218. doi:10.1177/1742395307081504.
  4. Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: A retrospective cohort study. Br J Gen Pract. 2011;61(582). doi:10.3399/bjgp11X548929.
  5. Turner G, Clegg A. Best practice guidelines for the management of frailty: A British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing. 2014. doi:10.1093/ageing/afu138.
  6. Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol Med Sci. 2001;56(3):46-56. doi:10.1093/gerona/56.3.M146.
  7. NHS England. England Safe, Compassionate Care for Frail Older People Using an Integrated Care Pathway.; 2014. .
  8. Gill TM. Transitions Between Frailty States Among Community-Living Older Persons. Arch Intern Med. 2006. doi:10.1001/.418.
  9. Gill TM, Gahbauer EA, Han L, Allore HG. The relationship between intervening hospitalizations and transitions between frailty states. Journals Gerontol – Ser A Biol Sci Med Sci. 2011;66 A(11):1238-1243. doi:10.1093/gerona/glr142.
  10. Deeg DJH, Portrait F, Lindeboom M. Health profiles and profile-specific health expectancies of older women and men: The Netherlands. J Women Aging. 2002;14(1-2):27-46. doi:10.1300/J074v14n01_03.
  11. Gijsen R, Hoeymans N, Schellevis FG, Ruwaard D, Satariano WA, Van Den Bos GAM. Causes and consequences of comorbidity: A review. J Clin Epidemiol. 2001;54(7):661-674. doi:10.1016/S0895-4356(00)00363-2.
  12. Rockwood K, Howlett SE, MacKnight C, et al. Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging. J Gerontol A Biol Sci Med Sci. 2004;59(12):1310-1317. doi:10.1093/gerona/59.12.1310.
  13. NHSIQ, Kent County Council. Population Level Commissioning for the Future Implementing Capitated Budgets within Long Term Conditions for People with Complex Needs LTC Year of Care Commissioning Programme.; 2014.
  14. Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of multimorbidity and morbidity burden for use in primary care and community settings: A systematic review and guide. Ann Fam Med. 2012;10(2):134-141. doi:10.1370/afm.1363.
  15. Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007;356(11):1130-1139. doi:10.1056/NEJMsa063979.
  16. Leendertse AJ, Egberts ACG, Stoker LJ, van den Bemt PML a. Frequency of and Risk Factors for Preventable Medication-Related Hospital Admissions in the Netherlands — Leendertse et al_ 168 (17) 1890 — Archives of Internal Medicine. Arch Intern Med. 2008;168(17):1890-1896. doi:10.1016/S0084-3873(09)79549-5.
  17. Zhang M, Holman CDJ, Price SD, Sanfilippo FM, Preen DB, Bulsara MK. Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: retrospective cohort study. BMJ. 2009;338.
  18. Bähler C, Huber CA, Brüngger B, et al. Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study. BMC Health Serv Res. 2015;15(1):23. doi:10.1186/s12913-015-0698-2.
  19. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-397. doi:10.1016/j.jamda.2013.03.022.
  20. Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Aff (Millwood). 2011;30(12):2437-2448. doi:10.1377/hlthaff.2011.0923.
  21. Buckinx F, Rolland Y, Reginster J-Y, Ricour C, Petermans J, Bruyère O. Burden of frailty in the elderly population: perspectives for a public health challenge. Arch public Heal = Arch belges santé publique. 2015;73(1):19. doi:10.1186/s13690-015-0068-x.
  22. Rochat S, Cumming RG, Blyth F, et al. Frailty and use of health and community services by community-dwelling older men: the Concord Health and Ageing in Men Project. Age Ageing. 2010:1-6. doi:10.1093/ageing/afp257.
  23. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care. Journals Gerontol – Ser A Biol Sci Med Sci. 2004;59(3):255-263. doi:10.1093/gerona/59.3.M255.
  24. Bock J-O, König H-H, Brenner H, et al. Associations of frailty with health care costs — results of the ESTHER cohort study. BMC Health Serv Res. 2016;16(1):128. doi:10.1186/s12913-016-1360-3.
  25. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269-2276. doi:10.1001/archinte.162.20.2269.
  26. SIGN. Polypharmacy Guidance. NO LONGER AVAILABLE ONLINE. Accessed January 5, 2017.
  27. Crentsil V, Ricks MO, Xue Q-L, Fried LP. A pharmacoepidemiologic study of community-dwelling, disabled older women: Factors associated with medication use. Am J Geriatr Pharmacother. 2010;8(3):215-224. doi:10.1016/j.amjopharm.2010.06.003.
  28. Hovstadius B, Hovstadius K, Astrand B, Petersson G. Increasing polypharmacy – an individual-based study of the Swedish population 2005-2008. BMC Clin Pharmacol. 2010;10:16. doi:10.1186/1472-6904-10-16.
  29. Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation Making it safe and sound. Kings Fund. 2013:1-68. doi:10.1136/bmjopen-2013-002913.
  30. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564. doi:10.1056/NEJMsa020703.
  31. Kojima G, Bell C, Tamura B, et al. Reducing Cost by Reducing Polypharmacy: The Polypharmacy Outcomes Project. J Am Med Dir Assoc. 2012;13(9). doi:10.1016/j.jamda.2012.07.019.
  32. Mercer SW, Watt GCM. The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med. 5(6):503-510. doi:10.1370/afm.778.
  33. Gunn JM, Ayton DR, Densley K, et al. The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Psychiatr Epidemiol. 2012;47(2):175-184. doi:10.1007/s00127-010-0330-z.
  34. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007;370(9590):851-858. doi:10.1016/S0140-6736(07)61415-9.
  35. Coventry P, Lovell K, Dickens C, et al. Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ. 2015;350. Accessed April 20, 2017.
  36. Bodenheimer T, Berry-Millett R, Francisco S. Care management of patients with complex health care needs. Synth Proj Res Synth Rep. 2009; (19):1-6.
  37. LEONARD E. EGEDE, MD, MSDEYI ZHENG, MB P, KIT SIMPSON D. Comorbid Depression is Associated With Increased Health Care Use and. 2002;25(3).
  38. de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: a meta-analysis. Psychosom Med. 2001;63(4):619-630. doi:10.1097/00006842-200107000-00015.
  39. Panza F, Solfrizzi V, Tortelli R, Resta F, Sabba C, Logroscino G. Prevention of Late-life Cognitive Disorders: Diet-Related Factors, Dietary Patterns, and Frailty Models. Curr Nutr Rep. 2014;3(2):110-129. doi:10.1007/s13668-014-0080-8.
  40. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495. doi:10.1503/cmaj.050051.
  41. Luengo-Fernandez R, Leal J, Gray A. The economic burden of dementia and associated research funding in the United Kingdom. Accessed December 20, 2016.
  42. Ensrud K, Ewing S, Taylor B, et al. Comparison of 2 Frailty Indexes for Prediction of Falls, Disability, Fractures, and Death in Older Women. doi:10.1001/archinternmed.2007.113.
  43. WalkRoundsTM. Reducing harm Patient Safety from falls. 2009:45.
  44. Kadam UT, Croft PR. Clinical multimorbidity and physical function in older adults: A record and health status linkage study in general practice. Fam Pract. 2007;24(5):412-419. doi:10.1093/fampra/cmm049.
  45. Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes. 2004;2:51. doi:10.1186/1477-7525-2-51.
  46. Bayliss E a, Bayliss MS, Ware JE, Steiner JF. Predicting declines in physical function in persons with multiple chronic medical conditions: what we can learn from the medical problem list. Health Qual Life Outcomes. 2004;2:47. doi:10.1186/1477-7525-2-47.
  47. Department of Health. Long Term Conditions Compendium of Information – Third Edition.; 2012.
  48. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet (London, England). 2012;380(9836):37-43. doi:10.1016/S0140-6736(12)60240-2.
  49. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: A systematic review. J Am Geriatr Soc. 2012;60(8):1487-1492. doi:10.1111/j.1532-5415.2012.04054.x.
  50. Chen C-Y, Wu S-C, Chen L-J, Lue B-H. The prevalence of subjective frailty and factors associated with frailty in Taiwan. doi:10.1016/j.ijge.2013.12.002.
  51. Lang IA, Hubbard RE, Andrew MK, Llewellyn DJ, Melzer D, Rockwood K. Neighborhood Deprivation, Individual Socioeconomic Status, and Frailty in Older Adults. J Am Geriatr Soc. 2009;57(10):1776-1780. doi:10.1111/j.1532-5415.2009.02480.x.
