Keeping Up to Date with Frailty Related Issues

This is the last post in the Frailty Matters Coaching and Teaching programme which you have all been participating in. Frailty and the care of people with frailty, like all areas of health and social care is an area constantly being researched and best guidance on care as a result changes. It is important therefore to keep up to date with what is going on in Frailty care and management so that you and your team continue to deliver the best care possible. So this post is going to offer a few tips for keeping up to date.

The first resource to mention is one that we have used already within the programme, which is the British Geriatric Society Frailty Hub https://www.bgs.org.uk/resources/resource-series/frailty-hub The Hub was created in June 2020 and will be the place where the BGS will hold its national guidelines and best practice relevant to frailty. The BGS also have their own Journal Age and Ageing and on their website they host a collection of articles from the Journal that looks at Frailty in older people. You can access their collection at https://www.bgs.org.uk/resources/age-and-ageing-collection-frailty-in-older-people

The Royal College of Nursing (RCN) also host a a page on frailty where you will find advice and resources on identifying frailty in older patients and choosing the right interventions to help manage their condition. See: https://www.rcn.org.uk/clinical-topics/older-people/frailty

They also have a larger frailty resource held on their magazine website called the RCNi frailty resource collection. https://rcni.com/features/frailty-resource-collection-84906 This is not open access however, you need to be subscriber to one of the RCNi Magazines listed here. https://rcni.com/journals to get access to their online materials.

NHS England has two specialist groups that deal with frailty issues. They are the Acute Frailty Network. Their ‘Guidance and Resources’ pages in particular are useful and worth keeping track of. https://www.acutefrailtynetwork.org.uk/

There is also the NHS Specialised Clinical Frailty Network. on this site you will find a range of tools and resources to support the improvement of NHS specialised services for older people living with frailty.

On the Royal College of GP’s website there is a toolkit that provides a collection of relevant tools and information to assist primary care teams to implement a six-step model of collaborative care and support planning which is very useful for supporting the care a number of patients groups including adults living with frailty. See: https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/collaborative-care-and-support-planning-toolkit.aspx

It is also worth noting that Health Education England, NHS England and Skills for Health provides a single, consistent and comprehensive framework that sets out the skills, knowledge and behaviours expected of any person who is involved in the care and support for people living with frailty. https://www.skillsforhealth.org.uk/images/projects/frailty/Frailty%20framework.pdf?s=form which may prove useful when you are considering your own development and that of the members of your team.

Finally it is worth occasionally using the following terms in Google from time to time just to see what is produced by the Cochrane Library Database of Reviews. They don’t have a specific frailty collection yet but they do very frequently review topics of interest to health and social care professionals looking after people living with with frailty. Search Using “Cochrane Library Frailty” in Google and see what comes up.

Additional Teaching/Learning Resources

When planning the sessions coaching sessions for this project there were two ‘guests’ we were going to invite to discuss their work with you, Janis McDonald who is the Chief Officer of Deaf Scotland who was going to discuss frailty and hearing and sight loss and Alison Bunce, the Programme Lead for Compassionate Inverclyde who is a Queen’s Nursing Institute Nurse. See https://www.qnis.org.uk/queens-nurse/alison-bunce/ who was going to discuss Compassionate Inverclyde with you.

Since they were unable to speak to you in person online they decided to record what they were going to discuss for you to watch. Both videos are below.

The second video is below:

So far in the programme we have been using text and video resources but there are a number of resources that exist in podcast form that we have not utilised. Podcasts tend to be a bit longer than video resources but you can download and listen to them in your own time. So you can listed to them from your ‘phone, on a smart speaker, on a walk, in the car etc.. You can of course also listen to them and share them with your own team and as they tend to be published in series, then you and your team members can listen to those you/they want to hear or feel are most relevant at the time.

The first series we are going to point you to are a series of podcats from Eat Well Age Well is a national project tackling malnutrition in older people living at home in Scotland. Eat Well Age Well is brought to you by award winning Scottish Charity Food Train. The website for the project is at https://www.eatwellagewell.org.uk/

To access the first blog press play below

Their podcasts are all about sharing and discussing how we can support older people in Scotland to eat well, age well and live well. See https://anchor.fm/eatwellagewell#:~:text=Eat%20Well%20Age%20Well%20is,age%20well%20and%20live%20well.

The Royal National Institute for the Blind also have a series of Podcasts to aid in supporting people with sight loss. There are three different podcast series, focusing on:

Each podcast is less than 15 minutes long. They are designed for older people living with sight loss as well as those family members, friends and carers who support them, as well as anyone who supports and helps adults with complex needs – both in a home or care setting.

