NIHR Themed Review - Comprehensive care for older people living with frailty in hospitals

This review looks at the concept of ‘frailty’ in older people and what can be done to raise awareness amongst hospital staff, so that they identify and manage the needs of this group of people and avoid known potential problems. With the right support, patients can continue to live well at the end of their hospital stay.

This review features 53 studies funded by the National Institute of Health Research, which was set up to address the needs of the NHS. Thirty three of these studies have been published and have already changed the way hospital staff care for older people living with frailty. Twenty other projects are ongoing and will give us new understanding of how we can improve services for people living with frailty.

Whilst there are gaps in our evidence base and not all relevant research is captured here, this review should help healthcare staff make decisions with older people living with frailty. It may be of particular interest to staff in secondary care hospitals who do not have specialist training in older people’s care but look after patients with frailty on a day to day basis. It may also be useful to hospital managers, designing systems and allocating resources. This overview also paints a picture of what sort of research is taking place in the NHS and areas which need further investigation.

Assessment

Researchers have developed and tested a tool that uses data collected in GP practices to identify the most vulnerable older people living with frailty. Including this in the Summary Care Record could allow all secondary care hospitals to immediately identify the most vulnerable older people who come into their care.

Comprehensive Geriatric Assessment (CGA) by a multidisciplinary team and follow-on care planning reduces the number of people who are unexpectedly readmitted to hospital. CGA also increases the likelihood that an older person will be living in their own home up to twelve months later. For every 20 people assessed in this way, one long-term care home placement can be avoided.

Older people living with frailty can present to hospital with atypical symptoms and complex needs. Research shows that because of this, assessment in emergency departments can take more than four hours and models of care that reflect this may be more appropriate.

Identifying and managing symptoms associated with frailty in hospital 

Awareness of some of the symptoms associated with frailty, such as delirium, is very variable among acute hospital staff. Research is currently exploring how simple assessment tools might help with this.

A number of studies show that people living with frailty have better experience when cared for on specialised wards following CGA. There is mixed evidence about the impact outcomes.

Helping people to keep moving in acute hospitals is critical but challenging and researchers are looking at how using volunteers may help with this.

Preventing falls is complex and although technology such as pressure sensors can help, these devices do not make a difference unless it is part of a wider plan around how staff work with people at high risk of falls.

Older people are at risk of developing pressure ulcers and previous NIHR research has shown that many dislike alternating pressure mattresses, which are very often recommended as a result of risk assessments. A current randomised study is exploring whether high specification foam mattresses provide the same benefits.

Medication errors in prescription and administration can cause problems and pharmacist review of medicines within 24 hours of admission has been found to reduce inappropriate medication usage.

Discharge Planning

Researchers found that hospital staff need more support and training to assess the mental capacity of older people with cognitive impairment before their discharge.

Research co-produced with patients found that poor discharge planning caused considerable stress to families, and they recommend a mutually agreed written discharge plan.

There appears to be little difference in the cost or functional outcomes between older people’s rehabilitation schemes (although not stroke rehabilitation where a difference has been shown) in hospitals, care homes or a person’s own home, although researchers have found it difficult to compare different types of environment. More research is needed in this area.

Caring environments 

Older people living with frailty easily lose their independence in hospital, and staff must be vigilant around nutrition and hydration. Researchers have taken a simple, quick questionnaire originally designed for use in people’s own home and validated its use in hospitals. The questionnaire does not require physical measures such as height and weight which can be challenging to undertake with older people living with frailty. The results appear promising but it needs further testing.