People at the centre of health & care National Person-Centred Health & Care Programme Care Experience Breakout Sessions Trudi Marshall Nurse Consultant Older People NHS Lanarkshire Older Person’s Pathway

What is Frailty? NOT ALL OLDER PEOPLE ARE FRAIL ! Charles Eugster, 91 year old. At the age of 87, he decided to take up body building to counter muscle loss.  Last year (2010) he won the Strenflex World Championship (an international fitness competition) in the over 80-age group with the highest number of points ever scored.  His winning performance featured 57 dips, 61 chin-ups, 50 push-ups and 48 abdominal crunches, each in 45 seconds! He states that he doesn't need Viagra nowadays (not that he took it before). And as a once-divorced widower he is looking forward to his next internet date. His last relationship was with a 72-year-old synchronised swimmer.

What is Frailty? State of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for long-term care, and mortality. Commonly used to describe older persons at increased risk for morbidity and mortality. Typically involves alteration in multiple, not individual, body systems. Syndrome associated with reduced functional reserve, impairment in multiple physiological systems, and reduced ability to regain physiological homeostasis. (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004. Morley, Kim, Haren, Kevorkian, & Banks, 2005. Bartali et al., 2006) 

Why is Frailty Important ? Caring for frail older adults is difficult and challenging because they have an increased burden of symptoms, are medically complex, and often have increased social needs. (Espinoza & Walston, 2005) Frailty is a strong predictor of several negative outcomes including disabilities, institutionalization, and mortality. (van Iersel & Rikkert, 2006) Frailty has also been linked to acute illness, falls, and increased vulnerability. (Espinoza & Walston, 2005) The identification of frailty in its early stage is important because interventions may potentially prevent, or delay the clinical consequences of frailty. (Bartali et al., 2006) Screening for frailty and assessing levels of frailty in older adults can identify those most vulnerable and assist in targeting nursing interventions.

Comprehensive Geriatric Assessment (CGA) Social Circumstances informal support available from family or friends social network such a visitors or daytime activities eligibility for being offered care resources Medical co morbid conditions and disease severity medication review nutritional status problem list Environmental home comfort, facilities and safety use or potential use of telehealth technology etc transport facilities accessibility to local resources Functioning basic activities of daily living gait and balance activity/exercise status instrumental activities of daily living Mental Health cognition mood and anxiety fears

Well established MDT approach In depth MDT assessment Recognition of frailty Discharge planning

ACE Nurse Screening - signposting CGA AMT, functioning, social, urinalysis, L+S BP, Falls history, Meds reconciliation Supporting discharges Getting the assessment of older people right in the AMU has the potential to improve outcomes, reduce inappropriate hospitalisation, and potentially reduce the need for long-term care. (RCP, 2012)

Impact Over 85% of frail older people reaching speciality beds within 24 hours (prev 40-60%) All patients who require L&S are now having this assessment undertaken (prev 5%). Over 90% of AMT’s are now being completed (prev >5%)

Impact Reducing the average length of stay of emergency or unplanned admissions Reducing emergency inpatient bed days for people over the age of 65years Improving the quality of the patient care experience Supporting the increase in the level of older people with complex care needs receiving care at home Supporting “Shifting the Balance of Care”

Staff feedback “The nurse post in the emergency receiving unit makes a big difference to thorough assessment and early intervention for older people, we feel more informed and more in control of the acute care group.” (Consultant Geriatrician). “The nurse often finds out from carers/ relatives which community pharmacy the patient uses and if they use a compliance aid. This is vital knowledge for discharge and allows the ward pharmacists to contact the community pharmacist on discharge and communicate changes made. They also identify patients who are having difficulties which allows me time to resolve these problems which were previously often only identified on discharge.” (Pharmacist)