Professor Simon Conroy, Professor of Geriatric Medicine, University of Leicester – Written evidence (INQ0003)

The call for evidence focuses on prolonging the lifespan and ensuring that the added years are spent in relative good health. The evidence presented here is intended to highlight the needs of those people in the last 1-2 years of life, who do not enjoy such good health, and are currently being poorly served by healthcare systems, especially in the acute hospital context.

Demand for acute hospital care is rising annually, especially in older people [1],[2], who form one fifth of attendees at Emergency Departments [3], but account for 62% of all days spent in hospital [4]. For some older people, hospitalisation is associated with an increased risk of harm [5]; up to three-quarters of older people discharged from acute hospitals after even very short stays (<72 hours) will have one or more adverse outcomes (e.g. death, disability or readmission) in the three months following the initial admission [6]. Numerous efforts have been undertaken to identify those at greater risk of poor outcomes [7], many focusing upon frailty [8],[9]. Frailty describes a decline in function across multiple organ systems, linked to ageing but progressing at different rates in different people. It is characterised by vulnerability to poor outcomes in individuals exposed to an apparently innocuous stressor, such as a minor infection [10]. Frailty predicts the risk of falls, delirium, disability, readmission and care home admission [11],[12],[13]. In the most frail, much of this harm accrues in the first weeks and months following hospitalisation [14]; better identification of these individuals and closer liaison with relevant community services (rehabilitation, palliative care etc.), may improve patient outcomes. Examples of evidence based interventions that could help include Comprehensive Geriatric Assessment [15],[16]; prevention of delirium [17] and functional deterioration [18], identification of end of life care needs on a hospital wide basis [19],[20] and advance care planning [21],[22],[23].

While there are multiple tools available to measure frailty, most tools are too complex for use in acute care settings [24]. The Hospital Frailty Risk Score (HFRS) is derived from ICD-10 codes [25] and can be used to identify older people with recent hospitalisation who are at risk of frailty and associated adverse outcomes at the national level. In the national validation cohort (n=1,013,590), compared with the 42% patients with the lowest risk scores, the 20% patients with the highest HFRSs had increased odds of 30-day mortality (odds ratio 1.71; 95% CI 1.68–1.75), long hospital stay (6.03; 5.92–6.10), and 30-day readmission (1.48; 1.46–1.50).

In summary, it is possible to identify a cohort of older people at especial risk of poor outcomes during hospitalisation as well as in the months following. We know of established interventions that might ameliorate these outcomes, improving quality of life, dignity and potentially reducing unnecessary and unwanted hospitalisation. However, we do not yet have robust systems in place nationally that ensure that these evidence-based interventions are applied consistently and reliably. A focus on this area could release significant resources to enable a greater focus on prevention and promoting longer and healthier lives.

9 August 2019

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[4] National Audit Office. Discharging older patients from hospital. London: Department of Health, 2015

[5] Hubbard R, Peel N, Samanta M, et al. Frailty status at admission to hospital predicts multiple adverse outcomes. Age Ageing 2017:1-6. doi: 10.1093/ageing/afx081

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[8] Hubbard R, Peel N, Samanta M, et al. Frailty status at admission to hospital predicts multiple adverse outcomes. Age Ageing 2017:1-6. doi: 10.1093/ageing/afx081

[9] Buurman BM, van den Berg W, Korevaar JC, et al. Risk for poor outcomes in older patients discharged from an emergency department: feasibility of four screening instruments. European Journal of Emergency Medicine 2011;18(4):215-20

[10] Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet (London, England) 2013;381:752-62. doi: 10.1016/S0140-6736(12)62167-9

[11] Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. The Lancet 2013;381:752-62

[12] Fried L, Tangen C, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology: Medical Sciences 2001;56A(3):M146-56

[13] Boyd C, Xue Q, Simpson C, et al. Frailty, hospitalization, and progression of disability in a cohort of disabled older women. The American Journal of Medicine 2005;118(11):1225-31

[14] Keeble E, Arora S, van Oppen J, et al. Outcomes of even brief hospital admissions amongst frail older people: a role for secondary prevention of frailty crises in the community? British Journal of General Practice 2019; In press

[15] Parker SG, McCue P, Phelps K, et al. What is Comprehensive Geriatric Assessment (CGA)? An umbrella review. Age and Ageing 2018;47(1):149-55. doi: 10.1093/ageing/afx166

[16] How best to deliver Comprehensive Geriatric Assessment on a hospital wide basis (CGA): an Umbrella Review. European Geriatric Medicine Society; 2016 2016. European Geriatric Medicine

[18] De Vos A, Asmus-Szepesi K, Bakker T, et al. Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP). BMC Geriatrics 2012;12(7)

[19] Department of Health. End of Life Care Strategy. Promoting high quality care for all adults at the end of life. London: Department of Health, 2008

[20] Bakker FC, Robben SHM, Olde Rikkert MGM. Effects of hospital-wide interventions to improve care for frail older inpatients: a systematic review. BMJ Quality & Safety 2011;20(8):680-91. doi: 10.1136/bmjqs.2010.047183

[21] Weathers E, O'Caoimh R, Cornally N, et al. Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas 2016;91:101-9. doi: 10.1016/j.maturitas.2016.06.016 [published Online First: 2016/07/28]

[22] Martin RS, Hayes B, Gregorevic K, et al. The Effects of Advance Care Planning Interventions on Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc 2016;17(4):284-93. doi: 10.1016/j.jamda.2015.12.017 [published Online First: 2016/02/11]

[23] Cornally N, McGlade C, Weathers E, et al. Evaluating the systematic implementation of the 'Let Me Decide' advance care planning programme in long term care through focus groups: staff perspectives. BMC Palliative Care 2015;14(1):55

[24] Elliott A, Hull L, Conroy S. Frailty identification in the emergency department-a systematic review focussing on feasibility. Age Ageing 2017:1-5. doi: 10.1093/ageing/afx019

[25] Gilbert T, Neuburger J, Kraindler J, et al. Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study. The Lancet 2018; 391(10132):1775-82. doi: 10.1016/S0140-6736(18)30668-8