Assessing Older Patients in Acute setting:- Views from Registrar on Call
As a registrar, I wear two hats – my day-to-day geriatrician's hat, where I look after older patients on the geriatric ward in hospital and my medical registrar on-call hat where I am responsible for the medical take. Theoretically, the person under the hat should be the same [ie in terms of clinical approach, acumen and practice]. And if I see an older patient through the course of the acute take, then it could be construed that the patient has seen a specialist [akin to the Cardiology Registrar assessing a patient with a Myocardial infarction]. However, in reality the roles and setting produce two very different versions of me as a physician. The acute take hat brings out my very stream-lined, managerial, dictatorial at times confrontational doctor-in-me and my clinical assessment revolves around acute medical issues; performing or supervising procedures; can the patient go home; does the patient need ITU/HDU?
I find it difficult to amalgamate the geriatric hat into the acute setting particularly with regards towards assessing older patients particularly frail patients who need a comprehensive geriatric review[CGA]. The dawning of this realization came as a surprise to me as a trainee geriatric registrar (and perhaps the reader), for whom the CGA is considered bread and butter. The reasons are manifold:- time pressures, the bleep, the sick patient in resus, the odd hour of 0200 or the lengthening number of patients waiting to be seen usually defer or impede my ability to fully screen the patient. To list a few snags:
- AMTS and Prescription review :- generally the easiest to do as they are increasingly being incorporated into the clerking history
- Collateral history:- can be difficult if relatives absent; the carer is not present and odd time of day, at times exhaustive to fully explore decline, family dynamics and social circumstances
- Screening for dementia or delirium- ascertaining the long-standing nature of the confusion and is this just a normal fluctuation or acute delirium?
- Digital rectal examination:- enables the assessment of the sacrum for pressure areas and also constipation- oft neglected
- Vision and hearing:- maybe obvious from end of bed
- End of life decisions :- Is patient on end of life register, should he/she be palliated from the outset, this in turns merit discussion with next –of-kin
- DNAR decisions – should we involve patient or call the family at 0300
- Continence :- is that catheter new from A/E or Long-term?
- Assessment of Gait:- from A/E trolleys; ‘tubes, wires and monitors’; lack of appropriate footwear and chairs can be a hair-raising venture
Considering my own struggles, I am not surprised that the most common decision is to admit older, frailer patients with multiple co-morbidities with a presumed diagnosis of ‘Off legs’ or UTI. It is an easy, seductive and logical decision to defer the immediate clinical decision and just admit the patient for the morning/next-day review by the Post-take consultant or geriatric team (we have all been there). Of course holding onto this group of patients in hospital for an extended length of time opens the door to a potential cascade of knock-on effects:- worsening of confusion brought on by a change of environment (in a busy and usually noisy AMU setting), in-patients falls and fractures, Hospital acquired infections; decanting of these patients to other wards/beds in a bed crisis setting. The initial decision to admit, which was originally made with a good intentions, can usually lead to down-ward spiral.
At a consultant-level, the same hurdles and problems are faced the next morning. A geriatric consultant on an unselected general Post-take round :- faced with an older confused patient (and 15 more patients waiting to be seen) with only a few lines of history and scanty clinical exam jotted down. The BGS guidance on the Acute care of the Older Patient (BGS 2010) (Banerjee 2012) and developments of Acute Geriatric and Fraility Units along-with outreach services like OPAL (Harari, et al. 2007) are steps in the right direction. Can we achieve the Holy Grail and deliver a modified CGA- 24 hours a day and at the front-line of emergency services [both A/E and GP out-of-hours]? With the passing years, increased experience and seniority, I have noticed that I have developed and honed my ‘gut impressions’ that this patient can go home or is displaying signs of End of Life. It has been possible to incorporate various sections of the CGA into my initial medical assessment [such as detailed collateral and continence history, PR, and AMTS as routine parts of examination]. If we can incorporate basic elements of this at grass-root levels [medical students and Foundation year /GP/medical CT curriculum]and effect a ‘culture change’ this will go some-way to helping assessing older patients in the acute setting.
Banerjee, Jay and Conroy, SA. BGS -Sliver book - Q u a l i t y C a r e f o r O l d e r p e o p l e w i t h U r g e n t & E m e r g e nc y C a r e n e e d s. London: BGS, 2012.
BGS. "British Geriatrics Society." Good Practice Guides . 2010. http://www.bgs.org.uk/index.php?option=com_content&view=article&id=44:gp... (accessed March 22, 2013).
Harari, D, F Martin, A Buttery, SO O'Neill, and A Hopper. "The older persons' assessment and liason team OPAL: evaluation of comprehensive geriatric assessment in acute medical inpatients." Age and Ageing, 2007: Vol 36; 6 ;670-675.