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Global perspectives

Are we failing frail older adults? Lessons from international evidence

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Researchers have explored how clinically frail people are managed in Canadian hospitals and concluded that the ageist approach is unhelpful. This article reports on a Florence Nightingale Foundation travel fellowship

Citation: Dawson R, Jenkins L (2017) Are we failing frail older adults? Lessons from international evidence. Nursing Times [online]; 113: 6, 28.

Authors: Rhian Dawson is head of integrated services, Hywel Dda University Health Board and Carmarthen County Council; Lesley Jenkins is unit nurse director; both at Neath Port Talbot Hospital. 


The impact of the ageing population on health and social care services has been referred to in government policy for many decades, but it is only recently that frailty has become a focus of attention. Appropriate management of care of frail older adults when they present to hospital and during their admission improves outcomes at an individual level and, as a direct result, improves performance at an organisational level. Much of the available literature relating to the assessment and management of the clinically frail in hospital comes from North America. 

The primary aim of the study was to confirm research findings on the management of frail older people in Canada. The study objectives were to explore:

  • The culture, practices and ethics of health and social care professionals who provide care for frail adults in Nova Scotia, Canada;
  • Alternatives to assessing the frail older person in accident and emergency;
  • Whether roles can be redesigned to enhance the assessment process;
  • How can we better support anticipatory care and care planning for frail older people in the community.

The final objective was to: 

  • Make recommendations for service improvements and alternatives to care provision.

The scholarship

We undertook an observational study of the assessment and management of the clinically frail in Nova Scotia, Canada. The study covered care practices relating to frail adults in the community, emergency department and during their hospital stay. This last point focused on discharge planning and reducing length of stay while minimising patient harm. 

Results and discussion

The finding of the  study challenged whether we are optimising care for clinically frail and sick older patients. We explored whether our normative values relating to older age and its association with physical and cognitive decline compromised their recovery after an acute episode. Frailty should be considered a dynamic, potentially reversible and preventable condition (Boeckxstaens and De Graaf, 2011).

We found that an evidence-based care pathway for frail older adults relating to assessment and multiprofessional care planning can be embedded into clinical practice, particularly in relation to the emergency department and throughout the inpatient stay. This pathway provided person-centred care to achieve functional goals that were agreed with the person and their carer/family, and set by the senior clinician and the multidisciplinary team. Moreover, we found that this approach was critical to improve outcomes for the individual while also reducing length of stay and supporting efficient discharge. 

Outcomes of the scholarship

At a local and national level, it is not just the integration of services that is needed – rather an integration of culture and mindset is required. We need to frame sudden functional and/or cognitive decline in a more positive frame rather than the ‘ageist’ approach, in which frailty syndromes such as falls and delirium are normalised. Moreover, this ageist approach contributes to long lengths of stay, increasing levels of dependency and a greater reliance on health and social care services on discharge. 

Implications for practice

  • A multiprofessional education programme is needed to mitigate the ageist perspective and recognise clinical frailty 
  • Ensure communication is goal focused and includes mobility and functional goals  
  • Where possible, this group should bypass the emergency department
  • Develop Master’s-level module, aligned to the underpinning knowledge and skills required for comprehensive geriatric assessment
  • Introduce frailty pathway to promote care of frail older adults in hospitals
  • This article reports on a travel scholarship provided by The Florence Nightingale Foundation. The scholarships give nurses and midwives an opportunity to study practice elsewhere in the UK and/or overseas.
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Readers' comments (1)

  • In the 30 years I have been involved with Care of the Elderly I have seen a massive change from the Patient Culture in Hospitals to the Client Culture in Nursing Homes and in spite of what certain interested parties would like us to believe, there has been a massive improvement.
    Nurses can take a large proportion of credit for this but must remember that without the resources arranged for them nothing can be achieved.
    With the advent of the CQC we are now seeing more of an even hand approach with regards to the yearly inspections which is now clearly showing the disparity between the Public and Private Sectors with regards to value for money.

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