Managing elderly patients
This blog post is about taking care of our elderly population in the NHS -whom comprise a majority of our patients in every specialty.
Here are some useful resources:
https://sean9n.wordpress.com/2014/02/13/twenty-one-tips-for-junior-doctors-working-with-older-people/
http://aeme.org.uk/mini-gems/
http://thehearingaidpodcasts.org.uk
ON ADMISSION:
If you are the doctor on the acute take admitting new patients, here are some useful tips:
1. Get a collateral. Usually families are with their elderly relatives on admission initially and if it is not too late, try to talk to them before they go home. Ask about how the confusion/drowsiness started. Ask if they are constipated, if they had a cough, burning while passing urine Ask about medications, if they had recurrent falls, hit their head, etc.
If there is no one with the patient, call the next of kin ( if it is not too late at night) and get a full history.
2. Get a detailed social history:
Where do they live? Their own home, residential home, nursing home, sheltered accommodation
What level of care is provided if they live in a residential/nursing home or sheltered accommodation
If they live on their own, do they have carers? How many times do they come in? What do they help with?
Who does their shopping, washing, dressing, cooking ?
Whether they have stairs in their house and if they have stairs to access their house?
Do they have a bedroom and bathroom on the ground floor if they live in a house ( bungalows are usually single storey - however it is best to confirm) ?
Do they have a walk in shower?
Do they use any aids to walk?
To they still drive?
Ask if they go out of the house?
What their normal exercise tolerance is like?
All these questions will give you an idea of their performance status and how frail they are.
3. Get an alcohol and smoking history.
4. Examine the CNS in detail. These includes taking their socks off and checking their plantars and checking for sores, gout, cellulitis.
5. Feel the limbs and joints to r/o any fracture.
6. Check for any bruises/sores.
7. Do a detailed examination of their CVS - They usually have a murmur ( aortic stenosis is quite common) and this may explain the reason behind their heart failure ( if not previously diagnosed)
8. Check their AMTS - Even if they appear completely disoriented, ask these questions! They may answer half of these correctly and this will help to assess whether they are improving.
9. Do a PR if they have not opened their bowels for a few days
10. Confusion is not a diagnosis! Nor is delirium on its own. These are typical diagnosis:
- Delirium secondary to constipation/community acquired pneumonia.
- Falls - multi factorial, secondary to dementia, medications ( on furosemide, amlodipine, ramipril, codeine) and poor vision
10. Discuss resuscitation with the next of kin if the patient lacks capacity (especially if the patient is elderly). Give them an information leaflet about resuscitation as well. If the patient has capacity, then you can discuss it with him/her directly BUT make sure you are sure (s)he understands this and if it very late, then ensure than this is discussed with the next of kin in the morning if there is no one present with the patient.
You should be discussing this with 2 people ONLY - The patient and/or the next of kin. No one else. So make sure you know who is with the patient or whom you are talking to on the phone.
11. Do a confusion screen which includes urine dip (make sure you inform the nursing staff), confusion screen bloods ( B12, folate, iron profile, bone profile, Vitamin D and thyroid function tests). Consider a CT head.
12. Do a chest X ray and X ray any part of the body which is tender.
13. Rationalize their medications - documenting that they have falls due to polypharmacy and then not stopping the culprit medications is not a sensible thing to do.
14. Act on your plan! You can clerk a patient in as much detail as you want, however not acting upon it make the whole effort a waste of time.
You can see an elderly patient in 1 minute and make a quick plan, or take the time out and take a thorough history, do a detailed examination and make a good plan which your consultant would expect you to - it may take 30 minutes more but a good clerking is appreciated a lot and everyone looks at the clerking notes ( when the patient is transferred to the acute unit and to the care of elderly wards).
The typical time spent on clerking is around 30 to 45 minutes and may take longer especially if you discuss resuscitation with the next of kin.
Also read this guideline:
http://omarsguidelines.blogspot.com/2017/05/guideline-for-on-calls.html
ON THE WARDS:
Working on the care of elderly wards:
1.Always try to summarize the events leading to admission and events since admission in detail once every week - especially if the patient has been in for a long period of time.
2. Examine them in detail every day - especially their chest. They are at risk of hospital acquired pneumonias.
3. Ensure they are eating and drinking enough. Check their food chart and fluid charts.
Ask them/ their next of kins what their favorite food is if they are not eating enough. Ask their families to bring in food they like ( if it is not available in the hospital).
