Frailty in hospitals, everybody’s business

In November 2014, the HSJ/Serco Commission on Hospital Care for Frail Older People concluded that we should avoid wishful thinking that improving intermediate and community care (while perhaps the right things to do) will automatically mean we can disinvest significantly in hospitals. Instead, hospitals should radically improve their services to recognise that frail older patients are now part of their core business.

Frailty is a lack of resilience to cope with changes to health status that can lead to atypical and severe responses. We know from best estimates that 1.8 million people over 60 are already living with frailty.

This rises with age and, although not every old person is frail, almost two thirds of people over 90 live with frailty. As the baby boomers reach old age (by year 2040, nearly one in seven people are projected to be over 75), we need to get better at identifying and managing this small but highly significant cohort of people.

We know from best estimates that 1.8 million people over 60 are already living with frailty

Over the last 10 years, the National Institute of Health Research has invested in research on managing people with frailty within UK hospitals. In December 2017 the NIHR Dissemination Centre published a themed review of that evidence “Comprehensive Care: Older people living with frailty in hospitals”.

Whilst this is not a comprehensive review, it identified four key themes and a number of questions that providers should ask to assure themselves that they are achieving the highest standards.

Identification and assessment of frailty

Frailty is not always obvious and people can present in atypical ways. Research shows that staff who are not specialists in older people’s care do not always recognise it. The new (October 2017) GP contracts means that in future all GP practices will identify people living with frailty in the summary care record. This offers an opportunity to flag frailty early and ensure timely assessment.

There is strong UK and international evidence that Comprehensive Geriatric Assessment has a significant positive impact on outcomes of older people with frailty, including length of hospital stay, unplanned readmission to hospital and long term admission to care homes. For example, a Cochrane review found that for every 20 people assessed in this way, one long term care home placement can be avoided.

Research shows that staff who are not specialists in older people’s care do not always recognise it

This compares favourably with the 120 people that need to take daily aspirin to prevent a single person having a stroke. However, the National Audit Office in 2016 found that only a minority of hospitals (42 per cent) were undertaking early geriatric assessments. Maybe it is time to set standards for CGA in hospitals?

NIHR research shows the benefit of CGA is only realised when the CGA is conducted by a multidisciplinary team, rather than by a geriatrician alone, but this takes time. Current emergency care pathways can compromise this and one study suggests the need for specialist frailty assessment units that operate outside current access targets.

Assessing frailty needs is also important for elective admissions and this raises important questions about the expertise of the whole workforce that will need to be addressed in Health Education England’s new strategy Facing the Facts, Shaping the future.

In hospital care

Whilst there have undoubtedly been improvements in the identification and assessment of frailty since the HSJ Commission, we need to understand better how to help people in hospital who struggle with activities of daily living, such as mobility, continence and eating. Current models of care and staffing calculations do not recognise the time required for these.

Perhaps we need to consider community assets? One study in this review demonstrated the feasibility of using volunteers in busy wards to help people at mealtimes. Another is currently evaluating a programme in which volunteers are trained to encourage older people to walk or exercise in the chair for 15 minutes twice a day.

Planning for the next stage

Preparing older, frail people for discharge requires specialist skills. Many older people living with frailty are admitted to hospital in the last year of their life but research shows that this is not always recognised. In one study, only 29 per cent of people who met one or more of the Gold Standard Framework criteria for end of life care had a Do Not Attempt Resuscitation order and only 8.2 per cent had been referred to specialist palliative care.

The study found that both nurses and doctors were poor at recognising people at the end of their life. Again, this shows the need to review the core common knowledge and skills for all hospital staff with an increasingly ageing population.

Caring environments

Our review shows that caring environments bring more than a good experience. They can also deliver therapeutic benefits.

But caring environments need more than people with the right values – they need staff with time to consider patients as individuals. A number of studies show how the fast pace of acute hospitals can overwhelm older, frail people.

Admission to hospital can trigger acute confusional states, particularly for older people living with frailty. These patients are then frequently assigned an expensive, one to one, “enhanced care” carer; work that is usually assigned to an unregistered support worker (often through the bank or agency).

Rather than simply supervising these patients, NIHR research has demonstrated the importance of developing good relationships with these patients to re-establish their resilience, yet researchers found that only one third of NHS trusts provide their healthcare support workers with any training on developing good relationships.

Conclusion

Our themed review is solely focused on NIHR-funded research. The evidence raises some important issues and suggests that hospitals can do much more to ensure that older people living with frailty stay as independent as possible and return home safely.

The time is right for a radical rethink in how services are designed and we must ensure that new models draw of the well established evidence base, to ensure that they are better not just different

But this requires staff with specialist knowledge and expertise. In order to implement the evidence base, new models of in-hospital care will be needed and better use of technology to ensure that information is shared effectively across the health and social care system.

Older people can live well with their frailty, but it will need a step change to make hospitals truly age friendly. This message is timely as it reinforces much of what was written in the HSJ/Serco report.

With the current capacity challenges for acute care, the time is right for a radical rethink in how services are designed and we must ensure that new models draw of the well established evidence base, to ensure that they are better not just different.