Multimorbidity, dementia, and frailty: Building integrated care for an ageing population

As more older adults live with dementia, frailty, and multiple long-term conditions, health and social care systems must adapt to deliver truly coordinated, person-centred support

As the UK population ages, the prevalence of multimorbidity, dementia, and frailty among older adults is reshaping the landscape of health and social care. These overlapping conditions present significant challenges – not only clinically, but also in terms of policy, workforce capacity, and service integration. Addressing this complexity requires a shift toward coordinated, person-centred care that spans both health and social care systems.

The scale and impact of multimorbidity

More than 75% of people aged 75 and older live with two or more chronic conditions ⁽¹⁾. Among those with dementia, this figure rises sharply, with over 60% experiencing three or more comorbidities ⁽²⁾. Common conditions include cardiovascular disease, diabetes, respiratory disorders, and musculoskeletal issues, which collectively increase the risk of hospitalisation, adverse drug reactions, and premature mortality ⁽³⁾.

Cognitive decline associated with dementia further complicates care.

Individuals may struggle with medication adherence, recognising symptoms, and following treatment plans ⁽⁴⁾. This complexity demands a holistic approach that integrates physical, cognitive, and psychosocial care.

Frailty and its relevance in dementia care

Frailty is a clinical syndrome marked by reduced strength, endurance, and physiological reserve ⁽⁵⁾. It is highly prevalent in older adults with dementia and significantly increases vulnerability to falls, hospitalisation, and loss of independence ⁽⁶⁾. The progression of frailty accelerates cognitive and physical decline, making it essential to incorporate frailty assessments – such as the Clinical Frailty Scale (CFS) – into care planning ⁽⁷⁾.

The interplay of conditions and the need for an integrated policy

The coexistence of dementia, multimorbidity, and frailty creates a complex clinical picture that challenges traditional care models.

Fragmented services and siloed pathways often fail to meet the needs of individuals with multiple long-term conditions. According to The King’s Fund, improving clinical coordination is essential to avoid duplication, reduce hospital admissions, and improve outcomes for people with complex needs ⁽⁸⁾.

National policy in England is currently at a crossroads in how it treats dementia and frailty. The announced Modern Service Framework for Dementia and Frailty, which is due to be published next year, and the introduction of local multi-disciplinary teams in neighbourhood health centres, could both be pivotal in tackling this need head-on. The Social Care Institute for Excellence (SCIE) advocates for integrated care models that bring together health, social care, and voluntary sector services to support older adults holistically ⁽⁹⁾, and both of these Government initiatives for the NHS have aspirations to deliver just such a model. But to succeed, they will need to reliably and routinely address the complexity of dementia within the core of any structures and ways of working introduced.

Management strategies: a multi-disciplinary framework

Effective care requires a comprehensive, patient-centred approach. Key strategies include:

• Integrated care plans: developed by multi-disciplinary teams and regularly reviewed to reflect changes in health status. These plans should address medication management, rehabilitation, and psychosocial needs.
• Multi-disciplinary collaboration: as nurses, we play a central role in facilitating communication among clinicians, therapists, and social workers to ensure care aligns with patient goals
• Regular monitoring and assessment: ongoing evaluation of cognitive and physical health helps adjust interventions and prevent complications like polypharmacy ⁽¹⁰⁾
• Support for caregivers: education, emotional support, and access to respite services are needed to reduce caregiver burnout.
• Physical activity and rehabilitation: tailored exercise programmes improve strength, balance, and mobility, reducing frailty-related risks ⁽¹¹⁾
• Psychological and social support: cognitive stimulation and meaningful social engagement can help to improve mood and feelings of isolation
• Advance care planning: early conversations about end-of-life preferences ensure care remains aligned with the person’s values, beliefs, and wishes ⁽¹²⁾

The role of admiral nurses

Admiral Nurses, supported and developed by Dementia UK, are specialist dementia nurses. They provide free, expert advice, support, and understanding to help families care for their loved one, whether that’s sharing practical tips to help manage a person’s symptoms through to support navigating the transition of care or planning for the future.

There are more than 470 Admiral Nurses who work across a range of healthcare settings, including on Dementia UK’s free Helpline, in face-to-face and virtual clinics, and the community, in GP practices, hospitals, care homes, and hospices.

In addition to supporting families, as dementia specialists, Admiral Nurses also educate and advise other health and social care professionals on best practice in dementia care to enhance the support they already offer.

Policy recommendations

To meet the needs of older adults living with multimorbidity, dementia, and frailty, UK policy must:

• Deliver a modern service framework within England for dementia and frailty that truly invests in integrated care models that bridge health and social care.
• Drive an expansion in admiral nursing services to ensure specialist support is accessible in communities and neighbourhood health teams.
• Train the workforce in dementia and frailty management.
• Support carers with financial, emotional, and practical resources as an integral part of any dementia care pathway
• Leverage digital tools for shared care records and remote monitoring.
• Embed frailty and multimorbidity assessments into routine care planning.

Conclusion

The intersection of multimorbidity, dementia, and frailty is not just a clinical challenge; it is a societal one. As the population ages, we must move beyond reactive, siloed care and toward proactive, integrated, and compassionate systems. Admiral Nurses are leading the way, and we’re standing ready to help deliver a system that truly meets the needs of those who need it most.

If you need advice or support on living with dementia, contact Dementia UK’s Admiral Nurse Dementia Helpline on 0800 888 6678 or email helpline@dementiauk.org.

References

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