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Caring for Seniors in Our Community

28-Sep-2016

These 22 tips for physicians working with older people below were revised slightly by me from comments written in the context of advice to Dr. Sean Ninan’s colleague physicians in training. However they also serve as a wonderful reminder to all of us on how to care for our older patients within the circle of care.

1. Be good to older people. Many of your patients will be frail and vulnerable. Much of society may view them as a burden. You should not. These are mothers, fathers, husbands and wives. They have been on this planet two or three times as long as we have and many of them will have rich tales to tell. It is our job to look after them as well as we can, with empathy and kindness.

2. We are part of the team. Physiotherapists, occupational therapists, other allied health professionals and experienced nurses will know things that physicians do not know or may have forgotten or overlooked – both day to day information and nuggets of clinical wisdom. We should always introduce ourselves to them; ask about progress, and feedback relevant information. After all we are part of a multidisciplinary team.

3. Older people are really complicated. Acute coronary syndrome (to give just one example) will rarely be treated in a standardized fashion on an elderly ward. Some patients may be suitable for all the drugs on an ‘ACS protocol’. Others may not be suitable for more than one, or even any. Many will be in between. Remember there is very little black and white in care of older people and different doctors may do different things. The AGS guidelines on multi-morbidity provide a great insight into the reasoning of a thoughtful and knowledgeable physician. http://www.americangeriatrics.org/files/documents/MCC.principles.pdf.

4. Especially for residents and JURSIs, because they are complicated, it may be helpful to write summary lists of problems (active and inactive). It is also wise to ensure that we consider nutrition, mobility, continence, and mood; and document these periodically so that we record the progress of the patient in the notes. If we do this, we will be well on our way to performing a comprehensive geriatric assessment! (http://www.bgs.org.uk/index.php/topresources/publicationfind/goodpractice/195-gpgcgassessment)

5. Let’s remember to review the medications at all steps of the care process – poly-pharmacy and adverse side effects are common in the elderly. Always consider the Beers and Stop/Start protocols. This document from NHS Scotland is also very helpful. http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20guidance%20v2.pdf

6. With the patients consent, for those of us new into the training programs offer to and take time to talk to relatives, even if it’s just a quick “Hello, my name is…(............) and “I’ve been looking after your mom/dad/grandparent.” We should then quickly summarize their progress and we should use the opportunity to gain additional collateral history, especially about their pre-admission functioning. While we are very busy and may not have time in the moment for in-depth conversation with all relatives, however let’s put ourselves in their place; imagine you are a relative of a patient, with little idea of what is going on.

7. We can provide much reassurance. And unless it is in the best interest of the patient to spend a long time speaking to relatives, it is perfectly acceptable to convey in the interest of our other patients that we have to and say, “Sorry, but I must move to my next patient.”

It’s important that we show a willingness to engage with relatives as they are part of the patient`s support system and many relatives are truly grateful and can be very helpful in the creation and success of our patient`s discharge plan.

8. Speaking of collateral history – let’s always get one! If we are admitting an elderly patient with cognitive impairment who cannot provide a full history, we should pick up the telephone and speak to a relative/care home worker/ neighbour. If a patient arrives on our ward and our colleagues have not taken a collateral history, let’s please do so.

9. If the relatives are unable to visit the ward, or only able to visit when we are not there e.g. weekends or evenings, then (with the patient’s consent), give them a telephone call and offer to inform them of progress. Otherwise families may feel as if they are in the dark, or that nothing is happening.

10. We all need to fully understand what frailty means. In particular, we must understand that relatively minor stressors can result in significant decline in overall health and their identification is important to the assessment of the frail older patient. http://rcpjournal.org/content/11/1/72.full.

11. We need to be excellent at diagnosing and managing delirium. http://www.rcplondon.ac.uk/sites/default/files/concise-delirium-2006.pdf. We should treat infection (if it’s there), but don’t just treat infection. Reorientation and early mobilization are also important. We should carefully review the medications. Treat pain, dehydration and electrolyte abnormalities. We must look for constipation (which is often present) and urinary retention, but use urinary catheters for as short a time as possible. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842841/table/t2-1820465/

12. Pain can easily go unrecognized among older people. Is your patient agitated and distressed? Consider prescribing analgesia. Let’s ensure that if we really need to prescribe opioid analgesia that we prescribe laxatives too.

13. Monitor the patients’ bowels function is important as constipation can contribute to delirium, poor appetite, immobility and urinary retention.

14. Monitor the patient’s bladder function. Consider the possibility of urinary retention (another cause for agitation and distress) and we need to learn how to use the ward bladder scanner.

15. Don’t perform urine dipsticks for older people. The positive predictive value is disappointing and asymptomatic bacteruria is common in older people. Give antibiotics for UTI only if patients have acute urinary symptoms, or have bacteruria and evidence of systemic inflammation (fever/raised inflammatory markers) without another more likely source of infection. http://www.sign.ac.uk/pdf/sign88_algorithm_older.pdf.

16. UTI is commonly over-diagnosed in older people, partly because of excess weight given to features such as the character of urine and urine dipstick results. Don’t assume a UTI every time your patient becomes unwell but instead, perform a thorough clinical evaluation. Do not routinely send urine for culture and sensitivity unless truly clinically indicated. http://www.bmj.com/content/349/bmj.g4070.

17. Be excellent at managing falls. A ‘mechanical fall’ is a rare event. Most elderly people admitted to hospital will have acute illness and/or recurrent falls that may be multifactorial in nature. Patients with a history of a fall who are admitted for “social” reasons very often have other precipitating factors such as pneumonia, dehydration with acute kidney injury or urinary retention. Make the link – if a patient has recently started falling more frequently or “gone off their legs” there will be a reason! Treat acute illness e.g. infection, constipation, renal failure, but don’t give antibiotics if there is no evidence of infection. While that may seems like an obvious statement, we doctors can automatically reach for an antibiotic. Remember to thoroughly identify risk factors for falls, and initiate the appropriate management plan. You might wish to follow the advice in: http://www.americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.Guidelines.pdf

18. When we are doing tasks at the bedside e.g. venipuncture , cannulation, take the opportunity to find out a little bit more about your patients. We should ask them how they wish to be addressed, where they live, what their hobbies are, how long they have been married for etc. We will have a much richer picture of our patient as a person, and most of our patients will appreciate us more for talking to them, particularly on matters of interest or importance to them.

19. If our patient is hard of hearing, let’s make sure they have their hearing aids, refer them for hearing aids or use an electronic amplifier. There are instances when cognitive impairment is mistaken for deafness.

20. We will often get asked: “Do they have capacity?” Capacity is decision and time specific. A patient may have capacity to choose what they want for lunch but not to consent for endoscopy. We can read http://www.mental-capacity.com/abouttheact/assessingcapacity/index.html for more details of capacity assessment.

21. If a patient “sounds chesty” frequently and has recurrent pneumonia, consider the possibility of recurrent aspiration due to a swallowing issue. A speech language pathology review and resulting modified diet may reduce their risk of further aspiration.

22. Never diagnose a patient as “a social admission``. Patients who are labeled with this term usually have several co-morbidities, often have evidence of an acute illness, and always deserve a thorough assessment. http://www.ncbi.nlm.nih.gov/pubmed/24098878

Adapted from a posting by Dr Sean Ninan, a Geriatrician Registrar in Leeds UK by Dr. David J. McCutcheon, VP Physician and Integrated Health Services.