Falling through the cracks: a case study of how a timely integrated approach can reverse frailty

This paper is a follow-up article to one published in the British Journal of Community Nursing in 2019, entitled ‘Social frailty: the importance of social and environmental factors in predicting frailty in older adults’ (Freer and Wallington, 2019). This previous paper reviewed the concepts and models of frailty and discussed the interplay between social and environmental factors in this complex condition. The present paper describes the case of a 76-year-old man, Tommy, who was living with frailty, and it discusses how timely integrated care helped address Tommy's problems.

Tommy's case

Originally from Ireland, 76-year-old Tommy resided alone in the suburbs of a northern English town. He had worked as a teacher until he sustained a head injury many years previously. He had epilepsy, controlled with medication. Tommy drank alcohol on a regular basis and enjoyed classical music. His home was in a state of disrepair: thee was no central heating, hot water, fridge or cooking appliances, so he ate a limited diet of cold tinned or raw food. His environment was cluttered with boxes of papers, CDs, DVDs and wine, leaving a small path to navigate in each room, and a lawn mower obstructed his hallway. Any carpets were threadbare, and there was little furniture. His mattress was in a poor condition, with holes covered with cardboard and no clean bedding. Tommy had no laundry facilities; instead, he wore clothing for a long period and then discarded them. His appearance was dishevelled, and his long grey hair and beard were untended.

Tommy lived a reclusive solitary life. He had minimal contact with his neighbour, who occasionally provided a hot meal or completed odd jobs. He used a private shopper rather than venturing to the shops himself. Instead, Tommy only went out in the dark, when he would not be seen to access a cash point. He had a fall in the snow one evening and was taken to the emergency department. He sustained a muscular injury to his thigh, which affected his mobility, as well as a laceration to his head. He was reviewed medically, provided with a zimmer frame to mobilise with and referred to a domiciliary therapy team for further assessment. Tommy was not comfortable with professionals coming into his home but slowly warmed to engaging with services. He initially agreed to some equipment and, on subsequent visits, tentatively accepted support with personal care and advice regarding his general health. During the initial visits, he agreed for space to be cleared to enable safer navigating around his home and eventually allowed reablement home support to manage his basic care needs.

The effects of frailty

Frailty, now recognised as a long-term condition, has been documented through the decades in historical or medical texts to describe an individual who is not necessarily unwell but may be delicate in appearance, slow in moving and/or lacking in physical strength. It has multiple contributors, resulting in an unpredictable progression. Due to physical aspects, such as sarcopenia, and a decline in the regulation of the immune system and essential hormones, the body is constantly working to function productively (Topinkova, 2008; Berrut et al, 2013). Consequently, the body's inner reserves of energy are diminished (British Geriatric Society (BGS), 2014). Other factors-environmental, social and psychological-all interplay to increase susceptibility to frailty (Duppen et al, 2019; Ye et al, 2019).

This happened with Tommy, where the repeated stress on his body's performance compromised his inner reserves. Poor nutrition, sarcopenia, a disordered environment, underlying health conditions and lack of social contact further increased his vulnerability and exacerbated the effects of his fall. His response to a relatively minor physical or mental stressor would be excessive in comparison with the response of a more robust individual. It is known that, for a frail older person, the recovery period from an event like Tommy's fall takes longer, and their previous level of function may not be regained (NHS Rightcare, 2016).

With regard to the frailty phenotype model, Tommy's frailty exhibited itself in weight loss, reduced muscle function and slowed walking speed. Three or more of the phenotype descriptors indicate a frail state (Gwyther et al, 2018). However this model does not consider any of the social or environmental elements identified as potential contributors to the progression of frailty. For Tommy, Rockwood's cumulative deficits model includes several factors, such as asthma, activity limitation, anaemia, cellulitis, falls, hearing loss, social vulnerability and weight loss. The more the number of problems that accumulate, the more likely is it that there will be an adverse reaction (Rockwood and Mitnitski, 2007).

The term ‘frail’ is not well-liked by older people due to its negative associations with loss and dependence; yet, a common language is essential to understand frailty among health professionals (UCL Partners et al, 2014; Waldon, 2018). If health services are proactive in recognising frailty, the outcomes for the ageing population will improve (Wallington, 2016). So, too, will the burden of cost to the NHS if frailty can be reversed or better managed, with more people supported in the community (Turner and Clegg, 2014) and avoiding unnecessary hospital admissions. If Tommy had been admitted when he presented at the emergency department, his outcome may have been very different. Prolonged admissions for older individuals can lead to reduced function and weakness from immobility and the onset of delirium from being moved around wards (BGS, 2015; NHS Rightcare, 2016). Tommy returned home from the emergency department via a discharge to assess pathway, which provided wraparound support and assessments completed at home, thus avoiding a lengthy hospital admission (Oliver et al, 2014; Stott and Quinn, 2017); this is a positive example of local community strategy. As Moody (2016:14) stated: ‘people living with frailty have most to gain from integrated and person centred care’. There are also substantial financial benefits to this process, as hospital admission is significantly more costly than reablement support at home and community rehabilitation.

