Frailty (health and wellbeing needs in South Tyneside)

Frailty is defined as a state of health whereby an individual's physical and/or mental reserve is impaired due to age or comorbidity. This affects their ability to cope with insults such as change of environment, illness or medication, which in turn impairs quality of life and predisposes to earlier morbidity and mortality.

Evidence has shown that timely identification and assessment (using tools such as The Rockwood Frailty Scale, the Electronic Frailty Index and PRISMA 7) of such individuals allows for increased social and medical attention, thereby reducing risks of medical and social sequelae and promoting greater personal independence (NICE 2015). This in turn can reduce healthcare burden and produce a better quality of life for patients. This applies to both adults and children, however this paper will address the needs of adults only within the South Tyneside borough.

Within the UK, over 10% of patient of the population over the age of 65 have a degree of frailty, and 25.5% of those over 85 are defined as frail. Currently data is being collected using the Electronic Frailty Index throughout the borough so up to date prevalence rates on a local level are not available. Frailty is strongly associated with age and the consequences thereof, and is higher amongst women. With rising costs of medical care and reduced governmental spend on social care, the impact of frailty is becoming increasingly relevant.

1. The needs of the South Tyneside population are increasing as the population ages. According to the Joint Strategic Needs Assessment of South Tyneside for 2012 - 2013 it is estimated that the population of South Tyneside will:

• Increase by 6% as a whole over the next 20 years.
• The number of individuals aged 65 and over will increase by 40%, while over 85 will increase by 70%. This is of significant relevance to the local population health needs.

Compared to the rest of England, South Tyneside has a slightly higher proportion of older people (21% compared with 19% across England and 20% across the North East).

It is therefore estimated that the number of instances of dementia in the older population will increase by 14% in the near future. These are then predicted to further increase by 46% by 2030. This is not entirely attributable to inevitable ageing, but is most likely related to increased risks of multimorbidity.

2. The current medical and social approach within South Tyneside is a 'reactive' rather than 'proactive' towards frailty. Provisions so far are struggling to meet with demand.

3. Frail individuals are often acutely and repeatedly admitted to inpatient units due to illness or breakdown in social care. They may then remain in medical establishments for extended periods, while awaiting appropriate care packages. The probability of their developing further acute medical complications, such as Hospital Acquired Pneumonia or Clostridium Difficile, is then higher, thus further complicating their recovery. More preventative measures are required to both reduce acute admissions and shorten, or dispense with altogether, stays within hospital care.

4. Within South Tyneside, there are greater prevalence and incidence of long-term conditions such as Cardiovascular disease, Stroke and Respiratory disease. Life expectancy in the local population is lower than the rest of the UK. In 2012 there were 27,000 people aged over 65 living in South Tyneside, 15,000 of whom were suffering a limiting long-term illness. According to a paper by Turner et al 2000 this creates emotional problems in terms of illness 'behaviours' and wellbeing, and and also leads to a generalised functional decline in terms of daily functioning due to the nature of the underlying chronic conditions.

5. Frailty is not an inevitable consequence of ageing and chronic disease. Evidence exists to show that making healthy lifestyle changes can delay frailty and aid healthy ageing. Schemes within South Tyneside such as 'A Better U' and 'Change 4 Life' are such examples of ways to promote more effective self-care. Encouraging a 'prevention rather than cure' attitude, along with enabling patients to take more responsibility for their healthcare will reduce the incidence and burden of frailty.

6. Frail patients are at significant risk of falling. This not only affects an individual's confidence, but also increases the risk of morbidity, mortality and has a negative impact on family and carers. The cost to the NHS of fall victims is estimated at £2.3 billion per year (College of Optometrists / British Geriatrics Society, 2011). Addressing the needs of those who fall in a proactive manner can save the NHS and individuals in terms of health, healthcare costs and quality of life.

1. Encouragement of a shift towards more active screening for frailty and community support for prevention of the consequences of frailty (so called prehab), with adequate funding and resources for both patients and associated healthcare professionals. This would aim to identify those who are considered as 'mildly' frail and instigate processes to enable self care to reduce their risk of deteriorating further throughout the frailty spectrum.
2. Creation of community frailty teams, and the appointment of a clinical lead, such as a General Practitioner with specialist interest in frailty, to promote that more active shift towards proactive care.
3. Continuing support and development of the Community Falls Service through increased funding and increased communication between Primary and Secondary care teams.
4. Development of links between NHS and third party sectors, to enhance patient care.
5. Increase in funding, time and resources of General Practitioners, to manage the healthcare requirements of the frail. The introduction of the electronic frailty index (as part of the new GP contract) will go some way into identifying patients at risk.

