Kenneth Rockwood is Professor of Medicine (Geriatric Medicine & Neurology) and consultant geriatrician at Capital Health in Halifax, Nova Scotia, Canada and Honorary Professor of Geriatric Medicine at the University of Manchester.
Many older people leave hospital frailer than when they started. Some of that is preventable, but much of the damage done by acute illness is baked in to how frailty works. Some of it is reparable. That is why rehabilitation must be part of acute care: if we cannot prevent damage, we should at least treat it, especially damage that we inflicted unnecessarily.
The gist of it is easy enough. When frail patients are unwell enough to come to hospital, they typically are not thinking, functioning and moving like they were before they became ill. That is usually why they come. That, and whatever other symptoms (breathlessness, pain, something red or swollen) signal a problem. Even when fixing the precipitants, modern care often does nothing to address the worse thinking / mobility / function in which the problems were packaged. Such complexity of need defines frailty.
Frailty is not new, but population ageing means that it is coming to attention. We must help health care decision-makers to understand that even when care does not harm, there will be a gap between what cognition, mobility and function are like once the precipitants have been treated, and what people need in order to return home. The time is ripe for health care providers to hear this message.
Once the message is heard, the arithmetic is simple. For many patients, the number of things that they have wrong (i.e. their degree of frailty) at the end of their acute care stay is too high for them go home. That is why they require rehabilitation.
QED. Well, not quite.
To get there, someone must measure the degree of frailty at baseline. Conveniently, this can be estimated by asking about mobility, function and the like two weeks prior to admission. For the gap between the degree of frailty at baseline and the degree of frailty on admission to be known that too measured. None of this is especially new. To the requirement to “take a history” we must simply add that it include some indication of problems in cognition, mobility and function. Likewise, to “do an exam, assess and diagnose” we must stipulate that what is being examined allow us to know whether, when and how the patient might be able to return home.
This knowing precisely what people were like two weeks before they became ill needs to be clear to the care team. It gives them a specific way to talk to patients and carers about what must be achieved for the person to go home. How close to health two weeks ago do we need to come? Knowing what to aim for clarifies the gap between the patient’s degree of frailty and the degree of frailty that carers can manage. Aiming to close that specific gap is not some magic incantation, but a specific, auditable, patient-centred goal-oriented program.
From this, it is easier to move to the next step in better care. The people with the biggest gaps usually will be those who were frail at baseline. That is because they are the most vulnerable: the poor get poorer.
And there’s the rub. Frail people do worse not just due to their illness, but to their treatment. It’s not just that they are more susceptible to adverse drug reactions. A lot of what we do in hospital is harmful. No one benefits from sleep deprivation, or inadequate pain control, or not being mobilised, or inadequate nutrition, or being alone, but mostly, we get away with it. Not so for frail patients, especially when they are acutely ill. So some part of lessening the need for rehab to be part of acute care is to make acute care less hazardous.
Rehabilitation must be part of acute care if we wish to have fewer older people leave hospital frailer than when they started.