Assessing and managing frailty in people living with HIV
Assessment to confirm frailty and identify driving factors
If someone is identified as showing possible signs of frailty, or complexities and vulnerabilities that may put them at risk, it’s important to consider referring them for a more comprehensive assessment. This could be conducted within your service during a longer appointment and even by the same person who performed the initial screen, depending on the training and expertise available within your centre. Otherwise, you may need to refer them on to one or more colleagues, for example, their GP, a geriatrician or physiotherapist.
You may already have dedicated frailty services available that you can tap into. These will have defined processes and approaches to assessing, diagnosing and managing frailty. However, they may currently be tailored to a traditional geriatric population.
It will be important to strengthen your relationship with these services and ensure they understand why younger people may be referred to them and what aspects are important to cover. For more on this, read the next chapter on: Getting services ready.
This assessment could be performed by an HIV consultant, physiotherapist, geriatrician or senior nurse.
This may involve following a formal frailty assessment tool, such as:
Frailty and prefrailty are associated with recurrent falls in those living with HIV.40 Therefore, questioning people about previous falls in the past year is essential15 to assess this very common syndrome.
If needed, this may be supported by further questioning:
And/or one of the following performance tests (repeated since screening):
Refer to How to identify or screen those at risk? for further details on the performance tests.
This can be carried out by an HIV pharmacist and/or the individual’s primary care GP but should also involve an HIV consultant with relevant expertise as per recommendations in the BHIVA guidelines.
- Medication review e.g., “brown bag” method where patients bring all of their medications and supplements for review and discussion.
Where feasible, it is also advisable to assess additional domains too, particularly if they haven’t already been reviewed and/or if specific issues were identified during earlier screening. Such as:
- Cognition: MoCA
- Depression (mood): Patient Health Questionnaire (PHQ-9) / General Anxiety Disorder-7 (GAD-7) / Beck Depression Inventory II / Centre for Epidemiology Studies (CES-D)
- PTSD: PCL-5
If mood disorders, cognitive problems or substance misuse are the predominant feature, refer to psychology and/or relevant drug services first for support and involvement before trying to address functional or mobility.
- Social/financial: 3-item Multi-factorial Assessment of Perceived Social Support – Short Form
- Safeguarding: as per your service’s standard procedures
- Symptom burden: HIV Symptom Index
- Pain: Brief Pain Inventory-Short Form (BPI-SF)
- Sleep: Assessed as part of the CGA / Pittsburgh Sleep Quality Index (PSQI); various other tools are available
- Nutrition/weight: Rapid Nutrition Screening for HIV Disease (RNS-H)
- Substance abuse: Referral to relevant services for assessment and support engagement
- General: Time to talk/EQ-5D-5L, if not already completed
These domains and the associated tests have been based off the Comprehensive Geriatric Assessment (CGA). But, as with the CGA, it is not suggested that these all be assessed unless relevant, and nor do they have to happen in one go. Comprehensive assessments often require a multidisciplinary team to ensure factors are reviewed appropriately, but it’s acknowledged that this isn’t always feasible in every setting.
For more guidance on performing a CGA, review this CGA Toolkit for Primary Care Practitioners.
If someone is confirmed to have developed frailty, even if mild, remember that it is a multi-faceted state indicating accumulating complexity. But it does not have to be a fixed state, particularly if identified at an early stage. Small changes may be enough to reverse or stabilise frailty preventing decline in function, preserving independence and promoting successful ageing. Consider how quickly they need intervention and what the main contributing factors are to determine who else needs to be involved in supporting ongoing care and management.
For more on managing frailty, see: Care coordination.
You may find someone screens as ‘frail’ but a comprehensive or follow-up assessment finds that the underlying cause wasn’t due to the development of frailty. Perhaps they were experiencing more localised issues such as arthritis of the hips, their medication wasn’t optimised or maybe their falls are attributed to poor eyesight alone. This is why taking a holistic approach to screening supports the overall goal of helping people age well. Anything you can do to identify and address a contributing factor, however small, could make a big difference to someone’s life.
Everyone can play a part in actioning change.
Care coordination
The goal of frailty management is to act to optimise or where possible restore strength and daily functioning whilst addressing any issues that are impacting self-care and successful ageing. Individuals diagnosed with frailty will likely have multiple underlying vulnerabilities. Establishing a well-considered management plan and coordinating care between services will therefore be an important step in optimising their care.
Some professionals or team members, particularly community nurses, may find they are well positioned to support the coordination of frailty management as they already act as care coordinators in their role. Individuals may also nominate their HIV consultant or another trusted person to act as their care coordinator. However, a single care coordinator may not always be suitable and case coordination across a team (e.g., via an MDT) may be necessary. GPs and community frailty services are also important to consider as they too are often involved in much of the care coordination.
Holistic but comprehensive assessments should be performed in individuals identified as being at risk of frailty. These ideally should cover physical state, daily functioning or self-care, home and social circumstances, psychological state and current medication.
Services may need to adapt their appointment lengths to allow sufficient time for assessments, but not all domains need to be covered by a single person or in one sitting.
Referral to relevant services may benefit people screened as at-risk or exhibiting frailty so that a multi-disciplinary team is involved.
Care coordination will be an important part of effective frailty management that needs to be introduced into HIV care if not already present, preferably in the community via GPs.
