Dr Caroline NicholsonNational Nursing Research

Unitcaroline.nicholson@kcl.ac.uk

Florence Nightingale School of Nursing & Midwifery

Holding It Together : A Psycho-Social Exploration of

Frailty in Old Age

Why research frailty ?

Often unvoiced and under researched. Complexity what is frailty? Growing numbers Living with finitude The Palliative Care paradox

Trajectories of dying

Overwhelming majority (92%) of Medicare records mapped to 4 profiles - sudden death, terminal illness, organ failure and frailty

Lunney et al (2002) J Am Geriatric Soc

Defining Frailty

• Organ / Disease based : predicative/risk/Epidemiological ( Fried 2001, Abellan van Kan et al 2010)

• Wider bio-psycho-social: ( Van Campen 2011, Gobbens et al 2010, Bergman et al 2006, 2011)

• Clinically Operationalised ( e.g. The Bournemouth Criteria Allen et al 2005, W.H.O. 2002)

What is Frailty?

Now much debate on “frailty indicators”, even more since this table… e.g. Fried et al (2001) focus on 5 aspects and defined:

pre-frailty if any 1 or 2 of these 5 frailty if any 3 or more of these 5 poor mobility, weakness, malnutrition, low endurance or physical activity

Frailty Tension between objective and subjective

The unstable state created by a combination of deficits or conditions that arise with

increasing age.

(Nourhashemi et al 2001)

• A narrative (spoken, written, visual) and psychodynamically informed observational enquiry

• 13 individuals and 2 couples ( 15 cases) 5 men, 12 women

• 9 lived on their own, 6 with spouse, 2 with unmarried children

• Age 86-102

• 6 participants 90 years of age and over

• 9 experienced an unplanned hospital stay during fourteen months of data collection, all due to falls.

How and with whom?

Methods Biographical Narrative Interpretative Method (Wengraf and Chamberlayne 2004)

Main Narration“Please tell me the story of your life as an older person.”

Narrative questioning How people say what they say: deep structures/order importantPanel work : reconstruct experiencing of interviewee in terms of the events of their lives and how they recount it Largely text based

Tavistock Observation Method (Rustin 2003)

Uses self as a research tool. Observe and note emotional response to experienceBased on core concepts of psychoanalytical theory:

Free associationProjection/introjectionTransference/counter transference

Write up free associations afterwards Present back to supervisory groupLargely situationally based

Narratives using a Creative Expressions Pack

Seeing in a different way:

“But my confidence in life in general has gone, you know because you can't do things. I’m frightened to an extent, to a certain extent but it might be the

wrong word but in a general sense, the way the world is going everything. I haven't got the confidence anymore.”

Being seen in a different way:

at 8.00 a doctor comes. What’s your age? Why have you come? I said they brought me. You should go home. The doctor says, hello, the doctor says how old are you? You go, (laughing and crying) , this is the life. I know what

hospital means when you take the old there.

A liminal state or boundary condition: *Dis-connects (Losses) *Retaining connections *Creating connections

propels one into confrontation with one’s existential situation in the world.

Frailty in late old age …

Dis-connects: Losses• Universal sense of loss with increasing physical dependence • Being Old • Loss of trust in bodies: personal and organisational• Loss of independence• Loss of the future: more obviously and consciously inhabiting the

space between living and dying.

No, you think you’re going to go on the same way, at least I think most people do, don’t they? I never thought one day I should be sitting here, can’t do anything - never even

thought of it. Well, until I fell over that day, I don’t say I did so much but life hadn’t really changed..

“And then he doesn’t seem to be so strong-once we got nearly as far as nearly the pillar box ( on a walk) but now I don’t know he doesn’t want to go as far

as that. I’m just terrified he’s going to die.”

Sustaining Connection

• Rhythms of the day:Reliability

Rituals

Regulation

And I’m just laying there ( in bed) and it’s so comfortable that you feel as though, oh, yes, I’d love to stay like this but I know I mustn’t - you’ve only got

to start doing that. You see my friend there, she started staying in the chair, and she was comfortable in the chair so instead of going to bed she stayed in the chair and then it was staying in her dressing gown and she seemed to

just drop away then.

Creating Connections

• Creativity through the facility to take up different ways of relating to the world.

Well, that’s difficult for me so I’m now training a whole lot of junior gardeners. You’ll be surprised, I’m training Sally and anybody that

comes now who’s not a gardener; I’m training a whole new generation, because you see I have to remember every day. Now if it pours with rain they haven’t got to do it, but if it doesn’t then I’ve

got to remember how much rain there was, I’ve got to say each day and remember, have you watered the tomatoes? And sometimes they don’t do it properly, they get the leaves at the bottom. We’ve

now got to the stage when they have to be fed, that’s a new stage.

The sunset is so beautiful,but is surrounded by darkness.

(Taiwanese proverb)

Holding together Loss and Capacity

Acknowledgments

Supervisors:

Julienne Meyer, Mary Flatley, Cheryl Holman

The participants and carers whose stories underpin this study

Seein

g D

ifferenlty

The difference between ordinary and extraordinary is

a question of recognition

The extraordinary work of caring and being cared for..