7 Old age psychiatry7.2 Principles of service provision

7.2.5 Frailty and physical comorbidity

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Written by Resident Doctor Committee · Published

New in the 2027 syllabus

The College added this topic for exams from January 2027.

Frailty is reduced reserve

Frailty means a person has less physiological reserve across several body systems. As a result, a stressor causes a much bigger fall in function than you would expect. Keep frailty separate from two related ideas:

  • Multimorbidity means having more than one long-term condition. It overlaps with frailty, but having it does not mean the person is frail.

  • Disability means difficulty carrying out activities. A person can be disabled without being frail, and frailty can appear before any major disability.

In a frail person, a minor infection or a sedating medicine may lead to falls, delirium or loss of independence. What looks like a psychiatric presentation may be the first sign of physical illness.

Conceptual trajectories illustrate vulnerability after a stressor, not measured outcomes or an inevitable prognosis. Frailty, disability and multimorbidity overlap but are different concepts; individual recovery depends on illness, treatment and support. Original illustration drawn in Python for MRCPsychiatrist; see images/ATTRIBUTION.md

Recognising frailty

There are three main ways to identify frailty.

Approach

What it looks at

Limitation

Physical phenotype

Weight loss, exhaustion, weakness, slowness and low activity

Needs suitable measurement and careful interpretation

Deficit accumulation

The proportion of health deficits a person has built up

Depends on which deficits are counted and what data are available

Clinical assessment

Usual function, mobility, cognition and dependence

Needs judgement and knowledge of what the person is usually like

Acute illness can make performance worse for a while. Do not use physical performance tools to assess frailty during an acute illness. Instead, take a history to find out how the person usually functions.

A full assessment covers cognition, mood, nutrition, mobility, falls, continence, sensory impairment, medicines and social support.

Coordinated management

Geriatric assessment brings together medical, psychological, functional and social findings. These are then turned into a coordinated plan agreed with the person.

  • Look for reversible contributors: pain, dehydration, infection, depression, malnutrition and adverse effects of drugs.

  • Review medicines. For each one, weigh the benefit, how long it takes to help, the risk of falls, anticholinergic effects, sedation, interactions and the burden of monitoring.

  • Adapt activity and nutrition to the person's ability and goals. Involve rehabilitation and dietetic support when needed.

  • Agree priorities. These may differ from single-disease targets. For example, keeping someone mobile or easing their dizziness may matter more to them than adding another preventive medicine.

What this means for psychiatric practice

  • Base doses and monitoring on renal function, body composition and sensitivity to adverse effects, not on age alone.

  • Prevent delirium by treating illness, supporting sleep and hydration, helping the person mobilise, and making sure they use their hearing or visual aids.

  • Plan care together. Record the person's priorities, what will be reviewed, and who coordinates care across services.

Revision material for the MRCPsych examinations. Not clinical guidance, and not for use in patient care.