Based at the University Hospitals of Leicester, we serve the educational needs of healthcare practitioners in Acute & Emergency Medicine across the East Midlands, UK
Unlike patients with single presenting problems, older people will usually present with a range of issues, not just medical, that require addressing in order to achieve an effective management plan. It is not possible to describe every possible scenario; rather we offer a framework describing overarching principles that can be useful when assessing older people.
There are four key points to consider when assessing older people:
Functional decline and altered homeostasis
Older people with frailty will usually present non-specifically. This means that the textbook clues for diagnosis may not be present. Do not interpret a lack of specificity as a lack of seriousness or urgency. Recognise the non-specific presentations (off legs, falls, immobility, delirium etc.), and use them as a prompt to switch on your diagnostic antennae to focus upon objective points towards a diagnosis.
The non-specific presentation itself is a clue – it will be related to a communication barrier, such as delirium, dementia, dysphasia and/or sensory impairment.
Do not content yourself with a single system diagnosis; there will usually be multiple active issues, which often interact and compete for prioritisation. List the active diagnoses and stratify them in order of urgency, as this will help you prioritise those that need addressing now and those that can wait a few hours, but should not be forgotten.
Multiple comorbidities often bring polypharmacy; use the urgent care episode to discern if there are active adverse drug events, or opportunities for deprescribing.
Older people with frailty will often have pre-existing functional impairment, added to which they will often delay presentation with acute illness, either through inherent reticence or reduced access to support or event neglect by carers. This means that the impact of an acute event will already have started to manifest in terms of functional ability, which could be exacerbated by enforced bedrest. A period of rehabilitation will often be needed, and increasingly this should be done at home rather than in an institutional setting.
Older people with frailty will have altered homeostatic mechanisms, which means that their reserve is impaired, making them more vulnerable to apparently minor insults, but also altering their responses, for example, altered drug handling. Remember: ‘start low, go slow’ when introducing new drug treatments.
Those most in need are least able to access the services they require, and this can be due to intrinsic factors, such as cognitive or sensory impairment, or extrinsic factors, such as the lack of age-attuned services or broader socioeconomic factors.
Geriatric medicine addresses these issues through an evidence-based framework, named Comprehensive Geriatric Assessment (CGA), which offers a useful structure to ensure that your assessment is holistic, and therefore more likely to result in a management plan that will be successful. Mentally check off if you have sought out and identified issues in each of the domains of CGA when formulating your management plan.
Medical: have you got a working primary diagnosis, as well as a list of comorbidities that are active or important that also require attention?
Psychological: have you assessed for the presence of delirium, dementia or depression/anxiety? These will have a substantial impact upon on-going management.
Functional Ability: you may have made a diagnosis, but how will you get the patient ‘clinically stable for transfer’. Being ‘medically fit’ is meaningless if the person cannot mobilise to the toilet and back safely.
Social Circumstances: what support exists? What more is needed to enable a return home? Do you know how to access resources that can help?
Environment: is the home setting conducive to ongoing care needs, or are adaptations required? Do you know how to organise a home hazards review for people who have fallen?
A cornerstone of CGA is the interdisciplinary communication and coordination. These have traditionally been delivered using Multidisciplinary Team (MDT) meetings, typically on a weekly or occasionally daily basis. Clearly this frequency is not well-adapted to the urgent care setting, so alternative mechanisms are necessary.
In some settings, it might be possible to bring the team together for a rapid MDT discussion about patients, for example in ‘observation units’; such meetings should be at a fixed time every day and for a fixed duration so that expectations for attendance and duration are clear to all team members.
On average, each patient discussion should be for no more than one minute, and it might be helpful to structure the discussion using the domains of the CGA – physical/medical issues; functional/mobility issues; cognition/mood; social support networks and environment (home setting).
In the main area of the ED (Majors), coordination and communication can be more difficult, as it will be unusual to be able to have multiple staff members involved in the same patient at the same time. In this scenario, standardised documentation, again based on the principles of CGA, can help staff more easily navigate the issues that have been addressed, and identify where value can be added.
Even in a busy and noisy majors area, it is possible to bring most clinicians together every hour or two for a quick run through of the patients. In addition to addressing the domains of CGA, it is useful to consider situational awareness issues in this context.
The idea behind these is that they are more than just diagnoses, they reflect the problems identified in a given patient. This might be from any or even all of the domains of CGA. They might be a summary of the MDT discussion. The stratification should be in terms of urgency and importance. Finally, the problem list should be associated with a list of actions, which you could also measure once you have got to this stage.
To make the most out of the course, we encourage you to read and reflect upon the presented information, and if you feel so inclined, extend your learning using the following #FOAMed resources. Try to identify one or two patients with whom you have tried the CGA approach in the weeks leading up to the course, so that we may discuss in more details to illustrate the clinical application of the principles.
Fit for Frailty [BGS]
What is Frailty? [#EM3]
Sit Out, Get Out (S.O.G.O) [#EM3]