Structuring the care package \200 Tailor to the individual . A package usually consists o f between one and four visits per day, by one or two carers. A common pattern is for two vi sits daily, one early (wash, dress, toilet, food preparation) and one late (evening meal, r eady for bed). Lunch may consist of a pre-prepared meal, frozen and simply reheated by the patient, removing the need for a midday visit. Two carers are needed for \200\230double-ha nded care \200\231, eg turning or transferring a dependent patient Night-time visits are rarely needed, and dif \201 cult to provide reliably. Roles may incl ude toileting, pressure care (turns) or administering medication, but there may be other so lutions (eg other continence management, changing medication regimens) Continuous ( \200\23024hr \200\231) care is sometimes requested by patients or family, but close to impossible to provide \200\224 suf \201 cient staff are dif \201 cult to \201 nd, and the care would be extremely expensive; a move into a care home would usually be ch eaper. Therefore these packages are usually privately funded. Live-in carers are sometimes employed long-term, but cannot be on hand the whole 24hr, need holidays, and may go sick un predictably Access to the home by carers can be dif \201 cult if the patient is immobile and cannot get to the door. Combination locks or a key safe (conventional key locked within small combination \200\224 or key-accessed safe) provide a secure solution Equipment may be necessary before a patient can be discharged and a care package initiated, eg, hoist, bed, chair, cushion. OTs usually assess need and provide Commonly reported problems with care packages \200 Timing \200\224 unpredictable, or too early or late (eg 6pm visit to prepare for bed) Carers \200\224 variable quality, lack of continuity \200 Cost \200\224 often a signi \201 cant issue. Costs discourage some patients from taking an adequate (or any) care packa ge, and may result in it being stopped after a period Visits \200\224 may be brief; carer and patient feels rushed The Care Quality Commission ( M www.cqc.org.uk ) inspects and deals with complaints about social care providers. Nationa l Minimum Standards must be met if a care agency is to gain and retain a license. 40 CHAPTER 2 Organizing geriatric services Informal carers This term describes anyone who provides regular and substantive care to a p erson on a non-professional basis, usually without \201 nancial reward. This is often a f amily member, but may also be a friend or neighbor. \200 1 in 10 adults in the UK will pr ovide informal care to another person \200 A total of 6 million people acted as carers in 2003, and this is projected to rise to 9 million by 2037 Carers main bene \201 t is worth (in 2004) 44 per week, for an average of 35hr caring \200\224 just 1.26/hr \200\224 saving the economy 57 billion per year 12 % of the > 65s act as a carer, a third for > 50hr a week \200 The health of carers the mselves is poor \200\224 44 % have poor health, compared with 30 % of non-carers. The more demanding the caregiver role, the more likely th e carer is to experience ill health This vital group of individuals maintain many elderly patients in the com- munity and are t he backbone of the care system. For many, having an informal carer is the only way of stayi ng at home. A patient with cogni- tive problems (especially if mobile) may require constant supervision to ensure safety \200\224 a level of care that can only be provided by an inf ormal live-in carer (often a spouse). This level of care will often exceed that which can b e provided in a care home, leading to dissatisfaction when patients are temporarily or perm anently admitted to institutional care. The importance of this group is recognized in the government \200\231s national strategy Ca ring about Carers (2009), which aims to improve information and support to carers and impro ve the care they themselves receive. This includes the right of a carer to a \200\230carer \200\231s assessment \200\231, carried out by social services, which addresses the followi ng points: \200 Is the carer getting enough sleep? \200 Is the carer in good health? \200 Does the carer have time for themselves? \200 Are relationships adversely affected by the care giving? \200 Are there concerns about work? \200 Is the carer collecting al l available bene \201 ts? \200 Is all available help being provided (services include em otional support, help with household and caring tasks, accessing bene \201 ts and local activities, arrangi ng respite care \200\224 see Box 2.1 ) Support for carers is essential \200\224 caring can be relentless, unrewarding and often d epressing. Elder abuse is a rare but possible consequence of this highly stressful situatio n (see b \200\230Elder abuse \200\231, p.674). As well as government resources, a number o f charity and self-help organizations also provide support and practical help. Carers UK: M www.carersuk.org Princess Royal Trust for Carers: M www.carers.org Crossroads: M www.cross roads.org.uk INFORMAL CARERS 41 Box 2.1 Respite care Acting as a carer can be exhausting (both physically and mentally) for the carer and often the patient who may \201 nd accepting so much help from a loved one dif \201 cult. Part of any successful care \200\230package \200\231 is sustain- ability, which includes ensuri ng that everyone has a break from time to time. Some of the charities listed in the text (e g Crossroads) will offer a carer support worker to take over the caring role for a few hour s at a time, but a longer break may well be needed. In such situations, respite care in a residential establishment may provide the solution. M any care homes, particularly those in the independent