Silver Book II: Foreword and Introduction

Good practice guide
Good practices guides focus on providing information on a clinical topic.
Chris Carpenter
Jay Banerjee
Simon Conroy
Date Published:
22 February 2021
Last updated: 
22 February 2021

Silver Book II was written to address the care needs of older people, specifically older people with frailty, during the first 72 hours of an urgent care episode. It follows the first edition of the Silver Book which was published in 2012. This chapter sets out the context, scope and purpose of the publication.

It has been more than eight years since the original Silver Book was compiled. In the intervening period, the demographic predictions have continued unabated, and almost all health and social care professionals will be encountering older people at differing levels of frailty, on a daily basis. Our understanding of caring for older people has increased substantially, not least through the increasingly mainstream adoption of the frailty concept. A wide range of clinical teams are starting to think about how to better manage older people – witnessing, for example, the emergence of Perioperative Care for Older People and Geriatric Emergency Medicine.
Frailty is increasingly everyone’s business, so it seems timely to capture the latest concepts, not least to try and reach a common understanding of ’what good looks like’ in the care of older people in 2020 moving forwards.
As much as the clinical landscape has evolved, so too have methodologies for effecting improvement. Our understanding of improvement methodology has matured, as has our ability to deliver at scale, for example through large-scale collaboratives, such as the Acute Frailty Network (UK) and MOVE ON (Canada). In the world of research, care of older people with complex needs is now a key priority for national funders.

Simon Conroy

Professor of Geriatric Medicine, Leicester, UK

Chris Carpenter

Professor, Emergency Medicine, Washington University School of Medicine US

Jay Banerjee

Honorary Professor of Emergency Care, Leicester, UK

The original Silver Book has been downloaded over 200,000 times; we very much hope that the Silver Book II will act as a catalyst for yet more improvements in the care of older people living with frailty.

Assessing and caring for older people living with frailty is often not reflected in the education and training programmes of those working in the urgent care system. Hence there is the potential for a mismatch between population needs and health and social care system capability to meet these needs.

Silver Book II describes best practice, drawing upon international experts and consensus, supported by evidence. This executive summary distils the key message from each of the sections of which professionals need to be aware.

Frailty is a state of vulnerability that helps explain why older people with urgent care needs can experience major functional decline. It is easily measurable in the urgent care setting, for example using the Clinical Frailty Scale. Frailty prompts consideration of prognosis, and should be accompanied by holistic assessment (Comprehensive Geriatric Assessment) to generate the information necessary to embark upon a shared decision making progress. Frailty and illness severity together are powerful predictors of outcomes, so should be assessed at the first point of contact. Even in critically ill older people, such information should influence clinical decision making.

Comprehensive Geriatric Assessment (CGA) offers the best outcomes for older people with frailty; adapted approaches can be initiated and applied in the urgent care context, focusing upon what is urgent and important. The holistic assessment framework of CGA is a lens through which to identify and unpick geriatric syndromes, helping the professional to identify all causes (for example, of delirum or falls), and not just the most obvious. By ensuring that care addresses all of the issues, outcomes will improve. Importantly the CGA approach can be delivered by a multidisciplinary team with the right knowledge, skills and behaviours – it is not just about geriatricians! Different approaches to delivering CGA are required in different settings, whether that be primary care, hospital at home and/or rehabilitation, emergency care or the wider acute hospital (orthogeriatrics, perioperative care, cancer services, cardiology, etc). Aside from influencing clinical care, frailty and holistic approaches can also influence service design, environment and organisation – including disaster preparedness.

Recognising and being able to unpick the complexity of non-specific presentations is a particular skillset over which professional should seek to develop mastery – skillful management of delirium, falls, silver trauma, continence and skin integrity issues are likely to improve patient experience and outcomes. Important issues often underestimated in the urgent care context include mood disorders, substance misuse and elder abuse. For many older people with severe frailty and urgent care needs, the end of life can be measured in months rather than years, so being able to identify this state, and adapt from curative to palliative approaches is key.

