Views And Reviews Acute Perspective

David Oliver: Frailty in acute care

BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i5195 (Published 29 September 2016) Cite this as: BMJ 2016;354:i5195
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com

The National Institute for Health and Care Excellence recently published guidelines on assessing and managing patients with multimorbidity.1 2 These placed distinct and welcome emphasis on frailty—adding momentum to several recent, professionally led good practice resources and guidelines explicitly highlighting the importance of frailty in community and acute care and showcasing services that work.3 4 5 6 7 8

Much nuanced research has been published on frailty as a clinical and physiological entity.9 10 11 It’s increasingly prevalent with older age but can affect people in their 50s. To oversimplify: two large schools of thought exist on how to characterise people with frailty. One is the “frailty phenotype” (with at least three of: slow walking speed, muscle weakness, unintentional weight loss, low physical activity, and self reported exhaustion).12 The other is an “accumulation of deficits” conception, where the more long term conditions or impairments someone lives with, the higher their frailty score or index.13

In either event, people with frailty tend to have poor functional or homeostatic reserve. When presenting to acute care, an illness episode, drug side effect, or metabolic disturbance, which might seem inconsequential in younger, non-frail patients, can present with steep and sudden functional or cognitive decline.14

Frailty syndromes are now central to hospital activity—not the geriatrics niche they once were

Very common presentations of acute illness in people with frailty include delirium, acute or sub-acute loss of mobility or functional independence, falls, or a non-specific failure to thrive or cope. These are also commonly associated with admission in frail people who presented to hospital in other ways.3 7 15

Older people with complex comorbidities account for an ever growing proportion of emergency room attendances, admissions, and hospital bed days. A validation study of an electronic frailty index, based on the number of conditions in over 200 000 patients in English primary care, has shown that frailty multiplies the risk of acute admission.16 Frailty syndromes are now central to hospital activity—not the geriatrics niche they were when hospital medicine was predominantly concerned with single system or infectious diseases in younger people.

We must make our acute care systems fit for frail patients. Simple, pragmatic case finding tools can identify them. Multidisciplinary comprehensive geriatric assessment can improve their outcomes well beyond admission.17 Early specialist review and a focus on early rehabilitation and discharge planning can be a win/win for patients and hospitals, reducing bed occupancy and facilitating earlier discharge.18

We also need a shift in values and language. These illness presentations are not atypical in older people with frailty. Nor are these patients “social admissions” or “acopic.”19 When hospital doctors use such ill informed terms, they are effectively failing frail patients who are now their main customers, and for whom more traditional textbooks and curriculums will no longer do.

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