  52. Melzer D, Tavakoly B, Winder R, Richards S, Gericke C, Lang I. HEALTH CARE QUALITY FOR AN ACTIVE LATER LIFE. 2005.
  53. Kelaiditi E, van Kan GA, Cesari M. Frailty: role of nutrition and exercise. Curr Opin Clin Nutr Metab Care. 2014;17(1):32-39. doi:10.1097/MCO.0000000000000008.
  54. Inzitari M, Doets E, Bartali B, et al. Nutrition in the age-related disablement process. J Nutr Heal Aging. 2011;15(8):599-604. doi:10.1007/s12603-011-0053-1.
  55. National Institute of Clinical Excellence. Nutrition support for adults : oral nutrition support, enteral tube feeding and parenteral nutrition. 2006; (February).
  56. Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions (full report). 2015:96.
  57. Brotherton A, Simmonds N, Stroud M, Bowling T, Smith R, Todorovic V. Malnutrition Matters Meeting Quality Standards in Nutritional Care. Accessed December 9, 2016.
  58. de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JSM, Olde Rikkert MGM, Nijhuis-van der Sanden MWG. Outcome instruments to measure frailty: A systematic review. Ageing Res Rev. 2011. doi:10.1016/j.arr.2010.09.001.
  59. Office For National Statistics. Subnational population projections for England – Office for National Statistics. Accessed January 5, 2017.
  60. Institute of Public Care. Projecting Older People Population Information System. Accessed January 5, 2017.
  61. Elia M, Russell CA. Output of a Meeting of the Advisory Group on Malnutrition Combating Malnutrition: Recommendations For Action REPORT FROM THE ADVISORY GROUP ON MALNUTRITION, LED BY BAPEN Report From The Advisory Group On Malnutrition, Led By BAPEN.; 2008.
  62. European Nutrition for Health Alliance. Malnutrition among Older People in the community; 2006.
  63. National Institute of Clinical Excellence. Multimorbidity: Clinical Assessment and Multimorbidity: Clinical Assessment and Management Management NICE Guideline.; 2016.
  64. Diederichs C, Berger K, Bartels DB. The Measurement of Multiple Chronic Diseases – A Systematic Review on Existing Multimorbidity Indices. Journals Gerontol Ser A Biol Sci Med Sci. 2011;66A(3):301-311. doi:10.1093/gerona/glq208.
  65. Paterson DH, Jones GR, Rice CL. Ageing and physical activity: evidence to develop exercise recommendations for older adults. Can J Public Health. 2007;98 Suppl 2:S69-108. Accessed January 7, 2017.
  66. Chin A Paw MJM, van Uffelen JGZ, Riphagen I, van Mechelen W. The functional effects of physical exercise training in frail older people : a systematic review. Sports Med. 2008;38(9):781-793. . Accessed January 7, 2017.
  67. Daniels R, van Rossum E, de Witte L, Kempen GI, van den Heuvel W. Interventions to prevent disability in frail community-dwelling elderly: a systematic review. BMC Health Serv Res. 2008;8(1):278. doi:10.1186/1472-6963-8-278.
  68. Theou O, Stathokostas L, Roland KP, et al. The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review. J Aging Res. 2011;2011:1-19. doi:10.4061/2011/569194.
  69. de Vries NM, van Ravensberg CD, Hobbelen JSM, Olde Rikkert MGM, Staal JB, Nijhuis-van der Sanden MWG. Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: A meta-analysis. Ageing Res Rev. 2012;11(1):136-149. doi:10.1016/j.arr.2011.11.002.
  70. van de Rest O, van der Zwaluw NL, Tieland M, et al. Effect of resistance-type exercise training with or without protein supplementation on cognitive functioning in frail and pre-frail elderly: Secondary analysis of a randomized, double-blind, placebo-controlled trial. Mech Ageing Dev. 2014;136-137:85-93. doi:10.1016/j.mad.2013.12.005.
  71. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012;11(2):278-296. doi:10.1016/j.arr.2011.12.008.
  72. Murad MH, Elamin KB, Abu Elnour NO, et al. The Effect of Vitamin D on Falls: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2011;96(10):2997-3006. doi:10.1210/jc.2011-1193.