4. Ask their families to bring in their photographs and other familiar items ( like a radio, bed side clock, etc) as elderly (and especially dementia patients) tend to get confused where they are and then become agitated.
5. Ensure they are opening their bowels regularly - they stop drinking in hospital and then become very dehydrated. If they are not opening their bowels, do a PR - fecal impactions are common and a glycerine suppository (+/- an enema) can help a lot.
Constipation can cause delirium and delay discharge or assessments by PT/OT therefore it is important it is treated.
6. Managing the frail is a MDT approach - so talk to physiotherapists, occupational therapists, dietitians, discharge coordinators and families.
7. Actively participate in ( and try to lead) the ward MDTs in which all the members discuss discharge planning of patients.
8. Assess capacity of a patient if you suspect that they cannot make a decision about discharge. The capacity may fluctuate ( ie they may regain capacity if the delirium settles)
9. Make a detailed discharge summary.
The diagnosis is NEVER a single word- it is always something like this:
Primary diagnosis - Delirium secondary to urinary tract infection
Secondary diagnosis -
*Recurrent falls secondary to postural hypotension
*Hospital acquired pnuemonia
*Constipation with acute urinary retention
The clinical narrative can be tricky as the GP/ next of kin may miss important things in a long essay in a paragraph format.
Past medical history (Always mention the previous Dx - This is coded and the trust gets paid according to this)
Hypertension
Frail- Frailty score 5
Peripheral vascular disease
Ulcerative colitis
Here is an example ( This is completely factitious):
"This 95 year old gentleman was admitted with a fall - He was found on the floor next to his toilet by his son at 0900 AM. He was treated for:
1. DELIRIUM SECONDARY TO URINARY TRACT INFECTION
AMTS on admission was 5/10. CT head showed small vessel disease and no acute abnormality.
His inflammatory markers on admission bloods were high with a positive urine dip. CXR was normal. Treated with oral trimethoprim after a STAT dose of gentamicin in ED. MSU grew E coli sensitive to trimethoprim. His delirium improved and his AMTS was 9/10 on day 5.
2. RECURRENT FALLS SECONDARY TO POLYPHARMACY
Noted to have recurrent falls prior to admission. Had a significant postural drop on lying/standing blood pressure. Amlodipine, ramipril, furosemide stopped and remained well after this. His blood pressure remained under control.
3. HOSPITAL ACQUIRED PNEUMONIA
Developed a chesty cough on day 7 of admission. CXR confirmed right lower zone consolidation. Started on oral doxycyline and improved.
Was reviewed by the speech and language therapists who advised that he had a normal swallow thus continued on his normal diet and fluids.
To have repeat chest X ray in 8 weeks to ensure resolution of consolidation (Booked - Dr **** will follow it up).
4. CONSTIPATION WITH ACUTE URINARY RETENTION
Mr**** had a reduced appetite during his hospital acquired infection and needed regular laxatives with fluid encouragement. He was catheterized on Day 10 of admission as retained 700mls in his bladder. Opened his bowels and was trialled without a catheter successfully on day 14.
Mr **** recovered well from his infection and was deemed fit for discharge with a package of care and additional equipment at home after undergoing therapy.
Follow up plan:
- To have repeat chest X ray in 8 weeks to ensure resolution of consolidation (Booked - Dr **** will follow it up). "
Documenting falls on the ward:
Time and date of fall.
Nurse in charge of that bay.
Whether it was highlighted if the patient was at a high risk of falls.
Ongoing medical treatment (summary of clinical history, co morbidities, diagnosis)
Medication review - the Stop Start toolkit (search for it on Google - it is very helpful). Highlight what medications put the patient at a high falls risk. If you know the patient well, you can withold some (like furosemide if the patient is dry, ramipril, etc). DO NOT withhold anti-psychotics.
Latest bloods, investigations.
Get a history from the nurse who found the patient on the floor. Whether the patient had loss of consciousness, abnormal jerks, incontinence, any visible injury noted by the nurse. What the patient was doing if she witnessed it. Whether is was witnessed/un-witnessed. OBS when the patient was found on the floor. Blood sugar levels
History:
Ask the patient what happened. If there was any chest pain request an urgent ECG, if there was dizziness do a medication review.
Examination:
ABCDE as mentioned above.
