Achieving better outcomes for frail older people
Transforming services for older people requires a fundamental shift towards care that is co-ordinated around the full range of an individual’s needs (rather than care based around single diseases) and care that truly prioritises prevention and support for maintaining independence. Achieving this will require much more integrated working to ensure that the right mix of services is available in the right place at the right time.
As people age, they are progressively more likely to live with complex co-morbidities, disability and frailty. People over 65 account for 51 per cent of gross local authority spending on adult social care (Health and Social Care Information Centre 2013c) and two-thirds of the primary care prescribing budget, while 70 per cent of health and social care spend is on people with long-term conditions (Department of Health 2013c).
The NHS has designed hospital medical specialties around single organ diseases. Primary care consultations and payment systems do not lend themselves to treating patients with multiple and complex conditions (Beales and Tulloch 2013; Roland 2013).
Common conditions of older age receive less investment, fewer system incentives, and lower-quality care than general medical conditions prevalent in mid-life (Steel et al 2008; Melzer et al 2012). There is substantial evidence of ageism and age discrimination in health and care services, ranging from patronising behaviour to worse access to treatment (Centre for Policy on Ageing 2009a, 2009b, 2009c).
In addition, capacity in the community for the intermediate care and support services that help older people to remain well, manage crises, and recover from acute episodes is hugely variable and generally inadequate for demand (NHS Benchmarking 2013).
Why Elderly care?
Age can be a legitimate factor in differentiating care and treatment – for example, when assessing the balance of risk and benefit in relation to the side effects of certain drugs. But from self-management support to psychological therapies, there is ample evidence that care and support for older people with long-term conditions is unjustifiably inequitable (Centre for Policy on Ageing 2009a, 2009b, 2009c).
Managing frailty is a key issue for modern health and social care services, yet it has been neglected in many local strategies for long-term conditions (Clegg et al 2013). Clinically, older people who are frail have poor functional reserve, so that even a relatively minor illness can present with sudden catastrophic functional decline – causing the person to fall, become immobile or rapidly confused, or to present non-specifically with failure to thrive (Clegg et al 2013). Identifying and supporting people who are frail therefore requires a focus of its own.
Comprehensive geriatric assessment (CGA) is a ‘multidisciplinary, diagnostic process to describe the medical, psychological and functional capabilities of a frail older person in order to keep a co-ordinated, integrated plan for long-term treatment and follow-up’ (Stuck et al 2002).
Some Key Facts
A total of 43 per cent per cent of people admitted to hospital non-electively are over 65, accounting for 53 per cent of all bed days (Health and Social Care Information Centre 2013a); people over 65 also account for 80 per cent of hospital admissions that involve stays of more than 2 weeks (Poteliakhoff and Thompson 2011). There is a more than threefold variation between areas in rates of emergency admission and occupied bed days for people aged over 65 (Imison et al 2012; NHS Atlas of Variation 2011).
In a typical 500-bed district general hospital, there will be around 200 patients over the age of 65 with mental health problems (100 with dementia, 90 with depression and 60 with delirium) (Royal College of Psychiatrists 2005). Patients with dementia stay in hospital for seven days longer than others (Alzheimer’s Society 2009).
Older people are more likely to stay a long time in hospital, to be moved while there, to experience delayed discharge, and to be readmitted within a month as an emergency (McMurdo and Witham 2013; British Geriatrics Society 2012a; Cornwell 2012).
Real Age Discrimination
Successive audits have shown consistent failures to provide even basic assessments or treatment plans for some of the common harms of hospitalisation such as falls, acquired infections, pressure sores, delirium, immobility and malnutrition (Royal College of Psychiatrists 2013; Royal College of Physicians 2010, 2011, 2012d; Healthcare Quality Improvement Partnership 2012; Royal College of Nursing 2011; Power et al 2012).
There is considerable evidence of ageism and age discrimination in secondary care, ranging from patronising attitudes or language, to older people being denied treatment on the grounds of age alone, to common conditions of ageing being neglected in service planning, priorities and training of staff (Centre for Policy on Ageing 2009a, 2009b, 2009c).
The Keogh Review found that many patients who suffer critical deteriorations while in hospital had physiological signs that were not recognised or acted on soon enough (Keogh 2013). Strategies to reduce avoidable unexpected mortality should therefore ensure that adequate priority is given to older people with complex needs, including physiological warning scores, critical care outreach, regular senior review, and adequate access to high- dependency beds. Older people must not be denied treatment such as emergency surgery, stroke thrombolysis or coronary revascularisation on the grounds of age alone.
What does the evidence say?
There is good evidence that specialist acute geriatric wards deliver higher-quality care with shorter lengths of stay and lower costs (Baztan et al 2009; González-Montalvo et al 2010; Ellis et al 2011).
Comprehensive geriatric assessment is most effective on consultant-led speciality wards with a resident multidisciplinary team (Ellis et al 2011). Specialist stroke units have consistently been shown to save lives and improve outcomes (Chan et al 2013).
While the precise service model will vary, all acute hospitals should consider creating acute medical units or spaces within them designed for the short-term assessment and stabilisation of frail older people, with a view to expediting discharge (British Geriatrics Society 2012b).
