evolve the problem list and action plan This page intentionally left blank 56 CHAPTER 3 Clinical assessment of older people Taking a history Histories taken from older people vary as much as the patients them- selve s, but some common problems make the process more dif \201 cult: \200 Multiple pathology \200 Multiple etiology \200 Atypical presentation of disease \200 Cognitive impairme nt, both acute and chronic \200 Complex social situations Failing to recognize the import ance of obtaining an accurate and compre- hensive history risks misdiagnosis and mismanagem ent. There is often a dif \201 cult balance to be struck between being inclusive and being focused and ef \201 cient The patient interview The most direct information source, but requires patience and skill. \200 An elderly person with multiple problems may give a history that is hard to unravel. Someone with chronic back pain will answer positively to the closed questi on \200\230Do you have pain? \200\231, but it may be no worse than the last 10 years and n ot at all a part of the new presentation. Ask \200\230Is this new? \200\231 and \200\230I s it different from usual? \200\231 Allow time to volunteer symptoms. Avoid interrupting. If a symptom is mentioned in passing, return to it later to enquire about its nature, precipitants, etc. Interrupting may cause the main issue to be lost \200 The patient may underplay issues that are emotive (eg fail ing memory, carer abuse, incontinence) or perceived as leading to institutional care. Foste r an atmosphere of trust and mutual interest in problem solving Cognitive impairment Patients with dementia or delirium may not answer clearly or succinctl y, and symptoms may need to be teased out. Quantities of seemingly irrel- evant information may be interspersed with gems of important history. Don \200\231t get frustrated and give up \200\224 continue with a combination of open questions and careful listening, punctuate d by closed questions that may result in a clear \200\230yes \200\231 or \200\230no \200 \231. General enquiries such as \200\230Do you feel well? \200\231 and \200\230Does it hu rt anywhere? \200\231 can be rewarding. A patient who is made to feel silly will often dry up \200\224 if you are getting nowhere with speci \201 c ques- tions, then broaden the co nversation to get dialog \202 owing again. Sensory impairment Poor vision and hearing make the whole interview harder and more frighte ning for the patient. Use a well-lit, quiet room. Guide the patient to where you want them to sit. Ensure hearing aids are in, and turned on. Speak clearly into the good ear and do n ot shout. Use written questions if all else fails. Facilitate communication, however, labor ious \200\224 patients will worry that they appear stupid, and may elect to withdraw compl etely if obstacles cannot be overcome (see also b \200\230HOW TO Communicate with a deaf person \200\231, p.549, and b \200\230HOW TO Optimize vision \200\231, p.570). TAKING A HISTORY 57 Terms that should be banned and why (Table 3.1 ) Table 3.1 Terms that should be banned \200\230No history available \200\231 It is almost always possible to get a history: if not from the patient, then from family, c arers, GP, community nurse, or ambulance personnel. Nursing homes are staffed 24hr a day an d they all have telephones \200\230Poor historian \200\231 The historian is the person recording the history \200\224 this term is a self-criticism! If the patient is unable to give a history this is important and the reason should be docum ented along with evidence, eg AMTS, Glasgow Coma Scale (GCS) \200\230Social admission \200\231 A social admission is one caused solely by a change in the social situation, eg a carer who has died suddenly or a hoist that has broken. True social admissions are very rare and sho uld in general be avoided (admit to a non-hospital setting, eg care home, or increase care at home). If the patient \200\231s function has changed, eg new incontinence, falls, confus ion, and their unchanged social situation cannot cope then the admission is NOT social. Oft en there is a combination of altered health and social circumstances It is true that a younger patient might be able to stay at home with a minor change in heal th (eg Colles \200\231 fracture, \202 u) whereas an older patient needs hospital care; bu t by blaming only the social care the doctor is at risk of missing the medicine, stigmatizi ng the patient and labeling carers as failures \200\230Acopia \200\231 Usually a more accurate description of the clerking doctor than the patient! A grammaticall y incorrect and unhelpful term. Ask yourself why can the patient not cope? What problem has led to this presentation and can it be treated? \200\230Bed-blocker \200\231 Pejorative term that implies that the patient is actively hindering discharge. Delayed disc harge is a better term, as it removes any hint of blame from the patient 2Patients admitted with the labels \200\230social admission \200\231 or \200\230acopia \200\231 are frail and have a high in-hospital morbidity and mortality. Statistically they are more likely to die in this hospital admission than a patient with myocardial infarction (Kee YY, Rippingale C. (2009). Age and Ageing 38 : 103 \200\223105). Just because they are more challenging to diagnose and often require multidis- ciplinary assessment does not mea n that they should be regarded as time and resource wasters for the system. 