oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
It is generally accepted that elderly people fare best when care is provided in their own homes. However, some conditions require more intensive management than can be provided in the community. The admission of elderly patients to hospital, their treatment and subsequent discharge can prove challenging. Whilst self-sufficiency depends a lot on the underlying condition, delivering a package of care to an acceptable standard can make the difference between an individual who is a self-sufficient functioning member of the community and one who is disabled and dependent.
The Department of Health recognise the importance of providing quality care to the elderly and has produced a raft of guidelines outlining the sort of issues which need to be considered when planning services. Many of these are enshrined in the National Service Framework for Older People. A White Paper addressing the social aspects of elderly care, 'Our health, our care, our say: a new direction for community services', was published in 2006.
Concerns have been expressed about the standard of nutrition which elderly patients have received in hospital. This has prompted Age UK to issue its guidance 'Seven Steps To End Malnutrition'.
Patients should be treated according to clinical need rather than age. This might seem self-evident but may present pragmatic difficulties. Some clinicians might balk at the idea of referring an 85 year-old for coronary artery bypass surgery but, if the patient is otherwise fit for surgery and wants the operation, they should be offered the chance to have it. A report, 'Achieving Age Equality in Health and Social Care', was published in 2009 containing various recommendations supporting the concept of equality in healthcare for the elderly.
Patients should be treated as individuals and empowered to make choices about their own care. This involves providing information in a form that patients can understand and listening to their views and the views of their carers. Preserving dignity in a hospital setting is a major objective and includes separate toilet and washing facilities, single-sex wards and safe care for patients will mental disorders. The Government has announced that it will end the indignity of mixed-sex wards by the end of 2010.
Another raft of guidance involves the provision of end of life care and, whilst this may be of more relevant to community and palliative care services, it also impacts on community hospitals.
The aim here is to relieve pressure on acute hospital beds and provide care in a more community-based setting. The principles are the same whether care is provided by intermediate care teams in the patient's own home or in an intermediate care facility. The goal is to restore the patient to full function and avoid the need for long-term care by providing integrated rehabilitative support.
Specialist care whilst in hospital
With the change in demography in the UK, a significant proportion of people in hospital are now aged over 65 and secondary care needs to provide services tailored to the needs of its elderly population. The emphasis has been on improving access to care and the last few years have seen a significant increase in the number of elderly patients being admitted for cataract surgery, hip or knee replacements and interventional cardiac surgery. In addition to traditional geratologists and consultants in care of the elderly, many hospitals have set up specialist multidisciplinary teams led by nurses ('modern matrons' or nurse consultants) focusing on the needs of the elderly whilst in hospital and on discharge.
Evidence suggests that stroke patients fare best when admitted to specialised stroke units. The aim is to provide rapid access to diagnostic services, care provided in stroke units led by specialised physicians and multidisciplinary intervention to enable early discharge, rehabilitation and secondary prevention. Provision has been patchy but the release of the National Institute for Health and Clinical Excellence (NICE) guidelines on stroke in 2008 has helped to standardise care across the UK.
Management of falls
Falls are the leading cause of mortality in the over-75 age group. All patients who have had a fall should be offered a multifactorial risk assessment and multifactorial interventions. NICE recommends the following:
Multifactorial risk assessment
- Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial fall risk assessment. This assessment should be performed by healthcare professionals with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.
Multifactorial assessment may include the following:
- Identification of the history of the falls.
- Assessment of gait, balance and mobility and muscle weakness.
- Assessment of osteoporosis risk.
- Assessment of the older person's perceived functional ability and fear relating to falling.
- Assessment of visual impairment.
- Assessment of cognitive impairment and neurological examination.
- Assessment of urinary incontinence.
- Assessment of home hazards.
- Cardiovascular examination and medication review.
- All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention.
- In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):
- Strength and balance training.
- Home hazard assessment and intervention.
- Vision assessment and referral.
- Medication review with modification/withdrawal.
Elderly patients may have a different pattern of disease and different response to treatment than younger patients.
- Multiple pathology: the symptoms resulting in hospital admission may be caused by a combination of several disease processes and it important to identify which is contributing to the current difficulties (eg cataracts and arthritis resulting in falls). Multiple causes may need to be treated in order to relieve the presenting problem.
- Nonspecific symptoms: older patients may develop incontinence, immobility, instability, acute delirium or confusion in response to virtually any disease. NICE recommends that patients should be assessed for risk factors for delirium on admission to hospital. If there is an increased risk, a tailored multi-component intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention.
- Atypical presentation: myocardial infarction may occur without chest pain and chest infection may present without cough or sputum.
- Lack of physiological reserve: this phenomenon of older people results in rapid onset of illness, delayed recovery rate and increased incidence of complications compared with younger patients.
- Pharmacokinetics: a reduction in excretion and impaired metabolism of drugs may require a reduction of dosage. There may be less tolerance to side-effects and the problems presented by polypharmacy may also be an issue.
A significant proportion of patients who experience delayed discharge are elderly. Poor hospital bed management and a failure of communication between health and social care are the principle contributing factors. Hospital discharge should be a planned event and the planning of a discharge care package should begin at the point of hospital admission in partnership with the patient and their carer(s).
Issues to be considered include:
- Medicines management.
- Equipment provision - wheelchairs, hoists, grab rails, beds.
- Accommodation issues - stairs, access to toilet, portable alarms, ability to use the phone.
- Social network - family, friends, regular visitors, neighbours.
- Care in the community - the need for district nurses, community psychiatric nurses, social workers, information to GP.
- Nutritional needs - can the patient open tins, use a kettle, are 'meals at home' services required?
- Needs of the carer.
End of life care
Doctors are continually being reminded of the importance of obtaining consent for treatment and of involving patients in decisions about their care. However, difficulties can arise when patients are unable to understand decisions or give informed consent. In such situations, clinicians should take into account the following:
- The existence of an Advanced Directive or Living Will.
- Power of Attorney - this can be used for decisions about care as well as financial issues.
- Independent Mental Capacity advocates - advocates should be appointed to represent people who lack capacity and face serious decisions with no one to be an advocate for them.
Further reading & references
- Dignity in care campaign, Dept of Health, 2006
- National Service Framework for Older People; Dept of Health, 2001
- Our health, our care, our say: a new direction for community services, Dept of Health, 2008
- Seven steps to end malnutrition, Age UK, 2010
- Age equality in health and social care, Sir Ian Carruthers, Dept of Health, 2009
- Mixed-sex wards to be eliminated this year, Nursing Times, August 2010
- The National End of Life Care Programme, Dept of Health, 2009
- Stroke: The diagnosis and acute management of stroke and transient ischaemic attacks; NICE Clinical Guideline (July 2008)
- The assessment and prevention of falls in older people, NICE (2004)
- The Older Person in the Accident & Emergency Department, British Geriatrics Society - Best Practice Guide 3.2 (May 2008)
- Rai GS, Mulley GP; Elderly Medicine: a Training Guide, 2001
- Delirium, NICE Clinical Guideline (July 2010)
- Pharmacokinetics in the Elderly, Merck Manual, 2009
- Discharge from hospital: pathway, process and practice, Dept of Health, 2003
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr Laurence Knott