Service leaders should consider whether they have enough speciality beds to look after all frail older medical patients with complex needs, and enough consultant geriatricians, relevantly trained nurses and allied health professionals to deliver specialist care and assessment for them.
Given the case-mix of modern hospitals, it is likely that even with a large speciality inpatient bed base for geriatric patients, there will still be numbers of older people throughout general hospitals.
Proactive specialist ‘in-reach’ older persons’ assessment and liaison (OPAL) teams can be used to offer expert advice, follow-up and care co-ordination for older people throughout the hospital. OPAL models at St Thomas’ (Harari et al 2007) and Charing Cross hospitals (Nair et al 2008; National Hip Fracture Database 2013; Langhorne et al 1993) have contributed to improvements in clinical effectiveness and efficiency.
Proactive input from geriatricians working with multidisciplinary teams in the care of older patients with hip fracture has been shown to deliver a range of benefits (National Institute for Health and Clinical Excellence 2011b; National Hip Fracture Database 2013). Most patients with hip fracture are over 80 and many are frail, with complex needs.
Proactive geriatric liaison with older people undergoing surgery (POPS) models can also improve outcomes, reduce complications and shorten length of stay (Harari et al 2007; Dhesi and Griffiths 2012).
Future Hospital Commission The Future Hospital Commission established by the Royal College of Physicians (RCP) recognised, in its recommendations, the importance of care continuity and of named, accountable clinicians who can co-ordinate care (Royal College of Physicians 2013).
It also recommended that generalism be revived in hospital medicine to ensure continuity of care for patients with multiple conditions, and encouraged more widespread training in geriatric medicine (Royal College of Physicians 2013).
Senior, consistent supervision can also improve continuity and reduce length of stay. Minimising ward moves is an important part of providing continuity. Hospitals should have operational plans to reduce the number of ward moves, especially out of hours, with accompanying plans to mitigate their adverse effects on continuity of care for older people.
Falls assessment Falls – as the commonest safety incident in adults – merit especial focus, accounting for around 30 per cent of all incidents, with nearly 270,000 falls per year in English hospitals, and with the highest incidence in the over-80s.
They are a marker for how well we manage older people in hospital and can lead to serious injury, death, and prolonged hospital stay (Healey and Scobie 2007; Oliver et al 2010). Implementing best practice has the potential to reduce the rate of falls by around 20 per cent (Healey and Scobie 2007; National Institute for Health and Care Excellence 2013a; Cameron et al 2012).
Safe Discharge planning Poor quality discharge can lead to unnecessary readmission (Conroy et al 2013). Older people with complex needs, including long-term conditions and frailty, are at particularly high risk of readmission. Median rates of emergency readmission within 28 days are rising and stand at 14 per cent for people over 75, with major variation between acute hospitals (Health and Social Care Information Centre 2012).
Rehabilitation Older people should receive adequate rehabilitation and re-ablement when needed, to prevent permanent disability, greater reliance on care and support, avoidable admissions to hospital, delayed discharge from hospital, and to provide adequate periods of assessment and recovery before any decision is made to move into long-term care. Acute hospitals must play their part in ensuring adequate inpatient rehabilitation, but most rehabilitation services could be provided outside hospital settings.
Community hospitals rather than acute hospitals have been found to be a more effective setting for the rehabilitation of older people following an acute illness (Young et al 2007). Commissioners should ensure that there are enough beds and places for those requiring ongoing rehabilitation, including those needed to prevent people being admitted to acute hospitals. Commissioners should compare their provision and activity with localities with a similar demographic profile.
Long Term Care
Local service leaders should ensure that all older people for whom long-term care is being considered have a comprehensive assessment of need, adequate treatment of medical problems precipitating the decision to move, adequate rehabilitation and, wherever possible, are not moved into long-term care directly from an acute hospital setting.
Alternatives such as enhanced support at home, a move to age-friendly housing, carer support or end-of-life care at home should all be fully considered. Older people and their carers should be fully involved in decisions about future location of care.
End of Life Care
Older people who are nearing the end of life should receive timely help if they want or need it, to discuss and plan for the end of life. End-of-life care services should provide high-quality care, support, choice and control, and should avoid ‘over-medicalising’ what is a natural phase of the ageing life course.
The National Gold Standards Framework Centre (GSF) in End of Life Care provides comprehensive training programmes for staff combined with strategic support and tools that aim to ensure that end-of-life care services provide ‘the right care, for the right person in the right place at the right time, every time’ (see the Gold Standards Framework website).
The balance of evidence is clear that integration can improve people’s experience and outcomes of care, and deliver greater efficiencies (Curry and Ham 2010; Ham et al 2011; Goodwin et al 2013; NHS Future Forum 2011; NHS Confederation and Royal College of General Practitioners 2013).
It is important to recognise that achieving improvements for older people will also positively affect care for the rest of the population. More effective urgent care and post-acute rehabilitation and re-ablement services are important for people of all ages, while reducing inappropriate care and shortening acute lengths of stay for older people could release resources to meet other needs.
At the local system level, it will require leaders to set shared strategies and enable resources to be pooled across organisations. Innovations in commissioning and organisational forms such as family care networks may aid this (Addicott and Ham 2014). At the clinical or care team level, it will require shared information and new ways of working such as single assessment processes and shared care plans.