She had spent the
night on the bathroom floor following a fall. She had suffered three other falls
in the previous six months, two of which had led to hospital admissions. Her poor
eyesight and arthritis meant that she was at risk of falling again. On arrival
at A&E, Mrs B was suffering from confusion: she no longer knew where she
was , was unaware of the date or time, dozed during the day and tossed and
turned at night, was suffering from anxiety and cried out when she was not
depressed, complaining that money was being stolen from her and that hospital staff were trying to harm her. Though she had been widowed two years earlier, she claimed that her husband was going
to fetch her and take her away. Her clinical, lab and radiological examination
suggested early stage dehydration.
She was referred to
Care of the Elderly where the dehydration was treated; the confusion increased
and lasted a week, before receding rapidly. She had fortunately avoided a fracture
on this occasion, but had to be referred for rehabilitation since the fall had affected
her ability to walk: she was displaying symptoms of ‘post-fall syndrome’, specifically
retropulsion when walking – she would lean backwards – which threw her off
balance and made her very apprehensive as soon as she stood up. It would take
her several weeks of rehabilitation to become a little more sure of herself.
During her six-week
stay, a memory assessment revealed incipient Alzheimer’s disease. On her return
home, a new treatment regime was put in place for Mrs B., an intensified programme of
domiciliary care and home-based rehabilitation to master walking again. She is
being monitored by a home care network coordinated by her GP and is due to see
a neurologist. In retrospect, Mrs B talks of her fall and her admission to
hospital as a traumatic event, as a ‘collapse’.
Dreuil and Boury gave this case study as a striking example of
a condition known as frailty. It was an eye-opener to me, as I hadn't previously come across it, though it has been known
about for decades and has been attracting increasing attention in recent years. Intermediate between good health and incapacity, it is a state
in which a person is coping reasonably well with life but can be plunged through
a relatively insignificant event into a state, to use Mrs B.’s own word, of
collapse, characterised by multiple simultaneous pathologies: Mrs B had
multiple physical conditions, some related to her fall, some to other diseases
such as arthritis or the incipient Alzheimer’s, but was also suffering from
mental difficulties, specifically confusion and depression.
The event that had precipitated her difficulties was a fall, from her own height. In a completely healthy individual, that is unlikely to have any serious consequences – bruising or simply a little pain, at worst a sprain – perhaps the most serious consequence would be the hurt pride caused by the laughter and mockery or our so-called loved ones. But in a frail individual, the effect can be devastating.
From being able to cope, Mrs B. was plunged into a condition
where she could no longer manage her life at home. As well as healthcare, she needed social services far more intensively: domiciliary visits for now,
but with the prospect of residential care clearly on the horizon and increasingly
imminent.
This is a French example, but precisely the same type of
case is common, and indeed increasingly common, in Britain and other nations. And
certainly frailty is a condition that is being met throughout the wealthier nations more and more frequently –
and for the very best of reasons: although it can affect people of any age it
is much more likely to afflict the old, as is the case of Mrs B., and more and
more of us are living to increasing old age. That great success of
nutrition, of social care and above all of healthcare, is creating new
healthcare challenges – and frailty is one of the most significant.
Now let us look back at my previous post in this series. It
compared two women of 61 and 62, both of whom had suffered strokes, but one of
whom had been discharged from hospital very quickly. I focused on the other,
and by looking at her earlier record of treatment in both healthcare and social care, saw that she was suffering from multiple conditions that had
caused her to be treated repeatedly in hospital and to require significant
levels of domiciliary and residential care.
Doesn’t that sound similar to Mrs B.’s case? Though the
conditions were different and the 62-year old stroke patient was far younger,
don’t we again see many of the symptoms of frailty? Ill in multiple ways, undergoing repeated treatment of many different kinds. This feels like a woman who had been
in a frail condition and has now been precipitated into a state of collapse.
Understanding her case, as we saw, meant bringing
information together from many different sources: admitted patient care, outpatient
attendances, inpatient stays, community treatment in or out of hospital,
domiciliary care provided by social services or residential care.
The concept of frailty has been a bit of an eye-opener to
me. But the message I take it from it is one that I’ve stressed again and again
in these occasional posts: we need to monitor patients over the long term and we
need to do it across care settings, so that we understand what is happening to the patient in the many different areas of care he or she encounters.
A frail person suffering a collapse will need care provided by many different specialties
and professions. If the patient is to get the most of out of it, and society is
to deliver care in the most cost-effective way, we need to understand what they
are all doing and to ensure that their efforts are coordinated as fully as possible.
Frailty: in information terms it just means that it is more urgent than ever to break down data silos.
