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Falling through the cracks: a case study of how a timely integrated approach can reverse frailty

02 August 2020
Volume 25 · Issue 8


The article ‘Social frailty: the importance of social and environmental factors in predicting frailty in older adults’ published in the British Journal of Community Nursing in 2019 reviewed the concept and models of frailty and how the role of social and environmental circumstances interplay. To better inform interventions within the community, the impact of social isolation and environmental disorder on frailty and the wellbeing of an individual patient are further explored. This paper describes the case of a 76-year-old man, Tommy, who was living with frailty and how an individualised care plan was undertaken, evidencing the positive effects that an integrated approach from health, social care, housing and the voluntary sector can offer. Multifaceted interventions are described, which were used to reverse frailty and change Tommy's future for the better.

This paper is a follow-up article to one published in the British Journal of Community Nursing in 2019, entitled ‘Social frailty: the importance of social and environmental factors in predicting frailty in older adults’ (Freer and Wallington, 2019). This previous paper reviewed the concepts and models of frailty and discussed the interplay between social and environmental factors in this complex condition. The present paper describes the case of a 76-year-old man, Tommy, who was living with frailty, and it discusses how timely integrated care helped address Tommy's problems.

Originally from Ireland, 76-year-old Tommy resided alone in the suburbs of a northern English town. He had worked as a teacher until he sustained a head injury many years previously. He had epilepsy, controlled with medication. Tommy drank alcohol on a regular basis and enjoyed classical music. His home was in a state of disrepair: thee was no central heating, hot water, fridge or cooking appliances, so he ate a limited diet of cold tinned or raw food. His environment was cluttered with boxes of papers, CDs, DVDs and wine, leaving a small path to navigate in each room, and a lawn mower obstructed his hallway. Any carpets were threadbare, and there was little furniture. His mattress was in a poor condition, with holes covered with cardboard and no clean bedding. Tommy had no laundry facilities; instead, he wore clothing for a long period and then discarded them. His appearance was dishevelled, and his long grey hair and beard were untended.

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