Proactive Ageing Well Service: Our Frailty and Anticipatory Team

Rocky Gill MPHARM PGDIP works as part of a multidisciplinary team within  the community looking after people with moderate frailty and unmet needs. The team aims to improve the quality of life of their patients and minimise the risk of hospital admissions. Rocky has an interest in pharmacy services for older people, with a focus on reducing polypharmacy burden via deprescribing and optimising pharmaceutical therapies.

Our team’s vision is to work in a proactive manner and identify patients living with moderate frailty who have unmet medical and social needs. Often, we find catching potential problems at a moderate frailty stage can significantly improve a patient’s quality of life and optimise their healthcare.

Our team on the ground consists of a specialist nurse, physiotherapist, and pharmacist. We also have a specialist consultant geriatrician who sits in our weekly multidisciplinary meetings and a specialist GP who manages the Proactive Ageing Well Service (PAWs).  

During a pleasant day in April last year, my colleague and I were visiting Maggie, an 82-year-old patient. We had previously spoken to Maggie on the phone during an initial consultation, in which she described problems such as falling over, decreased mobility, pain and struggles with a heavy medication burden.  

After some minutes of pressing the doorbell, Maggie’s husband Patrick answered the door and was pleased to see us but also very curious as he had not heard of a frailty service. He guided us up two flights of stairs to the bedroom where Maggie would spend the majority of her day, due to her decreased mobility. Maggie was pleased to see us and wanted to eagerly share the problems that she was dealing with. We started to talk to Maggie and noticed one of the main things troubling her was a pain in her lower back which reduced her confidence in being able to walk as she worried about the pain. Whilst talking about the pain Maggie become tearful, as she felt that her health was declining. At this point my colleague and I reassured Maggie that we would try our very best to improve her health which led to her feeling much brighter about the whole situation. This was the first time since the pandemic that she had seen a healthcare professional face to face. Following on from this, we discussed Maggie’s falls and dizziness which were very troublesome for her. Later in the consultation, we conducted a physical examination and checked Maggie’s observations. From this we found that Maggie had very swollen ankles, which may have been caused by Maggie sitting down for most of the day. Furthermore, we found her blood pressure was low for her age. At the end of the consultation, we summarised the points that we would be focussing on for Maggie and she was very open to all the help she could receive. We could see we had offered Maggie a glimmer of hope in a difficult period for her.

Following our initial assessment, I reviewed Maggie’s medication and noticed many changes which we could implement to optimise her healthcare. These changes included stopping her antihypertensive which was causing her low blood pressure and ankle swelling, switching her to a blood thinner that would not require her to have frequent blood tests every week as well as restarting her bone protection medication and replacing her Vitamin D. Furthermore, I discussed having a regular schedule of paracetamol for Maggie so that her pain was well controlled throughout the day. Being on top of the pain would allow Maggie to practise her walking and improve her mobility. Following this, we discussed Maggie’s case with our team’s physiotherapist as she would be a pivotal part in improving Maggie’s mobility and confidence. During physiotherapy visits, Maggie was given strengthening exercises and her mobility improved during follow-up visits. Interestingly, we found that Maggie had BPPV (benign paroxysmal positional vertigo) that was causing her dizziness, which was treated by our team using physical therapy.

Many older people can have similar problems to Maggie which, if not dealt with early, can worsen frailty. This is the beauty of proactive work, which can significantly improve an older person’s quality of life through the actions of a multidisciplinary team. It is our hope that more teams such as ours will be established to ensure all older people living with frailty can access this type of service regardless of their location.

NB: Names and some details changed to protect the identity of the patient.


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