Older people benefit from comprehensive assessment in hospital

Research shows that for every 20 patients who receive comprehensive geriatric assessments on admission to hospital, one can avoid admission to a care home.

Research shows that for every 20 patients who receive comprehensive geriatric assessments on admission to hospital, one can avoid admission to a care home.

Nearly two million people over 60 are living with frailty in England. Picture: iStock


In England, 1.8 million people over the age of 60 live with frailty, a clinically recognised state of increased vulnerability (see panel). Of these, almost half are aged over 80.

Healthcare staff focus on managing older people with frailty, as a long-term condition, in their homes, but such people can experience a rapid decline when they are admitted to hospital.


Million people aged over 60 are living with frailty in England

Source: NIHR

Now the National Institute for Health Research (NIHR) has published a review of 53 NIHR-funded studies on identifying and supporting older people with frailty in hospitals. It provides a round-up of completed and ongoing research highlighting best practice in the area.

RCN professional lead for older people and dementia care Dawne Garrett, who provided input to the review, says nurses can use it as ‘a stocktake against best practice to know whether your clinical area is performing as it should be’.

Mirroring a person’s journey through hospital, the review is divided into four sections:

  • Approaching hospital.
  • During hospital stay.
  • Leaving hospital.
  • Caring environments.

The review highlights the importance of the ‘gold standard’ comprehensive geriatric assessment (CGA).

CGAs are carried out by multidisciplinary teams to determine people’s medical, mental, functional and social needs so that plans for treatment and follow-up care can be developed. For every 20 people assessed in this way, the review states, one long-term care home placement can be avoided.

Environment of care

Good frailty care should begin before hospital admission, however, and the review emphasises the importance of primary and secondary care services working together.

It cites a study that involved the development and validation of an electronic frailty index. The index is being used by GP practices to identify people aged 65 and older who live with frailty, and the findings could be shared with hospitals to alert them to the most vulnerable patients for targeted care planning.


Of people over 70 experience a reduction in their ability to undertake activities of daily living between hospital admission and discharge

Source: NIHR

The environment of care is important for older people with complex needs, such as those with frailty, and one way to improve the environment of care is to provide specialist staff.

Although the NIHR states that one study cited in its review lacks direct evidence for the effectiveness of dementia nurse specialists, it identifies the contribution of nurse specialists in a number of areas, such as preventing adverse events and improving patient experience.

Another concern raised throughout the review is delirium and, according to Ms Garrett, it is difficult for nurses and clinicians to differentiate between delirium and dementia.

Between 20 and 30% of people with delirium attend medical wards, and 10-50% of people who have surgery develop the condition. Yet, one study cited by NIHR found a variable level of awareness among ward staff about delirium.

To address this problem, an ongoing study is testing a rapid screening tool to identify the condition, which may be useful for ward staff. Use of screening tools is one of the questions the review recommends healthcare professionals ask themselves to help care for people with frailty (see panel).

Other evidence-based clinical interventions need not be complex. To keep people active, for example, Ms Garrett says: ‘Physiotherapy can be as simple as walking someone to the lavatory; it does not have to be highly technical.’

The review notes that more work needs to be done on the transition from hospital to home or long-term care. One study found that staff need more support and training on assessing mental capacity before discharging people with cognitive impairment.

End of life care

Although end of life care is vital to good frailty care, the NIHR review identifies that practice must be improved.

In a study investigating the transition to palliative care for older people in two acute hospitals, researchers found that medical and nursing staff assessments had ‘poor correlation’ with the Gold Standards Framework (GSF). Of 514 patients who took part in the study, 185 met the GSF criteria for palliative care needs but there was evidence of transition to a palliative care approach, such as a do not resuscitate order, in only 61 of these.


Prevalence of delirium in people on medical wards

Source: NIHR

Review author and clinical adviser at the NIHR Dissemination Centre Elaine Maxwell says: ‘We hope that, with this review, people will reflect: “We are working in a very fast-paced environment and we need to think about these people’s particular needs. Maybe this person is coming to the end of their life and we should have a discussion with them about how they would like the end of their life to be”.’

Dr Maxwell says the NIHR plans to use the review as a starting point for a quality improvement project in a hospital in collaboration with Wessex Academic Health Science Network. She suggests that, after reading the review, staff on the wards ‘begin with an audit and decide from there the areas to concentrate on’.

Frailty syndromes

People living with frailty commonly present with symptoms of at least one of five major syndromes:

  • Delirium: acute confusion or sudden worsening of confusion in someone with known dementia or memory loss.
  • Falls: collapse, where legs give way and person is found on the floor.
  • Immobility: sudden change in mobility, ‘off their legs’.
  • Continence problems: new onset or worsening of urinary or faecal incontinence.
  • Medicines management challenges: these include side effects and drug interactions

The presence of one of these syndromes should raise suspicion that a person is living with frailty and trigger a full assessment.

Questions for staff caring for older people

  • Do we use screening tools to help us identify people with syndromes related to frailty, for example, delirium, or who are at particularly high risk of harm, such as falls and pressure ulcers?
  • Are we training our staff to consider that people who present in atypical and non-specific ways may be living with frailty?
  • How do we ensure that older people living with frailty keep moving while in hospital?
  • How often do we review medications for older people living with frailty?
  • How can we encourage people living with frailty to maintain active minds?




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