11.4 Working with Adults Living with Frailty

1. What is Frailty?

The term frailty or ‘being frail’ is often used to describe older adults. Frailty is clinically recognised as a condition which is related to getting older and affects an adult’s overall stamina and their chances of recovering quickly from health problems. It is caused when a number of systems within the body gradually lose their built-in reserves. Adults living with frailty usually walk more slowly, get exhausted more easily and have difficulty getting out of chairs and / or climbing stairs. As a result, they are more likely to have to spend a lot of time at home or only be able to go out with support

Adults who are frail often have reduced muscle strength and so get more tired easily (fatigue). They may find it much harder to recover from health issues such as a urinary tract infection or leg ulcers.

Adults living with frailty may or may not have other major health conditions. Women are more likely to live with frailty than men, as are those from lower socio-economic groups who are also more likely to become frail earlier in life.

Frailty usually takes between five to ten years to develop, with the decline in functioning abilities being slow, rather than quick. Older adults with any degree of frailty (mild, moderate or severe) often first come to the attention of healthcare professionals when there is a crisis (for example, attending A&E after a fall).

While frailty may be seen as a fairly ‘minor’ health problem, in reality it can have a severe and long term impact on an adult’s physical and mental health and wellbeing. However, like most other long-term conditions, frailty can be effectively managed within primary care and other community-based services.

1.1 Impact of frailty

A National Audit Office report on Frailty found that:

• there were 1.51 million adults who were diagnosed by their GP as living with moderate or severe frailty (as of March 2025);
• the estimated annual cost of frailty to the UK healthcare system (2019) was £5.8bn;
• adults living with severe frailty are six times more likely to be admitted to hospital compared with those who are not living with frailty.

1.2 Identifying frailty

The NHS in England is systematically identifying adults, aged 65 and over, who are living with moderate and severe frailty using a population-based stratification approach. This can be done using the electronic Frailty Index (eFI) (or any other appropriate assessment tool). The eFI uses routine health record data to automatically calculate a score which can identify whether an adult is likely to be fit or living with mild, moderate or severe frailty.

GPs carry out routine frailty identification for patients aged 65 and over. Key interventions (such as a falls assessment, medicines review and promotion of the additional information in the summary care record) can be targeted at those most at risk, of adverse events including hospitalisation, nursing home admission and even death.  This approach which combines early identification with targeted support can help older adults living with frailty to stay well and live independently for as long as possible (See Identifying Frailty, NHS England).

2. Frailty and General Health

There are a number of conditions that are associated with being frail. Where practitioners are working together to support an adult, their carers and family, services should aim to provide support that will prevent the person’s frailty resulting in poorer health outcomes (see Promoting Wellbeing and Preventing, Delaying or Reducing Needs chapters). It is important that a well-planned, joined-up care and support package is in place, to prevent problems arising and provide a rapid, specialist response if the situation changes.

Where frailty is a concern, the following should be assessed and monitored on an ongoing basis as part of the adult’s care and support plan (see Assessment and Care and Support Planning chapters):

• general health;
• malnutrition and dehydration;
• bladder and bowel problems;
• dementia;
• delirium (confusion);
• mental health.

2.1 General health

As adults age their health needs change, but there are practical steps which can be taken at any age to improve health and reduce the risk of frailty.

All aspects of an adult’s health should be addressed as part of their general health needs. These include:

• looking after their eyes;
• looking after their mouth and teeth;
• keeping active, especially keeping as strong / maintaining as much muscle tone as possible;
• getting the right medicines;
• getting vaccinations;
• preventing falls;
• looking after their hearing;
• eating and drinking well;
• looking after their bladder and bowels;
• keeping mentally healthy;
• keeping their brain active.

There are other issues that can affect an adult’s general health, including:

• keeping warm;
• making sure their home environment is safe;
• preparing for winter as well as for heatwaves;
• caring and looking after themself.

Information about all of these issues can be found in A Practical Guide to Healthy Ageing (NHS and Age UK).

2.2 Malnutrition and dehydration

Having a balanced diet and sufficient (non-alcoholic) fluids is particularly important for a person living with frailty.

Malnutrition affects approximately 1 in 10 older adults and is a risk factor for becoming frail. It is a serious condition where an adult’s diet does not have the right amount of nutrients. This could be due to not getting enough nutrients (undernutrition) or getting more than is needed (overnutrition). Both these factors can contribute to health conditions. Nutrients are important to maintain physical health and promote healing after injury or illness.

Adults who are malnourished are more likely to visit their GP, have hospital admissions and take longer to recover from illness or operations. If an older adult loses weight, it could be due to a health condition, or a sign of malnutrition.

Older adults are also more at risk of dehydration, which is where the body loses more fluid than it is taking in. Symptoms of dehydration include:

• feeling thirsty;
• having dark yellow and strong-smelling urine;
• feeling dizzy or lightheaded;
• feeling tired;
• having a dry mouth, lips and eyes;
• not passing much urine – fewer than four times a day.

Dehydration is one of the most common reasons why older adults are admitted to hospital. It is also associated with increased risk of urinary tract infections, falls and pressure ulcers.

If it is suspected that an adult who is frail, or at risk of frailty, is malnourished or dehydrated, they (or their representative) should be advised to contact their GP as soon as possible.