Palpate all extremities very carefully - fractures are very common in elderly.
Check any bruises, lacerations.
AMTS
neurology examination - GCS, pupils, power, tone, visual fields.
Examination of chest, abdomen, heart sounds.
See footwear. Remove slippery shoes/slippers.
Ensure if the patient is wearing bifocals, ask him/her to take them off before getting up.
If the patient was getting up to walk to the toilet, ensure the call bell is next to the patient.
Ask the nurses to get a bedside commode if he is very unsteady.
Document:
Everything above
Ensure nurse in charge Datixes this.
Ask the nurses to do a lying standing blood pressure.
Diagnosis and plan:
Fall - multifactorial secondary to
1. Dementia : ensure nurse is around in the bay, call bell given to patient
2. Bifocals : reminded not to wear bifocals when attempting to walk
3. Medications: furosemide withheld as clinically dry.
4. Slippery footwear: Hospital footwear provided.
5. Glove and stocking neuropathy - secondary to diabetes
6. Zimmer frame away from bedside - put next to patient
Senior nurse (name) informed of above.
Further investigations:
Request X rays of any part of the body if the patient has tenderness. A missed fracture is not good!
Request a CT head if there is any change in neurology ( ensure you have witheld the anticoagulants)
In summary, it is basically finding out the cause of the fall, trying to prevent further falls ( simple things like slippery footwear can make a huge difference, meds review), ruling out anything like a fracture, bleed, document everything in detail and INFORM the nurse of what you have planned.
PS: If you do not have an inpatient post falls assessment sheet on your ward, you could do a QIP and make one with the aforementioned points.
It would be very helpful
After a few thorough assessments you will be able to do all of this in 15 to 20 min.
There have been a few cases in which fractures and subdurals have been missed which is why a detailed assessment is important. Having a proforma saves time too.
Join this group:
https://www.facebook.com/groups/IMGs.in.the.UK/
And read this document as well:
https://www.facebook.com/notes/international-medical-graduates-imgs-in-the-uk/advice-for-doctors-working-in-care-of-elderly/1757333234299710/
The bottom line is,
Treat your elderly patients with love and compassion just like you would treat your own family members. You will really enjoy it. Management of such patients helps in developing not only your clinical skills but also your communication, leadership and managerial skills.
Here are some useful resources:
https://sean9n.wordpress.com/2014/02/13/twenty-one-tips-for-junior-doctors-working-with-older-people/
http://aeme.org.uk/mini-gems/
http://thehearingaidpodcasts.org.uk
ON ADMISSION:
If you are the doctor on the acute take admitting new patients, here are some useful tips:
1. Get a collateral. Usually families are with their elderly relatives on admission initially and if it is not too late, try to talk to them before they go home. Ask about how the confusion/drowsiness started. Ask if they are constipated, if they had a cough, burning while passing urine Ask about medications, if they had recurrent falls, hit their head, etc.
If there is no one with the patient, call the next of kin ( if it is not too late at night) and get a full history.
2. Get a detailed social history:
Where do they live? Their own home, residential home, nursing home, sheltered accommodation
What level of care is provided if they live in a residential/nursing home or sheltered accommodation
If they live on their own, do they have carers? How many times do they come in? What do they help with?
Who does their shopping, washing, dressing, cooking ?
Whether they have stairs in their house and if they have stairs to access their house?
Do they have a bedroom and bathroom on the ground floor if they live in a house ( bungalows are usually single storey - however it is best to confirm) ?
Do they have a walk in shower?
Do they use any aids to walk?
To they still drive?
Ask if they go out of the house?
What their normal exercise tolerance is like?
All these questions will give you an idea of their performance status and how frail they are.
3. Get an alcohol and smoking history.
4. Examine the CNS in detail. These includes taking their socks off and checking their plantars and checking for sores, gout, cellulitis.
5. Feel the limbs and joints to r/o any fracture.
6. Check for any bruises/sores.
7. Do a detailed examination of their CVS - They usually have a murmur ( aortic stenosis is quite common) and this may explain the reason behind their heart failure ( if not previously diagnosed)
8. Check their AMTS - Even if they appear completely disoriented, ask these questions! They may answer half of these correctly and this will help to assess whether they are improving.
9. Do a PR if they have not opened their bowels for a few days
10. Confusion is not a diagnosis! Nor is delirium on its own. These are typical diagnosis:
- Delirium secondary to constipation/community acquired pneumonia.
