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St Christopher’s Hospice Clinical Guidelines: Anticipatory end-of-life care medication for the symptoms of terminal restlessness, pain and excessive secretions in frail older people in care homes
  1. Julie Kinley, Research Nurse,
  2. Louisa Stone, Practice Development Nurse for Care Homes,
  3. Jo Hockley, Nurse Consultant
  1. Care Home Project Team, St Christopher’s Hospice, London. Email:

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The term ‘frail older people’ has been defined as people over 75 years of age with geriatric syndrome, i.e. the presence of numerous chronic diseases and signs and symptoms such as incontinence, falls, cognitive impairment and reduced mobility (Saavreda Muñoz and Barreto Martín, 2008). However, some older people are ‘frail’ before the age of 75 years. Therefore, frailty in older people should generally be associated with older people who have advanced, progressive, incurable illness and/or considerable health and social needs (Department of Health, 2001).

The process of dying in frail older people requiring 24-hour care appears to differ from, for example, the process of dying in mid-life from cancer (Hockley and Clark, 2002). People dying with a cancer diagnosis generally maintain high functional capacity up until the final 3 months of life, when there is a marked decline (Lunney et al, 2003; Costantini et al, 2008). However, frail older people tend to follow a dwindling trajectory towards death in that they gradually become more disabled (Lynn and Adamson, 2003). Their functional deterioration particularly worsens in their final year of life, when they can become much more dependent in terms of activities of living (Lunney et al, 2003; Costantini et al, 2008). Death in frail older people can also be relatively unexpected, e.g. frail older people can die ‘suddenly’ from silent pneumonia or quietly in their sleep (Lynn and Adamson, 2003).

Frail older people often have multiple morbidities, which may be complicated by varying degrees of dementia/cognitive impairment (Rashidi et al, 2011). For example, Lievesley et al (2011) undertook a survey of all residents living in Bupa’s UK care homes in 2009. The most commonly occurring disorders were dementia (43.6%), stroke (20.2%), heart disease (20.6%) and arthritis (18.3%). Although these data are only from one care home …

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