Adapting the workforce and work environment to the needs of older people with frailty requires a methodology. Quality Improvement is an established approach with evidence of benefit and has the advantage of being inclusive and so promoting sustainable change.

Outcomes that older people with frailty typically value include autonomy, function and well-being among other true Patient Reported Outcome Measures (PROMs) – more so than service-orientated metrics such as length of stay. Systems that are able to capture PROMs and feed them back to clinicians, services and the broader system will start to truly focus upon the delivery of patient-centred care.

Each of these issues is discussed in more detail in individual sections of Silver Book II, and additional reading or on-line learning resources are included to allow individuals and teams to develop and optimise their care for older people with frailty and urgent care needs.

Despite much urgent care being delivered in the primary care setting, an increasing number of older people are attending emergency departments and accessing urgent care services. This is partly related to the demographic shift that has resulted in a rapid increase in the number of older people, but may also be due to lower thresholds for accessing urgent care.1 It is well established that most societies are ageing, but more importantly, associated comorbidity (including dementia) and disability are also set to increase.2,3 There are growing concerns for the safety of older people who are admitted to acute hospitals: older people are admitted to hospital more frequently, have longer stays and occupy more bed days in acute hospitals compared to other patient groups.1,4
Aims of the guide

The focus of this guide is on care for older people over the first 72 hours of an urgent care episode, with the specific remit to:

  • Help decrease variation in practice
  • Influence the development of appropriate services across urgent care systems
  • Identify and disseminate best practice
  • Influence policy development
  • The Silver Book II, like its predecessor, is a multiprofessional document, prepared by international contributors. It is not owned by any one individual organisation, but this version was initiated and sponsored by the British Geriatrics Society (BGS). The BGS hold Intellectual Property rights of the Silver Book II to prevent commercial exploitation.

  • The content and literature underpinning each chapter were authored by the international group, with the author for each chapter being expert on the subject, evidenced by their academic track record.

  • The authors have not referred to the hierarchies of evidence with regards to the different recommendations to avoid differential implementation, as recommendations are considered to be of equal importance.
Purpose and scope of this document
The scope of this document is to address the care for older people, specifically frail older people, during the first 72 hours of an urgent care episode. The document describes the urgent care needs of older people and the competencies required to meet these needs. It does not describe how these competencies should be commissioned and delivered, as this will vary according to local needs, resources and policies. The older person’s care needs might be delivered in the emergency department, the acute inpatient unit or a community setting depending on local service configuration but they need to be delivered as part of a whole systems strategy.
This document represents clinical best practice and suggested standards, written by clinicians for clinicians. This is the complete version of the Silver Book II, available as a web document on the BGS website; the intention is to allow readers to access sections of interest as and when the need arises.
The purpose of this document is to:
  • Help understand the issues relating to older people accessing urgent and emergency care in the first 72 hours irrespective of geographical setting and provider group
  • Describe the challenges of health and social care for older people at the interface between primary and secondary care, and pre-hospital and hospital care
  • Outline best practice in the urgent care for older people
  • Improve satisfaction and outcomes for older people and their families and carers in urgent care
  • Improve satisfaction and delivery of care by staff.

This report seeks to inform the following:

  • Policymakers: Departments of Health and related services
  • Commissioners: commissioning groups, health and wellbeing organisations, Accountable Care Systems and Organisations, adult social care, voluntary organisations and charities
  • Providers of services: family medicine practitioners, ambulance services, community-based services, acute providers especially emergency and internal medicine teams in hospitals, mental healthcare providers, voluntary sector, older people’s champions
  • Regulators of services at a national level in participating countries
  • Organisations with the remit to commission and deliver undergraduate and postgraduate specialist training for health and social care professionals
  • National professional bodies who are involved in providing care including those for older people.

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