Frail Elderly: The Physiotherapist's Role in Preventing Hospital Admission

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Introduction

This 10 hour online learning resource is tailored towards final year students and newly graduate physiotherapists, aiming to increase your knowledge and understanding of how you can use physiotherapy to prevent hospital admission in the community dwelling, frail elderly population. The module will also hopefully help you in applying this information in practice.

Aims

• To provide a learning resource for final year physiotherapy students or junior physiotherapists with an introduction to contemporary and emerging issues in the field of reducing hospital admissions in the frail elderly population and current management strategies.

• To provide you with an introduction and overview of the physiotherapists’ role in the prevention of hospital admissions in the frail elderly population by using a holistic, patient centred approach
  

Learning outcome

By the end of this Wiki module you will be able to…

• Synthesise current evidence and guidelines surrounding frailty and preventative pathways.

• Evaluate and reflect upon the physiotherapists’ role in the holistic assessment and treatment of frail persons to reduce the risk of hospital admission.

• Critically evaluate and reflect upon the skills and knowledge gained from this resource and recognise appropriate application in clinical practice.

Frailty

Costs

Length of stay and cost implications NHS

The latest published statistics which are being used in the literature relate to the years 2012 and 2013. Within this time frame 2,211,228 people over 60 were admitted to hospital in an emergency (DOH 2013b).

Graph 1 insert

Graph 2 insert

70% of day beds are occupied by people over 65; this is more than 51,000 beds at any one time. 85 year olds on average stay in hospital eight days longer than their younger counterparts (RCP 2012).

A table to show the cost of average stays in hospital
Type of stay	Short stay	Extra bed day	Visit to A and E
Cost	£1489	£273	£114
			(DOH 2013b)

Most emergency admissions to hospital happen through accident and emergency (DOH 2013b). On average a person over 85 spends 11 days in hospital (RCP 2012). If they pass through accident and emergency the total spent is approximately £3241 per patient, per visit.
However, More than a 25% of over 85 year olds stay for 2 weeks and 10% stay longer than a month, when admitted as an emergency (Cornwall et al. 2012). This means that even more money is spent.

Table 2 insert

410,377 elderly persons were admitted to hospital due to a fall in 2013. Appropriate strategies could prevent this by up to 30% (Age UK, 2015).

Length of stay and cost implications worldwide

Across the world there are varying amounts of elderly people in hospitals, how much time they spend in hospital and how much it costs.

Graph 3 insert

In terms of falls 59,046 males and 113,632 females were admitted to hospital following a fall in Australia in 2013-2014 (AHIW 2015).

Table 3 insert

92% of this care was paid for by insurance companies (Weiss and Elixhauser 2014).

Comparing this to the UK we can see that although most people stay in hospital for fewer days than in the USA, in the UK elderly people remain in hospital for longer. This may have negative health impacts. The UK is 16th in the world when it comes to average length of stay in hospital (health at a glance 2013).

Health and Social Care Integration

The Department of Health (2013b) report that although there are high numbers of emergency admissions through accident and emergency, which is very costly, at least one fifth could be dealt with in the community. Some ways of doing this are through: telemedicine, risk prediction tools, case management and alternatives to hospitals.
The integration of the health and social care systems in the UK was designed to improve service delivery and the effectiveness of care. There are nine outcomes which this incorporation is meant to achieve.

1. To allow people to look after and improve their own health
2. To allow as many people as possible to live independent lives
3. To ensure users have positive experiences of their health and social care
4. To maintain or improve users quality of life
5. To reduce health inequalities
6. To ensure unpaid carers are supported with their health and wellbeing needs
7. To ensure everyone; staff and users, are safe from harm at all times
8. To ensure staff employed in health and social care services feel involved in the work they do. They should also feel supported to implement change when needed.
9. To ensure that all resources are used effectively

The planning, resources and delivery of care will be now carried out together by the local authority or health board (The Scottish government 2015). This will mean that health and social care can run smoothly as one entity and users will experience a continuity of care.
One way this will have an effect is by reducing hospital admissions by allowing patient information to be shared more freely between hospitals and the community. This will allow for more effective multidisciplinary care in the community (Cornwall et al. 2012).
It has been said that better communication between health professionals, especially between those in hospitals and the social sector, may help reduce emergency admissions and help people return home sooner. However, there may be some barriers preventing this such as; differing funding levels, contrasting cultures, performance management and no sufficient way to share patient data. (DOH 2013b).

Policies and Guidelines

This section will present the most relevant guidelines and policies in relation to frailty and highlight the most useful points.
The policies and guidelines included in this wiki resource are:

Healthcare Improvement Scotland[1]	Think Frailty	Fit for Frailty

For the purpose of this learning resource the chosen guidelines and policies were Scottish and UK related. If you intend to work or are currently working without the NHS you might be required to be familiar with policies in relation to your workplace.

Older People in Acute Care improvement programme (OPAC)

As the number of older people in the population is increasing, there is an increased need to ensure appropriate care for older people. Improving older people's acute care is a priority for the Scottish Government and in 2012 “The Older People’s Acute Care improvement programme (OPAC)” was commissioned by the Scottish Government.

