Palliative Care, Frailty, and Older People

  • Caroline NicholsonEmail author
  • Catherine Evans
  • Sarah Combes
Reference work entry


This chapter provides an overview of the symptoms of frailty, the tools used to recognize and assess older people living with frailty such as the frailty phenotype and frailty index, and some of their common palliative care needs. Further, it details some of the perceived challenges of frailty to current palliative care practice, namely, recognizing dying, multiple morbidities and symptom burden, and the focus or goals of care. Palliative care for older people with frailty requires a broader disability rather than a single disease focus. Coordination and interdependencies with other care providers become as important as the discrete patient/professional clinical encounter. The centrality of the older person with frailty and their “family” living and dying over time means the social environment becomes paramount local resources; support and the interplay between services and community are vital. While evidence on the best ways to provide palliative care to this population is still developing, the chapter offers some examples of current services and suggests key elements derived from the literature and practice. The authors suggest there is a moral and clinical imperative for palliative care services to engage with older people with frailty and their caregivers, both lay and professional. This imperative brings opportunities and challenges, including revaluing living and dying rather than an overemphasis on care in the last days of life and remodeling palliative care services to focus more on need than diagnosis and the reorientation of palliative care, so that it can be integrated with older people’s services.


  1. Ávila-Funes JA, Helmer C, Amieva H, Barberger-Gateau P, Goff ML, Ritchie K, et al. Frailty among community-dwelling elderly people in France: the three-city study. J Gerontol: Ser A. 2008;63(10):1089–96.Google Scholar
  2. Barclay S, Arthur A. Place of death—how much does it matter? Br J Gen Pract. 2008;58:229.PubMedPubMedCentralGoogle Scholar
  3. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380:37.PubMedGoogle Scholar
  4. Bone AE, Morgan M, Maddocks M, Sleeman KE, Wright J, Taherzadeh S, et al. Developing a model of short-term integrated palliative and supportive care for frail older people in community settings: perspectives of older people, carers and other key stakeholders. Age Ageing. 2016;45(6):863–73.PubMedPubMedCentralGoogle Scholar
  5. Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med. 2014;28(8):1000–25.PubMedGoogle Scholar
  6. Brown PJ, Roose SP, Fieo R, Liu X, Rantanen T, Sneed JR, et al. Frailty and depression in older adults: a high-risk clinical population. Am J Geriatr Psychiatry. 2014;22(11):1083–95.PubMedGoogle Scholar
  7. Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenat Res. 2013;16(2):105–14.Google Scholar
  8. Campbell SE, Seymour DG, Primrose WR. A systematic literature review of factors affecting outcome in older medical patients admitted to hospital. Age Ageing. 2004;33(2):110–5.PubMedGoogle Scholar
  9. van Campen C. Frail older persons in the Netherlands. Summary. The Hague: Netherlands Institute for Social Research, SCP; 2011.Google Scholar
  10. Carey I, Shouls S, Bristowe K, Morris M, Briant L, Robinson C, et al. Improving care for patients whose recovery is uncertain. The AMBER care bundle: design and implementation. BMJ Support Palliat Care. 2014;5:12. Scholar
  11. Cesari M, Gambassi G, Abellan van Kan G, Vellas B. The frailty phenotype and the frailty index: different instruments for different purposes. Age Ageing. 2013;43 (1):10–2.PubMedGoogle Scholar
  12. Choi J, Ahn A, Kim S, Won CW. Global prevalence of physical frailty by Fried’s criteria in community-dwelling elderly with national population-based surveys. J Am Med Dir Assoc. 2015;16(7):548–50.PubMedGoogle Scholar
  13. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752–62.PubMedGoogle Scholar
  14. Clegg A, Bates C, Young J, Ryan R, Nichols L, Ann Teale E, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016;45(3):353–60.PubMedPubMedCentralGoogle Scholar
  15. Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51(4):451–8.PubMedGoogle Scholar
