• Overview
• Definition
• Incidence, prevalence and trends
• Risk factors
• Health consequences
• Costs
• Contributors

Health Consequences

Ageing, lifestyle choices (for example smoking, activity level), and long term conditions impact on health and wellbeing in older age. Frailty can lead to sudden and unpredictable deterioration following minor illness and lead to falls and delirium. Only 2% of patients with long term conditions account for 30% of emergency hospital admissions and 80% of GP consultations. ¹ Most of these are older people.

Health and social care systems internationally are addressing these issues as a priority. In the UK each country (Northern Ireland programme is under development) is implementing a specific programme of work. ^{2 3 4} The timetable for reconfiguration spans several years.

Dependency

Postponing disabling diseases such as stroke, chronic heart failure, peripheral vascular disease, and osteoporosis should improve healthy life expectancy. ⁵ This is the medical approach promoted by the general medical services contract for GPs.

Encouraging activity and exercise is an evidence based population approach to preventing dependency. Walking, dancing, bowling, or gardening provide the same benefit as formal exercise sessions and can be carried out by most older people. ⁶ Even very frail older people in care homes get health gains from appropriately constructed activities. ^{7 8} Opportunities and incentives for increasing activity levels in older people need to be established. ⁹

Many older people, usually with several long term limiting conditions, present with declining functional abilities, often with associated carer stress ¹⁰ ). This carer stress can precipitate an acute admission to a hospital or care home ¹⁰ . Once established, declining function is commonly progressive. Decreasing activity results in physiological cardiovascular and skeletal muscle changes (deconditioning) that lead to further decline.

A comprehensive geriatric assessment by specialist multidisciplinary teams should provide an individualised management plan that typically includes rehabilitation. Care systems should ensure responsive access to comprehensive geriatric assessment and rehabilitation with adequate service capacity and integration with mainstream services. ^{11 12}

Falls

Acute illness, such as a stroke or acute coronary ischaemia, can present as falls. But this accounts for only about 10% of falls. ¹³ Most occur through an interaction between personal and environmental risk factors. ¹⁴

Falls are under-reported because the injury or fracture becomes the focus of attention and the code for the care episode. Over one third of falls go unreported in computerised accident and emergency (A&E) department records, which means opportunities for preventing further falls are missed. ¹⁵ Less than 10% of falls result in a fracture, ¹⁴ but most of these fractures in older people (particularly in people older than 75) will be related to osteoporosis. ¹⁴ Improving the bone health of older people could reduce fracture rates. ¹⁶

A common consequence of unexplained or spontaneous falls in older people is that they become fearful of further falls. This means they can become housebound and develop features of anxiety or depression. ^{17 18} There is reliable evidence that individually based, multidisciplinary, multicomponent falls risk factor assessment and intervention is effective and that between 20% and 30% of falls can be prevented. ¹⁹ The National service framework for older people has described the appropriate service responses based on multiagency, integrated falls prevention services. ⁴ The National Institute for Health and Clinical Excellence has produced guidance on the structure and components of such a service. ¹⁸

Hip fractures threaten older people’s survival and future independence. They are mostly fragility fractures in which a low impact fall (from lower than head height) causes a fracture in a person with osteoporosis. Hip fractures account for 50% of injury related hospital admissions and 66% of bed days in trauma wards for people older than 75. ²⁰ There are several well established national guidelines for managing hip fracture in older people. ²⁰

Delirium

Delirium (also referred to as acute confusion) is a common presentation of illness in frail older people. ²¹ It is a clinical syndrome with several pathological entities (such as Alzheimer’s’ disease and cerebrovascular disease) in which there is chronic confusion, typically characterised by impaired memory. Delirium develops quickly with fluctuating awareness and confusion linked to one or more triggering factors. The two clinical syndromes can coexist; dementia is the major risk factor for delirium.

Research suggests that delirium is frequently under-recognised or misdiagnosed as dementia, or simply recorded as "a confused elderly patient." Not detecting delirium in A&E departments is associated with increased mortality. ²² The Royal College of Physicians has produced guidelines to improve the management of delirium. ²³

The development of delirium is associated with a twofold increase in mortality, an increase in hospital stay, worse physical and cognitive recovery, and increased institutional care. ²⁴ Addressing this requires better systems of routine care, which has been achieved in the US. ²⁵

Urinary incontinence

Transient urinary incontinence may develop in older people during acute illness, particularly if mobility is affected. Established urinary incontinence has several pathological causes ²⁶ :

• Stress

• Overactive bladder

• Urge incontinence

• Mixed.

Making an accurate and reliable diagnosis is essential before starting treatment. You can achieve this by carrying out a clinical assessment. ²⁶ Invasive urodynamic investigation is required afterwards only if the diagnosis is uncertain or initial treatment is unsuccessful. ²⁶

There are several evidence based, effective treatments. These include ²⁶ :

• Bladder training (urge or mixed incontinence)

• Bladder stabilising agents (overactive bladder)

• Pelvic floor exercises (prevention and for stress incontinence)

• Surgery (stress incontinence).

Most patients will be benefit from conservative therapy. You should use long term catheters only rarely because of the inevitability of ascending urinary infections. Continence aids (including absorbent pads) are useful but expensive and should be used only after you have explored other corrective measures. ²⁶