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.

Mental Well-being in Later Life

Much of the literature on Frailty has focused on physical health, however mental health including cognition, sleep, social interactions and positive aspects like well-being are just as important.

In 2014 in the UK general population about 300 in every 1,000 people experienced mental health problems. Of those 300 people, 230 visited a GP and 102 were diagnosed as having a mental health problem. For people with frailty who are at higher risk of mental ill-health, these figures will to be higher. National Surveys of NHS patients indicate that approximately 91 per cent of people with a mental health problem are treated within the primary care system, meaning that very few are referred to specialist mental health services. Figures also suggest that at least 25% of individuals with symptoms of mental health conditions such as depression and anxiety do not report them to their GP. People living with frailty will behave similarly. There is also an assumption by some that mental health problems are a ‘normal’ aspect of ageing, but most older people don’t develop mental health problems, and they can be helped if they do.

Healthcare professionals in the community are ideally positioned to make a difference. Age UK has identified key steps that every healthcare professional can take:  

  • Remember that mental health is just as important as physical.
  • Try to get into the habit of asking about the emotional well-being of the people you see. 
  • Look out for signs that your patients are struggling with their mental health. 
  • Start the conversation. It can seem awkward bringing up mental health but older people do say that they want to be asked and find talking useful.    
  • Think about language. Older people can be put off by terms such as mental health and depression. Try to use more informal language. 
  • Remember mental health problems are not inevitable. With the right support older people can recover. 

We have looked at two of the biggest causes of mental illness in frail older people already. See the earlier post on Loneliness which is at http://frailtymatters.uws.ac.uk/2019/12/04/the-value-of-social-support/ and our post about Dementia which is at http://frailtymatters.uws.ac.uk/2020/02/27/dementia-some-guidance/

One of the main issues we have not examined relating to mental health is DEPRESSION. It has been estimated that 1 in 4 older people have symptoms of depression that require treatment, but fewer than 1 in 6 older people will seek help. Care home residents are also at an increased risk of depression. Depression in later life can be a major cause of ill-health and can have a severe effect on physical and mental well-being. Older people are particularly vulnerable to factors that lead to depression such as bereavement, physical disability, illness and loneliness. Depression in older people can be treated effectively through talking therapies and antidepressants. See the NICE Clinical Knowledge Summary on Depression mentioned below. Effective interventions to prevent depression in older people include reducing loneliness and isolation through encouraging learning, physical activity and any form social interaction including volunteering. Many of these are difficult at this time but a useful guide to ‘Keeping Well at Home’ which was devised for all older people whose interactions are restricted currently because of COVID-19 has been produced by the Healthy Ageing Research Group at Manchester University. You can download the booklet at http://documents.manchester.ac.uk/display.aspx?DocID=49104

There is limited guidance from the Royal Colleges for those in primary care on what to do to maintain older people’s mental well-being but there is NICE guidance that you can refer to. NICE Guideline 32 is all about mental well being and independence in older people and there is also a NICE Quality Standard 137 which is on the same topic. You can look at the NICE flowchart and download both documents at

NICE (2020) Mental wellbeing and independence in older people overview: Interactive Flow Chart

You might also find the following NICE Clinical Knowledge summary on Depression useful. https://cks.nice.org.uk/topics/depression/

England (2014), writing for the Royal College of GP’s has stated that community practitioners need to take responsibility for coordinating and signposting to services beyond health care, in particular social care, housing and benefits to effectively tackle mental well-being in older people. The more collaborative form of working integrated care heralds will move community staff from gatekeepers to that of navigators. Community healthcare workers need to take responsibility for co-ordination and signposting to services beyond health care and builds bridges with many community services, patients’ families and their communities, if improving the mental welfare of our older people is the goal.

If you want to know more about this topic an intersting report to read is by Lee, M. (2006) Promoting mental health and well-being in later life: A first report from the UK Inquiry into Mental Health and Well-Being in Later Life. London, Age Concern & Mental Health Foundation. 

The report highlights discrimination; participation in meaningful activity; relationships; physical health and poverty; as important parts of promoting mental health and well-being that also need to be considered

Looking After Yourself and Your Team during COVID-19

This may be the last Blogging piece for a while but the project and this Blog will resume in due course. In the meantime we thought we should leave you with some resources that you and your team can turn to and try out in the coming weeks as this unprecedented, once in a hundred years, health crisis continues.

The first thing that we would like to share is some timely advice from the Queen’s Nursing Institute, Scotland (QNIS) from Hilda Campbell, Chief Executive of COPE Scotland and QNIS Honorary Fellow has provided the following wee ideas of things that could help you look after yourself and create some ‘me time’. Even if it is just a few minutes. You can access Blog here

It also includes other links within it which are worth following up. It would also be a good idea to share this resource with all the staff that you are working with.

The next resource we are going to suggest is from the Kings Fund and it looks at compassionate leadership in this time of crisis. it discusses the idea of an ABC of compassion at work, suggesting that leaders need to help provide Autonomy and Control, a sense of Belonging and a promote feelings of Competence. working in a compassionate way will aid in supporting your whole team through this stressful time. For more about this see: https://www.kingsfund.org.uk/blog/2020/03/covid-19-crisis-compassionate-leadership

On a similar theme this is a paper recently published in the BMJ by Greenberg N., Docherty M., Gnanapragasam S., Simon W. (2020)  Managing mental health challenges faced by healthcare workers during covid-19 pandemic BMJ; 368 :m1211 You can access it here.

https://www.bmj.com/content/368/bmj.m1211

The paper looks at measures that healthcare managers need to put in place to protect the mental health of healthcare staff having to make morally challenging decisions. Its brief and well worth reading particularly about aftercare; what needs to happen once this crisis passes.