58 CHAPTER 3 Clinical assessment of older people Other sources of information Many patients, especially those with acute illness, are unable to give a full and reliable history. If so, a history must be obtained from other sources. The family Often a rewarding source of information, especially at the initial assess- ment. Older people may underplay their symptoms, fearful of being thought unable to cope, or not wishing to fuss. The family will often have concerns and it is useful to establish these a s they may (or may not) be justi \201 ed; weigh them up as more information is gathered. Family members often wish to speak away from the patient \200\224 this can be useful and is acceptable if the patient gives consent. 2Your duty is to the patient and you are their advocate. Family members may have louder voices, but take care to listen to t hose for whom you are responsible. Elderly people are allowed to take risks (eg live at hom e with a high risk of falling) providing that they are competent. Neighbors/friends Elderly patients with no family nearby may be very well known to their ne ighbors \200\224 perhaps they have been found wandering at night, or unusual behavior has been noted. The neighbor may not feel obliged to volun- teer this information and it may ne ed to be sought. Neighbors may also act as informal carers and may contribute more care tha n family or formal carers. Common law partners are often heavily involved, yet may not be a s prominent in hospital as other family members. Rifts may exist between established family and new partners and these need to be understood when planning care. Professional carers They will know the usual functional and cognitive state of the patient, and will often have alerted medical services to a change. They are rarely present at the m edical assessment. Contact them and obtain all the infor- mation that you can. General practitioner and community nurse They may well know the patient very well, and have good insight into the dynamics of the care arrangement and family concerns. They can help clarify the medication and past medical history. If a confused patient arrives during GP pr actice hours, an initial clerking should always include a telephone call to the GP surgery. Patients who are housebound or who have leg ulcers, urinary catheters, or other nursing ne eds, are usually best known to community nurses. OTHER SOURCES OF INFORMATION 59 Ambulance crew The ambulance crew may be present during the initial hospital assessment of a sick older patient. Ask them what they know \200\224 this is a useful source of informat ion that is under-utilized. If they have left, examine written ambulance team documentation \200\224 this includes timing, symptoms, and clinical signs including vital signs. Parame dics may also hold information about social situation, eg state of housing, informal carers , etc. Nursing and residential homes When patients are admitted from institutional care, a good hi story can almost always be obtained: information should be sent with the patient (many home s have a transfer of care document), but if not it can be sought by telephone immediately. Information about usual functional state, past medical history, medications, and acute illn ess should be kept on \201 le at the home. Old medical notes Obtain them as quickly as possible, as they will provide essential medica l information. A search for any MDT assessments can be fruitful but remember that this is n ot always \201 led with the medical record. If the patient is not local, arrange for info rmation (letters, discharge summa- ries etc.) to be faxed or to speak to health professiona ls who know the patient. 