Stuart Parker is Professor of Geriatric Medicine at Newcastle University and a consultant physician at Newcastle upon Tyne Hospitals NHS Trust where he is helping to develop an acute inpatient service for frail older people. Here he discusses the Urgent care for frail older people – Hospital Wide Comprehensive Geriatric Assessment Meeting on 25 May in Leeds.
Frailty is now widely recognised as a key component of declining health and function in old age. Older people with urgent care needs are particularly likely to experience frailty. New acute illness can trigger the onset of frailty in an older person who, in whom the limits of their functional capacity may be urgently revealed. Older people are increasingly the main users of urgent care services. Accordingly, urgent care services for older people need to be able to recognise, evaluate and manage frailty.
To an audience of clinical specialists in health care for older people, these statements describe well known and uncontroversial truths. They are part of our understanding of what we do and how we use the health (and other) technologies at our disposal to assess and manage the wide variety of clinical problems that can precipitate the need for urgent care in an older person who is frail.
The British Geriatrics Society has supported a number of initiatives to increase awareness and effective care for older people who are frail such as “Frail Safe” and, “Fit for Frailty” and the medical journal Age and Ageing has developed a “Frailty Collection” of relevant, high quality research and review articles on the topic.
Older people with urgent care needs who are frail, have some very specific needs over and above medical assessment and optimisation of the purely “medical” components of their care. They present a challenge to practitioners to recognise and manage the clinical syndromes associated with frailty, which are classically loss of mobility, falls, confusion and incontinence and also the frailty associated adverse drug effects and interactions that are commonly seen. They demand that practitioners take into account not only the underlying clinical issues (such as delirium, dehydration, malnutrition, deconditioning and hospital acquired illness) but also the life cycle including the recognition of end of life issues, family relationships, social and environmental resources and most importantly functional health status and the potential for recovery, recuperation and rehabilitation.
These issues are probably best managed using a multidimensional, multidisciplinary approach to assessment and management. The evidence supporting this statement is particularly well developed for older hospital inpatients. The health technology that encapsulates this approach is known as “Comprehensive Geriatric Assessment”, CGA for short.
We know that CGA is an effective approach to managing older people in the hospital inpatient setting that can result in improved outcomes for both the patient and the health care system (such as more time spent at home, and reduced likelihood of nursing home admission). However it is not universally available, or usually practiced in some forms of inpatient care. It is most likely to be found in wards specialising in providing care for older people, including hip and stroke units. It is less likely to be found in medical inpatient wards, inpatient surgical settings and oncology services, although in a recent survey, notable exceptions to this pattern were observed. A particular issue of current interest is the availability of appropriate assessment and management of frailty in the first few hours of presentation with urgent care needs “at the front door”.
A challenge for the hospital inpatient care system then, is to deliver CGA to all patients who can benefit from the intervention and to do it across the traditional disciplinary or institutional boundaries. One key component of this challenge is to find ways to identify and alert practitioners that they are caring for a patient who has a high risk of frailty and its associated adverse clinical consequences. Another is to equip those practitioners with the tools and services they need to enable high quality multidisciplinary assessment and care to be delivered.
In essence, these were the challenges that were taken on in the NIHR funded “CGA-HoW” study, which has developed a frailty risk score based on hospital episode data and produced and piloted a toolkit for the delivery of CGA on a Hospital Wide basis.
These issues will be discussed and further developed in the forthcoming meeting “Urgent care for frail older people – Hospital Wide Comprehensive Geriatric Assessment” Organised by the British Geriatrics Society, Royal College of Emergency Medicine and the Society of Acute Medicine, in Leeds on 25th May.