Rehabilitation: stopping the dominos toppling

1 December 2012

Timely phone calls after discharge can help the frail elderly stay well and stay home. FIONA CASSIE reports on Dr Claire Heppenstall’s PhD research into the frail elderly recently presented to the College of Nurses symposium.

For the frail elderly, it doesn’t take much to start the ‘dominos’ tumbling and a rapid decline in health and well-being, says aged care researcher Claire Heppenstall.

She says health professionals often feel a sense of futility when faced with a frail patient but research shows that interventions can improve outcomes and keep the dominos standing.

Heppenstall, a doctor specialising in aged care and research fellow in University of Otago, Christchurch’s older adult health department, received Health Research Council funding to study fragile elders.

Her PhD research first looked at frailty in general and then focused on the frail elderly admitted to Canterbury District Health Board’s inpatient Older Person’s Health Service (OPHS) for rehabilitation after an acute hospital admission.

Heppenstall says frailty as a concept has become increasingly defined in recent decades with physical symptoms like weight loss and decreases in muscle strength and activity along with psychosocial factors like health, attitude, social supports and financial resources.

“Sometimes, a urinary tract infection (UTI) can just tip someone over to frailty.”

Or there can be a domino effect of being less active (through choice, angina, or arthritis) leading them to getting less vitamin D from sunshine, weaker muscles that can increase the fear and risk of falling, and lead to even less activity. Multiple drugs and inappropriate prescribing also impact on the outcomes of the frail elderly.

What has been proven to help includes comprehensive geriatric assessment, multidisciplinary team (MDT) rehabilitation, medication review, exercise, and nutrition.

What keeps the frail elderly independent?

Heppenstall’s Maintaining Independence Study set out to find out what factors influenced outcomes of the frail elderly post-hospital discharge and how the OPHS could improve

those outcomes.

Phase two involved recruiting 159 older people as they were discharged from the service and using their notes and face-to-face interviews to gather data on their level of frailty, co-morbidities, mental health, medication, cognition and social circumstances.

The patients, average age 81 and more than half living alone, were phoned at three months and six months post-discharge to ask them whether they felt their health had improved, stayed the same, or worsened since they came home from hospital. Heppenstall says that people’s self-reported health was linked to their risk of moving into residential aged care, with 40 per cent of people reporting “deteriorating health” at three or six months being four times less likely to be still living at home 12 months after leaving hospital than those reporting improving health.

Overall, 12 months after discharge from the DPHS 14 per cent of the cohort were dead and 67 per cent were still living in their own home (which compared favourably to an American study finding older people who failed to regain their previous functioning level after a hospital admission had a 41 per cent chance of death within a year). Three-quarters had had a further hospital admission.

Her study found that dementia was the biggest predictive factor for moving into residential care, with people with dementia 4.3 times less likely to be still living in their own home 12 months after discharge. The next biggest risk factor was further hospital readmissions (3.7 times the risk), followed by visual impairment (2.7 times the risk), and frailty and quality of life were lesser factors at 1.3 and 1.4 times the risk, respectively. She also found that men were four times more likely to have hospital readmissions than women.

The qualitative phase of her study included a series of face-to-face interviews with 16 older people – half of whom remained at home (stayers) and half moved into rest homes (movers) – and their carers.

Tripping the dominoes

Risk factors raised by the ‘movers’ included further hospital admissions with one interviewee telling her “the doctor, the hospital, they put me in here. The virus. For instance … I caught the Norovirus.”

Heppenstall says the domino effect of cascading illness and disability also was reported, with one family carer telling her that the first ‘domino’ to fall was a “leg ulcer that seemed to be persistent and not improving … morphine and immobility caused her to get constipated, she ended up with abdominal pain and was in so much pain that she pressed her alarm and went to hospital … then she got the diarrhoea bug …”.

The ‘stayers’ reported being busy and able to function independently enough to do housework and bake a cake, while the ‘movers’ reported struggling to walk more than 20 paces or being unable to do the supermarket shopping.

Other factors for moving was not the need for a higher level of care but their usual carer becoming unwell, becoming worried about the level of stress placed on their caring spouse, or not wanting to be a burden on extended family.

Heppenstall reports that attitude also played its part with a ‘stayer’ reporting “no use lying down … I’ve always worked hard” compared to a ‘mover’ reporting “nothing further could have been done; it was inevitable”.

The final phase was to trial an intervention based on her finding that self-reported deterioration in health was a risk factor for moving into residential aged care. She hoped finding out about deterioration earlier rather than later would make a difference, so she trialled an intervention of regularly telephoning a group of 26 frail elderly, following their hospital discharge to ask them whether their health had improved, stabilised, or deteriorated.

Heppenstall rang them fortnightly or monthly (depending on their level of need) and any who reported ‘deteriorating’ health triggered a comprehensive medical review and MDT intervention.

Seven of the 26 did report deteriorations prompting interventions. Two of the patients were admitted to hospital before a review could be carried out and one of those died soon after. A third reporting weight loss and difficulty in swallowing and preparing meals had a medical review but support with meals failed to start so the person was admitted to residential care. The other four reported issues from weight loss to depression and after review were all able to stay home with a range of support from psychiatric services, dietitians, and the MDT service.

Heppenstall says, overall, 21 of the 26 older people involved remained at home (three died, one went to residential care, and another to an independent unit) and most of them reported they found fortnightly telephone calls useful and that it helped their health.

While there were some teething problems and some feasibility issues needing further assessment, she believes her telephone-based intervention proposal can improve outcomes for the frail elderly living at home.