60 CHAPTER 3 Clinical assessment of older people Problem lists Useful tools to help formulate plans for complex elderly patients in any sett ing. They act as aides-memoire for multiple pathology and prompt clinicians to consider int eracting problems. Problem lists should include: Acute problems May be a symptom (eg fall) rather than a diagnosis \200 List possible causes with a plan for investigation Chronic conditions How stable is the disease? \200 What management is already in place? \200 What else can be done? Lists can be generated at any stage in an illness \200\224 ideally at presentation \200 \224 but need to be worked on and evolve as time goes on. Involve members of the MDT and ma ke the list part of goal setting and discharge planning. Example \200 An 86-year-old woman who lives at home alone with a carer once a day is admitted to the medical assessment unit with confusion following a fall She has a past medical history of osteoarthritis, MI, and polymyalgia rheumatica She has been \201 nding it increasingly dif \201 cult to cope at home in the last year or so and getting occasionally confused \200 Her daughter who lives abroad is very c oncerned An initial problem list is suggested in Table 3.2 . Table 3.2 An example of an initial problem list Acute problem Fall and confusion Possible causes Sepsis Constipation Action plan Septic screen (midstream urine (MSU), CXR, blood cultures, C-reactive protein (CRP), erythr ocyte sedimentation rate (ESR), white blood cells (WBCs)) Rectal examination Background problems Osteoarthritis Vascular disease Polymyalgia rheumatica She is found to have an Escherichia coli urinary tract infection (UTI), which is treated, b ut remains much less able than prior to admission She is transferred to a rehabilitation ward and the MDT involved PROBLEM LISTS 61 A problem list at this stage is shown in Table 3.3 . Table 3.3 An example of a problem list for the next stage Problem Status Action Coliform UTI Recovering Complete antibiotic course Osteoarthritis Particularly affects left hip Regular analgesia Pain limits mobility Look into possible joint replacement Takes prn paracetamol Physiotherapy for walking aids and to improve muscle strength OT to adapt environment to limitations Consider stopping nitrates as no angina. Vascular disease MI in 1980s, no angina for years Consider statins or ACE inhibitors to limit progression of cerebrovascular disease. Progressive mobility and cognitive decline likely due to diffuse cerebrovascular disease MDT input to adapt to chronic changes Takes aspirin, atenolol, nitrates. Polymyalgia rheumatica Diagnosed in 1991 Slow steroid withdrawal On prednisolone 5mg and calcium and vitamin D Consider bisphosphonate Asymptomatic Action as above, this table, for each disease Frailty Likely multifactorial: osteoarthritis, cerebrovascular disease, steroid myopathy, probable steroid-induced osteoporosis Physiotherapy to improve stamina and con \201 dence Deafness Noticed by nurses Referral for hearing aid Progressive and bilateral Patient attributes to \200\230getting older \200\231 Likely presbyacusis Family concerns Daughter lives abroad, and is unable to help Meet with daughter (with patient \200\231s permission) and explain problems and action plan The patient makes a slow but steady recovery, and regains mobility with a Zimmer frame, bei ng independent for activities of daily living \200 She is successfully withdrawn from ste roids and begins appropriate secondary prevention measures Her home is adapted for downstairs living, and she returns there with a twice daily care package after 5 weeks in hospital 62 CHAPTER 3 Clinical assessment of older people General physical examination There are two major ways in which examining an older patient c an be more time-consuming and challenging: \200 The extent of the examination is wider : There are more systems with presenting symptoms \200 You often need to \200\230screen \200\231 (by examining a wide selection of systems) where presenting symptoms are vague The chance of detecting incidental pathology (eg asymptomatic aortic stenosis, skin cancers) is much higher The procedure itself is more dif \201 cult : Physical constraints \200\224 patients are less agile so undress more slowly and cannot al ways adopt optimal positions for examination (eg lying \202 at). They may wear many layer s of clothing. They are more likely to have pain or to tire during the examination Cognitive constraints \200\224 examinations that require complex instructions to be rememb ered and followed (eg visual \201 eld examination) may be too much for a confused elderly person Despite these challenges, there are great rewards: \200 There is a much higher prevalence of physical signs \200 The examination more often makes the diagnosis, eg a patient with a non-speci \201 c presentation may have an undiscovered abdominal mass or a lobar consol idation General advice \200 Given the challenges, it is tempting to take short cuts leading to a sub- optimal examination, but this must be resisted \200 There are differing degrees of this \200\224 it might be reasonable to auscultate a chest through a thin shirt or nightdress but it is useless to examine an abdom en through a rigid corset or with the patient sitting in a wheelchair Sub-optimal examination is dangerous, especially if inaccurate \201 ndings are documented and then acted upon by others. It is better to record that you haven \200\231t