The frail patient

A frail person typically suffers from multimorbidity (multiple illnesses) and has associated polypharmacy (multiple medications). They often have cognitive impairment, visual and hearing loss, low bodyweight, poor mobility due to muscular weakness, unstable balance and poor exercise tolerance. Their general functional reserve and the capacity of individual organs and physiological systems are impaired, making the individual potentially vulnerable to the effects of minor illnesses. Frailty is likely to be a response to chronic disease and the ageing process.

Whilst frailty increases with advancing age and is usually seen in older patients, it can also occur in younger people.

Identifying frailty proactively can help target those patients who will benefit from specialised assessment and management. There are many tools available to identify and stratify the level of frailty. One commonly used scale is the Clinical Frailty Scale, which uses an individual’s functional ability and level of dependency to determine their degree of frailty ( Fig. 17.1 ).

Assessment of the frail patient

When an individual is identified as frail, Comprehensive Geriatric Assessment is an evidence-based process that improves outcomes. It involves taking a history from the patient and, with the patient's consent, from a carer or relative, followed by a systematic assessment of:

cognitive function and mood
nutrition and hydration
skin
pain
continence
hearing and vision
functional status.

The extent and focus of the assessment depend on the clinical presentation. In non-acute settings such as general practice or the outpatient clinic or day hospital, focus on establishing what diseases are present, and also which functional impairments, symptoms and problems most affect the patient's life.

In acute settings, such as following acute hospital referral, focus on what has changed or is new. Seek any new symptoms or signs of disease and any changes from baseline physical or cognitive function.

The complexity of the problems presented and the need for comprehensive and systematic analysis mean that assessment is divided into multiple components, undertaken at different times by different members of the multiprofessional team ( Box 17.1 ).

17.1

The multiprofessional team

Professional	Key roles in assessment of
Physician	Physical state, including diagnosis and therapeutic intervention
Psychiatrist	Cognition, mood and capacity
Physiotherapist	Mobility, balance, gait and falls risk
Occupational therapist	Practical functional activities (self-care and domestic)
Nurse	Skin health, nutrition and continence
Dietician	Nutrition
Speech and language therapist	Speech and swallowing
Social worker	Social care needs

Factors influencing presentation and history

Classical patterns of symptoms and signs still occur in the frail patient, but modified or non-specific presentations are very common due to comorbidity, drug treatment and ageing itself. As the combination of these factors is unique for each individual, presentations will be different in each patient. Some general patterns can be recognised, however ( Fig. 17.2 ). The first sign of new illness may be a change in functional status: typically, reduced mobility, altered cognition or impairment of balance leading to falls. Common precipitants are infections, changes in medication and metabolic derangements, but almost any acute medical illness can produce these non-specific presentations. Each of these presentations should be explored through careful history taking, physical examination and functional assessment.

Fig. 17.2, Functional decompensation in frail people.

Communication difficulties, cognition and mood

Disorders of communication, cognition and mood are common and should always be considered at the start of the assessment of a frail adult.

Communication can be challenging for a variety of reasons ( Box 17.2 ). As a result, the history can be incomplete, difficult to interpret or misleading, and the whole assessment, including physical examination, may be more time-consuming.

17.2

Communication difficulties: the seven Ds

Problem	Comment/causes
Deafness	Nerve or conductive
Dysphasia	Most commonly due to stroke disease but sometimes a feature of dementia
Dysarthria	Cerebrovascular disease, motor neuron disease, Parkinson′s disease
Dysphonia	Parkinson′s disease
Dementia	Global impairment of cognitive function
Delirium	Impaired attention, disturbance of arousal and perceptual disturbances
Depression	May mimic dementia or delirium

Whenever possible, assess the patient somewhere quiet with few distractions. Introduce yourself clearly, make your patient comfortable and ensure that they understand the purpose of your contact. Provide any glasses, hearing aids or dentures that they need and help them to switch on and adjust their hearing aid if necessary. If they still cannot hear you, use an electronic communicator, or if they can read easily, write down simple questions and instructions.

Cognitive function includes the processes of perception, attention, memory, reasoning, decision-making and problem solving (p. 320). Cognitive impairment increases with age and has implications for assessment, treatment, consent and prognosis. Consider cognitive impairment if a patient who appears to hear you has limited ability to cooperate with you, cannot recall their medical history or provides no specific symptoms. Other problems, including low mood or dysphasia, can mimic cognitive impairment. Some patients present with apparently good social skills or ‘façade’ and cover their impaired memory by diverting the conversation to another topic. Never ascribe changes in cognition to age alone, without excluding dementia or delirium (p. 377).

