Addressing frailty in the elderly

The Hunter New England and Central Coast Primary Health Network (HNECC PHN) recently concluded an innovative Frailty Early Intervention Program aimed at altering the trajectory of frailty in the ageing population, improving health outcomes and quality of life.

The program engaged 19 general practices across the Hunter, New England and Central Coast regions.

Frailty involves a decline in cognitive, physical and social functions, increasing risks such as falls, prolonged hospital stays, functional decline, institutionalisation and mortality.

Early intervention can reverse this decline, helping individuals maintain their health and activity levels longer.

Twenty per cent of the population in the three regions is aged 65 and over, with 30 per cent of GP visits made by that dempgraphic.

Frailty affects up to 25 per cent of patients aged 70 and over, with 50 per cent of individuals aged 75 and over take at least eight medications, heightening frailty risk.

The program was established following research revealing that current GP practices for patients over 65 are insufficient for comprehensive frailty assessments and interventions.

Many consultations are brief or conducted via telehealth, limiting time for frailty screening.

Health assessments presented a significant opportunity for frailty screening and interventions, prompting the need for additional support and incentives for general practices.

Launched in June 2023, the pilot involved delivering training workshops for general practices, followed by frailty screenings using the validated Frail Scale for older Australians (70+, or 50+ for First Nations people).

Patients identified as pre-frail or frail received targeted interventions or referrals aimed at improving their frailty trajectory and preventing further decline.

Throughout the program, more than 1,800 patients were screened for frailty and given referrals, information and resources to help prevent frailty or prevent further deterioration.

Results showed a consistent distribution of frailty levels across the regions.

The PHN partnered with BMP Consulting to deliver educational workshops, supported by bi-monthly practice meetings led by Dr Chris Bollen and Registered Nurse Jane Bollen of Bollen Health.

General practices interested in incorporating frailty screening can use the resources and information on the PHN Healthy Ageing and Frailty page, including Frailty Fundamentals, a user-friendly guide for conducting frailty assessments and implementing appropriate interventions.