Patients considered to be higher risk are:

• Those who have sensory, physical or mental disabilities for which activities of daily living prove more challenging.
• Those with chronic pain due to age or disease such as arthritis or diabetes.
• Those with poor mental health due to endogenous depression or as a result of other chronic disease.
• Older people with reduced BMI, general muscular weakness, low speed and low physical activity, communication issues, visual/hearing impairment and continence problems.
• Those with long term conditions such as all forms of Cardiovascular Disease (predisposing to heart failure, strokes and reduced exercise tolerance and functioning), Respiratory Disease resulting in frequent admissions and reduced quality of life and diabetes causing systemic multi organ failures.
• Those with a diagnosis of dementia and those 'institutionalised' in social care such as care homes.

Across all English Local Authorities in 2015 / 16, the borough of South Tyneside had the 6^th highest rate of permanent admissions of individuals aged over 65 to residential or nursing care homes.

No accurate data could be found as to the level of 'frailty' (this is in itself being quite a spectrum) within South Tyneside.

However where it can be assumed that ageing will in its own right lend to an increased risk of frailty, then the number of older people is estimated to increase significantly as already quoted.

This coupled with other factors such as income disparity and levels of deprivation within the area (quoted as being within the top 20% of Local Authorities with the highest level of deprivation in the country) will in turn lead to an additional healthcare burden. A report in September 2012 by South Tyneside Clinical Commissioning Group estimated that there will be a requirement of over 130 beds and an additional 18million pounds to the Borough in 10years to time to meet the projected level of need.

1. Carers for patients are a vulnerable group of society with additional pressures placed upon them. Anecdotally using audit data from South Tyneside Hospital, several admissions are due to carer breakdown.

Recommendations for increased support for carers include:

• Short break care
• Emergency service provision by community teams, particularly for carers of those suffering with dementia
• Increased advocacy services for carers
• Flexible long term support as an alternative to residential care
• Information about access to services and assessment / eligibility

2. There remains a large gap, in respect of communication and provision of services, between primary and secondary care regarding management of the needs of frail patients. Whilst community geriatricians for example are keen to pursue a community geriatric service, the lack of availability of staff from the trust prevents this from occurring. The employment of a General Practitioner with a specialist Frailty (GPwSI) or Elderly Care interest would help in bridging this issue.

Alternatively, a frailty nurse role is currently being piloted by a practice within South Tyneside. This aims to identify 'high risk' patients by way of various scoring systems, thereby optimising their medical care and instigating future care planning. Integrated care teams currently exist within the borough, however require additional staffing to be able to attend to the level of demand.

3. Proactive care, or 'prehab', is an important stage in addressing frailty, particularly with regards to falls. The current provisions in the local area can be used more proactively by the local community through promotion by health care professionals.

Occupational health waiting times are also long. Important, simple changes in environment for a frail individual can improve quality of life and promote independence, which will in turn reduce the potential healthcare costs associated with frailty.

Age UK are currently going through a restructuring process and it remains to be seen what the level of support provided will be in future.

4. Falls can be a significant risk for those with frailty, particularly in the elderly. A 2012 - 2013 Joint Strategic Needs Assessment in South Tyneside identified certain boundaries to minimisation and impact of falling:

• The rate of admissions for falls has increased in recent years.
• Issues included lack of primary care in the falls treatment and prevention process, and in secondary care.
• The development of an 'at risk' falls screening pathway was suggested. Funding is currently being provided by Vanguard to allow this to be implemented for approximately one year.
• A falls clinic provision exists, which looks at holistic care and incorporates a multidisciplinary team including occupational therapists and physiotherapists.

Further information and a more in-depth analysis can be found at the JSNAA Falls paper due to be published.

A 2011 study by Guthride and Wyke (University of Glasgow) identified that most over 65 year olds suffer from two or more long term conditions, and the majority of over 75 year olds will have 3 or more conditions. The Projecting Older People Population Information System (POPPI) predicts that those health conditions that will particularly increase the cost of healthcare by 2020 will be:

• Profound hearing loss (increase of 16%)
• Dementia (increase of 14%)
• COPD
• Learning disabilities.

South Tyneside face a challenge insofar as multi-morbidity rates of common conditions are higher in the borough than other areas of a similar demographic. This is particularly true of heart disease, stroke, colorectal and bowel cancer. The prevalence of hypertension is also expected to rise to 34% of patients in South Tyneside by 2020.

In addition, it was estimated in 2012-2013 that a further 2,500 patients had not been identified as having COPD, while it is predicted that, by 2030, 10.4% of the population of South Tyneside will suffer from diabetes.

Suggestions for recommendations include:

• Evaluation of the potential appointment of a GPwSI in Older People's Medicine, and of an 'Older People Nurse Specialist'. Both roles could provide a good platform for the instigation of Emergency Health Care Plans and Do Not Resuscitate forms in a proactive manner, thereby reducing the burden on the health system through admissions, and improving the experience for patients and families. Examples of such a model have been cited by the Royal College of General Practitioners with respect to suggestions for innovative working.
• Implementation of a more prominent role for involvement and promotion of the voluntary sector, such as Age UK. This could provide increased input into social prescribing.

