The acute clinical problems and needs of older patients are often substantially different from those of younger patients. Despite evidence for processes that lead to better outcomes for such patients, these are not applied consistently throughout the NHS.
- Because of demographic changes, the rise in emergency admissions to hospital, and a focus on both quality and cost-effectiveness in the NHS, there is a need to define best practice with regard to acute medical care of older people. This includes people presenting to urgent care services, and those within acute hospitals.
- Models of service provision will vary, but there are key principles, outlined in this Guide, that should underpin any service dealing with acutely ill older people. These include the right of older people to a medical diagnosis, to be able to access comprehensive geriatric assessment, including therapy and mental health services, and to be able to access treatment in the most appropriate setting without unnecessary delay or unnecessary admission to hospital.
- Provision of acute services based around the needs of older people is a challenge. However, there is a growing clinical and cost-effectiveness evidence base that should assist healthcare providers in designing services around the specific needs of frail older people who present with acute illnesses.
- The role of geriatricians and other professionals who specialise in care of older people is crucial in implementing best practice in terms of leadership, involvement, education and training.
The demand for acute medical admissions has risen relentlessly over recent decades and older people constitute the fastest growing section of the admitted population. The rise in demand for acute admissions has been accompanied by a decline in the number of acute hospital beds and greater use of early supported discharge schemes. The impact of admission avoidance schemes is uncertain, although it is recognised that many acute medical conditions can be dealt with comprehensively and safely in the community, provided systems are in place to allow this to happen.
The clinical problems and needs of older patients are often substantially different from those of younger patients. Many older patients are admitted with acute or sub-acute medical illness, which often presents in non-specific manner, and may be accompanied by cognitive or functional deterioration. Furthermore, many older patients have multiple co-morbidities, polypharmacy and complex social care needs. Complex vs non-complex older patients are less likely to be discharged from the acute medical unit, have significantly longer length of stay in hospital if admitted, and have higher re-admission rates. Many physicians and junior doctors not trained in geriatric medicine find such patients challenging to manage.
Comprehensive Geriatric Assessment (CGA) provides an evidence-based model for the provision of the co-ordinated multi-disciplinary care that these patients need. The involvement of geriatricians in acute medical care has substantially increased in recent years, but there is a definite tension between delivering an acute medical service, characterised by large volumes of patients being rapidly processed in acute medical units (length of stay usually less than one day) and the time required to deliver a specialist geriatric assessment which is a necessary component of CGA.
Over the last 10 years, it was recognised that care and outcomes for heart disease and stroke in the UK needed to be better, and the NHS invested time and effort to re-organise services around an evidence-based multi-disciplinary model of care. We now need to do the same for acute medical care of older people.
3. Definitions / Terminology
- Older people: geriatric medicine is mainly concerned with people over the age of 75, although many ‘geriatric’ patients are much older. However, geriatric medicine in the UK is broadly from the age of 65 onwards. Frail older people are those with multiple diseases, that often includes dementia, with reduced functional reserve who tend to present to hospital with ‘geriatric syndromes’ such as falls, confusion and immobility.
- Acute medicine is that part of general (internal) medicine concerned with the immediate and early specialist management of adult patients suffering from a wide range of medical conditions who present to, or from within, hospitals requiring urgent or emergency care.
- Acute medical unit (AMU): an area of the acute hospital where patients suffering from acute medical illnesses are admitted, assessed, treated and then either discharged or transferred for ongoing care to a specialist ward. These are increasingly led by Consultants who specialise in Acute Internal Medicine.
- Comprehensive Geriatric Assessment is a multi-disciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for treatment and long term follow up.
4. Health Policy and Guidance
The following section summarises the main relevant national documents relevant to this Guide:
1. Department of Health. National Service Framework for Older People. DH, London, 2001. This laid out 8 standards, all of which are relevant to acute medical care for older people: rooting out age discrimination, person-centred care, intermediate care, general hospital care, stroke, falls, mental health and the promotion of health and active life in older age. The intermediate care standard was that, ‘older people will have access to a range of services [closer to home] to promote their independence by providing enhanced NHS and [social care] services to prevent unnecessary hospital admission, and effective rehabilitation services to enable early discharge from hospital and prevent premature and unnecessary admission to long-term residential care.’