Another larger podcast resource which has a wider remit than just frailty is a resource called MDT Education on Ageing: which has been designed for anyone working with older adults. They are part of a podcast family of site called the Hearing Aid Podcasts. You can access all of their podcasts (there are 9 series) at http://thehearingaidpodcasts.org.uk/

A guide to all their podcasts can be found at http://thehearingaidpodcasts.org.uk/previous-series/

Covid-19 and Frailty

During this pandemic, older people living with frailty and long-term conditions will continue to experience episodes of ill-health, falls or other unforeseen events. While COVID-19 will be the main concern for the healthcare system as a whole, much of the care that community and social care teams provide will be the routine care that they always provided. Efforts will be made to provide more care at home or in community settings, keeping older people out of hospital until it becomes necessary.

A key reason for this is that frailty is a strong predictor of adverse outcomes for older people hospitalised because of COVID-19 infection. A study of an acute hospital ward in Greater Manchester has shown how risk of death from COVID-19 increases with age, frailty and comorbidity. The study which you can access here examined the outcomes of 215 patients with COVID according to age group and levels of frailty, 86 of which sadly died. Tragically, 16% of the patients who were younger than 65 years died, 37% of the patients aged 65 to 75 years died: 53% of the patients aged 75 to 85 years died , and 62% of the patients aged above 85 years died. Frailty was measured using the Rockwood Clinical Frailty Score which scores people from 1 (very fit) to 9 (terminally ill), 16% of patients with a score of less than 5 died, 42% of patients with a score of 5 died, 67 % of patients with a score of 6 died, 82% of patients with score of 7 and 8 died, and 100 % of patients with a score of 9 died early. There is no doubt that avoiding the illness if you are over 65 and frail is the most effective strategy until there is a widely available effective vaccine.

It is highly likely that some older people you are looking after will unfortunately die from this disease or will die with this disease from their underlying health conditions over the coming months. It is important to remember that while older people are the most likely to be seriously affected by COVID-19, many will recover from it. Treatment for the virus must be determined by clinical need and best evidence and not by age alone.

It is worth noting also that there is a growing body of evidence that indicates that COVID-19 can occur with atypical presentations, especially in older people. For example in Italy, 24% of COVID-19 patients who died during pandemic had no fever, 27% had no dyspnea, and 61% had no cough. There are also descriptions of older people with COVID-19 presenting with a history of falls or delirium suggesting that there is a need for an early assessment of frailty in the community and careful monitoring of physical and cognitive status during this current period of social restriction In addition, the lack of physical activity in those restricted or those sheilding may be contributing to muscle mass loss, weakness, and falls, as well as having an impact on their mental health status. Again early assessment of frailty can be extremely useful to identify frail people who at risk of deterioration due to these factors.

Finally, people recovering post-COVID-19 may still exhibit extra-pulmonary manifestations, including neurological, cardiovascular, and musculoskeletal disorders increasing their likelihood of frailty or worsening already existent frailty. Hence, most of the older people post virus may require functional, neuromotor, respiratory, and cardiac rehabilitation, which all warrant frailty assessment. 

The key message in all of this is that frailty assessment which is being encouraged by NICE for all older adults being admitted hospital is equally and perhaps more valuable for all people in the community at risk from the COVID-19 virus. It should perhaps be considered as a vital sign, at least until the current crisis is over.

On a practical note it also worth noting that the British Geriatric Society have compiled a page of resources for keeping older people safe at home. It is particularly relevant for shielding and isolated older people but also applies more generally to older people who live without assistance in their own homes and might be exposed to other risk factors or hazards. You can find it at:

https://www.bgs.org.uk/resources/keeping-older-people-safe-and-well-at-home

They also have a page of wider advice designed for health and social care professionals which can be found at : https://www.bgs.org.uk/resources/resource-series/coronavirus-and-older-people

Guidance for providing care and support at home to people who have had COVID-19 was published by the Social Care Institute for Excellence (SCIE) this week (14th of November 2020).You can find it at:

https://www.scie.org.uk/care-providers/coronavirus-covid-19/home-care/recovering-at-home

Palliative Care in Frailty

Ask any community nurse and they will say that delivering care for patients who are considered palliative is one of the most satisfying parts of their job.   This is not surprising when the main aim of palliative care is to relieve suffering and to improve the quality of the person’s life.  Traditionally,  the focus of palliative care was on those with a terminal diagnosis of cancer where a clear trajectory is more predictable.  However, frailty is a complex long term condition with a less predictable end trajectory and as such, it becomes more difficult to identify when palliative care should be considered. 

The following diagram was created from stakeholder and focus group discussions in an attempt to develop a short term palliative support model for older people with frailty.  It illustrates the unpredictable illness trajectory associated with frailty  highlighting opportunities for a more integrated and palliative approach and a need to anticipate support and care across this journey.

from Bone et al (2016)

In earlier posts on this site, we have discussed the complex care and support needs for people across the frailty trajectory, but when should we consider palliative care?  If you are not clear about when this is, ask yourself; “Is the patient at risk of missing out on very important elements of their care as they head towards the end of their life?” When asking, you must also consider the patient’s family as they could also be deprived of the opportunity for improved support at this time.

