Frail seniors at risk at Canadian hospitals

Usually when you're discharged from hospital, you breathe a sigh of relief. You're on the mend and on the road to recovery. But a new and disturbing trend is emerging with frail elderly patients with more and more of them dying within days of being sent home from hospital. A study just published today in the Canadian Medical Association Journal is flagging concerns about this growing problem.

Frailty means a patient who has diminished physical reserves. It also means a patient who is less able to resist the physical stresses associated with illnesses. A hardy 70 year old gets a new hip, recovers and starts golfing.  A frail 90 year old gets a new hip and dies of pneumonia a couple of week later. Being frail also means being vulnerable to side effects that don't happen to younger patients.  For instance, frail seniors who get a bladder infection are more likely than younger patients to develop confusion and delirium.

Seniors with mild frailty have difficulty with one or more of shopping, preparing meals, doing housework or handling their finances.  Moderate frailty means difficulty bathing, dressing or climbing stairs.  Severe frailty means being dependent on someone else for three or more activities of daily living. Frailty is common - anywhere from 4 to 60% of older patients living in the community and 27 to 80% of hospitalised patients.  Despite that, doctors often fail to recognize when an older patient is frail.

In the study published this week in CMAJ, researchers from the University of Alberta looked at the fate of nearly 500 patients at two Alberta hospitals. Doctors used a tool called the Clinical Frailty Scale to assess seniors in hospital to see how frail they are - mild, moderate or severe based on the things I talked about.  One third of the 500 patients were classified as mildly frail or worse. Within 30 days, 85 patients had to be readmitted to hospital or had died.  Patients who were frail were at greater risk of readmission or death. The frailer they were, the more likely they were to have bad things happen. The Clinical Frailty Scale helped doctors identify patients at greatest risk of dying or having to be readmitted to hospital.

Speaking anecdotally, as an ER physician, I see lots of frail seniors who get sent home and who end up being readmitted to hospital within a day, a week or perhaps a bit longer. There are many reasons for this.  When patients are discharged home or back to the nursing home from which they came, there's no guarantee they'll get the follow up doctors' appointments they're supposed to get. If the doctor prescribes a new medication, the patient may not 
take it properly or even receive it.

This study is important because it forces us to reexamine our traditional view of hospitals.  In the past, we have thought of them as places where (more often than not) patients get better.  As discussed in the article, just being in hospital increases frailty.  Patients who are bedridden throughout their hospital stay get weaker and less steady on their feet.  They don't eat as much and get malnourished.  They get put on new medications that cause side effects.  While in hospital, they're sleep deprived and under cognitive stress.  

All of those factors set frail  patients up for failure and even worse when they're discharged.  Doctors call it "post-hospital syndrome." Patients who are already frail at the time of the first hospitalisation are more sensitive to the stresses of being in hospital and therefore at higher risk of being readmitted. What's really interesting is that the cause of death and the reason for the readmission to hospital may not be the same as the reason for the original hospital stay; an entirely new problem caused by being in hospital.  

What can be done to reverse the trend? Identifying patients at risk is a good start, but we need to figure out how to pull frail seniors back from the brink.  It probably means keeping hospital stays as short as possible.  It also means avoiding risky procedures and treatments.  For instance, it used to be routine for older patients to have a urine catheter put in so that they didn't have to be accompanied to the bathroom.  We know now that many bladder catheters are unnecessary and harmful.  

We need to encourage seniors to walk the hallways while they're in hospital so they keep their strength.  We need to follow up on frail seniors who are discharged from hospital to make sure they take their new prescriptions and that they go to their follow up appointments.  I'd be in favour of having mobile medical teams that do house calls on recently discharged patients.

In my opinion, we also need families to look for signs of frailty in the aging loved ones. Observe how slowly they walk and how stead they are on their feet.  When you greet them, don't just give them a peck on the cheek, but shake their hand.  That way, you can feel how strong their hand grip is.  Recent studies show that a weak hand grip is an early sign of frailty.  See how well your loved one is able to do things like shopping and taking care of their home.

If you're still in doubt, ask your loved one's family doctor or nurse practitioner for their input.  If you want to get really specific, ask the doctor if he or she would be surprised if your loved one died within the next six months to a year.  If your loved one's health care provider would not be surprised by an imminent death, then he or she is telling you that your loved one is frail. That likely means providing extra support for your loved one, and watching them like a hawk should they require a stay in hospital.