What proportion of older adults in hospital are frail?
Authors: Samuel D Searle, Kenneth Rockwood
Journal: The Lancet (2018)

Despite the increasing level of knowledge about individual illnesses, modern health-care systems seem lost when seeing patients whose diseases come not one at a time, but all at once—especially when they come with equally complex social needs. Although some geriatricians proclaimed the end of the disease era1Cesari M Marzetti E Thiem U et al.The geriatric management of frailty as paradigm of “The end of the disease era”.Eur J Intern Med. 2016; 31: 11-14Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar to focus on the complexity of frailty in geriatric assessment,2Rutenberg AD Mitnitski AB Farrell SG Rockwood K Unifying aging and frailty through complex dynamical networks.Exp Gerontol. 2017; (published online Aug 25.)http://dx.doi.org/10.1016/j.exger.2017.08.027Crossref PubMed Scopus (40) Google Scholar the argument is falling flat. Disease-focused specialists who push on with the only course they know sometimes decry their frail patients as being unsuitable or requiring social support or failing to cope or thrive.3Kumeliauskas L Fruetel K Holroyd-Leduc JM Evaluation of older adults hospitalized with a diagnosis of failure to thrive.Can Geriatr J. 2013; 16: 49-53Crossref PubMed Scopus (9) Google Scholar Many hospitals—and practitioners—still somehow expect patients to present with primary complaints that give rise to well defined problems, which they can manage successfully using pathways that can be audited, such as time to thrombolytic event in an acute stroke or myocardial infarction. How does health care get on track? Language should be the starting point. Elderly people whose multiple, interacting medical and social problems put them at greater risk of adverse outcomes have come to be called frail. Hospitals must be encouraged to expect and thereby plan for frail patients as a part of what is required of them. To make this requirement clear, they need the right tools. In The Lancet, Thomas Gilbert and colleagues4Gilbert 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.Lancet. 2018; (published online April 26.)http://dx.doi.org/10.1016/S0140-6736(18)30668-8Summary Full Text Full Text PDF Scopus (236) Google Scholar used International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in electronic records to develop a hospital risk stratification tool. The tool was validated in a large English inpatient database (n=1 013 590), and its generalisability tested using various hospitals. Frail or non-frail information was dichotomised and frailty further graded into low, intermediate, and high risk. In a cluster analysis, these frail groups accounted for a fifth of patients and almost a half of all hospitalisation days. The tool classified individual mortality risk no more than moderately well, but, as the investigators point out, individual risk stratification was not their objective. Instead, their goal was to identify “a group of patients who are at greater risk of adverse outcomes and for whom a frailty-attuned approach might be useful”. A metric that identifies for hospitals the extent to which they are serving patients with frailty should signal the need to change from a most responsible diagnosis model to practices that can reduce the hazards of hospital stays for patients who are frail, and perhaps even focus on the goals of patients and their families.5Papoutsi C Poots A Clements J et al.Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK.Age Ageing. 2018; 47: 311-317Crossref PubMed Scopus (8) Google Scholar Stratification of risk groups might also offer a similarly useful role for the electronic frailty index, based on general practice records.6Stow D Matthews FE Barclay S et al.Evaluating frailty scores to predict mortality in older adults using data from population based electronic health records: case control study.Age Ageing. 2018; (published online March 13.)http://dx.doi.org/10.1093/ageing/afy022Crossref PubMed Scopus (20) Google Scholar These hypotheses need to be tested. To show what must change, consider a student on her first clinical rotation who encounters a patient with pneumonia. Most of what she has learned about pneumonia must now be set aside. Uncomplicated cases are rarely referred to specialty services; those patients get antibiotics and go home. Her patient cannot give a history. He is not coughing. He cannot even sit up so that she can auscultate his lungs properly, something she knows she must do. Her patient does not have a fever or an increased white cell count. Vague markings on the chest film alone support the diagnosis. No matter; the real issue, apparently, is that her patient cannot go home. She might now turn to her teachers and ask: “What have you been teaching me about pneumonia if none of it works in the patients I'm supposed to see?” More likely, insidious acculturation will lead her to conclude that this patient really does not belong in her hospital. By contrast, those skilled in the care of older people will recognise the delirium and immobility that are typical presentations in a frail patient with pneumonia. They will ascertain whether the cognitive impairment and being bedfast are new. From this information, they will formulate a differential diagnosis and focused examination, and a pragmatic course of action; the term of art is a care plan. Although they will know all this as if by reflex, they will also be aware of when they too needed to be taught these skills; they will know that failure to learn them costs life lived at home.7Ellis G Gardner M Tsiachristas A et al.Comprehensive geriatric assessment for older adults admitted to hospital.Cochrane Database Syst Rev. 2017; 9 (CD006211.)PubMed Google Scholar When they become ill, people who live with frailty pose existential questions for how health care is organised. If frail patients account for nearly half of hospital bed-days, their care cannot be other than an essential part of what we do. New tools are needed. From routinely collected data, Gilbert and colleagues have allowed us to know how many frail patients we are seeing. Going further would be to undertake a performance audit for outcomes beyond tracking disease-centred processes. Health-care providers must undertake the journey from doing interventions to patients that they know they need, to doing interventions for patients that they know they want.8Rockwood K An unsuitable old age: the paradoxes of elder care.CMAJ. 2005; 173: 1500-1501PubMed Google Scholar The signposts will be patient-centred outcomes. Together, health-care systems must set a course to better mobility, function, cognition, continence, pain control, and social engagement for patients. SDS declares no competing interests. KR has asserted copyright of the Clinical Frailty Scale through Dalhousie University, which is free for research, educational, and not-for-profit care. KR founded and is President and CSO of DGI Clinical, which has contracts with pharmaceutical companies for outcome measurement and advanced data analytics. He receives operating support from the Canadian Institutes of Health Research, and career support from the Dalhousie Medical Research Fund as Kathryn Allen Weldon Professor of Alzheimer Research. Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational studyThe Hospital Frailty Risk Score provides hospitals and health systems with a low-cost, systematic way to screen for frailty and identify a group of patients who are at greater risk of adverse outcomes and for whom a frailty-attuned approach might be useful. Full-Text PDF Open Access