completed an examination and put a note at the end of your history that yo u, or another doctor, needs to complete or repeat the procedure It is sometimes reasonable for a comprehensive examination to take two or three sessions, but start with the most useful elements \200 Make use of nurses, r elatives or other carers to decrease the physical problems of examination. Use electric beds and lifting and handling aids to make examinatio n more comfortable, effective, and safe Try to examine all aspects of one portion of the body at the same time. If organized, you s hould not have to sit a patient up, roll them over or stand them more than once per examina tion Always inspect the patient fully. For example, look under clothing (especially sacrum and b reasts), between toes, and under wound dressings, wigs, and prostheses GENERAL PHYSICAL EXAMINATION 63 HOW TO Assess gait in an older person When? \200 Almost always useful whether inpatient, eg acute admission, outpatient, eg falls, movement disorder clinics, or rehabilitation settings eg functional p rogress Why? \200 Provides vital diagnostic information \200 Often appears time consuming but c an be surprisingly ef \201 cient \200\224 a normal gait is a good screening test and an a bnormal one will focus further examination, eg on a single joint or system How? \200 Ensure the patient is suitably clothed (bare feet, open hospital gowns and falling down trousers do not encourage a normal gait!) Have a nurse or relative \200\230stand by \200\231 the patient if there is any risk of falls so that you can concentrate on observing If they normally use a walking aid provide this (but you may also wish to try them without or with different aids) Ask them to stand and walk to a speci \201 ed point in the distance ideally a few meters away (eg sink, end of the room) Observe setting off, stride height, length, symmetry and \202 uidity, trunk position, and sway If safe encourage them to keep going, turn and return \200 Consider if speci \201 c exam inations indicated, eg tone for Parkinson \200\231s, Romberg \200\231s test if wide-based gait Functional assessments may be timed to quantify changes over time eg \200\230Get up and go test \200\231 = speed and stability while they sit to stand and walk speci \201 ed distan ce \200 Carefully record your \201 ndings Common patterns Leaning back \200\224 Common with pseudo-Parkinson \200\231s (see b \200\230Diseases masquerading as Parkinson \200 \231s disease \200\231, p.164) Leaning forward and grabbing furniture \200\224 Common in p atients with multiple falls and loss of con \201 dence; no single diagnosis Veering to one side \200\224 Consider stroke or balance problems Limping/antalgic \200\224 Consider hip or knee or foot problems Unsteady on turning \200\224 Consider ENT pathology (see b \200 \230Vertigo: assessment \200\231, p.560) Unsteady when \201 rst stands \200\224 Consider postural hypotension (see b \200\230Orthostatic (postural) hypotension \200\231, p.118) D if \201 culty setting off \200\224 Consider Parkinson \200\231s (see b \200\230Parkinson \200\231s disease: presentation \200\231, p.158) Wide based \200\224 Consider cerebellar, subcortical disease and normal pressure hydrocephalus (see b \200\230Normal pressure hydr ocephalus \200\231, p.216) Freezing/halting \200\224 Consider anxiety and fear of falling, Parkinson \200\231s disease or frontal brain lesions Footdrop \200\224 Consider stroke or localized anterior tibialis lesion Dif \201 culty rising from chair \200\224 Consider pr oximal muscle weakness 64 CHAPTER 3 Clinical assessment of older people Table 3.4 provides an overview of the physical examination. Table 3.4 Physical examination \200\224 systems System Of particular importance Examples/notes General examination Body shape and height Comments in this category are powerful in drawing the overall picture eg \200\230a thin (5 2kg) anxious lady with stuttering but clear speech \200\231 is very different from \200 \230an obese cheerful lady with unkempt clothes and a strong smell of stale urine \200\231 Nutritional status Hydration Mood, eg cooperation, insight, anxiety Hygiene Clothing Intellect/presentation Speech Temperature Hypothermia is more common Fever may be absent/minimal on presentation \200\224 recheck later Looks ill/well? If the patient looks ill state this and try to say in what way Cognition Assess and quantify Should already be partially assessed during history Conscious level (GCS) If unusual/delusional thoughts record, eg \200\230thinks I am her mother \200\231 or \200 \230repeated agitated shouts of \200\234get off \200\235 \200\231 Orientation (time, place and person) Assessment scale, eg MMSE, AMTS or clock-drawing test (CDT) Jaundice, clubbing, lymphadenopathy, cyanosis Signs of systemic disease Thyroid Breasts Consider examination in all women Skin/nails