Older Persons Summit

“When I was young, I despised old people. I was provincial and narrow-minded. It’s the reason I stayed stupid so long. If you only get involved with young people you don’t learn anything about the world.”

— Edmund White

Leicester Hospitals recently ran an Older Persons summit for Emergency physicians, Acute Physicians and Geriatricians, as well as allied health professionals. The aim of the summit was to focus and update knowledge on two key topics: delirium and end of life care. This post brings together some thoughts and discussion points from the evening. It doesn't necessarily provide the answers but hopefully will start you thinking about some of the areas where practice can be improved.

Great turnout & dynamic interdisciplinary discussion and debate between ED/Geris/Acute Med tonight. Tasty curry too! pic.twitter.com/fIurSovZXT

— Sarah Turpin (@drsarahturpin) November 19, 2015

Delirium

A common presentation in the ED (CAP 8). It has been identified in at least 3% of ED presentations.

Delirium can present as:

• disturbance of cognition

• impairment of consciousness

• psychomotor disturbance - hypo or hyperactivity

• emotional disturbance

• sleep-wake cycle disruption

Remember: Those with delerium have increased mortality, increased morbidity and increased service utilisation.

There are many precipitating factors - but if you have more pre-disposing factors you need fewer precipitating factors

Predisposing Factors:

• older age

• male

• sensory impairment

• physchiatric co-morbidity (dementia, depression)

Prevention and Management:

• Identify any cause and treat

• Normalise oxygen, electrolyte, dehydration

• Review medications

• Encourage a healthy sleep wake cycle

• Involve a geriatrician 

• Consistent nursing staff

• Avoid transfers

• Explain interventions to patients

• Modify the environment: keep it calm, large clocks, lighting, participation in ADLs

• Remove catheters

• Avoid physical restraint

• Correct sensory deficits

Beware! Benzodiazepines can aggrevate delirium and are less effective than antipsychotics.

Challenges in the ED:

The following challenges where discussed, however providing solutions to each point is difficult.

• The ED is not a good environment to be seeing patients with confusion - noise, crowding, multiple staff and investigations

  • Read about our new Frailty Friendly ED

• Lack of history/ dnar form can make decisions harder

• Is admission needed? - a grey area where often more time is needed

• Often given abx and IVI in ED - but is this needed? This is a balance between time pressures and "not missing" infections. However overuse can expose patients to risk of c.diff and abx resistance.

• Flow and bed availability over the day can mean transfers are made at unusual times and this can be disorientating.

Some changes that were considered?

• could a direct admission unit for older persons mean a bypass of ED and a difficult environment + an inevitable transfer from ED to a ward?

  • however would skipping ED mean patients miss out on a key step for recognition of significant illness?

• would a specific geriatric ED, set up to be a more suitable environment (similar to a paeds ED) be beneficial?

Further Resources:

1. #EM3 Foundation module: Collapse & Elderly Care
2. #EM3 ACCS module: Headache, Confusion & Delirium

End of life Care

“Would you be surprised if this patient died in the next year?”

— gold standards framework

@EM3FOAMed v sad statistic. Ensuring a good death is the final & most privileged duty we owe our patients

— Dan Rogers (@leicdan) November 19, 2015

Fewer people are dying in the community, 31% in 1974 and 18% in 2003

Advanced care plans do offer benefit for frail patients in care homes (data from outside UK), but the benefits outside this group are less.

“Advances in medicine and technology have blurred the distinction between saving life and prolonging suffering”. We need to consider that just because we can do something does't mean we should. This discussion must involve the patient and their family were able. However this can be challenging in a crisis and family may not be available.

Perhaps discussion of DNAR is also not enough should we be documenting a full escalation plan instead?

• Should we start dialysis?

• Should we transfuse?

• Should we insert a CVC if peripheral access fails?

• Should we start NIV?

• Should we continue obs/ monitoring?

• Should we resuscitate?

Of course if a care plan is present can we access it, do we access it and do we adhere to it? Has it been discussed with the family and are they onboard with it?

Do we routinely ask at handover from ambulance does this person have an escalation plan or DNAR? Should we be asking these things?

Further Resources:

1. #EM3 ACCS module: Medical Ethics, Consent & Law
2. #EM3 ACCS module: Breaking Bad News, NHS Management & Structure

Final Thoughts

One thing became very clear throughout the evening, older people do have specific needs that need to be considered. Involvement of different professionals is vital, but as we are the front door Care of the Elderly will always require the ED team. We can learn from geriatricians and other specialists, but they can also learn from us...