Can better frailty care alleviate the pressures on the NHS?

The Getting It Right First Time (GIRFT) national report for geriatric medicine identified that over 4,000 people are admitted to hospital every day in England as a result of frailty. The report found that frailty care varies across the UK and has the most scope for improvement.

The Royal College of Physicians (RCP) and the GIRFT programme recently held a joint webinar looking at how to improve frailty care in acute general hospitals. It is the first of three webinars aimed at sharing initiatives that can help alleviate the pressures on the NHS.

The webinar began with an introduction from Professor Tim Briggs, consultant orthopaedic surgeon and chair of the GIRFT programme and Dr John Dean, clinical vice chair of the RCP. They said frailty is everybody’s business and all healthcare professionals should provide the best care in collaboration with multidisciplinary colleagues.

• Further reading: The role of nutrition in prevention and management of frailty

They added that the aim of the webinar was to discuss alternatives to hospital visits, how barriers could be removed for safe and efficient discharge, and how primary, community and secondary care could work together to keep older patients out of hospital.

Frailty care in acute and general hospitals – how can we improve?

The first speaker was John Soong, Consultant Physician, National University Hospital, Singapore, who said that the ageing population was a global phenomenon and there are quite striking parallels between Singapore and the UK. In Singapore, almost 20% of the population is aged 55 and over and for the first time in 2018, the number of children equalled the number of older people. Dr Soong said that this has hit their healthcare systems hard and, as a result, managing frailty is something they have become quite focused on.

He said that there has been an inexorable rise in acute care utilisation, which far outstrips population growth. This is largely due to fragmentation of care. Studies show that almost 40% of people who have specialist outpatient care have three or more specialists. This also impacts on patient care with higher emergency department attendance, acute hospitalisation, and increased length of hospital stays.

Therefore, frailty screening is important. The Clinical Frailty Scale in the acute care setting is an independent predictor of inpatient mortality, transfer to a geriatric ward, and long length of stay. There is also a five-point scale called FRAIL which looks at fatigue, resistance, ambulation, comorbidity and loss of weight.

Dr Soong said that identification of frailty syndromes, which are clinical manifestations of frailty such as grip strength and weight loss, are also a useful way of predicting poor outcomes for hospitalised patients.

He added that a key tool would be Comprehensive Geriatric Assessment (CGA). This is a multidisciplinary diagnostic and treatment process to identify different dimensions of frailty, such as medical, psychosocial and functional limitations, to create a coordinated plan to maximise overall health. He said there is reasonable evidence that if you do this in the acute care setting, patients are more likely to go back to their own homes.

He ended his talk by saying that demographic shifts mean that acute care demand is rising worldwide, so effective assessment of frailty is now the norm. There are screening tools that can identify a high-risk cohort and improve patient outcomes. But the current focus is on service redesign, creating new structures and processes where frailty can be managed more effectively and appropriately.

Improving frailty care in acute general hospitals: top tips for the non-geriatrician

The second talk was given by Dr James Adams, University of Southampton, who gave his top tips for non-geriatricians on how to improve frailty care.

He said that the ageing population has led to a rise in frailty presentations to emergency departments. Therefore, it is critically important that health and care systems are built around older patents’ needs. Otherwise, there will be a vicious cycle of very poor-quality care delivery with poor outcomes for older people that leads to greater costs to the system.

Early identification of frailty within acute trusts and Comprehensive Geriatric Assessment (CGA) is key to this because of deconditioning.

He added all physicians should understand older people’s needs in hospital, but also understand the harms that can be done to them by being in hospital. This is because hospitals are traditionally built on a disease-based paradigm. But if physicians cannot recognise frailty in the first place, they cannot acknowledge the actual needs of the patient.

Geriatricians, therefore, often spend time in the acute medical unit (AMU) de-medicalising older patients. For example, this could mean taking people off cardiac monitors or taking catheters out and ambulating them to prevent deconditioning.

He said CGA is absolutely critical to this, but there are not enough frailty experts around to deliver effective CGA. Therefore, skills around frailty recognition and frailty care in the general wider workforce from healthcare assistants to consultants need to be obtained. This is the only way to meet the needs of an ageing population.

So, what exactly is frailty? Dr Adams says it is multi-morbidity leading to cognitive deficits over time, causing poor physiological reserve. Significant deterioration in the functional status can then occur due to a very minor stressor.

It is usually this underlying stressor event that precipitates presentation to hospital and a frailty crisis developing. Patients can also present with hallmark frailty syndromes such as acute confusion, delirium, or sudden changes in functional status and mobility. Therefore, it is important to take a step back to see the bigger picture, not just the medical problem.

Using Comprehensive Geriatric Assessment (CGA) and optimisation

The final talk was given by Dr Judith Partridge, a geriatrician from Guy’s and Thomas’s Hospital, who wanted to unpick some of the mystique around Comprehensive Geriatric Assessment (CGA).

She said that CGA is basic methodology which underpins geriatric medicine and when it is done well, it can have very clear benefits for older patients.

The British Geriatric Society defines CGA as “a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up.”

Dr Partridge says the multidimensional part is important as frailty and multi-morbidity are multidomain issues and therefore need a multidomain approach.

CGA helps identify all problems that an older person may have – medical conditions, psychosocial health or functional ability – in order to treat those issues. It is about what interventions can actually improve outcomes.

She said that when carrying out CGA, the first thing is to take a full history and examine the patient looking at known and previously unknown issues. Targeted investigation, as with all other medical assessments, should aim to confirm or refute diagnoses. After that, it is about working with multidisciplinary colleagues to identify the functional and environmental aspects that doctors can’t fix. It is not just creating a problem list, but trying to do something about it. This ranges from accessing benefits to advanced care planning.

In the acute medical setting, it is known that CGA and optimisation improve clinical outcomes and are cost effective. So who can deliver this? With a limited geriatric medicine workforce, physicians from other settings, nurses and pharmacy colleagues can all be trained and upskilled in delivering these kinds of services.

It becomes a one-stop shop, she said. This helps patients get away from this concept of going to seven or eight different clinics in order to have overlapping medical conditions and frailty managed.