If the adult is likely to become malnourished or dehydrated, ensuring sufficient intake of nutrition and fluids should be included in their care and support plan including working with them to ensure they have access to food and drink that they like and can tolerate.

2.3 Falls

See also Preventing Falls chapter.

Falls can be common in older adults sand can result in serious health issues. Once someone has experienced a fall, particularly if it resulted in a significant injury, it can cause a loss of independence. After a fall, the fear of falling again can result in a loss of confidence which can result in people becoming increasingly inactive, which in turn leads to a loss of strength and a greater risk of further falls.

Working with someone to prevent them falling or from having further falls can include a number of simple practical measures such as:

• making simple changes to their home;
• ensuring they have the right medication;
• ensuring they have the right prescription glasses; and
• doing regular exercises to improve their strength and balance.

See Falls Prevention (NHS)

2.4 Bladder and bowel problems

Urinary and bowel incontinence and constipation are very common, particularly in older adults. However, embarrassment and stigma about these issues mean people often delay seeking help and support. If such conditions are poorly managed, they can cause a lot of distress. Not eating an appropriate diet or drinking enough fluids can lead to bowel and urinary problems.

If there are concerns that an adult who is frail is experiencing incontinence or constipation, they – or their representative – should be supported to speak to their GP.

For further information about these issues, see:

Urinary incontinence (NHS)

Bowel incontinence (NHS) 

Constipation (NHS) 

2.5 Dementia

More than 900,000 people in the UK are estimated to be living with dementia. People who are living with frailty and who also have dementia are at increased risk of poor health as they may struggle to care for themselves adequately, particularly if they are living alone.

For further information see the chapter on Working with Adults Living with Dementia.

2.6 Delirium

Delirium is an episode of acute confusion. It can often be mistaken for dementia, but it is preventable and treatable. Older adults are more at risk of developing delirium and it can be quite common (particularly for those who have cognitive impairment, severe illness or have broken their hip or have a urinary tract infection for example).

Older adults with delirium may have longer stays in hospital, have an increased risk of complications such as falls, accidents or pressure ulcers and be more likely to be admitted into long-term care.

For further information please see:

Sudden confusion (delirium) (NHS) 

Delirium (sudden confusion) (Dementia UK)

2.7 Mental health problems

Mental health problems such as depression and anxiety can be quite common for older adults, and can have a major impact on their quality of life. Mental health problems in older adults may not be reported and so often go undetected and are therefore under-treated.

Where there are concerns that an adult may have mental ill health issues, they should be encouraged to speak to their GP or other relevant agencies.

See also Your Mind Matters (Age UK)

3. Related Issues

3.1 Loneliness and social isolation

Many elderly adults suffer from loneliness. This can have a serious effect on their mental and physical health and wellbeing.

Loneliness and social isolation can have additional negative impacts on someone who is already living with frailty. There are different ways that loneliness can be addressed, depending on the needs, wishes and interests of the adult. Discussions should take place with them to see what local services they may be interested in to support them to feel less lonely and isolated.

For further information see Combating Loneliness (Age UK)

3.2 Physical activity

The benefits of physical activity for older adults is well evidenced, with multiple health benefits including promoting general health, improving cognitive function, lowering the risk of falls and reducing the likelihood of developing some long-term conditions and diseases.

Depending on the needs, wishes, interests and physical ability of the adult, there will be different options and organisations for them if they want to get involved in activities in their local area.

See also Being Active as you get Older (Age UK) and Strength Exercises (NHS)

3.3 Safeguarding

Adults who are frail may experience, or be at risk of, abuse or neglect. This may be a result of their frailty or in combination with other mental or physical health conditions. They may be directly targeted by perpetrators who perceive them to be vulnerable or suffer unintentional abuse. Abuse may be committed by strangers or people they know such as family, friends or carers.

Adults living with frailty may experience health and social care services that are not suited to their individual needs. They can also be vulnerable to receiving poor quality healthcare and services. In such circumstances they or their representative should be supported to make a complaint, as appropriate, to ensure that they receive the care and support to which they are entitled. This may need to involve the local authority and / or the Care Quality Commission if there are safeguarding concerns related to a service provider.

For further information see Adult Safeguarding chapter.

3.4 Supporting adults at the end of life

Advance care planning is key to ensuring  that adults receive good, personalised care at the end of their life. Adults (and their families and carers) should be encouraged to have early discussions about their wishes for care at the end of life and details recorded. These discussions should include advance decisions to refuse treatment and do not attempt resuscitation decisions.

See Advance Care Planning and End of Life Care chapters.

4. Living with Frailty

Adults living with frailty can be supported to live as full a life as they wish and are able, although this may mean they need to adapt how they live their life and find new ways to manage daily tasks and activities. This may apply to their family and friends too.

If someone is living with frailty, it does not mean they cannot lead a full and independent life or that they lack mental capacity and cannot make decisions about their daily life or wider issues such as finances and where they live for example. They may need some practical support to put those decisions into practice. See Mental Capacity and Best Interests chapter.

Frailty can deeply challenge an adult’s sense of themself as well as change how they are perceived and treated by others, including health and care professionals. Ensuring they receive person centred care and support and their wishes and desires are listened to and acted upon wherever possible therefore, is key to their sense of self-esteem and ongoing enjoyment of life. See Personalisation chapter.