  73. Rejnmark L, Avenell A, Masud T, et al. Vitamin D with Calcium Reduces Mortality: Patient Level Pooled Analysis of 70,528 Patients from Eight Major Vitamin D Trials. J Clin Endocrinol Metab. 2012;97(8):2670-2681. doi:10.1210/jc.2011-3328.
  74. RCPG, BGS. Integrated Care for Older People with Frailty.; 2016.
  75. QIPP LTC Year of Care Funding Model Project Team. QIPP Long Term Conditions Supporting the Local Implementation of the Year of Care Funding Model for People with Long- Term Conditions.; 2012.
  76. National Health Service. FIVE YEAR FORWARD VIEW.; 2014. Accessed January 7, 2017.
  77. Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord. 2002;68(2-3):167-181. Accessed January 7, 2017.
  78. Glied S, Herzog K, Frank R. Review: The Net Benefits of Depression Management in Primary Care. Med Care Res Rev. 2010;67(3):251-274. doi:10.1177/1077558709356357.
  79. Thota AB, Sipe TA, Byard GJ, et al. Collaborative Care to Improve the Management of Depressive Disorders. Am J Prev Med. 2012;42(5):525-538. doi:10.1016/j.amepre.2012.01.019.
  80. GILBODY S, BOWER P, WHITTY P. Costs and consequences of enhanced primary care for depression. Br J Psychiatry. 2006;189(4).
  81. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative Care for Depression. Arch Intern Med. 2006;166(21):2314. doi:10.1001/archinte.166.21.2314.
  82. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative Care for Patients with Depression and Chronic Illnesses. N Engl J Med. 2010;363(27):2611-2620. doi:10.1056/NEJMoa1003955.
  83. Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet (London, England). 2008;371(9614):725-735. doi:10.1016/S0140-6736(08)60342-6.
  84. Cameron ID, Fairhall N, Langron C, et al. A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. doi:10.1186/1741-7015-11-65.
  85. Nazir A, Unroe K, Tegeler M, Khan B, Azar J, Boustani M. Systematic Review of Interdisciplinary Interventions in Nursing Homes. J Am Med Dir Assoc. 2013;14(7):471-478. doi:10.1016/j.jamda.2013.02.005.
  86. Care Quality Commission. Building Bridges, Breaking Barriers.; 2016. . Accessed January 8, 2017.
  87. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016;45(3):353-360. doi:10.1093/ageing/afw039.
  88. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. Scientific World Journal. 2001;1:323-336. doi:10.1100/tsw.2001.58.
  89. Fit for Frailty Fit for Frailty Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings The British Geriatrics Society. 2014.
  90. Beswick A, Gooberman-Hill R, Smith A, Wylde V, Ebrahim S. Maintaining independence in older people. Rev Clin Gerontol. 2010;20(2):128-153. doi:10.1017/S0959259810000079.
  93. Baztán JJ, Suárez-García FM, López-Arrieta J, Rodríguez-Mañas L, Rodríguez-Artalejo F. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ. 2009;338.
  94. González-Montalvo JI, Alarcón T, Mauleón JL, Gil-Garay E, Gotor P, Martín-Vega A. The orthogeriatric unit for acute patients: a new model of care that improves efficiency in the management of patients with hip fracture. Hip Int. 20(2):229-235. . Accessed January 30, 2017.
  95. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343.
  96. The Health Foundation. Improving Patient Flow | The Health Foundation. . Accessed January 30, 2017.
  97. Fox MT, Persaud M, Maimets I, Brooks D, O’Brien K, Tregunno D. Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: a systematic review and meta-analysis. BMC Geriatr. 2013;13(1):70. doi:10.1186/1471-2318-13-70.
  98. Shepperd S, McClaran J, Phillips CO, et al. Discharge planning from hospital to home. In: Shepperd S, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2010. doi:10.1002/14651858.CD000313.pub3.
  99. Foster G, Taylor SJC, Eldridge SE, Ramsay J, Griffiths CJ. Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database Syst Rev. 2007; (4):CD005108. doi:10.1002/14651858.CD005108.pub2.
  100. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. In: The Lancet. Vol 381. ; 2013: 752-762. doi:10.1016/S0140-6736(12)62167-9.