The programme focuses on 2 key areas

• Frailty
• Delirium
  

In relation to frailty, the programme focused on identification and immediate management of frailty. This included screening for frailty and ensuring that older people who were identified as frail received a comprehensive geriatric assessment within 24 hours of admission. The document “Think Frailty” explored the strategies implemented in practice in more depth and will be discussed in Section 3.2 – Think Frailty
Healthcare Improvement Scotland (2015) reported the impact of the programme and found that:

• Frailty screening in 3 surgical wards at the Royal Infirmary of Edinburgh decreased the length of stay, number of falls and number of complaints
• A reduced length of stay in NHS Grampian
• 50% decrease in the number of falls per month in 2 wards in NHS Greater Glasgow and Clyde

The report emphasises the importance to continue building on this work and Healthcare Improvement Scotland is committed to continue working with NHS Boards and staff to support learning and improvement of skills in relation to the management of frailty and delirium (REF report)

Fit for Frailty

Summary 

Physiotherapy assesment

The comprehensive geriatric assessment

All the guidelines outlined above state a need for a comprehensive geriatric assessment (CGA) to be completed to diagnose patients who may be frail. From this assessment a holistic interdisciplinary treatment program can be devised to suit the problems and needs of the individual. The assessment is usually carried out by a geriatrician or another trained professional (Martin 2010; BGS 2014).
This assessment usually takes place when a patient is identified as possibly being frail; during acute illness, prior to surgery or when returning to a community environment. It is a multi-dimensional program, which looks at the patients; health (physical and mental), mobility and social status. This approach was introduced in 2001 by the Department of Health. There are five domains in which assessment takes place.
Below is a table adapted from Martin 2010 which identifies and outlines what should be included in each domain.

The methods used to achieve this are specific to the region of the UK in which you work. However, the measurement tools should be standardised and reliable. For example, the 6-minute walk test is commonly used to test gait and balance. Some measures identify problems while others examine their severity.
The assessment will allow health professionals to identify the associated effects of frailty to the patient, now and in the future. Once specific problems have been identified onward referral can be made to appropriate healthcare professionals. This can then allow for a more in depth assessment to be made around these problems. For example a patient may be referred to physiotherapy to help increase mobility (Martin 2010).

Follow up is part of the CGA and identifies effectiveness of treatment. These sessions usually occur when people are readmitted to hospital. A study examined whether a comprehensive assessment after an emergency admission is more effective when carried out by a team trained in a using a CGA. The paper showed that this approach reduced; costs, length of hospital stay, deterioration, mortality. Yet this approach is not yet taken in the community (Ellis 2011).

In hospitalised patients it has been shown to improve the accuracy of diagnosis and enhances management in both the long and short term (Ellis and Langhorne 2004; Sergi et al 2011). In the community completing a CGA can prevent reductions in mobility and problems which arise from poor mobility by implementing treatment programmes tailored to all the patients’ needs (Tikkanen et al. 2015). It can also reduce hospital stay, increase the likelihood of keeping patients out of hospital (Nikolaus et al. 1999; Barer 2011) and reduce mortality (Frese et al. 2012).

Quiz

– How many of the key points can you recall? Who carries out a comprehensive geriatric assessment? Where can it take place? What are its key components? What effects can completing a CGA have? Reflection- this activity should take 10 minutes to complete. Use the reading in this section and your prior knowledge to reflect upon any problems that you think may arise when carrying out this type of assessment.

Medical

As people age the number of medications taken by the elderly increases to help tackle the effects of aging, such as; heart problems, cholesterol, depression and discomfort.

Some of the causes of adverse drug reactions (ADRs) can occur with multiple medications or improper drug or dosage selection. Fall, distress, depression, anxiety, confusion and insomnia are a few of the symptoms of ADRs in elderly population.

Risk factors for ADR is such as:
- Age (≥85)
- Multiple prescribers
- Long duration of use
- Multiple chronic disease
- History of drug reactions
- Regular alcohol intake

Common medication and their side effects 

Medication	Conditions used to treat	Common side effects	Examples
Beta Blockers	Angina, Heart failure, Atrial fibrillation and Heart attach	Angina, Heart failure, Atrial fibrillation and Heart attach Dizziness, tiredness, Blurred vision, slow heartbeat, diarrhoea and nausea	Atenolol, bisoprolol, acebutolol, metoprolol
Antidepressants	Depression	Dizziness, insomnia, headaches, loss of appetite, anxious, feeling agitated and blurry vision	Tricyclic antidepressants, Selective serotonin reuptake inhibitors, Serotonin- noradrenaline reuptake inhibitors
Benzodiazepines	Relief of severe anxiety	Drowsiness, difficulty concentrating, headaches and vertigo	Diazepam, lorazepam, Chlordiazepoxide
Non-Steroidal Anti- Inflammatory drugs	Relieve pain, reduce inflammation and a high temperature	Short term use of NSAIDs is unlikely to have any side effects. However long term use causes indigestion and stomach ulcers	Ibuprofen, Aspirin, diclofenac, naproxen

Side effects of medication such as drowsiness, blurred vision and insomnia can interfere with the treatment session and also delay any recovery, it is therefore important for physiotherapists to know if the patient is on any medication to modify treatments.