Bruising, rashes, purpura Carefully record bruising positions if any suggestion of abuse or accident If you don \200\231t record it you won \200\231t remember to refer to the podiatrist/chirop odist Toe nail onychogryphosis Venous disease or ulceration, cellulitis Always inspect the heels and sacrum of immobile patients Pressure sores Skin tumors Basal cell and squamous cell carcinomas and even melanomas are common incidental \201 ndi ngs GENERAL PHYSICAL EXAMINATION 65 Table 3.4 (Contd.) System Of particular importance Examples/notes Consider BP readings in both arms \200\224 peripheral arterial disease is common and can c ause major discrepancy Cardiovascular Check the BP yourself especially if it has been abnormal Postural BP (see b \200\230HOW TO Measure postural blood pressure \200\231, p.121) Respiratory rate is very useful (se nsitive marker and part of many EWS) Respiratory pattern Normal 12 \200\22316/min in older people Respiratory You may need to watch for > 1min to detect Cheyne \200\223Stokes breathing 30 % of normal e lderly chests will have \200\230basal crepitations \200\231 Crepitations only helpful if \200 don \200\231t clear wit h cough \200 mid or upper zon e \200 associated with changes in percussion and air entry Chest shape and expansion Respiratory impairment due to kyphosis common and important Listen and examine any sputum S ilent retention common Constipation as well as bowel and prostate abnormalities Cough Bladder Rectal examination is almost always relevant Abdomen Mouth Note if vision obviously impaired and why Thrush, ulcers, and teeth Visual \201 elds tricky but important in those with new visual loss or stroke Cranial nerves If hearing poor check for wax Some loss of up gaze is normal Note hearing aids/glasses Look for patterns, eg: \200 Asymmetry of muscle bulk, Peripheral nervous system Some normal elderly will lose ankle jerks and distal (toe) vibration sense power, sensation Sensory levels \200 Peripheral neuropathy \200 Global hyperre \202 exia If tremor try to qualify (see b \200\230Tremor \200\231, p.154) Gait and balance (see b \200\230HOW TO Assess gait in an older person \200\231, p.63) Musculoskeletal Restricted range or de formity See also functional assessment, this table Hot/painful joints Gouty tophi Usually through observation during your examination Functional Don \200\231t help unless they struggle \200\224 can they dress (including butttons/socks) get on/off bed, lie to sit, rollover? 66 CHAPTER 3 Clinical assessment of older people Investigations Investigations are often less focused in older patients because: \200 Pres entation is more frequently non-speci \201 c \200 Multiple pathology is more common \200 Screening for many diseases (eg thyroid disease) is appropriate Simple investigations Almost all older people who present with new symptoms should have: \200 Full blood count (FBC), ESR \200 Urea, creatinine, and electrolytes (U, C + E) \200 Glucose \200 Liver function tests (LFTs) \200 Calcium and phosphate \200 CRP \200 Thyroid function tests (TFTs) \200 CXR \200 ECG \200 Urinalysis These tests are inexpensive, well tolerated, rapidly available, and have a high yield. Coupled with a comp rehensive history and examination, they will usually give suf \201 cient information to gu ide initial management and further investigations. The urgency with which these tests are o btained is often determined more by hospital policy and the need for fast turna- round than by clinical need. \200 Don \200\231t order repeat tests automatically until you have see n the results of the \201 rst set \200\224 only abnormal ones need to be repeated the ne xt day If you order a test, record that you have done so in the notes (most doctors write a list o f suggested investigations and then tick the ones they have themselves arranged) Ensure that results are reviewed and record them in the notes Further investigations Although it is often tempting to order further investigations at pre senta- tion it is often not helpful as it may mislead the clinician, lead to unnec- essary patient anxiety, and to further time-consuming and expensive assessments. Often the correct course of investigation is very different when an experienced clinician reviews with the b ene \201 t of initial results and a short period of observation. Do not request an investigation if it will not alter management, eg: Carotid Doppler is unnecessary if endarterectomy would be inappropriate (eg poor functional status) Urgent CT head scan will not alter management for a deeply unconscious patient dying of stroke INVESTIGATIONS 67 Will it change management? Sometimes making a diagnosis has value even where de \201 nitiv e treatment is unsuitable. An investigation may alter management even if \200\230aggressiv e \200\231 treatment options are inappropriate. For example, sigmoidoscopy and