Additional resources

The cost of malnutrition in England and potential cost savings from nutritional interventions (short version)
A review and summary of the impact of malnutrition in older people and the reported costs and benefits of interventions
Making the Case for Self-Care Education
Patient Leaflet on Personalised Care Planning
Patients at Risk of Re-Hospitalisation Predictive Models
Workforce Development Strategy – Skills for Care
Grey Pride – a Manifesto, Anchor
Help them Home: The Royal Voluntary Service

Signed off by

Julie George: Public Health Consultant

Appendix A and B


The Frailty Index (87,88) is a continuous measure with the largest array of variables that enable risk stratification and monitoring in response to interventions. It is also the most cited measure along with Fried’s Phenotype measure. Many of the other assessments lend themselves to different scenarios; for example, the PRISMA 7 questionnaire is a self-report questionnaire that can be easily completed remotely and potentially as part of a two-step process before clinical evaluation. The gait speed test is a very easy test to perform in primary care and the community as it involves no additional tools. The Edmonton Frail Scale, for example is a good tool for surgical outpatients because it identifies elements of frailty that can be optimised pre operatively. The Electronic Frailty Index (eFI) is convenient in General Practice, because it has now been incorporated into their IT management systems EMIS and VISION and can calculate the eFI score based on existing coded records. It is important for the user to select the appropriate tool based on their own needs and limitations. The table below summarises them:

SUBJECTIVE Strawbridge Questionnaire (Strawbridge 1998) 16 item questionnaire about physical, cognitive, sensory and nutritive problems   >2 Two deficits  
Clinical Frailty Scale (Rockwood et al 2005) Clinical evaluation of mobility, energy, physical activity and function   Score from 1-7 Inter rater reliability 97%
Relative risk of mortality = 3.1
Groningen Frailty Indicator
(Steverink et al 2001)
15 self-report questions about mobility, physical fitness, vision, hearing, nourishment, morbidity, cognition and psychosocial   >4 : frail Internal Consistency ranked as 73-76%
Frailty Index (Mitnitski et al 2002) Number of health deficits recorded from 40 symptoms, signs, disabilities and investigation results.   Continuous measure Risk of mortality 1.03- 11 times higher in frailty
Second most cited measure
Tilburg Frailty Indicator (Gobbens et al 2010) 2 parts: A – questions on multimorbidity; B – quality of life, disability and healthcare utilisation   >5 indicates frailty. Internal Consistency ranked as 73-79%
Test Retest reliability: (Pearson correlation coefficient: 0.79)
PRISMA 7 Questionnaire 7 item questionnaire including age, gender, multimorbidities, disability and support Can be completed by post.
Can also be used in those who are acutely unwell and so likely to do worse on the walking speed test or the TUGT
>3 indicates frailty Very sensitive but also likely to falsely identify the non-frail as frail
Sensitivity 0.83 Specificity 0.83
OBJECTIVE Walking (Gait) Speed test
(Studenski et al 2011)
Time taken in seconds to walk 4m Ideal during outpatient appointments, social services reviews or ambulance visits >5seconds indicates frailty Very sensitive but also likely to falsely identify the non-frail as frail
Sensitivity 0.99 Specificity 0.64
Timed Up and Go Test (TUGT) Time taken to stand up from a chair, walk 3 metres, turn, walk back to the chair and sit down Ideal during outpatient appointments, social services reviews or ambulance visits >10 secs indicates frailty Very sensitive but also likely to falsely identify the non-frail as frail
Sensitivity 0.93 Specificity 0.62
MIXED Edmonton Frail Scale (Hilmer et al 2009) Questions including 9 domains: cognition, general health status, self-reported health, functional independence, social support, polypharmacy, mood, continence and nutrition Outpatient Surgical appointments, particularly pre-operatively. 0-5 : Not frail
6-7 : Apparently vulnerable
8-9 : Mildly frail
10-11 Moderately frail
12 – 17 : Severely frail
Quick, clinically feasible and identifies elements of frailty that can be optimised pre operatively e.g. Nutrition.
Internal consistency: 62%
Inter-Rater reliability: 77%
Frailty Phenotype
(Fried et al 2001)
Presence of muscle weakness, subjective fatigue, reduced physical activity, slow gait and weight loss.   1-2 deficits: prefrail
>3 deficits: frail
Reliability not assessed
Risk of mortality 1 to 6 times higher with frailty
Most cited measure
(Hyde et al 2010)
Assessment of fatigue, resistance, mobility, illness and weight loss.   3-5 : Frail
1-2: Pre frail
0: Robust


