Frailty, the follow on

In my last blog I included four exercise programmes which had been published in the position statement of the Italian group OrtoMed. One of my readers responded thus:

“If one followed this exercise programme it represents a pretty intense programme for someone who is already an ‘exerciser’ let alone a frail person needing a programme to avoid the worst effects of age and frailty. Not that one shouldn’t try to do it, but this is where  Cardiac Rehab can be very helpful in introducing candidates to regular exercise and embedding a programme into one’s life, however ‘late in the day’ it was but as I say, following it to the letter, will take up quite a lot of time.”

Very reasonable considering that there are 15 sessions per week in the OrtoMed programme! The suggested regime sets a high bar at a level which few will wish to follow. There rubs the problem – just how near to the ideal should the recommendations go? If the bar is set too high, most people will believe that they cannot attain that level and probably not try it at all. Any exercise programme must be a compromise between what is best and what people are prepared to do. As Voltaire said “The perfect is the enemy of the good”. Or even, as Chesterton had it. “If something is worth doing, it is worth doing badly”!

So, please take the OrtoMed programmes – aerobic, resistance, balance and flexibility – as an indication of the direction to aim at – not a set of rules to be followed slavishly.

Back to Frailty. Last time I described some recent publications which, it seemed to me, give a narrative on the outcomes of being inadequately active, starting with the trends in frailty over the past 80 years and moving on to prevention and treatment. Today it is all about the undesirable outcomes.

Waiting times in A&E Departments

The more frail the individual, the greater the risk of being admitted to the Casualty (A&E) Department. A report from the Royal College of Emergency Medicine this year showed that rising numbers of elderly and frail people are stuck in A&E, often on trolleys in corridors, for far too long. The length of wait is, curiously, age-related. For people aged 60-69, 15% wait 12 hours or more while for those aged 90 or more the number rises to 33%. While waiting, few of the patients are screened for dangerous conditions like delirium, fewer than half are checked for risk of falls and only just over half are screened for frailty.

Impact in the A&E Department.

Published in the British Medical Journal was a report on mortality rates in Casualty Departments in England. Prolonged waits in A&E have been growing steadily – from no 12 hour waits in 2010 to more than 10% of patients spending that long by 2025 – when more than 1.7 million people waited for more than 12 hours. The  results include increasing death rates in the unfortunate patients – a 22% increase in standard mortality for those waiting eight hours or more compared to those waiting less than four hours. This accounts for  about 15,000 to 26,000 excess annual deaths. A different analysis, from the Office for National Statistics, has estimated that there are many as 57,000 excess deaths from overlong waits in A&E – due to such factors as delayed treatment, fatigue, delirium and crucial omissions in monitoring and care.

Effects during hospital admission

Yet more bad news here – the degree of frailty, as indicated by Hospital Frailty Risk Score, shows an association with length of hospital stay. Both hospital mortality and overall costs of care are alos increased. The incidence of frailty among patients admitted rises with age and reaches nearly 50% in those over the age of 95. . In this group the length of hospital stay was 15 days longer than for those in the same age group without a frailty diagnosis and the costs were £2557 higher. The death rate was also higher.

Conclusion

Don’t allow yourself to get frail! And if you don’t know how to do that, you have not been paying attention!! Oh, and stay well clear of A&E Departments.

Next week we will get away from frailty (phew) and move on to the role of exercise in the prevention and management of cancer.