There is an argument that palliative care should commence on diagnosis of any life limiting condition.  This is to allow individualised care and support planning and optimal symptom management as well as the opportunity for early anticipatory care planning discussions.  Add frailty to this and consideration should also be given to the person’s physical, psychological  and possible cognitive decline as well as their expected inability to bounce back from episodes of acute illness.

Does the surprise question apply in this situation?  There is some evidence to suggest that the ‘surprise question’ is useful in identifying when the patient would be considered palliative or would  benefit from palliative care support (White et al 2017). The surprise question involves any healthcare professional asking themselves “ …would you be surprised if this person were to die (within a specified time period) such as within the next 6 months or within a year”.   This type of question has now been incorporated into a number of clinical guidelines as well as the Gold Standards Framework    https://www.goldstandardsframework.org.uk/

If this is the case then you should be considering comfort measures for the patient including de-prescribing of unhelpful medications, a focus on symptom management within the context of a comprehensive geriatric and palliative care assessment, good communications and family support.  Please check out the excellent BGS resources highlighted in the end of life blog.

Bone, A.E., Morgan, M., Maddocks, M., Sleeman, K.E., Wright, J., Taherzadeh, S., Ellis-Smith, C., Higginson, I.J., Evans, C.J. (2016)  Age and Ageing, 45, (6), pp. 863–873, https://doi.org/10.1093/ageing/afw124

Hamaker, M.E., van den Bos, F., Rostoft, S. (2020) Frailty and Palliative Care. BMJ Supportive and Palliative Care, 10: pp. 262-264. doi:10.1136/bmjspcare-2020-002253

White, N., Kupeli, N., Vickerstaff, V., Stone, P. (2017) How accurate is the ‘surprise question’ at identifying patients at end of life? A systematic review and meta-analysis.  BMC Medicine, 15:139 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540432/pdf/12916_2017_Article_907.pdf

End of Life Care in Frailty

There is little need for us within this project to write about end of life care in frailty because an extensive, near comprehensive and free to access resource on this topic prepared by the British Geriatrics Society (BGS) already exits.

Rather than condense what this resource says we will just introduce it to you. The aim of the BGS guidance is to support clinicians and others in considering the needs of and providing high quality care for frail older people as they move towards the end of their lives.  It sets out to prompt and support timely discussions about preferences for care, ideally at a time which facilitates the input of the older person themselves. They hope their guidance will provide practical advice to help staff working with frail older patients so they can provide them with the best opportunity to live and die well. 

You can access this resource at: https://www.bgs.org.uk/resources/resource-series/end-of-life-care-in-frailty

It is worth noting that in the BGS End of Life Care in Frailty resource, where it discusses Advanced Care Planning refers you to the Advance Care Planning Resource for England and Wales at http://advancecareplan.org.uk/

Scotland has its own Anticipatory Care Planning Resource which has an earlier focus designed to give control to people with long term conditions control over their management plans at an earlier stage than end of life. You can find the Scottish Resource at https://www.nhsinform.scot/campaigns/anticipatory-care-planning

There is also an Anticipatory Care Planning Toolkit available at Healthcare Improvements iHub. See https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/

They have also produced a number of videos about Anticipatory Care Planning of which this one, Anticipatory Care Plans (ACP’s) in a Care Home may have the most resonance when you consider ACP’s for the frail people that you encounter.

You can watch it here.

Frailty and Falls

This post will look at falls which is one of the most written about topics in relation to the care of older people and people living with frailty.

The reason for this are quite clear. With an ageing population and more people living longer with complex health needs falls present an important challenge. In Scotland in 2017–2018, over 37,000 people – 22,400 of whom were over the age of 65 – were admitted to hospital because of a fall.

The Scottish Government have stated that we all need to do more and offer opportunities earlier in the lifespan to help older people age healthily to avoid or postpone the time at which they may fall or sustain a fracture.

Frailty can contribute to falls and result in a person making a slower or poorer recovery following a fall. Conversely, a fall can trigger or accelerate the progression of frailty. Some actions and approaches to prevent falls will also help prevent or slow the progression of frailty. These include being physically active and less sedentary, improving muscle strength and balance, promoting continence, and ensuring good medicines management and adequate nutrition.

The following SWAY presentation looks at the issues involved in managing frailty and falls in the community we hope you find it useful

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It is worth noting that the Scottish Government was consulting on a new ‘National falls and fracture prevention strategy for 2019-2024.’ which has not been published yet. The consultation document is at https://www.gov.scot/publications/national-falls-fracture-prevention-strategy-scotland-2019-2024/pages/1/