  16. Crocker T, Young J, Forster A, Brown L, Ozer S, Greenwood DC. The effect of physical rehabilitation on activities of daily living in older residents of long-term care facilities: systematic review with meta-analysis. Age Ageing. 2013;42(6):682–8.PubMedGoogle Scholar
  17. De Bock R, Van Den Noortgate N, Piers R. Validation of the supportive and palliative care indicators tool in a geriatric population. J Palliat Med. 2017.Google Scholar
  18. de Labra C, Guimaraes-Pinheiro C, Maseda A, Lorenzo T, Millán-Calenti JC. Effects of physical exercise interventions in frail older adults: a systematic review of randomized controlled trials. BMC geriatrics. 2015;15(1):154.Google Scholar
  19. Downar J, Goldman R, Pinto R, Englesakis M, Adhikari NK. The “surprise question” for predicting death in seriously ill patients: a systematic review and meta-analysis. Can Med Assoc J. 2017;189(13):E484–E93.Google Scholar
  20. Elliott M, Nicholson C. A qualitative study exploring use of the surprise question in the care of older people: perceptions of general practitioners and challenges for practice. BMJ Support Palliat Care. 2017;7(1):32–8.PubMedGoogle Scholar
  21. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.PubMedPubMedCentralGoogle Scholar
  22. Evans CJ, Ison L, Ellis-Smith C, Nicholson C, Costa A, Oluyase AO, Namisango E, Bone AE, Brighton LJ, Yi D, Combes S, Bajwah S, Gao W, Harding R, Ong P, Higginson IJ, Maddocks M. Rapid scoping review of service delivery models to maximise quality of life for older people at the end of life prepared for the World Health Organisation (WHO). King’s College London; 2018. Available from:
  23. Fortin M, Stewart M, Poitras M-E, Almirall J, Maddocks H. A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Ann Fam Med. 2012;10(2):142–51.PubMedPubMedCentralGoogle Scholar
  24. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Ser A Biol Med Sci. 2001;56(3):M146–M57.Google Scholar
  25. Fulop T, Larbi A, Witkowski JM, McElhaney J, Loeb M, Mitnitski A, et al. Aging, frailty and age-related diseases. Biogerontology. 2010;11(5):547–63.PubMedGoogle Scholar
  26. Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of disability in the last year of life. N Engl J Med. 2010;362(13):1173–80.PubMedPubMedCentralGoogle Scholar
  27. Gott M, Ingleton C. Living with ageing and dying: palliative and end of life care for older people. Oxford: Oxford University Press; 2011.Google Scholar
  28. Grande GaK J. Needs, access, and support for older carers. Living with ageing & dying: palliative and end of life care in older people. In: Gott M, Ingleton C, editors. Living with ageing and dying: palliative and end of life care for older people. Oxford: Oxford University Press; 2011. p. 158–69.Google Scholar
  29. Hall S, Petkova H, Tsouros AD, Costantini M, Higginson IJ. Palliative care for older people: better practices. Copenhagen: World Health Organization; 2011.Google Scholar
  30. Hawley PH. The bow tie model of 21st century palliative care. J Pain Symptom Manag. 2014;47(1):e2–5.PubMedGoogle Scholar
  31. Highet G, Crawford D, Murray SA, Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study. BMJ Support Palliat Care. 2014;4(3):285–90.PubMedGoogle Scholar
  32. Iles V. Dying is the most grown-up thing we ever do: but do health care professionals prevent us from taking it seriously? Health Care Anal. 2016;24(2):105–18.PubMedGoogle Scholar
  33. Jennings R. Who is the palliative care physiotherapist? In: Taylor J, Simander R, Nielan P, editors. Potential and possibility: rehabilitation at the end of life. Munich: Elveseir; 2013.Google Scholar
  34. Jerant AF, Azari RS, Nesbitt TS, Meyers FJ. The TLC model of palliative care in the elderly: preliminary application in the assisted living setting. Ann Fam Med. 2004;2(1):54–60.PubMedPubMedCentralGoogle Scholar
  35. Kelley AS, Covinsky KE, Gorges RJ, McKendrick K, Bollens-Lund E, Morrison RS, et al. Identifying older adults with serious illness: a critical step toward improving the value of health care. Health Serv Res. 2017;52(1):113–31.PubMedGoogle Scholar
  36. Knight SJ, Emanuel L. Processes of adjustment to end-of-life losses: a reintegration model. J Palliat Med. 2007;10(5):1190–8.PubMedGoogle Scholar
