Friday night, admissions unit is where we first met Cathy……
I say met; we heard her before we met her – Cathy was shouting out, incoherent, clearly agitated. In her room, we found a tiny lady lost in a huge nightie, scrunched up on the bed, clinging onto the bedrail. Cathy was 95, frightened and distressed.
Cathy had been transferred from another hospital, for assessment of pain. It was impossible to know if Cathy was in pain or not – she couldn’t tell us.
We looked at her notes…
With a diagnosis of dementia and arthritis, Cathy had been living fairly independently with carer support, hadn’t been in hospital for some years.
A few weeks before, carers worried that Cathy may have fallen, an ambulance was called. Cathy went to ED – no broken bones, but concern that Cathy couldn’t mobilise safely resulted in admission.
Over the next 6 weeks, Cathy was moved seven times between three different hospitals, from community to acute and back; staff worried about pain, falls and possible injuries, worried they were missing something, worried that more tests were needed…
Over this time, staff reported increasing difficulty with Cathy’s behaviours and confusion; she was distressed, agitated and uncooperative. Other patients were frightened. Staff felt unable to manage. Cathy was prescribed sedation.
Cathy by now was very confused, unable to communicate what she needed, not eating, not drinking. She had become incontinent.
Back to Friday night…….
The sight of Cathy was heart-breaking; crying out, unable to tell us why, unable to understand what we were doing. She was dehydrated, in pain and encumbered by various medical contraptions.
We talked to Cathy’s family. We decided that Cathy didn’t need any more interventions or hospital moves. We did our best and made her comfortable.
Cathy died six days later…
Cathy, like many people admitted to hospital, was frail; she was frail before she came to hospital that first time.
If we had recognised her frailty at the hospital’s front door and intervened, well, perhaps Cathy’s story might have been different – different conversations, different interventions, different decisions and different plans made.
We talk a lot about frailty but it’s not always easy to explain or to understand. Frailty is one of those words that get bandied about but what do we mean when we call someone frail?
The dictionary definition is “the condition of being weak and delicate”, something we all feel at times, but not really helpful in identifying frailty in our patients.
Within medicine, after years of vagueness and uncertainty, we have defined frailty as “the reduced ability to withstand illness without loss of function”.
A minor illness or injury, that would be no more than troublesome to you or I, affects a frail person more profoundly, leaving them struggling to walk, to wash or to dress, to eat or to communicate.
In reality though, how do we recognise the frail patient? Does it matter? Does it make any difference?
Age alone does not make people frail – people don’t become frail simply because they live too long. Frailty doesn’t come with a diagnostic test, but there are signs we can look for – older people, with cognitive problems, mobility problems or functional problems, people on many medications or who live in care homes. People who present to us with falls, incontinence or confusion.
“Frailty is everyone’s business”
The population is getting older and frailer, particularly here in Dumfries and Galloway.
Older, frail people have higher demands on health and social care services and more unplanned hospital admissions. Once admitted, frail people are more susceptible to hospital-acquired infections, delirium, nutritional problems, falls and skincare issues.
In comparison to other patients, frail elderly patients are more likely to have prolonged hospital stays, to lose their mobility and functional abilities; they are more likely to be admitted to residential care, more likely to die.
I am a geriatrician. I’m not at the glamorous end of medicine and I don’t have a bag full of fancy equipment, tests and treatments. But within our medical specialty, we do have one intervention that has been shown to improve outcomes for the frail elderly –Comprehensive Geriatric Assessment
CGA means that frail older people are much more likely to be well and living at home 12 months after admission, and much less likely to be admitted to care homes or to die within those twelve months.
CGA is a multidisciplinary assessment of a patient and their physical, psychological and functional needs. It allows us to develop a personalised, holistic and integrated plan for that patient’s care, now and in the future. We think about how patients walk, talk, eat, drink, see, hear, think, remember, socialise, mobilise, and take their medications. We think about how we can make all of those things better and easier for frail elderly people and their carers and families.
We all need to understand and recognise frailty. Think about it, see it and talk about it, and allow a person’s frailty to influence decisions for their care and future.
Over 18 months we are working collaboratively with other health boards and Health Improvement Scotland to improve recognition of frailty at the front door.
Hopefully, if we get it right we can influence a better outcome, one that recognises and considers the specialist needs of our frail elderly people, one that supports them to continue to live happily and safely in a place that they can call home…
“We’ve put more effort into helping folks reach old age than into helping them enjoy it…”
Frank A. Clark, American Politician 1860-1936
Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary.