Objectives and brief methodology
There are over two million unplanned hospital admissions a year for people aged over 65 in England accounting for 40% of hospital bed days. For many older people a brief stay in hospital is tolerated well, with recovery from acute illness, and return to physical and functional baseline. For people living with frailty, recovery following an illness or insult may be protracted and incomplete. Frailty describes an abnormal health state characterised by poor physiological reserve. In the 1960s, Bernard Isaacs described five ‘Geriatric Giants’; key syndromes that commonly occur during acute illness in frail older people: falls, delirium, incontinence, immobility, loss of function. Whilst in hospital, older people are at particular risk of development or exacerbation of these manifestations of frailty (MoF) due to the physiological stresses of acute illness and pre-existing homeostatic failure e.g. sarcopenia, but also the many additional, and potentially modifiable, risk factors introduced during a hospital stay.
The MoF are important causes of excess in-hospital morbidity, contributors to adverse events (including hospital acquired infections, injurious falls and pressure ulcers), excess costs and longer term adverse outcomes. The MoF are also independently associated with poor outcomes: prolonged lengths of hospital stay; excess mortality; and requirement for increased care packages or institutionalisation post discharge.
Many identified risk factors for the MoF are iatrogenic and, at least in part, modifiable. Unfamiliar and noisy environments, forced dependency (meals, tablets, toileting, washing and dressing, bed-times), sensory impairment, polypharmacy, medical tests (or fasting for these), prolonged sedentary behaviour or periods of bed rest are all implicated in falls, development of delirium and incontinence, reduced mobility, and ultimately acquired functional impairment that may persist after discharge.
There are currently separate strategies to target prevention and management of the MoF in hospitalised older people. For example, there is separate National Institute for Health and Care Excellence (NICE) guidance for each of falls, delirium and incontinence (22-24). NICE guidance advocates risk factor assessment and strategies to modify contributing factors where possible (i.e. multicomponent interventions). However, these recommendations focus more on the need for these interventions to be in place, rather than an evidence based framework of constituent components. Due to the overlap in risk factor profile for the MoF, this results in duplicated assessments, multiple systems of care, overlapping care pathways, separate and duplicative national audits and a lack of consistency in approach across the NHS. Moreover, the guidance fails to acknowledge or address multimorbidity in individuals (e.g. coexisting frailty), or the complexity of the health systems within which these interventions are to be interpreted and applied. National audits (falls, dementia and incontinence) have highlighted that adoption of guidance is not universal (e.g. 36% of people over 65 in hospital did not have a falls care plan, 55% had not been assessed for delirium and 40% of trusts did not have a pathway for managing incontinence (4, 25, 26)).There is a need for a coordinated approach to deliver key interventions to target an individual’s risk factors for development of the MoF in hospital.
Aims & Objectives
- To identify through interviews (with patients and carers) and focus groups (with ward staff), key modifiable risk factors contributing to the development of MoF in hospital where there are gaps in the research literature. To prioritise through consensus, modifiable risk factors to be addressed in a novel system of care for hospitalised older people.
- To identify existing evidence based care actions to address the prioritised modifiable risk factors and where there are gaps in the evidence. Interventions could be effective discrete components of care or environmental adaptation e.g. a timely medication review to reduce the risk of delirium, falls and polypharmacy.
- To agree best practice interventions to address prioritised risk factors in the absence of research evidence.
Study 1: Qualitative: Interviews with patients and their carers to determine additional risk factors for development of the MoF not previously identified.
Participants: Patients aged 65 years and over admitted to an older person’s ward for more than five days; willing and able to be interviewed at home by a researcher within four weeks of discharge; or alternatively a relative/carer if cognitive impairment means they are unable to complete an interview. N = 20 (10 from each of 2 wards).
Study 2: Qualitative: Focus group with members of ward based hospital staff to discuss potential risk factors from the perspective of healthcare workers.
Participants: Ward based hospital staff (nurses, nursing students, healthcare assistants, doctors, porters, domestic services staff, volunteers) working with older people, who are willing and able to attend a 1 hour focus group. N = 6-8 (staff members from each of 2 wards)
Study 3: Focus group and Consensus study to prioritise modifiable risk factors
a) Focus group x1 (8 – 10 Patients and carers from Study 1)
b) Group consensus x1 (12-14 clinical and academic leaders)
Systematic Review – Systematic literature and evidence review to identify care actions that have been evaluated as effective in addressing risk factors for MoF identified in pre-PDG work and PDG studies 1-3 (described in detail in separate protocol).
Study 4: Focus group and Consensus study to reach consensus on best practice care actions for modifiable risk factors
a) Focus group x1 (8-10 Patients and carers from Study 3a)
b) Group consensus x1 (12-14 clinical and academic leaders from Study 3b)
Partners & Collaborators
The research team is led by Dr Elizabeth Teale who is based at the Elderly Care and Rehabilitation Team at the Bradford Institute for Health Research. The team includes experts from the University of Leeds, University of Leicester, Exeter University, Bradford Teaching Hospitals NHS Foundation Trust, The Mid Yorkshire Hospitals NHS Trust and the University Hospitals Of Leicester NHS Trust.
01/04/2019 – 20/09/2020
National Institute for Health and Care Research
Further information and contact details
Elizabeth Teale – Chief Investigator contact: firstname.lastname@example.org Tel: 01274 382824
Kristian Hudson – Research Fellow contact: Kristian.Hudson@bthft.nhs.uk Tel: 01274 383403
This study/project is funded by the National Institute for Health and Care Research (NIHR) [Programme Development Grants RP-DG-0218-10001 – Developing a novel system of care targeting risk factors for five manifestations of frailty to maintain the independence of older people in hospital and post-discharge]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.