Appendices
Screening Toolbox
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In summary: our recommendations
In the absence of a consensus definition for frailty or any best practice guidelines for HIV services, the following recommendations have been compiled to equip HCPs and centres with actionable steps they can take today to:
- Support earlier identification of people living with HIV who are experiencing, or at-risk of, frailty
- Establish frailty care pathways for people living with HIV
Recommendations:
1.
HCP activation: deliver education and training to all staff in contact with older people living with HIV (>50 years old)
Actions:
- Make it everyone’s role to look for signs of frailty at every encounter, including the first, and ensure they know what to look for, why it’s important and what to do next if they have concerns
- Limit the fear of HIV (and frailty). Show that addressing frailty doesn’t need to be complicated and uses a lot of skills and knowledge that everyone has already have so they feel empowered to act
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2.
Embed a holistic approach to identifying frailty risk factors in people living with HIV
Actions:
- Early identification of factors that limit someone’s ability to age well may help to prevent physical frailty from developing
- Simple questions exploring someone’s activities of daily living, ability to self-care, continence, quality of life, mood or mental health and general well-being may be enough to identify possible issues for further investigation and can be easily integrated into everyday conversations with individuals
- The ‘FRAIL in HIV’ framework aims to reframe the concept of frailty in people living with HIV and act as a reminder to consider a wider picture when looking for signs of frailty
Further information:
3.
Triage large and/or complex cohorts to gain experience while maintaining feasibility
Actions:
- For services with a large or complex cohort, screening a subset of patients based on specific risk factors first may help services gain experience, and introduce a process that they can monitor and improve in a manageable way
- While frailty among people living with HIV is not specific to just one age group or clinical factor, it’s better to introduce services on a small scale than not at all, e.g., in those over the age of 50
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4.
Introduce pre-clinic consultations or questionnaires, including virtual or remote visits, to initiate screening in a flexible and inclusive way
Actions:
- Many people who are frail or at risk may be experiencing challenges that can pose a barrier to engaging with services or attending physical appointments
- Others may not see the value in additional appointments for aspects beyond their HIV needs
- Simple screening questions could be introduced as part of a pre-appointment survey, phone call, virtual consultation or remote visit, and/or embedded within an annual review
- Consideration should be given to ensure those who speak little or no English as any verbal or written questions will need to be easy and clear for them to understand
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5.
Patient activation: develop or utilise appropriate patient-facing material and conversations
Actions:
- Many people will not relate to the term frailty, which is why it’s important to be sensitive with language, while being transparent about why certain questions are being asked or screening tools being used
- Make sure people understand why further checks are being done, what the rationale is and importantly what the next steps are
- Direct people screened for frailty to appropriate material that’s relevant to them in the context of living with HIV
6.
Perform a comprehensive assessment of those screened as exhibiting signs of frailty, or other vulnerability that may put them at risk
Actions:
- This could be a Comprehensive Geriatric Assessment, or equivalent. Depending on the factors identified during screening only certain domains may need further exploration and these may vary depending on the practitioner performing the assessment
- As a minimum though, services should aim to gain insight on an individual’s:
- ~Physical health
- ~Functioning and mobility (i.e., activities of daily living)
- ~Current medication
- ~Psychological and mental state; and
- ~Home and social circumstances
- If other issues are flagged during an earlier screen, these should also be explored, either at the same time or separately with relevant practitioners
7.
Establish diagnostic and care pathways that integrate existing resources and services
Actions:
- A variety of factors could leave someone vulnerable to developing frailty, therefore diagnosis and/or management will likely involve multidisciplinary teams
- Connecting with existing services, and/or frailty pathways, is likely to be the most feasible approach for most centres
- Ensure everyone understands the reason for referrals and feels empowered to act in their role, whether its supporting diagnosis or coordinating/managing care. Show that everyone can make a difference
8.
Consider nominating a ‘frailty champion’ to identify and communicate available resources and services
Actions:
- Services should aim to build connections with available resources and services that could support frailty care pathways. This can include geriatrics, physiotherapy, occupational therapy, community and third-sector organisations
- Having a dedicated point-of-contact (such as a frailty champion) that maintains a database and acts as point of contact to signpost and communicate or coordinate services will help to ensure people receive tailored and timely support
9.
Build an evidence base to ensure adequate provision is in place for the future, and to support best practice development
Actions:
- Services with a higher proportion of older or complex patients, and those in areas of greater socioeconomic deprivation, may need greater support over the next 20 years. Services should review their cohort and make plans to ensure adequate provision is in place to accommodate the anticipated needs
- Gathering information about the number of people screened, assessed and diagnosed will be helpful to start building our understanding around the prevalence of frailty within the HIV-positive population, and could support future models of care