sector are able to provide extremely \202 exible respite care packages. These can range from a 2-week visit (eg to cover a hol iday), to day care or even an overnight stay. A regular arrangement can be made, where, eg, 1 week on every eight is spent in residential care. Most local authorities operate a discretionary policy in terms of paying for respite care i n care homes, and may fund several weeks a year of respite to help sustain a care arrangeme nt. This is means tested. NHS respite is rare these days, but does still exist. Patients with psychiatric needs will often have respite on psychogeriatric wards. Long-standing arrangements on community hospit al wards and long-stay wards (becoming increasingly rare) may persist. Terminal care patien ts will often be offered respite care in hospices or community hospital wards. These servic es are free to the patient. 42 CHAPTER 2 Organizing geriatric services Other services Day centers \200 Traditionally run by health and social services but now i ncreasingly run by voluntary organizations (eg British Red Cross, Age Concern) \200 Accessed via social s ervices, (who assess need) or by self-referral \200 Offer regular visits (eg once or twic e a week) with transportation if needed \200 There is a charge that varies with requireme nts (eg transportation, meals) \200 Vary enormously, but may include: Catering (eg coffee, tea and lunch) \200 Social support network \200 Personal care (eg bathing facilities, hairdressing etc.) \200 Respite for carers \200 Skills development (arts and crafts, adult learning classes) \200 Access to services (eg podiatry, district nurse) \200 Leisure activities (eg quizzes, reminiscence, music, gardening, keep \201 t, trips out) Enables monitoring of progressive conditions (eg dementia) and early referral for extra support to prevent crisis Rehabilitation and independent living skills (may occasionally have OT, physiotherapy and s peech and language therapy (or therapist) (SALT) input) Day centers differ from DHs (see Table 2.3 ). Attendance is usually long term and cognitive impairment is more common. Social clubs Many different types that vary from county to county. Usually run by vol- unta ry organizations. Information on locally available clubs can be obtained from libraries, th e local county council or Age Concern. They include: \200 Lunch clubs (often with transpo rtation) \200\224 meet up for a hot midday meal \200 Bingo clubs \200 Tea dances \200 Keep \201 t groups \200 Special interest groups (eg all-male, all-female, ethnic grou ps, hobby groups \200\224 gardening, model railways, etc.) Befriending Scheme run primarily by Age Concern, providing lonely, isolated older people wi th a regular volunteer visitor who will sit and chat and help with minor jobs such as fetch ing library books, etc. Pet schemes Volunteers bring pets to visit people who can no longer keep them, eg in care h omes. Holiday support Voluntary organizations can provide information on suitable holidays for th e disabled, and some will offer \201 nancial assistance. OTHER SERVICES 43 Table 2.3 Differences between DHs and day centers DH Day center Medical input Yes \200\224 patients clinically unstable No \200\224 medically stable clients Attendance Usually short term Long term Staff:patient ratio Higher Lower Functional aim Improvement expected Maintenance and monitoring Activities Rehabilitation bias Social bias Relationship with hospital Close Distant Role Complex geriatric assessment and treatment Socialization Rehabilitation Carer respite 44 CHAPTER 2 Organizing geriatric services Chronic disease management \200 Around 60 % of the adult population has a chronic conditi on (commonly asthma, diabetes, hypertension, and cardiac failure), and older people make up th e bulk of this group Multiple chronic diseases lead to increasingly complex healthcare needs and are a particula r phenomenon among elderly people, who become increasingly frail with the accumulation of c hronic problems \200 Most of this pathology is managed in primary care, but it impacts fr equently on secondary care \200\224 10 % of the population (who have chronic disease) acco unt for 55 % of inpatient days There has been a shift in UK political emphasis away from acute sector targets, towards the proactive management of chronic disease \200\224 referred to as \200\230long-term condit ions \200\231. Lessons have been learned from so-called \200\230managed care organizations \200\231 (such as Kaiser Permante in California) in the USA, where comprehensive healthcar e is provided to a de \201 ned popula- tion. There are built-in incentives to actively man age chronic disease as this substantially reduces acute expenditure. There are a number of levels of chronic disease, summarized as follows: \200 Level 1 \200\224 accounts for 70 \200\22380 % of patients, who have a sing le chronic disease (eg hypertension). Management is enhanced by increasing personal respons ibility for the condition with education and encouraging active participation in care. Pati ent experts are developed who take on some of the education of their peers Level 2 \200\224 more complex patients, but still with commonly recognized complications o f disease (eg Parkinson \200\231s disease). Management is at a population level, with broad guidelines for care, protocols, and patient pathways. The approach is multidisciplinary wi th innovative ways of delivering a set standard of care (email, telephone, group meetings, nurse clinics etc.) Level 3 \200\224 highly complex patients with individual needs (eg frail elderly patient w ith multiple interacting pathologies). Active case management by a key worker (often a nurs e) promotes early intervention to prevent crisis and facilitates joined-up