2. Department of Health. Our health, our care, our say: a new direction for community services. DH, London, 2006. This outlined four main goals: better prevention services, more patient choice, improving access to community services, and more support for people with long term needs. Importantly, it set out a longer term aim to bring about the sustained re-alignment of the whole health and social care system, with health and social services being more integrated and delivered closer to home, and an accompanying shift of resources from secondary to primary care.
3. Philp I. A recipe for care – not a single ingredient. Clinical case for change: report by Professor Ian Philp, national clinical director for older people. Department of Health, London, 2007. This highlighted that many of our existing health services are not designed with older people in mind, and that there is evidence that early intervention and assessment, easy access to specialists by community nurses, alternatives to hospital admission, as well as equal access to specialist in-patient care when needed can improve outcomes and utilisation of resources.
4. Royal College of Physicians. Acute Medical Care – the right person, in the right setting – first time. Report of the Acute Medicine Task Force. RCP. London, 2007. This report emphasised the need for early senior clinical decision-making and access to diagnostic support, including for older people in long-term care facilities. It promoted acute medicine as a specialty and outlined standards for acute medical units, workforce and training. Emergency care networks were promoted as a means of co-ordinating urgent care across primary and secondary care. Standardised evidence-based care pathways and national clinical performance indicators for acute medical care were also recommended.
5. Department of Health. High Quality Care for All. NHS Next Stage Review Final Report. DH, London, 2008. This review, led by Lord Darzi, outlines the future focus for the NHS – locally led, patient centred and clinically driven; responsive to changes in healthcare and society including an ageing population; and a focus on quality and quality improvement methods.
6. NHS Institute for Innovation and Improvement. Focus on: frail older people. London, 2009. www.institute.nhs.uk. Part of the ‘delivering quality and value’ series, this resource document outlines a number of key characteristics of organisations that provide high quality care and value for money with a specific focus on care of frail older people.
5. Models of Service Provision
How acute care for older people is currently organised varies throughout the UK and is outlined in Appendix 1.
Comprehensive geriatric assessment: covers medical diagnoses, medication review, mental health assessment, functional ability, and a review of social circumstances. Randomised controlled trials show that GCA and its interventions lead to improved function and quality of life, and also reduce hospital stay, re-admission rates and institutionalisation, but only if a geriatrician is included in the multi-disciplinary team.
Ambulatory care: the NHS Institute of Innovation and Improvement has drawn together an evidence-based directory of ambulatory emergency care for adults.
Rehabilitation: acute illness in older people often has functional consequences, especially in relation to mobility and self-care. Rehabilitation is an evidence-based intervention and requires a multi-disciplinary team. There is randomised controlled trial evidence that rehabilitation interventions can improve outcomes for older people with the following conditions:
- Knee arthritis
- Parkinson’s Disease
- Chronic lung disease
- Old age and multiple conditions (frailty)
Intermediate care: The evidence-base for intermediate care is patchy, most likely because a) there is evidence that some models of intermediate care are more effective than others, b) some intermediate care services may be too small to make a difference, and c) intermediate care needs to be better developed before large scale robust studies can be performed. Needs-based assessments of intermediate care showed that a surprisingly high percentage of patients in hospital were eligible in some studies, but few intermediate care services have the capacity to support this magnitude of workload.
Acute Medical Units: Well-managed AMUs that include a multi-disciplinary team reduce in-patient mortality and length of stay without affecting re-admission rates. Acute geriatric unit care has been shown to provide a functional benefit when compared with conventional hospital care, and increases the likelihood of living at home after discharge.
Although AMUs have the advantage of immediate access to clinical staff and rapid diagnostics facilities, they do not always cater well to the needs of frail older people. A consequence of the difficulty in delivering CGA within the AMU is that a high proportion of frail older people are admitted to base wards, some of whom might be better managed in alternative settings.
