17.1 Frailty, Falls, Polypharmacy, Continence & Pressure Ulcers

Frailty, Falls, Polypharmacy, Continence & Pressure Ulcers

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Frailty

Frailty is a state of reduced physiological reserve, so that a minor stressor (an infection, a new drug, a fall) causes a disproportionate decline in health and independence.

• Presentations ("frailty syndromes"): falls, delirium, immobility ("off legs"), incontinence, and susceptibility to medication side effects.
• Assessment tools: the Clinical Frailty Scale (1 = very fit to 9 = terminally ill), the electronic frailty index in primary care, gait speed and the timed up and go test.
• Comprehensive geriatric assessment (CGA): a multidisciplinary assessment of medical problems, function, cognition and mood, medicines, social circumstances and goals, leading to a personalised care plan. CGA improves the chance of being alive and at home after an acute admission.
• Frailty should shape decisions about treatment intensity, escalation and resuscitation, made with the patient and family (see section 15.4).

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Falls

About a third of people aged 65 and over fall each year. Ask older people about falls during routine contacts.

Multifactorial Falls Risk Assessment

Postural (orthostatic) hypotension: a fall in systolic BP of at least 20 mmHg, or diastolic BP of at least 10 mmHg, within 3 minutes of standing. Manage by reviewing culprit drugs, ensuring adequate hydration, slow position changes and compression stockings; specialist options include fludrocortisone or midodrine.

Interventions

• Strength and balance exercise programmes (for example Otago or FaME) are the most effective single intervention.
• Medication review and deprescribing of fall-risk drugs.
• Home hazard assessment by an occupational therapist; vision correction (cataract surgery).
• Treat osteoporosis and consider vitamin D and calcium where deficient.
• After a long lie, check for rhabdomyolysis (CK), pressure damage, dehydration, hypothermia and AKI. A head injury in someone taking anticoagulants may need CT (section 1.5).

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Polypharmacy & Deprescribing

Taking many medicines increases adverse drug reactions, interactions, falls, delirium and hospital admissions.

• Structured medication review: check that each medicine still has an indication, is effective, is the safest option and is acceptable to the patient. Tools include STOPP/START criteria (potentially inappropriate and omitted medicines in older people) and anticholinergic burden scales.
• High-risk examples:
  • Anticholinergics (oxybutynin, amitriptyline, chlorphenamine): confusion, constipation, urinary retention, falls.
  • Benzodiazepines and Z-drugs: falls, sedation, dependence (taper gradually).
  • NSAIDs: GI bleeding, AKI, heart failure (especially with ACE inhibitors and diuretics, the "triple whammy").
  • Antipsychotics in dementia: stroke and death; use only for severe distress after non-drug approaches.
  • Over-treatment of diabetes and blood pressure: hypoglycaemia and postural hypotension in frail people; relax targets.
• Give sick-day guidance (temporarily stopping metformin, SGLT-2 inhibitors, ACE inhibitors, ARBs, diuretics and NSAIDs during dehydrating illness).
• Use adherence aids and involve the pharmacist; communicate changes to the GP and patient.

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Incontinence in Older People

Urinary incontinence is common but not a normal part of ageing. Look for reversible causes: delirium, urinary infection, atrophic vaginitis, drugs (diuretics, sedatives, anticholinergics causing retention), excess urine output (hyperglycaemia, heart failure), reduced mobility and constipation or faecal impaction.

• Types: urge (overactive bladder), stress, overflow (prostatic obstruction, neurogenic bladder, anticholinergics), and functional (cannot reach the toilet in time because of mobility or cognitive problems).
• Assessment: urinalysis, bladder diary, post-void residual volume (bladder scan), digital rectal examination for impaction and prostate size, review of drugs.
• Management: treat reversible causes, bladder training and prompted toileting, pelvic floor exercises, antimuscarinics with caution (cognitive effects; mirabegron is an alternative), and avoid long-term catheters except for retention that cannot otherwise be managed, because of infection risk.
• Faecal incontinence in older people is often overflow around faecal impaction; treat the constipation first.

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Pressure Ulcers (NICE CG179)

Localised damage to the skin and underlying tissue, usually over a bony prominence (sacrum, heels, hips), from pressure or pressure combined with shear.

• Risk factors: immobility, frailty, malnutrition, incontinence (moisture), reduced sensation, poor perfusion and acute illness.
• Prevention: risk assessment with a validated tool (for example Waterlow or PURPOSE-T), regular skin inspection, repositioning (at least every 6 hours for adults at risk, every 4 hours if at high risk), high-specification foam mattresses, heel off-loading, nutrition and continence care.

Hospital-acquired category 3 or 4 ulcers are reported and investigated, and neglect raises safeguarding concerns. Treatment includes pressure relief, wound care, managing infection (osteomyelitis can underlie deep ulcers) and nutrition.