Assessment of needs and frailty identification

Tommy's needs were assessed holistically, in accordance with the Comprehensive Geriatric Assessment (CGA), encompassing physical and mental health conditions, function of daily activities, social circumstances and the environment (Turner and Clegg, 2014). The frailty syndromes, namely, incontinence, falls, delirium, medication and immobility, all of which are commonly associated with frailty, were also considered (Gwyther et al, 2018). The assessment completed was therapy-led, without the medical input accessible as an inpatient. Tommy's condition was scored on the Rockwood Clinical Frailty Scale (CFS) (Rockwood et al, 2005). This is a frailty assessment tool recently adopted as an opportunistic screen for patients in the service to be used only after a holistic assessment (Rockwood et al, 2020). It accords with the International Conference of Frailty and Sarcopenia Research (ICFSR) guidance for over 65s (Dent et al, 2019). It is simple and accessible to execute in the community and provides an outcome that can be shared among services. The CFS has a functional scale, from 1, being very fit, to 9, indicating terminal illness. Tommy had a CFS score of 5, indicating mild frailty; he had slowed in his physical activity, was unable to go shopping and struggled with heavier housework (Rockwood et al, 2005). It is important to score from the person's baseline 2 weeks previously if they are acutely unwell at the time of screening (Abbott and Dykes, 2017). Although the CFS characterises frailty from only a physical and functional perspective, this is acceptable, as the screen is evidenced as a robust predictor of detrimental outcomes (Rockwood et al, 2005).

Tommy's level of frailty and reduced function could have been accelerated by social frailty. He was isolated from the local community, with limited outside contact, barring occasional visits from his neighbour and a weekly shopping delivery. This detachment led him to pay less attention to his appearance, which further fuelled his decision to minimise social interactions. It is likely that his dishevelled appearance had led to antisocial behaviours, where he avoided social contact by going out unseen at night. In turn, Tommy was also less physically active, which contributed to sarcopenia and reduced stamina to complete household chores. His restricted diet-the same cold, raw foods for each meal and excess levels of alcohol-depleted his body of essential nutrients, further contributing to the development of frailty (Gobbens and van Assen, 2016). Tommy was residing in an impoverished environment over a long time. The unclean, cluttered rooms placed him at risk of falls and ill health, but he did not have the internal reserve to take positive actions to correct this. Prior to health and social care involvement, Tommy was not aware his wellbeing could be improved and would not have taken the necessary steps to make any positive changes. When provided with support to make informed choices, Tommy was an active participant in the journey to improve the disorder in both his home and appearance.

Timely integrated community intervention

Frailty is a dynamic continuum that can both advance and abate (Fairhill et al, 2011; Wallington, 2016). Topinkova (2008) suggested an optimal intervention window to guide the direction that frailty takes. In Tommy's case, a multidimensional approach was adopted for maximum gain (Waldon, 2018), incorporating housing adaptations, treatment of underlying conditions, purposeful activity, increased social interaction, improved nutrition, falls prevention and exercise (Carlsson et al, 2017). A holistic, individualised management plan and person-centred goals, as recommended by the World Health Organization and BGS, were agreed collaboratively with Tommy to target the frailty and his specific needs (BGS, 2014; de Carvalho et al, 2017). The interventions demonstrated excellent joint working between domiciliary nursing, therapy, social care, housing and community resources. Table 1 summarises the interventions provided.

The cross-services intervention entailed nursing input to address Tommy's immediate ailments and education regarding alcohol consumption and diet. Occupational therapy provided equipment to increase safety and independence, minimise environmental hazards and establish a healthier, purposeful routine. Tommy learnt new skills in therapy to prepare a variety of nutritious, hot meals. Physiotherapy input focused on falls prevention and increasing muscle strength and physical activity. Reablement home services provided support at key points to encourage a healthier functional routine, and they were instrumental in removing hazards and clutter from Tommy's home. The council's Care and Repair Team accessed grants and initiatives for a downstairs shower adaptation, renewal of electrics and central heating to improve his environment and benefit Tommy's health and wellbeing. Age UK's Home from Hospital Team assisted Tommy in purchasing key items for his home, for example, appliances, carpets, shelving, furniture and supportive footwear. They helped him navigate community activities and dial-a-ride services to attend social events independently. Tommy was also encouraged to re-establish contact with his estranged sister.