  37. Kojima G, Iliffe S, Jivraj S, Walters K. Association between frailty and quality of life among community-dwelling older people: a systematic review and meta-analysis. J Epidemiol Community Health. 2016;70(7):716–21.PubMedGoogle Scholar
  38. Leibovici L. Long-term consequences of severe infections. Clin Microbiol Infect. 2013;19(6):510–2.PubMedGoogle Scholar
  39. Leslie P, Sandsund C, Roe J. Researching the rehabilitation needs of patients with life-limiting disease: challenges and opportunities. Prog Palliat Care. 2014;22(6):313–8.Google Scholar
  40. Lloyd L, Calnan M, Cameron A, Seymour J, Smith R. Identity in the fourth age: perseverance, adaptation and maintaining dignity. Ageing Soc. 2014;34(1):1–19.Google Scholar
  41. Lloyd AKM, Cardiff E, Cavers D, Kimball B, Murray SA. Why do older people get less palliative care than younger people? Eur J Palliat Care. 2016;23(3):132–7.Google Scholar
  42. Lowson E, Hanratty B, Holmes L, Addington-Hall J, Grande G, Payne S, et al. From ‘conductor’ to ‘second fiddle’: older adult care recipients’ perspectives on transitions in family caring at hospital admission. Int J Nurs Stud. 2013;50(9):1197–205.PubMedGoogle Scholar
  43. Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. J Am Med Assoc. 2003;289:2387.Google Scholar
  44. Maas EAT, Murray SA, Engels Y, Campbell C. What tools are available to identify patients with palliative care needs in primary care: a systematic literature review and survey of European practice. BMJ Support Palliat Care. 2013;3(4):444–51.PubMedGoogle Scholar
  45. Maddocks M, Kon SS, Canavan JL, Jones SE, Nolan CM, Labey A, et al. Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study. Thorax. 2016;71:988–95. Scholar
  46. Malley JN, Towers A-M, Netten AP, Brazier JE, Forder JE, Flynn T. An assessment of the construct validity of the ASCOT measure of social care-related quality of life with older people. Health Qual Life Outcomes. 2012;10(1):21.PubMedPubMedCentralGoogle Scholar
  47. Martin J, Nicholson, Caroline and George, Rob. The approach of dying and death, and the mourning process of the survivors. Oxford textbook of geriatric medicine third edition. Jean-Pierre Michel BLB, Finbarr C. Martin, and Jeremy D. Walston, Oxford: Oxford University Press; 2018.Google Scholar
  48. McCue JD. The naturalness of dying. JAMA. 1995;273(13):1039–43.PubMedGoogle Scholar
  49. McNicoll G. World population ageing 1950–2050. Popul Dev Rev. 2002;28(4):814–6.Google Scholar
  50. Morley JE. Anorexia and weight loss in older persons. J Gerontol Ser A Biol Med Sci. 2003;58(2):M131–M7.Google Scholar
  51. Morley JE. Frailty and sarcopenia: the new geriatric giants. Rev Investig Clin. 2016;68(2):59–67.Google Scholar
  52. Morrison RS, Meier DE, Capello C, editors. Geriatric Palliative Care. Oxford University Press 2003.Google Scholar
  53. Murray SA, Kendall M, Mitchell G, Moine S, Amblàs-Novellas J, Boyd K. Palliative care from diagnosis to death. BMJ: Br Med J (Online). 2017;356:j878.Google Scholar
  54. Musa I, Seymour J, Narayanasamy MJ, Wada T, Conroy S. A survey of older peoples’ attitudes towards advance care planning. Age Ageing. 2015;44(3):371–6.PubMedGoogle Scholar
  55. National Institute for Clinical Improvement. Improving supportive and palliative care for adults with cancer NICE guidelines. London, 2004.Google Scholar
  56. Nicholson C, Meyer J, Flatley M, Holman C, Lowton K. Living on the margin: understanding the experience of living and dying with frailty in old age. Soc Sci Med. 2012;75(8):1426–32.PubMedGoogle Scholar
  57. Nicholson C, Meyer J, Flatley M, Holman C. The experience of living at home with frailty in old age: a psychosocial qualitative study. Int J Nurs Stud. 2013;50(9):1172–9.PubMedGoogle Scholar
  58. Nicholson C, Morrow EM, Hicks A, Fitzpatrick J. Supportive care for older people with frailty in hospital: an integrative review. Int J Nurs Stud. 2017;66:60–71.PubMedGoogle Scholar
  59. Nicholson C, Davies, J, Smith, B, Pace, V, Harris, L, George, R, Noble, J, Hansford, P, Murtagh, F. What are the main palliative care symptoms and concerns of older people with multimorbidity? A service evaluation using routinely collected Phase of Illness, Australian Karnofsky Performance Status and Integrated Palliative Care Outcome Scale data. Ann Palliat Med. 2018 (In Press).Google Scholar
