Assessment and management in an urgent situation
As noted above, the presentation of an older person with frailty in an urgent situation is not always straightforward. Frailty syndromes can mask serious underlying illness and the response to a crisis call from an older person with frailty should reflect the potential underlying illness and not the symptom itself. It is not acceptable for ‘just a fall’ to be regarded as a non urgent situation without reviewing the patient in person.
A health and social care professional being asked to attend an older person with frailty in an emergency situation will therefore need to act according to the clinical condition of the patient. However, prior knowledge that the person has frailty- because of access to their previously agreed care and support plans - will help make appropriate decisions. Although ideally such plans will be shared electronically, it is important always to check with the person being assessed (and their carers if appropriate) to determine if there are any care plans and advance directives in the house.
- Assess clinical condition – measure vital signs and consider if any red flags are present which suggest the patient needs acute hospital care - such as hypoxia, significant tachycardia or hypotension (if possible compare readings with what is usual for the patient – these should be recorded in the care and support plan).
- Assess current function - can they get out of bed, can they walk, have they been able to use the toilet? Is there any evidence of a frailty syndrome – falls, immobility, new onset incontinence?
- Are they confused – is this usual (may need help from carers to assess this) or worse than usual? The patient may have delirium even if they have a prior dementia. This would also signal frailty.
If the patient is stable and at their usual level of function but has a temperature or evidence of delirium, they will need timely medical review but will not necessarily need immediate conveyance to hospital.
If a patient is not severely unwell but is unable to maintain their usual status quo in the community due to a temporary change in their care needs, it is good practice and better for an older person with frailty to transfer care to a responsive community service rather than admission to hospital. This could be either a rapid response type ‘hospital at home’, or a community based intermediate care service such as a ‘step up bed’. There will be some variation in local schemes.
A doctor assessing an older person with frailty as an emergency needs to strike a balance between being alert for serious underlying illness masquerading as a frailty syndrome and over medicalisation of common problems such as falls and dementia. For example, over diagnosis of urinary tract infection as a single cause for falls, immobility and delirium in older people with frailty is common and a judicious clinical assessment is required. If in doubt (i.e. the patient is not febrile and appears to be otherwise well) then a set of bloods to look for raised inflammatory markers should be done without necessarily conveying the patient to hospital.
There are many national guidelines on managing these problems; for example SIGN guidance for diagnosing UTI 18 and there should be local protocols which direct people to the local alternative for hospital admission.