Some barriers to integrated working were apparent during this episode of care: communication was hampered between health and social care services due to disparate processes and technology. Ideally, sharing records between health, social care and other services, including primary care, ambulance service and acute settings, would improve patient outcomes (de Carvalho et al, 2017).

Reversing frailty

The personalised interventions and collaborative goal setting empowered Tommy to look after himself better (NHS England, 2016) and enabled him to function with greater ease and renewed purpose. Following the provision of an intact mattress, clean bedding, a haircut and clean clothes, Tommy recommenced completing regular personal care. This concurs with the study by UCL Partners et al (2014), which found that, when interviewed, older people valued independence to complete daily tasks themselves at their own pace, as this provides them with a sense of achievement and identity. Tommy began to take a pride in looking after himself and his home and employed a cleaner to support him with this task. Developing cooking skills and being supported to purchase appliances such as a fridge, microwave and toaster have improved his diet. Tommy became more motivated to prepare regular meals, which can be challenging for older people living alone (Whitelock and Ensaff, 2018). In addition, he enjoyed luncheon clubs and meals on wheels, which contributed to a healthier nutritional intake, as well as reducing social isolation. Tommy regained his confidence and physical performance through mobility practice and exercises, and he no longer required a walking aid. Thus, the physical aspect of frailty was reversed, as was the likelihood of further falls (BGS, 2014). Tommy's participation in community coffee mornings and luncheon clubs as well as assistive shopping at the local supermarket increased his level of activity and social interactions, reducing their impact as contributors to frailty.

From the timely health and social intervention received within the community setting, Tommy's occupational performance was maximised. At the time of writing, he was no longer nutritionally compromised and was socially connected, and the factors accelerating sarcopenia had been minimised, thereby reducing his level of frailty and vulnerability.

Tommy had been unnoticed prior to his fall; he had adopted a reclusive lifestyle with little contact from services and not previously been placed on the frailty continuum. Following his fall, his outcome may have been less favourable if he had been admitted for a prolonged stay in hospital, as falls are a major risk factor for admission. Or, if he had been overlooked and unsupported at home, the fall could have impacted significantly on Tommy's independence and confidence, leading to further physical inactivity and loss of muscle function (BGS, 2014). The BGS (2015) advocates longer-term support, but the health and social care services involved with Tommy could only be offered for a limited period, usually 6 weeks.

Once Tommy was managing independently within his improved environment and routines, he did not have any further contact with health or social care, whose input are needs- and goal-focused. Reliance was instead placed on voluntary organisations and informal care to continue to support Tommy to maintain his enhanced wellbeing. Tommy has been exposed to how services can support him, and it is hoped he will continue to make positive decisions himself. An important part of his journey has been the realisation there was an alternative to living the way he had been and that he was able to make his own lifestyle choices to improve his situation.

Conclusion

Tommy's case described here demonstrates that frailty can have multiple contributors, including physical, psychological, social and environmental elements. It reinforces the recommendations to complete opportunistic assessments for frailty and the need for integrated and multidimensional interventions in a community setting. It also emphasises the value of joined-up care and highlights how, without the community asset-base, Tommy's aspirations would not be realised or sustained. This timely input, implemented when Tommy was found to have only mild frailty, resulted in improved wellbeing and quality of life. He had significant home improvements to enable him to age in place and support to make his environment safer and habitable. He has also learned new skills and was empowered to lead a healthier life in terms of increased physical activity, improved nutritional intake and increased social interaction. The literature supports the notion that Tommy's frailty was reversed, although further research would be beneficial to establish a stronger evidence base in the UK for standardised assessments and interventions in the community. For Tommy, it is imperative to his future wellbeing that he continues to maximise his occupational performance when services are no longer involved. If Tommy had not fallen and presented at the emergency department and had instead continued within his previous lifestyle and environment, his frailty may well have been accelerated.

KEY POINTS

• Early identification of frailty can led to timely proactive interventions to slow or reverse frailty
• Avoiding hospital admission and supporting individuals in the community can reduce potential harm and adverse outcomes
• Frailty is complex and should be considered from a multidimensional perspective considering social and environmental elements in addition to physical factors
• A shared approach between health, social care, housing and community organisations can make the difference.

CPD REFLECTIVE QUESTIONS

• Reflect on how your interventions could be enhanced by working closer with other services or disciplines. What barriers did you identify and how could you overcome them?
• Tommy's case study demonstrates the multiple factors contributing to frailty. What elements can your practice have a positive effect on to slow or reverse its effects?
• Consider how social isolation affects your patients and the specific impact on their health and wellbeing. What actions can you take to address this?