- Falls - multi factorial, secondary to dementia, medications ( on furosemide, amlodipine, ramipril, codeine) and poor vision
10. Discuss resuscitation with the next of kin if the patient lacks capacity (especially if the patient is elderly). Give them an information leaflet about resuscitation as well. If the patient has capacity, then you can discuss it with him/her directly BUT make sure you are sure (s)he understands this and if it very late, then ensure than this is discussed with the next of kin in the morning if there is no one present with the patient.
You should be discussing this with 2 people ONLY - The patient and/or the next of kin. No one else. So make sure you know who is with the patient or whom you are talking to on the phone.
11. Do a confusion screen which includes urine dip (make sure you inform the nursing staff), confusion screen bloods ( B12, folate, iron profile, bone profile, Vitamin D and thyroid function tests). Consider a CT head.
12. Do a chest X ray and X ray any part of the body which is tender.
13. Rationalize their medications - documenting that they have falls due to polypharmacy and then not stopping the culprit medications is not a sensible thing to do.
14. Act on your plan! You can clerk a patient in as much detail as you want, however not acting upon it make the whole effort a waste of time.
You can see an elderly patient in 1 minute and make a quick plan, or take the time out and take a thorough history, do a detailed examination and make a good plan which your consultant would expect you to - it may take 30 minutes more but a good clerking is appreciated a lot and everyone looks at the clerking notes ( when the patient is transferred to the acute unit and to the care of elderly wards).
The typical time spent on clerking is around 30 to 45 minutes and may take longer especially if you discuss resuscitation with the next of kin.
Also read this guideline:
http://omarsguidelines.blogspot.com/2017/05/guideline-for-on-calls.html
ON THE WARDS:
Working on the care of elderly wards:
1.Always try to summarize the events leading to admission and events since admission in detail once every week - especially if the patient has been in for a long period of time.
2. Examine them in detail every day - especially their chest. They are at risk of hospital acquired pneumonias.
3. Ensure they are eating and drinking enough. Check their food chart and fluid charts.
Ask them/ their next of kins what their favorite food is if they are not eating enough. Ask their families to bring in food they like ( if it is not available in the hospital).
4. Ask their families to bring in their photographs and other familiar items ( like a radio, bed side clock, etc) as elderly (and especially dementia patients) tend to get confused where they are and then become agitated.
5. Ensure they are opening their bowels regularly - they stop drinking in hospital and then become very dehydrated. If they are not opening their bowels, do a PR - fecal impactions are common and a glycerine suppository (+/- an enema) can help a lot.
Constipation can cause delirium and delay discharge or assessments by PT/OT therefore it is important it is treated.
6. Managing the frail is a MDT approach - so talk to physiotherapists, occupational therapists, dietitians, discharge coordinators and families.
7. Actively participate in ( and try to lead) the ward MDTs in which all the members discuss discharge planning of patients.
8. Assess capacity of a patient if you suspect that they cannot make a decision about discharge. The capacity may fluctuate ( ie they may regain capacity if the delirium settles)
9. Make a detailed discharge summary.
The diagnosis is NEVER a single word- it is always something like this:
Primary diagnosis - Delirium secondary to urinary tract infection
Secondary diagnosis -
*Recurrent falls secondary to postural hypotension
*Hospital acquired pnuemonia
*Constipation with acute urinary retention
The clinical narrative can be tricky as the GP/ next of kin may miss important things in a long essay in a paragraph format.
Past medical history (Always mention the previous Dx - This is coded and the trust gets paid according to this)
Hypertension
Frail- Frailty score 5
Peripheral vascular disease
Ulcerative colitis
Here is an example ( This is completely factitious):
"This 95 year old gentleman was admitted with a fall - He was found on the floor next to his toilet by his son at 0900 AM. He was treated for:
1. DELIRIUM SECONDARY TO URINARY TRACT INFECTION
AMTS on admission was 5/10. CT head showed small vessel disease and no acute abnormality.
His inflammatory markers on admission bloods were high with a positive urine dip. CXR was normal. Treated with oral trimethoprim after a STAT dose of gentamicin in ED. MSU grew E coli sensitive to trimethoprim. His delirium improved and his AMTS was 9/10 on day 5.