Comprehensive Geriatric Assessment:

Different tools suit different settings but the Comprehensive Geriatric Assessment (CGA) is the gold standard tool (89). A multidimensional and integrated assessment, management and review that is delivered by a multidisciplinary team, the CGA usually includes doctors, nurses, physiotherapists, occupational therapists, community psychiatric nurses and social workers. Usually a CGA would address functional status, cognition, depression, nutritional status, and medication use and initial assessment can be done by an individual with appropriate knowledge, skills and time, not necessarily a geriatrician. There is good evidence that CGA with at least six months follow up helps to increase the chance of a frail patient being at home and alive following an emergency admission to hospital (90). To avoid one long-term care placement, we would need to treat 20 people; In context, this is 6 times less than the number of people we must give daily aspirin to prevent a stroke.

Frailty Units:

Hospitals have been advised to consider creating acute medical units for short-term assessment and stabilisation of frail older people, with a view to expediting discharge (91). In some areas like Poole, these frailty units have seen 80% increases in 0-2 day discharge and a 22 per cent reduction in monthly occupied bed days (92). ‘Frailty Units’ have demonstrated very positive outcomes in the acute setting, by delivering higher quality care with shorter lengths of stay and lower costs (93–95).

Discharge to Assess:

Discharge to assess models have been developed to prevent frail patients becoming entangled in the inpatient hospital system and instead to identify people who might be able to be supported in their own home with appropriate assessment and support. In this case, the acute team identify and stabilise any acute illness and discharge to a community wraparound team to complete a holistic assessment and provide ongoing care and support. A number of individual studies have shown the benefits of early senior review linked to these models in terms of reduced admission rates, reduced bed occupancy, and higher rates of discharge home within 24 hours of presentation (96,97). Discharge to assess has also been shown to improve outcomes in stroke patients (98) and patients themselves report enhanced confidence and satisfaction. These services represent an ideal opportunity to involve the voluntary sector. Case studies have shown that home improvement and handypersons agencies and charities providing adaptations have also helped to reduce readmissions and improve post-discharge support. Effective discharge-to-assess models require timely expert assessment on initial acute presentation to hospital and adequate capacity for providing ongoing assessment and support at home.


Self-management is also considered a key factor in management of multimorbidity. Good self-management could be described as patients who have an understanding of their conditions and treatments, are able to self-manage their symptoms and medications, recognise the impact of their illness on their physical and mental function and interact and work well with health professionals. Self-management can be learned and involves the broader concept of managing the impact of illness on daily life. Self-management programmes can provide real benefit to people in terms of confidence to manage their own health, self-rated health perceptions, frequency of aerobic exercise as well as pain, disability, fatigue and depression (99). Targeted self management programmes can have positive results across wider society. As well as savings for the health sector in the ratio of £3.00 for every £1.00 invested there is a wider social return in the ratio of up to £6.00 for every £1.00 invested, depending on the type of programme (47) as shown by the Expert Patient Programme Social Return on Investment study.