Life and how to live it

So my page broke this week.  When I say broke more bits fell off but ever the stoical page that it is it’s kept going.  Over the years it has experienced many unexplained falls, there’s been several episodes of acute confusion as it struggled to tell me extension numbers (usually resolved by a new battery) and on occasion it just became unresponsive.  The exact cause of this has never been fully established but I strongly suspect it has an intermittent fault caused by degenerative, wonky wiring.

In short I think my page might be frail.

The assessment made I’ve made a few adjustments to it (micropore tape) and it continues to happily bleep me again.  We both know the time will come when we need to be honest about how it can continue fulfil its role but we’re not there yet. Until then I will do as much I can so my page can continue to enjoy many bleeping years to come.

Frailty is a concept I have struggled with over the years.  And yes I know as a Geriatrician that could be seen as blasphemy. I’m just being honest though.  I am frustrated that we are still to agree a formal definition that can be easily translated into operational use.  And yet I find myself in a position where I am trying to do just that.

So what is it exactly?  Well, I can tell you what it’s not so that seems as good a place as any to start.

You don’t have to be old to be frail.

My colleague Rowan Wallace gave a presentation years ago which sought to challenge the concept of frailty by showing a photo of her grandparents and asking who was the frailer of the two. Spoiler alert it wasn’t the ‘old looking one’.

It is true that in the very old (>85yrs) around a quarter will be frail but it’s worth remembering that some younger people will also be frail.

Think of it this way.  Take stroke.  It affects all ages but your risk of it increases with age.  The same is true of delirium when superimposed on dementia.  Heart failure is another example.

So I tend to think of it as a long term condition and that makes more sense. In thinking about it that way you might start to ask why is it bad? How do you screen for it?  What  do you about it?  Why should I care? And why is every man and their dog banging on about it?

I think we’re in uncharted territory at the moment and this is why no one can quite articulate why frailty is now a thing.

As I reflect on another weekend on call I am beginning to see why.  We have gotten used to good health such that when a person (especially an older one) becomes unwell it is met with surprise not just by families but by the person themselves.  I used to think it was just the concept of dying that we had lost the ability to talk about but I actually think it goes deeper than that.  People have this amazing contradictory expectation about their own health.  They expect to live for a very long time, with a good quality of life and with a NHS that will attend to their every person specific need.  Death also comes on their terms.  What I saw this weekend was a receiving unit full of broken, unwell people accompanied by their equally broken and exhausted relatives and carers.

This is frailty in action.  And this is what we need to be talking about as openly and honestly as possible.

However we continue to be surprised when these people turn up at our acute medical receiving units.  We are unprepared for them as we continue to function as a reactive service.  One that is risk adverse and offers little in the way of alternative options.

So we need to do things differently and that starts by changing up our approach.  It’s common sense really but when people are exhausted it can feel too difficult.  Of course we don’t make it easy either with increasing silo working which further reduces the ability to share information.

We need to start by how we define risk. I would argue there is a disconnect between what we mean versus what we do. Specifically we seek to manage our own risk but present it as managing the risk to the patient.

We need to be get away from this idea that if we had infinite resources we could deliver a much better service.  This is true to some extent but I predict we will see continued paternalism rather than re-enablement.  Seven day working is a fabulous concept but re-enablement shouldn’t stop just because there isn’t an OT on the ward on a Sunday morning…..

So lets begin again.  Lets agree that frailty exists.  These people will turn up at our front door so we need to be able to recognise who they are regardless of age. We need to be able to offer them some kind of intervention or model of care.  Lets call that Comprehensive Geriatric Assessment (should it even contain the word Geriatric anymore….???).  Let’s admit the very sick as that will always be the right thing to do.  For the others lets see what alternatives we can offer – it could be a community team of therapists, nurses, doctors, pharmacists and third sector.  We could deliver it in their own home or a local centre.  Why not even via Skype or FaceTime?  (crazy talk I know, it’s the stuff of Sci Fi!)

We should continue the conversation around what the person would and would not want as life progress.  We should share that information with as many relevant people as possible, most importantly with their own families.

We should talk to each other in health and social care with improved IT systems but also an actual conversation is pretty good too.

It shouldn’t be hard. This is life and it’s up to us how to live it……

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