2. RECURRENT FALLS SECONDARY TO POLYPHARMACY
Noted to have recurrent falls prior to admission. Had a significant postural drop on lying/standing blood pressure. Amlodipine, ramipril, furosemide stopped and remained well after this. His blood pressure remained under control.
3. HOSPITAL ACQUIRED PNEUMONIA
Developed a chesty cough on day 7 of admission. CXR confirmed right lower zone consolidation. Started on oral doxycyline and improved.
Was reviewed by the speech and language therapists who advised that he had a normal swallow thus continued on his normal diet and fluids.
To have repeat chest X ray in 8 weeks to ensure resolution of consolidation (Booked - Dr **** will follow it up).
4. CONSTIPATION WITH ACUTE URINARY RETENTION
Mr**** had a reduced appetite during his hospital acquired infection and needed regular laxatives with fluid encouragement. He was catheterized on Day 10 of admission as retained 700mls in his bladder. Opened his bowels and was trialled without a catheter successfully on day 14.
Mr **** recovered well from his infection and was deemed fit for discharge with a package of care and additional equipment at home after undergoing therapy.
Follow up plan:
- To have repeat chest X ray in 8 weeks to ensure resolution of consolidation (Booked - Dr **** will follow it up). "
Documenting falls on the ward:
Time and date of fall.
Nurse in charge of that bay.
Whether it was highlighted if the patient was at a high risk of falls.
Ongoing medical treatment (summary of clinical history, co morbidities, diagnosis)
Medication review - the Stop Start toolkit (search for it on Google - it is very helpful). Highlight what medications put the patient at a high falls risk. If you know the patient well, you can withold some (like furosemide if the patient is dry, ramipril, etc). DO NOT withhold anti-psychotics.
Latest bloods, investigations.
Get a history from the nurse who found the patient on the floor. Whether the patient had loss of consciousness, abnormal jerks, incontinence, any visible injury noted by the nurse. What the patient was doing if she witnessed it. Whether is was witnessed/un-witnessed. OBS when the patient was found on the floor. Blood sugar levels
History:
Ask the patient what happened. If there was any chest pain request an urgent ECG, if there was dizziness do a medication review.
Examination:
ABCDE as mentioned above.
Palpate all extremities very carefully - fractures are very common in elderly.
Check any bruises, lacerations.
AMTS
neurology examination - GCS, pupils, power, tone, visual fields.
Examination of chest, abdomen, heart sounds.
See footwear. Remove slippery shoes/slippers.
Ensure if the patient is wearing bifocals, ask him/her to take them off before getting up.
If the patient was getting up to walk to the toilet, ensure the call bell is next to the patient.
Ask the nurses to get a bedside commode if he is very unsteady.
Document:
Everything above
Ensure nurse in charge Datixes this.
Ask the nurses to do a lying standing blood pressure.
Diagnosis and plan:
Fall - multifactorial secondary to
1. Dementia : ensure nurse is around in the bay, call bell given to patient
2. Bifocals : reminded not to wear bifocals when attempting to walk
3. Medications: furosemide withheld as clinically dry.
4. Slippery footwear: Hospital footwear provided.
5. Glove and stocking neuropathy - secondary to diabetes
6. Zimmer frame away from bedside - put next to patient
Senior nurse (name) informed of above.
Further investigations:
Request X rays of any part of the body if the patient has tenderness. A missed fracture is not good!
Request a CT head if there is any change in neurology ( ensure you have witheld the anticoagulants)
In summary, it is basically finding out the cause of the fall, trying to prevent further falls ( simple things like slippery footwear can make a huge difference, meds review), ruling out anything like a fracture, bleed, document everything in detail and INFORM the nurse of what you have planned.
PS: If you do not have an inpatient post falls assessment sheet on your ward, you could do a QIP and make one with the aforementioned points.
It would be very helpful
After a few thorough assessments you will be able to do all of this in 15 to 20 min.
There have been a few cases in which fractures and subdurals have been missed which is why a detailed assessment is important. Having a proforma saves time too.
Join this group:
https://www.facebook.com/groups/IMGs.in.the.UK/
And read this document as well:
https://www.facebook.com/notes/international-medical-graduates-imgs-in-the-uk/advice-for-doctors-working-in-care-of-elderly/1757333234299710/
The bottom line is,
Treat your elderly patients with love and compassion just like you would treat your own family members. You will really enjoy it. Management of such patients helps in developing not only your clinical skills but also your communication, leadership and managerial skills.
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