barium enema may be helpful in a patient with bloody diarrhea even if colonic resection is not feasible : pathology such as colitis could be treated, and if advanced cancer were found, then the i nformation would help direct: \200 Palliative management including \200\230surgical \200 \231 procedures such as stenting \200 Non-medical decisions, eg making a will \200 Disc harge arrangements, eg choosing care-home placement over home \200 The diagnosis itself c an be reassuring to patients and relatives These concepts often have to be explained carefu lly to patients, family and medical colleagues who may feel that some investigations are un nec- essary or that not enough is being done. Tolerating investigations In general, non-confused older people accept and tolerate investi gations as well as younger patients. There are a few exceptions, which include: Colonoscopy (increased risk of colonic perforation) \200 Bowel preparation for colonoscop y or barium enema (more susceptible to dehydration) Exercise tolerance tests \200\224 arthritis, neurological problems, etc. often mean that the patient cannot walk briskly. Consider bicycle or chemical provocation testing It is often helpful to discuss the procedure with the person performing the test (often a r adiologist) \200\224 they might have suggestions for modifying the test or substituting a different procedure to make it safer. You may need to allow more time for gaining consent or for the procedure itself especially if the patient is deaf or anxious. Elderly patients are less likely to be aware of what mod ern medical tests involve than younger patients. Particular problems occur with confused pa tients, who may bene \201 t from escort by a family member or trusted nurse. The cautious use of sedatives or anxiolytics is sometimes helpful. In the outpatient setting it is often the trip to hospital rather than the test itself that is traumatic. Minimize visits, eg by combining a clinic visit with a test or by arranging two tests on the same day. Try asking the GP or district nurse to remove 24hr tapes. Where a series of tests or complex management needs to be accomplished, admission to hospital may be the best option. 68 CHAPTER 3 Clinical assessment of older people Common blood test abnormalities A screening series of blood tests in an older person usuall y yields several that fall outside normal laboratory ranges. The examples that follow are t hose which are most commonly abnormal in the absence of relevant illness. Unless they are v ery abnormal or something in the presentation makes them particularly relevant, they can us ually be ignored. There are four broad categories: Different reference range in older patients \200 ESR may be as high as 30mm/hr for men an d 35mm/hr for women in normal 70 year olds (see b \200\230The ageing haematopoietic system \200\231, p.452) Hemoglobin . Some debate, but the reference range should probably be unchanged (see b \200 \230The ageing haematopoietic system \200\231, p.452) Abnormal result but common and rarely imply important new disease \200 Thyroid stimulatin g hormone (TSH) \200\224 often low with normal free T4 and T3 during acute illness: sick e uthyroid syndrome (see b \200\230The ageing endocrine system \200\231, p.420). Repeat 2 \200\2234 weeks after acute illness has resolved Low blood sodium \200\224 Very low levels should always be investigated (see Chapter 14 ) but some patients run with an asymptomatic persistently mild hyponatraemia ( (cid:116) 128m mol/L) due to (overall bene \201 cial) drugs or sometimes without obvious cause Alkaline phosphatase \200\224 if LFTs are normal, an isolated raised alkaline phosphatase (ALP) can represent Paget \200\231s disease (see b \200\230Paget \200\231s disease \200 \231, p.480), which is often asymptomatic. ALP remains high for weeks after fractures, incl uding osteoporotic collapse Normochromic normocytic anemia \200\224 always check B 12 , folate, and ferritin/iron/iron binding. If these haematinics, as well as an ESR and blood \201 lm are normal, then it i s usually fruitless to look for the cause of mild, non-speci \201 c anemia (see b \200 \230Investigating anemia in older people \200\231, p.453) \200\224 there is often chronic kidney disease or early myelodysplasia underlying. Acutely unwell patients are often haemoc oncentrated, with a temporarily normal Hb that then falls to a pathological level after a f ew days, when rehydrated Bacteriuria (see b \200\230Asymptomatic bacteriuria \200\231, p.620). Bacteriuria is a com mon \201 nding in older patients and does not always indicate signi \201 cant urinary in fection. As a rule treat urinary symptoms rather than the bacterial count. The presence of white cells on urine microscopy and nitrites on dipstick can also guide decisions. \200 H igh creatinine/low estimated glomerular \201 ltration rate (eGFR) (see b \200\230The ageing kidney \200\231, p.384). Very common especially in patients with multiple pathology and drugs. Changes in results over time more useful than absolute level s COMMON BLOOD TEST ABNORMALITIES 69 False negative result \200 Creatinine \200\224 low muscle mass can mask poor renal funct ion (see Chapter 13). Consider using a conversion formula to estimate GFR, eg when judging drug dosage Urea \200\224 as creatinine. In a frail older person, urea levels in the middle or higher range of normal are consistent with severe dehydration False positive rates very high \200 Anti-nuclear antibodies (ANA) \200\224 \201 gures of up to 1:80 are of doubtful signi \201 cance in older patients D-dimer \200\224 Any form of bruising, infection, or in \202 ammation will increase d-dim er. If it is negative (rarely) it can still a useful test but do not expect it to be useful test to exclude deep vein thrombosis (DVT)/ pulmonary embolism (PE) in a frail elderly pat ient with falls and a UTI Troponin \200\224 Although this test is very speci \201 c to cardiac muscle, low level release can occur with arrhythmias, PE, and heart failure. It is not a useful screeni ng test in older patients with no chest pain and a non- speci \201 c presentation 70 CHAPTER 3 Clinical assessment of older people Comprehensive geriatric assessment A comprehensive geriatric assessment (CGA) is the multid imensional evaluation of the patient in his/her environment. It encompasses medical, functi onal, and psychosocial elements which provide an interdisciplinary assessment and informs a plan for treatment and/or care. The manage- ment is goal-orientated with the aim of restor ing or maintaining an older persons function and independence. The team CGA usually involves a team including nurses, therapists, and social workers who w ork together with a common form of documentation and/ or regular meetings. Settings \200 Inpatient \200\224 in a designated area or utilizing a specialized roaming team \200 DH (see b \200\230Day hospitals \200\231, p.22) \200 Outpatients \200\224 specialized clinics aimed at admission avoidance and early supported discharge, or follow-up of recently discharged patients to optimize functio nal recovery Care homes \200\224 advise on suitability of long-term placement, eg after urgent placement to avoid hospital admission Interventions CGA usually leads to several recommendations/treatments with clear goal-setti ng and often regular review of progress. Interventions might include physical therapy, chan ges in medication, environmental modi \201 ca- tion or advice about care home placement. T he tool of CGA has been adapted to disease-speci \201 c management programs (eg heart fail ure) and to assessing the suitability of older patients for cancer treatments. The patients CGA is expensive and should be targeted to those most likely to bene \201 t a nd exclude those whose prognosis is very good or very poor regardless of intervention. Evidence It is dif \201 cult to compare data from such diverse interventions and settings, and little is known about the effectiveness of individual components of the \200\230black box \200\231 of CGA. However, there is good evidence that CGA can improve important outcom es such as survival, function, and quality of life, as well as reducing length of inpatient stay and reducing admissions to hospital and nursing homes. It is not surprising that CGA is more effective when coupled with: \200 Control over implementation of advice \200 Lo ng-term follow-up/review \200 Medical management interventions Further reading Ellis G , Langhorne P . ( 2005 ). Comprehensive geriatric assessment for ol der hospital patients . Br Med Bull 71 : 45 \200\223 59 . 71 Chapter 4 Rehabilitation Introduction 72 The process of rehabilitation 74 Aims and objectives of rehabilitation 75 M easurement tools in rehabilitation 76 Measurement instruments 78 Selecting patients for inp atient rehabilitation 80 Patients unlikely to bene \201 t from rehabilitation 82 HOW TO Plan a complex discharge 83 HOW TO Conduct a MDT meeting 84 Physiotherapy 86 Walking aids 88 Occupational therapy 91 Occupational therapy assessments a nd interventions 92 Doctors in the rehabilitation team 94 Nurses in the rehabilitation team 95 Other members of the rehabilitation team 96 Social work and care management 98 Communit y nurses and health visitors 99 72 CHAPTER 4 Rehabilitation Introduction Rehabilitation (rehab) is a process of care aimed at restoring or maxi- mizing physical, mental, and social functioning. Can be used for: \200 Acute reversible insults , eg sepsis \200 Acute non-reversible or partially reversible insults, eg amputation, MI \200 Chronic or progressive conditions, eg Parkinson \200\231s disease Involves both rest oration of function and adaptation to reduced func- tion depending on how much