Friday, 1 June 2018

Britain is a country awash with frail old men in hospital in need of a 'Frailty Risk Score'

In Britain, in England alone, 20% of hospital admissions in 2014–15 were among old men and women aged 75 years and over, accounting for around 40% of all days spent in hospital. Against this backgound a recent article in the medical magazine, 'The Lancet', published an article entitled :

'What proportion of older adults in hospital are frail ?' 

It began with : 'Despite the increasing level of knowledge about individual illnesses, modern health-care systems seem lost when seeing patients whose diseases come not one at a time, but all at once—especially when they come with equally complex social needs.' These are the old men and women who are labelled as 'frail.'

It made the point that disease-focused specialists, who push on with the only course they know, sometimes decry their frail patients as being "unsuitable" or "requiring social support"or "failing to cope or thrive." In addition, many hospitals and practitioners still somehow expect patients to present with primary complaints that give rise to well defined problems, which they can manage successfully using pathways that can be audited. An example might be an old man with acute stroke or heart attack.

It posited the case of medical a student on her first clinical rotation who encounters an old man with pneumonia. Most of what she has learned about pneumonia must now be set aside. If his case was uncomplicated he would not have been referred to speciality services, but given antibiotics and gone home. Her patient, however, :

* cannot give a history
* is not coughing
* cannot even sit up so that she can auscultate his lungs properly, something she knows she must do. r * does not have a fever or an increased white cell count
* has vague markings on the chest film which alone support the diagnosis.
* cannot go home

She might now turn to her teachers and ask : “What have you been teaching me about pneumonia if none of it works in the patients I'm supposed to see?” 

In time she will learn to recognise the delirium and immobility that are typical presentations in a frail patient with pneumonia. She will be able to ascertain whether the cognitive impairment and being bedfast are new and with this information, she will formulate a differential diagnosis and focused examination, and a pragmatic course of action - a care plan.

Her work might have been made easier if her hospital had planned for frail patients as part of what was expected of it. There is a growing body of opinion which says that hospitals must be encouraged to expect and thereby plan for frail patients as a part of what is required of them. To make this requirement clear, they need the right tools and one of those tools is the 'Hospital Frailty Risk Score' which provides hospitals and with a low-cost, systematic way to screen for frailty and identify a group of patients who are at greater risk of adverse outcomes and for whom a 'frailty-attuned approach' might be useful. On this basis frailty could be graded into 'low', 'intermediate' and 'high' risk.

Helen Roberts, Professor of Medicine for Older People at the University of Southampton, helped design and analyse the Frailty Risk Study. She said : “Frail older people admitted to hospital are at risk of deterioration in their physical and cognitive function but identifying this group of people is difficult. The Hospital Frailty Risk Score for the first time demonstrates how routine hospital data can offer a low-cost method of screening patients by frailty, to identify those at high risk of poor outcomes such as long length of stay, readmission or death, in all hospital departments. Implementing this score across hospitals could enable services to plan to meet the needs of frail people and improve their healthcare.”

Professor Simon Conroy, from the University of Leicester, commented : “It is hoped that by identifying and focusing upon this high-risk group that hospitals will be able to provide more holistic care to vulnerable older people to improve their outcomes.”

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