Targeted interventions empower patients to take charge of their health and well-being.
Singapore, 24 October 2024 – Frailty is a prevalent condition among elderly patients which increases their risk of falls, hospitalisations, disabilities and even mortalities. As Singapore’s population ages, the prevalence of frailty is expected to increase. The 2023 National Frailty Strategy Policy Report reported that the number of seniors aged 65 years and above will increase from 510,000 in 2017 to over 900,000 in 2030, when one in four Singaporeans will be 65 and above. Local studies conducted from April 2019 to December 2019 have found that at least 30% and 5% of our senior population were pre-frail and frail respectively. Resistance exercises and high protein diets are the most effective interventions for managing frailty in primary care settings .
In June 2022, the National Healthcare Group Polyclinics (NHGP) introduced the Frailty Programme to prevent the onset of frailty, reverse its progression and improve long-term health outcomes. The programme targets teamlet patients aged 65 years and above, who fall into Clinical Frailty Scale (CFS) scores 3 (Managing Well) and 4 (Living With Very Mild Frailty). Incorporating behavioural change techniques, the programme encourages the adoption of interventions that help reduce frailty.
Chief Executive Officer of NHGP, Dr Karen Ng said, “As Singapore’s ageing population continues to grow, frailty will be an increasing challenge, impacting the quality of life among the elderly. However, frailty can be prevented, reversed, or delayed with timely intervention. By focusing on early detection and proactive measures, we can prevent progression into frailty, optimising patients’ functional abilities, enhancing their participation in daily activities and improving overall quality of life. The NHGP Frailty initiative enables us to identify and manage frailty effectively, ultimately elevating the standard of care and outcomes for elderly patients.”
A Multi-Disciplinary Approach to Preventing and Reversing Frailty
“In the pilot phase of the Frailty Programme, we found that 55% of the patients screened belonged to CFS 3 and 4, highlighting an opportunity for NHGP to impact population health outcomes. Our focus was on preventing frailty in patients with CFS 3 and reversing it in those with CFS 4. Both groups consist of independent individuals who are physically inactive or showing early signs of frailty such as slow gait. As they age, their mobility declines, significantly impacting their ability to perform daily activities. However, through the collaborative efforts of the multi-disciplinary team, including doctors, care coordinators and clinical pharmacists, we have successfully improved frailty outcomes of these patients,” said Dr David Ng, Family Physician, Senior Consultant, Deputy Director, Clinical Services, Lead, NHG Polyclinics’ Frailty Programme, NHGP.
Professor Joe Sim, Group Chief Executive Officer of National Healthcare Group, emphasised the programme’s importance, “This Frailty Programme demonstrates NHG’s commitment to addressing the healthcare needs of Singapore’s ageing population by offering proactive, primary care interventions early. It aligns with our efforts to support our frail patients in Central and North Singapore regain their later years generally spent in poor health, and turn them into productive, healthy, and quality ones. This holistic, multi-disciplinary approach to care by our polyclinics is timely in not only mitigating the effects of frailty but also empowering elderly patients to lead healthier active lives.”
The Frailty Programme focuses on three key components: (1) Frailty intervention, (2) Referral to Community Exercise Programmes, and (3) Medication Deprescribing.
Frailty intervention
Care Coordinators (CC) within NHG Polyclinics’ Teamlet model plays a crucial role in screening patients for frailty using the CFS tool. For patients identified to be CFS 3 and 4, the CC measures patients’ hand grip strength to introduce behaviour change techniques and kickstart a conversation on frailty intervention. Thereafter the CC provides educational materials and lifestyle advice on ageing well, such as increasing resistance exercises, high-protein diets, and fall prevention.
When necessary, patients are referred by their doctors to dietitians and/or physiotherapists, particularly in cases where complex conditions such as chronic kidney disease (CKD) or musculoskeletal (MSK) issues require specialised interventions.
Community Exercise Programmes (CEP)
Another aspect of the Frailty Programme is facilitating access to Community Exercise Programmes (CEP). The CC introduces CEP to patients by checking on their interest to participate. For interested patients, CC will inform the doctor who assesses their suitability and refer them to appropriate exercise programmes coordinated by NHG's Community Health Team (CHT). CHT will then ensure patients’ participation in CEPs aligns with their preferences, CFS score, and location.
Ms Yeo Loo See, Deputy Director, Nursing Services, NHG Polyclinics, elaborated on the role of the Care Coordinator in this effort. “Our Care Coordinators are primarily responsible for preventive care. In addition to their regular duties of supporting NHGP Teamlets that look after patients with chronic conditions, they have been upskilled to assist in the Frailty Programme. By screening for frailty, the Care Coordinators play a key role in building trust and rapport between the care team and patients. This connection is crucial in encouraging patients to participate in the recommended Community Exercise Programmes. The contributions of our Care Coordinators are invaluable in ensuring the success of the Frailty Programme.”
Medication Deprescribing
Elderly patients are at a higher risk of experiencing adverse events, due to medication side effects. For instance, high doses of diabetes mellitus (DM) medications may lead to an increased incidence of low sugar levels (hypoglycaemia) and a higher risk of falls. In the Frailty Programme, if an elderly patient’s HbA1c level is below 6.5% and they are taking multiple diabetes medications, a clinical pharmacist reviews their medication plan and recommends adjustments to deprescribe medications. These recommendations are then further reviewed by the Family Physician.
Encouraging Results from Frailty Programme
From November 2020 to September 2024, over 7,100 patients were screened, and close to 3,600 with CFS 3 and 4 received interventions. At the 12-month follow-up, around 48% of CFS 3 patients and 31% of CFS 4 patients showed improved hand grip strength of one kilogram or more, which is associated with a reduction in mortality. 16% of CFS 3 patients and 31% of CFS 4 patients had improved CFS scores. These results highlighted the programme's success in reversing frailty and improving patient outcomes.
Future Developments
Launched officially on 20 June 2022, the Frailty Programme is currently available at NHG Polyclinics in Toa Payoh, Ang Mo Kio, and Hougang. By the end of 2025, NHGP will implement the programme to all its polyclinics in the central region where the population is older.
For the full description of Clinical Frailty Scale, please refer to Annex A.