In addressing the tension between delivering rapid acute medical care to all patients and the specialist needs of frail older people, there is a growing move to develop specialist services for frail older people in addition to usual care, both in acute settings and in general hospital care (for example, peri-operatively).
The following principles summarise current health policy and evidence which underpin this Good Practice Guide:
1. Rooting out age discrimination. Older people have a right to a medical diagnosis and should have equal access to specialist advice when needed. Those who present with geriatric syndromes (eg falls, confusion, reduced mobility) are more appropriately cared for in a service that can offer Comprehensive Geriatric Assessment. All older people should have access to treatments based on need, without an age-defined restriction to services.
2. Provision of Comprehensive Geriatric Assessment. Acute medical services should provide CGA. This requires early assessment by senior geriatricians, and the provision of diagnostic support, therapy, mental health teams, and access to care in the community 7 days a week. Rehabilitation has a strong evidence base and is of central importance in geriatric medicine. Access to appropriate rehabilitation teams and facilities is vital.
3. Breaking down barriers between health and social care. Services that provide acute care for older people should function as a single team to facilitate the patient pathway and avoid unnecessary duplications and delays in treatment and care. Duplication of services in the same area should be avoided. Geriatricians and teams who work in both the community and the ‘front door’ of the hospital is one effective way of facilitating better information and continuity of care for older people.
4. Streamlining care. With the increase in community geriatric services, decisions to send older people to hospital are being taken by a wider body of healthcare professionals, such as community matrons and intermediate care staff. Decisions to admit are often taken by the most junior medical staff. Access to a senior geriatrician and a multi-disciplinary team capable of performing CGA and its interventions may occur several steps later in the patient pathway. National reports highlight the importance of ‘the right person, in the right setting – first time’. Referring clinicians should have access to a simple referral system with an agreed policy provided by local geriatric, emergency medicine and acute medicine services. This should include the provision of expert advice and urgent assessment, as well as admission to hospital.
5. Focus on quality and quality improvement. Teams leading the provision of CGA should regularly measure their performance against key performance indicators. These should include things like conversion of attendance to admission rates from the emergency department, access to GCA, non-clinical delays, length of stay, re-admission rates, patient and carer satisfaction.
6. Responsibilities / Role of the Geriatrician
Geriatricians have a responsibility to engage in the acute medical care of older people through participation, development of innovative services, and education. All of these should be underpinned by evidence-based best practice.
Clinicians with expertise in the care of older people should:
- Highlight the importance of rapid CGA in the acute setting
- Develop and possibly lead integrated discharge teams on the AMU for frail older people, with strong community links
- Monitor the acute care of frail older people and work pro-actively to solve any deficiencies
- Teach and train junior staff and other colleagues
- Foster a positive attitude among colleagues towards the care of frail older people
- Develop strong links with primary care
7. Measurement and audit
The following regular measures are recommended:
- Conversion rates:
- proportion of older people attending emergency departments admitted to hospital
- proportion of older people admitted form acute medical units to the base wards
- Length of stay
- 30 day re-admission rates
- In-hospital mortality
- Non-clinical delays (eg waits for intermediate care or rehabilitation facilities)
- Time from presentation to GCA
- Patient and carer satisfaction
The following are important areas for audit:
- Proportion of older people undergoing cognitive assessment at presentation (ie AMT or MMSE)
- Assessment of patients presenting with falls (not due to acute illness)
- Prescribing in the acute medical unit (on the basis that many acute admissions may be precipitated by inappropriate prescribing)
- Diagnosis and management of urinary tract infection (over diagnosis may point towards inadequate assessment of frail older people)
The Royal Colleges of Physicians have recognised that training in geriatric medicine is important at the level of general professional training. Further efforts must be made to facilitate such experience in the training of future Consultants in all specialties by encouraging the inclusion of such posts in rotational training programmes and improving the educational value of foundation and speciality training posts in geriatric medicine.
All those who may be involved in the medical management of acutely ill older people should have specific postgraduate training in geriatric medicine. This includes those working in acute medicine, emergency medicine and general practice.
