Frailty is a key concept in recent times, recognised as a major issue for public health, increasing in its extent as populations worldwide reach higher ages in ever-increasing numbers. Frailty is a combination of conditions that include weakness, fatigue, slowing mobility, deterioration in physical activity, unintentional weight loss and, overall, finding it increasingly difficult to cope at home.

While it is not an inevitable condition, and most of the older population are not frail, it is important to identify as early as possible and support those who are frail or may be on the tipping point of the frailty spectrum, as many relevant conditions are amenable to improvement. Accordingly, frailty assessments have been implemented in various forms in hospital and community health care. 

Comprehensive Geriatric Assessment (CGA) is a detailed, goal-oriented assessment that aims to evaluate older people in terms of their impairments, functional capacities and needs in order to develop a holistic management plan that involves the patient and/or their family in the decision-making process. The premise is that this evaluation may identify a variety of treatable health problems that will benefit from a co-ordinated action plan.

The CGA identifies baseline status prior to the acute event/stressor that resulted in their current presentation to the health service, rather than being based on their current clinical presentation due to that stressor (eg. a UTI). Therapy, education and advice are provided as indicated, and onward referrals to other services are made, if necessary.

Current project

In 2018, a Frailty Intervention Team (FIT) was established at the emergency department of Wexford General Hospital (WGH). The team comprised a clinical nurse specialist, a senior occupational therapist and a senior physiotherapist. The service is available Monday to Friday. In 2022, support from a dietitian and speech and language therapist was added to the team – these two therapists prioritised all referrals coming from the FIT but were primarily ward based.

As limited data is available concerning the nutritional needs of this vulnerable population, our research project was carried out to analyse the first 50 ‘dietetic contacts’ as part of this service improvement.

Design

This was a retrospective service analysis, with audit committee approval and patient/carer consent. All patients aged 75 years or older attending the emergency department (ED) were assessed by ED nursing staff using a simple triage, incorporating the Variables Indicative of Placement risk tool. Those scoring as ‘at risk’ were referred to the FIT, who carried out a CGA, unless it was medically contraindicated.¹

As part of this assessment process, nutrition screening was conducted using the Mini Nutritional Assessment-Short Form (MNA-SF)² validated screening tool. Referral to the dietitian was triggered if the MNA-SF score was between eight and 11 (nutritionally at risk), seven or below (malnourished), if they are receiving oral nutrition supplements (ONS), or if there were any wound healing concerns. 

Results

The first 50 contacts over a nine-week period in early 2022, were aged 72-99 years (30% > 90 years) and had a clinical frailty score between four and seven (vulnerable to severely frail). 

Location: Of the total cohort, 13 (26%) were assessed and advised in the ED prior to discharge. Some 19 patients (38%) required hospital admission: their assessment and nutrition care plan were implemented in the ED while awaiting hospital admission. Eight (16%) were discharged before seen by the dietitian: seven of these had a telephone consultation within one week, and one did not respond to multiple phone messages and a letter. The remaining 10 patients (20%) were queries from the FIT where it was then agreed dietetic consultation was not necessary (eg. currently or recently known to a dietitian, or recent nutritional concerns but now nutritionally stable or improving). 

Assessment (n=50): Two in five patients (41%) were categorised as malnourished or at risk of malnutrition using the MNA-SF. BMI, where available, ranged 16-30kg/m2. Five percent had a pressure sore and 27% were already prescribed ONS (with variable adherence).

Intervention (n=39): The dietary advice provided related to high energy need, constipation, renal, dysphagia, eat well, and meal provision guidance (see Figure 1). Meal provision advice focuses on simple practical cookery advice, easy meal options, ready meal availability, meals on wheels or other local meal provision, as well as discussion of their social supports and available shopping/meal assistance. This was necessary in more than half (57%) of cases. In almost three-quarters (72%) of cases, review of or commencement of ONS was required.

Nutrition care plans implemented for those being admitted included commencing the recording of food and fluid intake, management of refeeding syndrome risk,^3,4 and prescription of appropriate therapeutic diets and ONS.⁵

Interventions in some cases included one or two follow-up telephone calls for additional support prior to discharge from the dietitian.

Outcome (n=39): Nineteen people (49%) had dietetic follow up during their hospital admission. Following dietetic advice, 13 (33%) were referred to the care of their GP, three were discharged to their usual dietitian for ongoing support, and four were discharged.

Discussion and conclusions 

This analysis confirms the extent of malnutrition/malnutrition risk in the older population attending the ED (41%), comparable to the University Hospital Limerick (UHL) OPTI-MEND study (36.6%).⁶

Dietetic needs in this population are diverse, as shown by the range of interventions necessary, including ‘simple’ practical advice concerning meal provision options that can often be overlooked or taken for granted.

During the study period, several of the referrals occurred on Friday afternoons with implementation of nutrition care plan for the weekend. This contrasts with the usual practice where patients would only have been referred to the dietitian after the weekend, having missed three or more days of recording their intake, or awareness/monitoring of their refeeding risk. 

Similarly, no time was lost in correct prescription of appropriate ONS, eg. where teams had verified usual medications but not documented the usual ONS, or where their usual product was not stocked by the hospital. While not all of these cases required full immediate dietetic intervention, a brief assessment ensured the correct product was prescribed and minimised risk of omission or error. 

Certain patients were too ill for dietetic consultation at time of referral, but this service facilitated early monitoring and subsequent intervention when more appropriate. As the patients presented in the ED, family members/carers were often on hand or nearby to provide collateral information, which is frequently a necessity with frail individuals. Those who were discharged before being seen by the dietitian represented times where the FIT assessment and/or ED assessment were ongoing at the end of dietetic working hours, or times when I was unavailable. This service improvement enabled rapid follow-up as part of ED outreach.

In relation to those identified as queries only, an informal service review six months later found these types of queries were uncommon, representing a learning opportunity for the multidisciplinary team, who despite being experienced at carrying out CGAs, were now focusing more on nutritional issues. 

It is worth highlighting that in practice some queries/discussions facilitate identification of cases involving reported or obvious nutritional imbalance or concern that do not necessarily trigger weight/BMI focused nutrition-screening tools commonly in use.

In summary, this service development facilitates prompt access to dietetic assessment and advice in this nutritionally at-risk group, assists as part of the FIT intervention enabling admission avoidance, and ensures early implementation of appropriate nutrition care plan for the high numbers necessitating admission.

This project was carried out as part of the Dietetics Department and Frailty Intervention Team service at Wexford General Hospital.