NHS Provisions:

• Community Falls Service: A multi-disciplinary team of physiotherapists, occupational therapist and nurses, covering both Sunderland and South Tyneside, with outpatient falls clinics. This would include rehabilitation services, comprising, among others, vestibular assessment and outreach services to see patients in their own home as needed.
• Falls and Syncope Clinic: Care of the Elderly physicians at South Tyneside District Hospital provide outpatient clinics for medical assessment along with clinical resources for the Community Falls Service. This would be directed at those who are the highest risk of falls, namely people who are elderly, frail or suffering from conditions affecting their autonomic function, or cardiovascular systems, or have polypharmacy are at risk of falls.
• Integrated Community Teams: Multidisciplinary teams providing acute nursing and rehabilitation for community patients.
• South Tyneside District Hospital: Providing acute inpatient and outpatient care for elderly or long term chronic disease management based on specialty.
• General Practitioners: Providing the majority of Primary Care, detection for long-term chronic disease.

Local authority provision:

These include, for the management of frail patients:

• Telecare services: For vulnerable adults at home.
• Transport: Bus passes and taxi sharing services to allow older adults to stay active and connected socially, along with improving access to healthcare.
• Equipment: The STAR Centre and local authority are able to provide equipment to improve functionality of patients based on needs assessed by occupational therapists.
• House Clearances and Warm Up North: Providing removal of waste to improve function and maintaining a warm home in winter months, thereby reducing associated healthcare risks for the frail.
• Haven Court: A 'step down' facility providing care to adults, which can be referred into by both primary and secondary care.
• Sheltered Accommodation and Extended Care Facilities: Allowing for safe home environments, namely to the elderly population with variable levels of supervision or needs assistance.

Currently these services are not coordinated, and further integration and communication across health and social care will be required to optimise their use.

Charitable and third party contributions:

Tyne and Wear Care Alliance provide training to care homes on fall prevention. Age Concern South Tyneside provide gym and exercise classes to build strength and balance, classes to improve social engagement and handyman services to maintain people's homes.

NICE Clinical Guidelines October 2015 provide clear guidance, which identifies the need for:

• Case identification using appropriate agreed scoring systems (in South Tyneside within Primary Care, the Rockwood score is employed).
• Leading by example within the public sector.
• Promoting healthy lifestyle through encouragement, and providing local support for this (for example by subsidised gym memberships or increased transport provisions for general health and wellbeing).

An informal discussion from an unrepresented sample of primary and secondary care clinicians in the borough identified the following issues:

Lack of communication of relevant patient information between healthcare professionals.

An increased need of input and mobilization of social care teams to assist patients at home in times of acute need (for example delirium due to an infection) in order to reduce risks of hospital admission.

An increased investment into community medical services to manage acute exacerbations of long term conditions.

Further investment required for resources, time and support for GPs for proactive and preemptive care.

A possibility of specialist GPs in frailty and ageing being employed within the community with linked consultant support.

An increased need for support from voluntary sectors.

Further clarity regarding both primary and secondary care services amongst clinicians and the general public.

A need for swifter access to mental health services for earlier diagnosis of cognitive impairment,

The Royal College of General Practitioners and the British Geriatrics Society summarise their key messages as needing to promote person centred and continual care, multidisciplinary working, collaboration and communication in a proactive manner along with support for professional development for those involved in the care of frail patients.

The Frailty Syndrome: Definition and Natural History, Clinical Geriatric Med, 2011 Feb 27(1): 1-15

Clinical Frailty Scale: K. Rockwood et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489-495

Development and validation of an electronic frailty index using routine primary care electronic health record data, Age and Ageing, 2016 45 (3): 353-360

PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities. Raiche M, Arch Geronotol Geriatr, 2008 Jul-Aug; 47(1):9-18.

Emotional dimensions of chronic disease, Turner J, West j Med. 2000 Feb; 172(2): 124-128

The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomized controlled trials. El-Khoury et al; BMJ 2013; 347:f6234

Pathways: Dementia, disability and frailty in later life

Wellbeing info: A Better U

NHS: Change for Life

Visit South Tyneside

Fingertips

British Geriatrics Society: Vision in falls

University of Glasgow: Improving the health of people with multimorbidity: the need for prospective cohort studies

Integrated care for older people with frailty. Innovative approaches in practice. Royal College of General Practitioners. Sourced 2016.

Institute of Public Care (2016) POPPI: Projecting Older People Population Information System accessed 29.9.16

Last Updated: September 2017