Similarly, nursing staff whose role includes the acute care of older people should receive specific training and professional development in this specialist area.
1. Acute medical units should have a clearly defined strategy and written operational policy for the delivery of acute medical care for older people.
2. Older people should have ready access to necessary investigations and specialist advice.
3. Rapid access to a senior geriatrician and CGA should be the goal of every hospital providing acute medical care for older people.
4. CGA necessarily includes therapy professionals and other members of a multi-disciplinary team and must include mental health team support, and easy access to social services and intermediate care 7 days a week.
5. Access to CGA for older people should be needs-based not arbitrarily age-based.
6. Closer liaison between geriatricians, the emergency department (ED) and AMU will benefit patients and improve staff training. There may be a role for a dedicated geriatrician embedded within ED/AMU focussing on frail older people. Hospitals should appoint a lead clinician for acute care of older people.
7. Ambulatory care or community care as an alternative to hospital admission requires rapid access to CGA and alternatives to in-patient care for those patients whose diagnosis, co-morbidity and illness severity do not require a hospital bed. Processes should be put in place to ensure staff are aware of what is available and how to access it, as part of a whole system co-ordinated approach.
8. A single referral point for primary care clinicians should be provided to ensure rapid advice, assessment or admission for an acutely ill older person. This should focus on frail older people and be separate from the general ‘on-call’ service.
9. Hospitals and primary care Trusts should consider appointing ‘interface geriatric’ teams who work part time in the hospital front door, and part time in the community, in order to facilitate better communication and continuity of care for frail older people.
10. Processes that are put in place to care for frail older people should be as streamlined as possible, avoiding duplication, unnecessary steps or waits.
11. Processes and quality of care should be regularly measured and presented to clinical teams as part of an ongoing improvement programme.
12. Medical and nursing staff in acute units must be trained appropriately in the assessment and care of older people and wards must be properly equipped for their needs.
Review date: Oct 2012
- Royal College of Physicians. Acute Medical Care – the right person, in the right setting – first time. Report of the Acute Medicine Task Force. RCP. London, 2007.
- NHS Institute. Delivering quality and value. Directory of emergency ambulatory care for adults. 2006. www.institute.nhs.uk. (accessed Sep 09)
- Royal College of Physicians of London. National clinical audit of falls and bone health in older people report. RCP. London, 2007.
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Models of acute medical care for older people in hospital.
a) THE NEEDS – RELATED MODEL
Patients are selected by non-geriatricians, for referral either to geriatric or general medical services. This model is based on the premise that geriatric medicine is the specialty which best deals with older people who present in a certain way ie non-specific symptoms combined with cognitive or functional decline, on a background of multiple pathology and complex social care needs. Particular problems (eg confusional states or recurrent falls) may be identified as automatically appropriate for geriatric medical care in some centres. All acutely ill patients are still initially managed on the acute medical unit.
b) THE AGE – DEFINED MODEL
All medical patients referred to hospital who are above a certain age (eg 75 years) are admitted to the geriatric service. This model has been justified on biological, screening and pragmatic grounds. However, biological distinction between younger and older adults is difficult to substantiate on medical grounds and age has not yet been shown to be a valid screening variable for identifying those patients who would do better under geriatric than general medical care. Surveys of age-defined services in the UK reveal that the defining age is often determined, on pragmatic grounds, by the number of patients which a geriatric service can accommodate within its current allocation of acute care beds. All acutely ill patients are still initially managed on the acute medical unit.
c) THE INTEGRATED MODEL
Geriatricians serve as members of multi-consultant medical teams, take equal part in acute general medical work and are also responsible for providing specialist geriatric services including rehabilitation, day hospital, outpatient, continuing care, and community liaison work. A Consultant geriatrician shares a team of junior doctors with other general medical colleagues: this is recommended by some as a rational response to the biological nature of ageing and the pattern of health and social needs of an ageing population. All acutely ill patients are still initially managed on the acute medical unit.
A combination of these models is possible, and may be appropriate.