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.