Currently NHS staff are also being granted free access to a number of mental health apps to support their health and wellbeing as they work around-the-clock to treat coronavirus patients.

The apps, which include platforms to proactively improve mental health as well as sleep improvement programmes, will be freely available until December 2020.They include Unmind, a platform that provides a range of tools to help with stress, sleep, connection and nutrition; Headspace, a mindfulness and meditation app aimed at reducing stress and building resilience; Big Health’s Sleepio, a clinically-evaluated sleep improvement programme, and Daylight, a cognitive behavioural technique to manage worry and anxiety. You can access them all via this page of the NHS Employers website https://www.nhsemployers.org/news/2020/03/free-access-to-wellbeing-apps-for-all-nhs-staff

The final resource and perhaps the most important is to be found on the Scottish Association for Mental Health (SAMH) website. They have collected together all the resources that can help and protect everyone’s’ mental health and wellbeing as they cope with the stresses brought about this pandemic and the stresses caused by of social isolation. We would urge to make use of this site and please share it with all your staff and patients 

https://www.samh.org.uk/about-mental-health/self-help-and-wellbeing/coronavirus-and-your-mental-wellbeing

That’s all for now folks and we hope to see you all safe and well when things start to get back to normal.

Dementia: Some Guidance

Caring for people with dementia in the community is one area which is currently expanding. Recently the Alzheimer Europe calculated that with an increasing, and increasingly ageing, UK population the overall numbers of people with dementia; estimated in 2018 to be 1,031,396 will by 2050 be 1,977,399. A rise from 1.56% of the overall population to 2 .67% in 2050. There is pressure therefore to get this right now ahead of this expansion.

There is no clear way to provide all the people and their carers who require support with what they will need, so new ways to provide effective care need to be considered. This blog will look at 3 existing resources that are already being used in Scotland.

The first resource we suggest that you consider using is the winner of the Scottish Digital Health and Care Award 2020; which was NHS Lanarkshire’s Online Post Diagnostic Support Website which you can access from HERE

Two things to be aware of before you go to the site. It might have been designed for people receiving post diagnostic support but the information and advice is far more extensive than this. It has been tailored to suit Lanarkshire, so some sections discuss services and processes available in Lanarkshire which may or may not be available within the NHS Ayshire and Arran area.

The advantage of using this resource is that the information that it provides is validated and conforms to NHS Scotland standards (the information sources and hwere to get more information are all ij the links given within the site). There is 24/7 access to information which you can return to easily. People living with dementia and their carers can all access it when desired. It can be used to enhance staff knowledge of dementia, post diagnostic support and the services which might be available to improve people’s support and experience.

Topics the resource covers include understanding the illness, Power of Attorney, Driving, Anticipatory Care Planning, support for carers and lots more. Please explore this resource and use as you see fit. Note that the easiest way to find the site is to type “Dementia NHS Lanarkshire” into Google.

The second resource you should consider using is the Social Care Institute for Excellence (SCIE) Dementia Gateway. The Dementia Gateway provides access to information, guidance, resources and training for anyone supporting people with dementia. It is a very extensive resource and worth taking a bit of time to explore. There is so much on it designed to be utilised by health and social care staff in the community both as a resource and as education that you will find something your team can utilise very quickly. A note of caution though. It has been designed for England and Wales which is particularly important when the information given refer to English legislation. You can access the Gateway HERE.

The third resource we suggest that you look at is work done by the “Focus on Dementia” Group who are part of Health Care Improvement Scotland. They are currently working on improving care co-ordination for people with dementia and their carers so that this becomes more integrated.

Their work can be found at https://ihub.scot/improvement-programmes/focus-on-dementia/integrated-care/ They have set about trying to identify the critical success factors for integrated care co-ordination of people with dementia in the community. The focus of their work has been Midlothian. Their overview of the Dementia Care Co-ordination Critical Success Factors is available on the site and is discussed in the video that you will find there. A more detailed report on the critical success factors is due to be published but the list of factors is something you might already be able to use. There is also other work done by Focus on Dementia that you can access from this site.

The Value of Social Support

In class yesterday we looked at the value of social support and the damaging effect of loneliness even without the addition of frailty. Social support is the perception and actuality that one is cared for and has assistance available from other people. It requires you to be part of a social network. These supportive resources include

Appraisal support: Information that is useful for self-evaluation; like what should I wear? Should I buy this?

Informational support:  Advice, suggestions, and information

Instrumental support: Tangible aid, for example lending or giving you money, help if you broke your leg, or a service like babysitting for you.

Emotional support: Expressions of empathy, love, trust and caring

Social support can be measured as the perception that one has assistance available, the actual received assistance, or the degree to which a person is integrated into a social network and/or their local community. Support can come from many sources, such as family, friends, pets, neighbours, co-workers or via external organisations.

Below is the Sway that we discussed in class which focuses on tackling loneliness

The BBC Scotland Documentary that was mentioned during the day was called the “Age of Loneliness” and was made in 2016. Its not currently available on the BBC iPlayer but there are many clips from it scattered across the internet. This is the director Sue Bourne discussing making it.