reversibilit y there is in the pathology. Rehabilitation is an active process done by the patient not to him/her. It is hard work for the patient (akin to training for a marathon) \200\224 it is not \200\230convalescence \200\231 (akin to a holiday in the sun). Rehabilitation is the \200\230secret weapon \200\231 of the geriatrician, poorly understoo d and little respected by other clinicians. Many geriatricians feel it is what de \201 nes their specialty and it can certainly be one of the most rewarding parts of the job. The \200\230black box \200\231 of rehabilitation contains a selection of non-evidence-based, co mmon sense interventions comprising: \200 Positive attitude . Good rehabilitationalists a re optimists \200\224 this is partly because they believe all should be given a chance and partly because they have seen very frail and disabled older people do well. A positive att itude from the team and other rehabilitating patients also improves the patient \200\231s e xpectations. Rehabilitation wards should harbor an enabling culture where the whole team en courages independence: patients dressed in their own clothes, with no catheter bags on show and eating meals at a table with other patients MDT coordinated working . By sharing goals the team can ensure all team members are consistent in their approach Functionally based treatment , eg the hemoglobin level only matters if it is making the patient breathless while walking to the toilet Individualized holistic outcome goals . These incorporate social aspects which are often neglected. The team concentrates on handicap rather than impairments (see B ox 4.1 ) Settings Specialized rehabilitation wards are not the only place for rehab. If the consider ations outlined are in place then successful rehabilitation can take place in: \200 Acute wards \200 Specialist wards (eg stroke units, orthopedic wards) \200 CHs \200 DHs \200 Nursing and residential homes \200 The patient \200\231s own home These alternative sites often employ a roving rehabilitation team, which may be based in a hospital or the c ommunity. INTRODUCTION 73 Box 4.1 World Health Organization (WHO) classi \201 cation (1980) IMPAIRMENT \200\224 pathological defect in an organ or tissue, eg homonymous hemianopia du e to posterior circulation stroke DISABILITY \200\224 restriction of function due to impairment, eg inability to drive due t o visual defect HANDICAP \200\224 the social disadvantage cause by disability, eg unable to visit friends in neighboring village as unable to drive It can be seen that some impairments produce no disability or handi- caps and some handicap s are due to multiple interacting impairments. The system allows the social circumstances t o be factored in, such as in the examples given, the disability produces no handicap if a r egular bus route exists. Doctors are generally focused on impairments, poor at assessing di sability, and rarely consider handicap. Despite the attractive logic of such a classi \201 cation, it is actually rarely used in c linical practice. This is probably because geriatricians intuitively consider the wider asp ects of illness without requiring the discipline of formal terms. The word \200\230handica pped \200\231 is now avoided due to negative connotations and stigma. The WHO issued a new classi \201 cation of Functioning, Disability and Health in 1999 which is a little more co mplex but has a broadly similar structure ( M www.who.int/classi \201 cations/icf/ en/inde x.html ). 74 CHAPTER 4 Rehabilitation The process of rehabilitation 1. Selection of patients See b \200\230Selecting patients fo r inpatient rehabilitation \200\231, p.80. 2. Initial assessment This is not like a medical clerking, you need to get to know your pat ient on different levels (eg their mood, motivation and expectations, complex social factor s). Remember it is more meaningful to assess the handicap not just the impairment. 3. Goal setting See b \200\230Aims and objectives of rehabilitation \200\231, p.75. 4. Therapy \200 Medical \200\224 doctor led (see b \200\230Doctors in the rehabilitatio n team \200\231, p.94) \200 Physical \200\224 mainly physiotherapy (see b \200\230Physi otherapy \200\231, p.86) and nurse led (see b \200\230Nurses in the rehabilitation team \200\231, p.95). Mobility, bala nce, and stamina. Con \201 dence is often a key issue Self care \200\224 mainly occupational therapy (see b \200\230Occupational therapy \200 \231, p.91) and nurse led Environmental modi \201 cation \200\224 aids and adaptations \200 Carer/relative traini ng \200\224 it is too late to leave this until just prior to discharge 5. Reassessment Usually at weekly MDT meetings (see b \200\230HOW TO Conduct a MDT m eeting \200\231, p.84). Goals are adjusted and new goals are set. Points 3, 4, and 5 are re peated in a cycle until the patient is ready for discharge.