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Identifying and managing frailty at the front door

With ten per cent of patients attending the Emergency Department being older people, probably with frailty, Simon Conroy, Jack Hawkins and Sarah Turpin set out a step by step scheme for identifying and managing frailty at the hospital’s front door.

Hospitalisation of an older person can be a sentinel event that heralds an intensive period of health and social care service use. This is especially true of ‘older people with frailty’, a distinctive late-life health state in which apparently minor stressors are associated with adverse health outcomes. Depending upon definitions, the setting and local service configuration, about five to ten per cent of Emergency Department (ED) attendees and about thirty per cent of patients in Acute Medical Units are older people with frailty. The purpose of focusing on older people with frailty is that they represent a relatively small proportion of all those accessing urgent care settings, but an increasing proportion of those at risk of harms and high resource use as they progress from admission onto inpatient care. It is in essence, an exercise in risk stratification - identifying a cohort at especially high risk of adverse outcomes.

 

Identifying a population at risk is all well and good, but you may be worrying about what to do with them once they are found. AFN principles 2 and 3 apply here: ‘put in place a multi-disciplinary response that initiates Comprehensive Geriatric Assessment (CGA) within the first hour’ and ‘set up a rapid response system for frail older people in urgent care settings.’

There is concern in clinical teams that there will be too many patients to manage if we measure accurately. Remember CGA is not just about geriatricians – AFN principle 7 applies, ‘put in place appropriate education and training for key staff’. This is not quick or easy, and a strong strategic approach is required. But unless the ‘demand’ is first identified (i.e. the number of older people with frailty and urgent care needs), and the gaps exposed – the proportion of that number that cannot be managed by frailty teams, it will be difficult to determine how much effort needs to be put into education and training. Don’t be anxious about the scale of the problem. It exists already, and ignoring it will exacerbate it.

There are many schemes and support tools available or in development that will help you and your colleagues deliver CGA (which is not just about geriatricians). For examples, see the resources at the end of this article.

Which frailty tool should I use?

There is limited evidence for the discriminant ability of frailty scales in the urgent care context: although most scales perform better than chance in predicting a range of poor outcomes, none of them performed adequately for individual clinical decision making, and most perform either poorly or very poorly. Until more accurate tools become available, simple, clinically acceptable criteria can be used to identify a large proportion of older people who are frail (sensitivity). Some patients will be incorrectly scored as not frail (specificity), this can be sorted by sensible discussion between clinical teams. Examples include:

  • Age 65+ AND presenting with one or more frailty syndromes (confusion, , Parkinson’s disease, presenting with fragility fractures and/or falls, care home residents) OR people aged 85+

AND/OR

  • Moderate or severe frailty (grade 6-9) using the Canadian Frailty Scale

It is important that geriatricians up and down the country use one tool consistently – at the moment we almost have a different tool in every hospital. This has no basis in science given that no one tool is better than any other, and moreover, it is confusing for clinicians, managers, and patients. It is critical that geriatricians as service leads for frailty adopt some consistency across the country (AFN principle 5: ‘adopt clinical professional standards to reduce unnecessary variation’) – variation harms patients.

How do we embed the use of frailty tools in our setting?

It takes time, but it is not that difficult! There are four key steps, each of which is a PDSA cycle.

  1. The ambulance service will almost certainly be able to provide the information necessary to use one of the frailty tools above. This admission interface covers the vast majority of patients relevant to frailty services.
  2. When the ED or AMU nurse takes a handover from the ambulance service, they need to populate a frailty box on the proforma that all hospitals will use (again slightly different versions in different hospitals, but they all have some sort of handover/immediate assessment form).
  3. This frailty score can then be added to your electronic hospital record– again different systems operate in different hospitals, some covering just ED, some also including the AMU and the rest of the hospital. If your setting is IT ready, then ask your IT team to create a frailty field, which can be used for tracking purposes.
  4. The final step is to check that the frailty identification leads to an action – depending on your setting, this might be a referral to a frailty team, frailty unit, or special documentation – however your deliver CGA, check that it is being done for older people with frailty and urgent care needs.

The PDSA cycles

Step 1 check that the ambulance crew provide most of the information required

For this you will need a clinical data collector – nurse specialist, doctor, therapist - so long as they know what the information means and can turn it into one of the two frailty scores above. Check the process works using run charts – remember, you don’t need to check many patients – perhaps just ten older patients (65+) should be enough. You’ll then get a run chart that looks something like this where 1 means that patient could be scored and 0 means they could not:

 

This chart shows that two patients could not be coded – you need to understand why not, and if appropriate, change the process to ensure that they can be coded in the future. It might be that the ambulance service are not capturing information on cognition, in which case you need to get them to start doing so. It might take a while to sort, but if the ambulance team scan see how this will help their patient, and reduce their waits in ED, then they will be happy to help. You might need to get some senior support – but because you are part of the AFN and have executive support already, that should not be a problem! Test again after the process change.