  60. O’mahony D, O’sullivan D, Byrne S, O’connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–8.PubMedGoogle Scholar
  61. World Health Organization. World report on ageing and health. Geneva: World Health Organization; 2015.Google Scholar
  62. Pialoux T, Goyard J, Hermet R. When frailty should mean palliative care. J Nurs Educ Pract. 2013;3(7):75.Google Scholar
  63. Puts M, Shekary N, Widdershoven G, Heldens J, Lips P, Deeg D. What does quality of life mean to older frail and non-frail community-dwelling adults in the Netherlands? Qual Life Res. 2007;16(2):263–77.PubMedGoogle Scholar
  64. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. Can Med Assoc J. 2005;173(5):489–95.Google Scholar
  65. Rodda J, Walker Z, Carter J. Depression in older adults. BMJ-Br Med J. 2011;343(8):d5219.Google Scholar
  66. Sallnow L, Richardson H, Murray SA, Kellehear A. The impact of a new public health approach to end-of-life care: a systematic review. Palliat Med. 2016;30(3):200–11.PubMedGoogle Scholar
  67. Sampson EL. Frailty and dementia: common but complex comorbidities. Aging Ment Health. 2012;16(3):269–272.PubMedGoogle Scholar
  68. Sawatzky R, Porterfield P, Lee J, Dixon D, Lounsbury K, Pesut B, et al. Conceptual foundations of a palliative approach: a knowledge synthesis. BMC Palliat Care. 2016;15(1):5.PubMedPubMedCentralGoogle Scholar
  69. Searle SD, Rockwood K. Frailty and the risk of cognitive impairment. Alzheimers Res Ther. 2015;7(1):54.PubMedPubMedCentralGoogle Scholar
  70. Seymour J, Witherspoon R, Gott M, Ross H, Payne S. Dying in older age: end-of-life care. Bristol: Policy Press; 2005.Google Scholar
  71. Sharp T, Moran E, Kuhn I, Barclay S. Do the elderly have a voice? Advance care planning discussions with frail and older individuals: a systematic literature review and narrative synthesis. Br J Gen Pract. 2013;63(615):e657–e68.PubMedPubMedCentralGoogle Scholar
  72. Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manag. 2017;53(5):821–32. e1Google Scholar
  73. Teunissen SC, de Haes HC, Voest EE, de Graeff A. Does age matter in palliative care? Crit Rev Oncol Hematol. 2006;60(2):152–8.PubMedGoogle Scholar
  74. The Clinical Frailty Scale.
  75. Thomas K. The Gold Standards Framework (GSF) in community palliative care. Eur J Palliat Care. 2003;10:113–115.Google Scholar
  76. Thomas K. Overview and introduction to advance care planning. In: Advance care planning in end of life care. Oxford, UK: Oxford University Press; 2011. p. 3–15.Google Scholar
  77. Thoonsen B, Groot M, Engels Y, Prins J, Verhagen S, Galesloot C, et al. Early identification of and proactive palliative care for patients in general practice, incentive and methods of a randomized controlled trial. BMC Fam Pract. 2011;12(1):123.PubMedPubMedCentralGoogle Scholar
  78. Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing. 2014;43(6):744–7.PubMedGoogle Scholar
  79. Velissaris D, Pantzaris N, Koniari I, Koutsogiannis N, Karamouzos V, Kotroni I, et al. C-reactive protein and frailty in the elderly: a literature review. J Clin Med Res. 2017;9(6):461.PubMedPubMedCentralGoogle Scholar
  80. WHO. WHA67.19. W. Strengthening of palliative care as a component of comprehensive care throughout the life course. Geneva: World Health Organization; 2014.Google Scholar
  81. Wolff T, Browne J. Organizing end of life care: parallel planning. Paediatr Child Health. 2011;21(8):378–84.Google Scholar
  82. Ziere G, Dieleman J, Hofman A, Pols HA, Van Der Cammen T, Stricker B. Polypharmacy and falls in the middle age and elderly population. Br J Clin Pharmacol. 2006;61(2):218–23.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Caroline Nicholson
    • 1
    • 2
    • 5
    Email author
  • Catherine Evans
    • 3
    • 4
  • Sarah Combes
    • 1
    • 2
  1. 1.King’s College London, Florence Nightingale Faculty of NursingMidwifery and Palliative CareLondonUK
  2. 2.St Christopher’s HospiceLondonUK
  3. 3.King’s College LondonCicely Saunders Institute of Palliative Care, Policy and RehabilitationLondonUK
  4. 4.Sussex Community NHS Foundation TrustBrighton General HospitalBrightonUK
  5. 5.Supportive and End of Life Care (Nursing)St. Christopher’s Hospice/King’s CollegeLondonUK

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