Holistic medical review by GP
Once a person has been identified as frail, a holistic review will allow for optimisation of the person’s health and for considered forward care planning. It may involve onward referral for a more Comprehensive Geriatric Assessment by an interdisciplinary team (see appendix 1 and figure 1 above for flow chart). An appropriate period of time should be put aside to allow for this holistic review (it is likely to take at least 45 – 60 mins - depending on how well the individual is known to the GP or specialist nurse doing the assessment). It may be appropriate to invite relatives and carers to be present at the assessment as well as any care workers involved with the individual. The setting of the review can be agreed with the patient; however the physical examination needed as part of this assessment will limit choice.
Underlying diagnoses and reversible causes for these problems must be considered and addressed as part of the assessment. [See case example A in list - Eric’s Story]
In looking for cognitive impairment, it is helpful to use a standardised cognitive assessment such as the 6-CIT cognitive test (which has been validated in primary care) (www.patient.co.uk) or the Montreal Cognitive Assessment (http://www.mocatest.org/).
New medical problems, which can present atypically, should be enquired about in the structure of a systems review. Previous diagnoses and long term conditions and their management should be reviewed. As patients with frailty commonly have other long term conditions, it is important to assess the impact of these as a whole and consider if national and local guidance is appropriate for the individual. A medication review is also important in this context (see below). A complete physical examination including eyes, ears and a neurological examination is vital.
The assessor (whether the patient’s GP or another) must ensure that there is a diagnosis or explanation for all newly discovered symptoms and signs. It is vital to look for reversible medical problems and to ensure that the agreed care plan (see next section) includes the appropriate investigations needed to look for treatable disease - as agreed with the patient.
In some situations, it might be helpful to consider an assessment structured under the domains used in Easycare (ref https://www.easycarehealth.co.uk/) which are;
- Seeing hearing and communication
- Getting around
- Looking after yourself
- Housing and finances
- Safety and relationships
- Mental wellbeing
- Staying healthy
However this less medical centred approach does not remove the obligation on the person doing the assessment to look for reversible medical problems and underlying diagnoses.
Assessment of Capacity. If there are concerns about cognitive function, it is important to consider mental capacity which might influence subsequent care and support planning. The principles of the Adults with Incapacity (Scotland) 2000 and Mental Capacity Act (England and Wales) 2005 are:
- Assume Capacity
- Help people to have capacity in all practical ways before deciding they do not have capacity
- People are entitled to make unwise decisions
- Decisions for people without capacity should be in their best interest and the least restrictive possible.
The 4 point capacity test is:
- Can they understand the information given?
- Can they retain the information given?
- Can they balance, weigh up or use the information?
- Can the person communicate their decision?
If the answer to any of these is ‘no’ then the person does not have capacity.
However it is also important to remember that capacity may fluctuate and that it is time and decision specific. All health and social care professionals must recognise their responsibilities with respect to mental capacity and be prepared to reassess capacity if the situation changes.
Drugs/Medicines Review. Medication reviews are important – many drugs are particularly associated with adverse outcomes in frailty such as:
- antimuscarinics in cognitive impairment
- long acting benzodiazepines and some sulphonylureas, other sedatives and hypnotics increase falls risk
- some opiate based analgesics increase risk of confusion or delirium
- NSAID can cause severe symptomatic renal impairment in frailty
Conversely, some drugs which would offer symptomatic benefit are omitted because of concerns about frailty, when with careful monitoring they would be safe to use (such as ACE inhibitors in heart failure).
With ageing the metabolism of drugs changes and this needs to be taken into account when prescribing as it may affect dosage.
The use of multiple medications by older people with frailty is likely to increase the risk of falls, adverse side effects and interactions, hence the need to individualise the interpretation of national guidelines for single long term conditions in the context of multimorbidity in general and frailty in particular.
A discussion about the stopping of preventative chronic disease medication such as statins and warfarin for atrial fibrillation and sedatives and antihypertensives should include the potential impact on the hoped for long term outcomes for the individual in question. It might be appropriate to consider using validated medication appropriateness checklists such as the STOPP and START Guidelines 17.
At the end of the assessment, which should also have included a discussion about individual goals and aspirations, the person doing the assessment should help the individual and, if relevant, their carers should draw up an individualised care and support plan. There is more information about this in the next section.
The plan may include referrals to other community services such as intermediate care, mental health, a geriatric service or a falls service. This plan may therefore feed into a larger review which would constitute full CGA (see appendix 1).
It is also important to develop an escalation plan which helps individuals and their carers identify what they should look out for and when and who they should call for help and advice. It should include an urgent care plan which, at a time of future crisis, could guide the emergency or out of hours services as to the appropriate decisions to take around emergency department conveyance and hospital admission.
It may be appropriate to start to explore, sensitively, issues around end of life planning. If there are advance directives, it would be important to review and record this in locally agreed systems for future reference.