Step 2 checking capture in clinical practice

The next stage is to check that the nursing staff in ED/AMU are able to capture the data and interpret it correctly. The same principles apply, except this time you might want to measure the proportion of people aged 65+ who are correctly coded as frail vs. not frail. You’ll need to check how they are doing this by looking at the patient’s notes and checking to see if frailty has been correctly coded (yes/no).

Step 3 Checking capture on hospital system

This will be relevant if you are using an IT system to capture frailty and track it though the hospital. Again it is a simple case of checking that older people coded as frail are captured on the computer system. If there are problems, find out why, correct the process and keep measuring until it is correct and stable – it will look something like this:

You may find that you have to run a few cycles to get the process right.

Step 4 frailty identification leads to an action

Now that you have a stable process in place that ensures that people with frailty are identified, all you need to do is check that those identified as frail are receiving CGA! This is a case of defining what you mean by CGA – using the principles below, we would suggest that you look for evidence of assessment in each of the five domains of CGA, evidence of an MDT discussion and stratified problem list. You could do this by counting how many of the seven elements listed previously have been undertaken. As your service matures, you could look at the individual components to check that they are each being delivered consistently.

How to deliver CGA – for geriatricians and non-geriatricians alike

Unlike patients with single presenting problems, older people will usually present with a range of issues, not just medical, that require addressing in order to achieve an effective management plan. It is not possible to describe every possible scenario; rather we offer a framework describing over-arching principles that can be useful when assessing older people. There are four key points to consider:

  • Non-specific presentations
  • Multiple comorbidities
  • Functional decline and altered homeostasis
  • Differential challenge

Non-specific presentations

Older people with frailty will usually present non-specifically - meaning the textbook clues for diagnosis may not be present. Do not interpret a lack of specificity as a lack of seriousness or urgency. Recognise the non-specific presentations (off legs, falls, immobility, delirium etc.), and use them as a prompt to switch on your diagnostic antennae to focus upon objective pointers towards a diagnosis.

The non-specific presentation itself is a cue – it will be related to a communication barrier (think delirium, dementia, dysphasia and/or sensory impairment).

Multiple comorbidities

Do not content yourself with a single system diagnosis; there will usually be multiple active issues, which often interact and compete for prioritisation. List the active diagnoses and stratify them in order of urgency; this will help you prioritise those that need addressing now, and those that can wait a few hours, but should not be forgotten.

Multiple comorbidities often bring polypharmacy; use the urgent care episode to discern if there are active adverse drug events, or opportunities for deprescribing.

Functional decline and altered homeostasis

Older people with frailty often have pre-existing functional impairment, added to which, they often delay presentation with acute illness, either through inherent reticence or reduced access to support or even neglect by carers. This means that the impact of an acute event will already have started to manifest in terms of functional ability, which could be exacerbated by enforced bed-rest. A period of rehabilitation will often be needed – increasingly this should be done at home rather than in an institutional setting.

Older people with frailty will have altered homeostatic mechanisms, meaning that their reserve is impaired, making them more vulnerable to apparently minor insults, but also altering their responses, for example, altered drug handling. Remember ‘start low, go slow’ when introducing new drug treatments.

Differential challenge

Those most in need are least able to access the services they require – this may be due to intrinsic factors, such as cognitive or sensory impairment, or extrinsic factors, such as the lack of age-attuned services or broader socioeconomic factors.

Comprehensive Geriatric Assessment

Comprehensive Geriatric Assessment (CGA) offers a useful structure to ensure that your assessment is holistic, and therefore more likely to result in a management plan that will be successful. Use  a check-list for each of the domains of CGA (see Table over page) when formulating your management plan:

The problem list  
  • Delirium/Dementia
  • Bradycardia (medications: atenolol/donepeqil)
  • Neurological deficit (previous stroke)
  • Hypotension - medications and fluid depletion due to reduced oral intake
  • Reduce/stop beta-blocker as BP low and likely to be contributing to falls risk; will require on-going monitoring (POLYPHARMACY)
  • Stop and review later the Bendroflumethazide (or Furosemide) given dehydration and low BP (also limited evidence of benefit from tight BP control in established dementia) (POLYPHARMACY)
  • Do not stop donepezil (likely to help with delirium recovery), but monitor ECG response to withdrawal of beta-blocker (POLYPHARMACY)
  • Nurse in an environment less likely to aggravate delirium (reduced noise, low lighting, and orientation cues)
  • Later, arrange a home hazards review, consider assistive technology such as pressure sensors as several fixed irreversible drivers of falls risks – stroke, dementia (ENVIRONMENTAL factors)

Reduced oral intake due to:

  • Delirium
  • Reduced appetite during illness
  • Constipation
  • Inaccessible drinks
  • Start off with iv fluids
  • As recovery kicks in ensure cups in reach
  • Ensure food appetising and accessible
  • Monitor fluid balance

 Constipation due to:

  • Opioids
  • Reduced mobility etc.
 Treat bowels - enema for impaction, add in laxatives as likely to need to restart opioids for shoulder pain (POLYPHARMACY)

Urinary retention due to

constipation/facecal impaction +/- donepezil causing UTI (drug resistant) and Acute (mixed pre and post-renal) kidney injury

  • Treat bowels
  • Treat UTI
  • Hydrate
  • No catheter! If in pain consider in-out catheter
  • Repeat UE tomorrow at 7am

 Polypharmacy

  • (opiates/beta blockade/thiazide)
  •  Medication review as described above and below
 Hypoactive delirium secondary to issues above

Delirium - (NON-SPECIFIC PRESENTATION)

  • Address hydration (consider parenteral fluids given drowsiness and likely lower oral intake), hypoxia, hypothermia, hypotension and hypoglycaemia
  • Treat infections - consider broad spectrum antibiotics given established resistance to many antibiotics (including Trimethoprim), pending CSU obtained from in-out catheter to drain bladder
  • Consider urinary retention: plan to follow up bladder scans rather than insert a catheter
  • Hold opioids temporarily to facilitate recovery from delirium, but continue paracetamol (NSAIDs contraindicated due to acute kidney injury) (review POLYPHARMACY)

Medical: have you got a working primary diagnosis, as well as a list of comorbidities that are active or important that also require attention?

Psychological: have you assessed for the presence of delirium, dementia or depression/anxiety? These will have a substantial impact upon on-going management.

Functional ability: you may have made a diagnosis, but how will you get the patient ‘clinically stable for transfer’. Being ‘medically fit’ is meaningless if the person cannot mobilise to the toilet and back safely.

Social circumstances: what support exists? What more is needed to enable a return home? Do you know how to access resources that can help?

Environment: is the home setting conducive to on-going care needs, or are adaptation required? Do you know how to organise a home hazards review for people who have fallen?

Multidisciplinary meeting in urgent care settings

A cornerstone of Comprehensive Geriatric Assessment is interdisciplinary communication and coordination. These have traditionally been delivered using Multidisciplinary Team (MDT) meetings – typically on a weekly or occasionally daily basis. Clearly this frequency is not well-adapted to the urgent care setting, so alternative mechanisms are necessary.

In some settings, it might be possible to bring the team together for a rapid MDT discussion about patients – for example in observation units. Such meetings should be at a fixed time every day and for a fixed duration so that expectations for attendance and duration are clear to all team members. On average, each patient discussion should last no more than one minute, and it might be helpful to structure the discussion using the domains of Comprehensive Geriatric Assessment – physical/medical issues; functional/mobility issues; cognition/mood; social support networks and environment (home setting). For an example see here: https://vimeo.com/132073531.

In the main area of the ED (‘majors’), coordination and communication can be more difficult, as it will be unusual to be able to have multiple staff involved with the same patient at the same time. In this scenario, standardised documentation, again based on the principles of CGA, can help staff more easily navigate the issues that have been addressed, and identify where value can be added. Even in a busy and noisy majors area, it is possible to bring most clinicians together every hour or two for a quick run through of the patients. In addition to addressing the domains of CGA, it is useful to consider situational awareness issues in this context.

Stratified problem lists

The idea behind these is that they are more than just diagnoses – they reflect the problems identified in a given patient. This might be from any or even all of the domains of CGA. They might be a summary of the MDT discussion. The stratification should be in terms of urgency and importance. Finally, the problem list should be associated with a list of actions, which you could also measure once you have got to this stage.

Simon Conroy and Jack Hawkins
Clinical Leads
Sarah Turpin
Clinical Fellow in Geriatric Emergency Medicine

Tags: hospital, acute care, frailty

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