1. People at the centre of health & care National Person-Centred Health & Care Programme
Care Experience Breakout Sessions
Trudi Marshall
Nurse Consultant Older People
NHS Lanarkshire
Older Person’s Pathway

2. What is Frailty? NOT ALL OLDER PEOPLE ARE FRAIL !
Charles Eugster, 91 year old. At the age of 87, he decided to take up body building to counter muscle loss.  Last year (2010) he won the Strenflex World Championship (an international fitness competition) in the over 80-age group with the highest number of points ever scored.  His winning performance featured 57 dips, 61 chin-ups, 50 push-ups and 48 abdominal crunches, each in 45 seconds! He states that he doesn't need Viagra nowadays (not that he took it before). And as a once-divorced widower he is looking forward to his next internet date. His last relationship was with a 72-year-old synchronised swimmer.

3. What is Frailty?
State of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for long-term care, and mortality.
Commonly used to describe older persons at increased risk for morbidity and mortality.
Typically involves alteration in multiple, not individual, body systems.
Syndrome associated with reduced functional reserve, impairment in multiple physiological systems, and reduced ability to regain physiological homeostasis.
(Fried, Ferrucci, Darer, Williamson, & Anderson, Morley, Kim, Haren, Kevorkian, & Banks, Bartali et al., 2006) 

4. Why is Frailty Important ?
Caring for frail older adults is difficult and challenging because they have an increased burden of symptoms, are medically complex, and often have increased social needs. (Espinoza & Walston, 2005)
Frailty is a strong predictor of several negative outcomes including disabilities, institutionalization, and mortality. (van Iersel & Rikkert, 2006) Frailty has also been linked to acute illness, falls, and increased vulnerability. (Espinoza & Walston, 2005)
The identification of frailty in its early stage is important because interventions may potentially prevent, or delay the clinical consequences of frailty. (Bartali et al., 2006)
Screening for frailty and assessing levels of frailty in older adults can identify those most vulnerable and assist in targeting nursing interventions.

5. Comprehensive Geriatric Assessment (CGA)
Social Circumstances
informal support available from family or friends
social network such a visitors or daytime activities
eligibility for being offered care resources
Medical
co morbid conditions and disease severity
medication review
nutritional status
problem list
Environmental
home comfort, facilities and safety
use or potential use of telehealth technology etc
transport facilities
accessibility to local resources
Functioning
basic activities of daily living
gait and balance
activity/exercise status
instrumental activities of daily living
Mental Health
cognition
mood and anxiety fears

7. Well established MDT approach
In depth MDT assessment
Recognition of frailty
Discharge planning

8. ACE Nurse
Screening - signposting
CGA
AMT, functioning, social, urinalysis, L+S BP, Falls history, Meds reconciliation
Supporting discharges
Getting the assessment of older people right in the AMU has the potential to improve outcomes, reduce inappropriate hospitalisation, and potentially reduce the need for long-term care. (RCP, 2012)

9. Impact
Over 85% of frail older people reaching speciality beds within 24 hours (prev 40-60%)
All patients who require L&S are now having this assessment undertaken (prev 5%).
Over 90% of AMT’s are now being completed (prev >5%)

10. Impact
Reducing the average length of stay of emergency or unplanned admissions
Reducing emergency inpatient bed days for people over the age of 65years
Improving the quality of the patient care experience
Supporting the increase in the level of older people with complex care needs receiving care at home
Supporting “Shifting the Balance of Care”

11. Staff feedback
“The nurse post in the emergency receiving unit makes a big difference to thorough assessment and early intervention for older people, we feel more informed and more in control of the acute care group.” (Consultant Geriatrician).
“The nurse often finds out from carers/ relatives which community pharmacy the patient uses and if they use a compliance aid. This is vital knowledge for discharge and allows the ward pharmacists to contact the community pharmacist on discharge and communicate changes made. They also identify patients who are having difficulties which allows me time to resolve these problems which were previously often only identified on discharge.” (Pharmacist)