Depression is common in frail people and may be difficult to diagnose. Consider this if your patient struggles to concentrate, is withdrawn or is reluctant to interact. Standardised rating scales are available, such as the Geriatric Depression Scale. A formal psychiatric assessment may help.

Patients are often fearful that they will be admitted to the hospital or not return home after admission, and they may understate their symptoms or functional limitations. Always try to corroborate the history from a partner, carer, relative or friend, with the patient's consent.

The history

The presenting symptoms

Frail patients often have multiple symptoms. Take time to detail each symptom and separate those arising from a new acute illness from those due to background disease and disabilities.

Ask:

How long have you had a particular symptom?
Has it changed recently?
When were you last totally free of the symptom?

Try to establish what the patient's symptoms, functional abilities and mental status were before the new presenting problem. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) can help family members compare current with past cognition. This helps set realistic goals for treatment and rehabilitation.

The patient's perspective may vary from the clinician’s, particularly in acute settings. For example, a patient referred following sudden loss of consciousness may be unconcerned by this but anxious about longstanding back pain. These symptoms should never be disregarded; if they are important to your patient, they should be important to you.

Common presenting symptoms

Decreased mobility

Ask about:

the patient's usual mobility, when it changed and if the change was abrupt
what factor, or factors, are causing the impaired mobility. Commonly, pain, weakness or loss of balance will be present, alone or in combination. Each may have a remediable cause.
any falls
use of walking aids
history of recent head injury, fevers or rigors, dizziness or poor balance
lower limb weakness, numbness or paraesthesia
joint pain, especially in the back, neck or lower limbs
any bladder or bowel symptoms
current drug treatment and whether this has changed recently
how the change in mobility is affecting their daily life.

Confusion

Check that the patient can hear you clearly and ask if they would like a friend or relative to be with them. Although a confused patient may find it difficult to give an accurate history or a clear description of symptoms, never ignore what they tell you, as their perspective remains important to your care. Take a collateral history.

Establish:

the person's normal cognitive state and whether the change has been abrupt or gradual (see earlier). Acute change, developing over hours or days, that fluctuates is suggestive of delirium
any symptoms of common infections, such as urinary frequency, productive cough, fever or rigors, which can precipitate delirium
whether the person has any pain, and if so, where
current drug treatment and adherence, with any recent changes
alcohol use.

If delirium is suspected, carry out a cognitive screening test, for example, 4A’s test (4AT) (p. 377), to help confirm the diagnosis.

Falls

A collateral history is helpful if a fall has been witnessed.

Establish:

the patient's usual mobility
how many falls they have had, over what time frame and whether injuries, including fractures or head injury, have been sustained
whether the patient can rise from the floor unassisted
whether the patient has a falls alarm or other means of calling for help
the presence of dizziness or lightheadedness, and whether the problem is true vertigo or worse on standing (p. 194)
the presence of palpitations, limb weakness, paraesthesia or any joint pain, especially in the back, neck or lower limbs
quality of vision
any problems with the feet
any recent symptoms of infection
current drug treatment and any recent changes.

Past medical history

Detail the past history and known comorbidities from all available sources, including any previous records. Comorbidities may not be directly relevant to the current problem but may influence prognosis and the feasibility and appropriateness of potential investigations and treatments ( Box 17.3 ).

17.3

How comorbidities or drugs can influence symptoms or clinical signs

Drug history

Polypharmacy is associated with drug interactions, adverse events and difficulties with adherence. Take a detailed drug history, supplemented by the following:

Identify all medications, including over-the-counter preparations.
Ask whether any drugs have been started or stopped recently, or doses of regular medications altered.
Ask the patient if they think any of their medications are causing any of their symptoms.
Explore the patient's ability to self-administer drugs; ask if they use a dosette box or if a carer helps with administration.
Explore the ability to read labels, open bottles or use inhalers correctly.
If patients have their drugs with them, go through them together. Ask patients what they believe each one is for, how it affects them and how often they take it.
Ask if there are any drugs that they sometimes omit, such as diuretics on days when they are going out.
Ask carers if there are partially used supplies of drugs in the house.
Clarify any ‘allergies’ or previous adverse events. Explore what symptoms the patient believes to be caused by their drugs, as some may be unrelated. If in doubt, regard the allergy as significant.
Contact the prescriber, if necessary, to confirm details of the drug history.

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