Trainee Advanced Clinical Practitioner Diary- Day 19

The Emergency Department is one of the biggest Elderly Care departments in the hospital, and it is not well designed to look after them. In the US patients 65 years and older represented 40% of hospitalised adults but compromise less than 13% of the population.

Problems with movement of patients, tethering devices (IV lines, urinary catheters etc.), positioning of the elderly, sensory deprivation, skin care can increase their risk of what might already be a confused state leading to greater problems for them. Hazards of hospitalization of the elderly Ann Intern Med 1993.

Due to their possible multiple co-morbidities and complicated social situation it can often take longer to assess the elderly compared to the younger patient.

Older patients also have a longer average length of stay. US data confirms this and it would be reasonable to be able to expect the same in the UK.  National Hospital Discharge Survey 2005 CDC 2007. They are more prone to chronic illnesses with all the implications for their care that may have. Prevalence of chronic diseases and multimorbidity among the elderly population in Sweden. AM J Public Health 2008

Common problems with elderly patients in hospital can be:

• Infections- heightened clinical suspicion is necessary to identify infection in older patients as they may demonstrate only atypical symptoms.
  • C Diff diarrhoea
  • HAP- older patients treated with anyipsychotics are at increased risk for developing aspiration pneumonia Antipsychotic Drug Use and Community-Acquired Pneumonia Curr Infect Dis Rep 2011
  • UTI- those associated with indwelling catheters are the leading cause of secondary nosocomial bacteremia.
• Malnutrition which can be caused by impaired cognition, poor appetite, nausea, constipation, restriction of movement, lack of dentures or difficulty in self feeding. Simple interventions can reduce mortality Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial J Am Geraitr Soc 2011.
• Delirium which can be multifactoral. Insomnia among hospitalized older persons Clin Geriatr Med 2008, Postoperative delirium: the importance of pain and pain management Anesth Analq 2006.
• Falls. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes JAMA 1995. The risk of falls and its consequences is well understood by the elderly. Quality of life related to fear of falling and hip fracture in older women: a time trade off study BMJ 2000. Falls are a common problem for the elderly in formal care settings. Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors J Am Geriatr Soc 1996
• Loss of mobility
• Discharge/plan of care (package of care will be cancelled when admitted to hospital) 40% of patients aged 85 and above are discharged to a nursing facility. Hospital Utilization among Oldest Adults, Statistical Brief. 2008
• Worsening function when they go home
• A week in bed can lose them 10yrs of mobility- deconditioning. Use it or lose it–the hazards of bed rest and inactivity West J Med 1991.

There can sometimes be family pressure to admit to hospital- lack of awareness of the implications of risks of admission versus discharge.

Other difficulties when caring for the elderly patient can include:

• Complexity- it can sometimes be very hard to establish a diagnosis because of the many issues that may be involved. Even in environments other than Emergency Departments this can take a lot of skill Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993, Comprehensive geriatric assessment: making the most of the aging years. Curr Opin Clin Nutr Metab Care 2002
• Protocol driven care sometimes makes treatment difficult.
• Hard to assess how the patient is doing at home. they will often be doing better than we think. Patient will do better at home because they are in their environment.
• Confusion/delirium-
  • pain, interruption in sleep patterns and several classes of medications are important risk factors for delirium. If sensory input is impaired this can also worsen the problem, for example if the person does not have access to glasses or hearing aids. This is an acute condition and the key is to try to find the cause as it is potentially reversible.
  • Cognitive assessment should be done (AMT4- Age, birthday, place, year). Evaluation of a shortened version of the Abbreviated Mental Test in a series of elderly patients Clin Rehabil 1997.
• Dementia- the burden of dementia is increasing worldwide Alzheimers Disease: Facts and Figures Alzheimers Association 2012
• Urinary tract infections are over diagnosed and over treated in older people. A positive urine dip to leukocytes can be due to chronic colonisation of the bladder due to age Optimal management of urinary tract infections in older people. Clin Interv Aging 2011