care The emphasis is on proactive management, rather than a \200\230 \201 re- \201 ghting \200\231 approach. The 2005 NSF on long-term conditions is about chronic neurological disea ses, eg motor neuron disease (MND)/Parkinson \200\231s but much has wider applicability. Cl inical nurse specialists often lie at the heart of the management framework. Frail elderly patients, however, are less predictable and so key workers need broader skills and are less able to rely on protocols. The following are useful ways of managing these patients: \200\230Frailty registers \200\231 to identify and risk stratify patients \200 Use of in formation systems and shared patient records \200 Specialist nurses, eg community matrons with close medical back-up \200 Involving community MDTs, district nurses and health vis itors \200 Coordinated care \200\224 using care managers CHRONIC DISEASE MANAGEMENT 45 Increased liaison between primary and secondary care with free and frequent sharing of info rmation and care goals, and easy access to urgent clinical review (eg in urgent assessment clinics) GPs with a special interest in geriatrics \200 Utilization of DH to monitor those most at risk of acute deterioration Further reading NHS Plan for Long Term Conditions ( 2005 ) online: M www.natpact.nhs.uk . N ational Service Framework for Long-Term Conditions ( 2005 ) online: M www.dh.gov.uk . Lewis R , Dixon J . ( 2004 ). Rethinking the management of chronic disease . BMJ 328 : 220 \200 \223 222 . 46 CHAPTER 2 Organizing geriatric services Primary care \200 90 % of older people see their GP at least once a year \200 Around 20 % of general practice consultations are for elderly people (who actually make up around 15 % of the population) Consultations tend to be more complex than in younger patients \200 Of these consultation s, about a third will need a home visit, compared with less than 10 % of the general popula tion \200\224 the trend for HV is declining, but older people remain the biggest user grou p GPs tend to be aware of the health problems of their older patients \200\224 those that do not attend tend to be healthy The most common consultations are for respiratory and musculoskeletal problems (whereas secondary care sees more complications of vascular diseas e such as ischaemic heart disease and stroke) Half of the > 65s are on a regular medication, and 17 % are on three or more \200\224 trea tment is usually prescribed and monitored by the GP Many older people have chronic conditions (such as arthritis, COPD, diabetes etc.) and the day-to-day management is usually carried out by GPs. Input from secondary care may come at a time of crisis (admission to hospital, rapid referral clinics) or may be more structured in the case of more complex chronic diseases, with regular clinic follow-up or day hospital attendance. GPs act as a vital link between hospital and com- munity services, identifying patients at particular risk of crisis so allowing preventative action to be taken (a skill more intuitive than evidence based, which comes with experience). \200 Patients with mul tiple co-morbidities and/or extreme frailty may bene \201 t from identi \201 cation (so-called \200\230frailty registers \200\231) and e lective review \200\224 a possible role for DHs, GPs with a special interest in geriatrics , district nurses, health visitors or the new community matrons GPs with a special interest in geriatrics can act as community specialists, working with other MDT members and liaising with hospital departments. They wi ll often take the diploma in geriatric medicine \200 GPs play a key role in the long-term management of risk factors for disease \200\224 now highlighted by the 2004 GP contract ( see Box 2.2 ) \200 Inpatients in many community hospitals are looked after by GPs. Primar y care has been subject to much reform in the last decade \200 In 2000, the UK government revealed the NHS Plan , which aimed to modernize the structure, organization and delivery of healthcare \200 In 2002, PCTs were created (each with responsibility for a population of 100 000 \200\224 375 000) and given resources and responsibilities to improve the healt h of their local population. PCTs are overseen by Strategic Health Authorities, that focus on long-term planning and national priorities (eg NSF priorities \200\224 see b \200\230T he National Service Framework for Older People \200\231, p.28) The GP contract was introduced in 2004 \200 Further changes are planned by the current (2 011) UK government PRIMARY CARE 47 Box 2.2 The 2004 UK GP contract This contract sets priorities for many GPs. Payment points Delivery of services is reimbursed via a system of payment points based on a chievements in certain clinical areas: coronary heart disease (CHD) \200\224 including hea rt failure (121 points), stroke/TIA (31 points), hypertension (105 points), diabetes (99 po ints), COPD (45 points), epilepsy (16 points), cancer (12 points), mental health (41 points ), hypothyroidism (8 points) and asthma (72 points). Points are also awarded for organizational aspects (184 points), additional services, eg ce rvical screening (36 points), the patient experience (100 points), holistic care payments ( 100 points) and quality practice payments (30 points). For example, the following refers to cardiac failure: \200 Register of patients with CHD who have left ventricular dysfunction \200\224 4 points 90 % of patients with diagnosis con \201 rmed by ECHO \200\224 6 points \200 70 % of pa tients being treated with an angiotensin-converting enzyme (ACE) inhibitor \200\224 10 points The standards do not have an upper age limit, all patients needing to have good blood press ure control etc., which diminishes any potential ageism in management. In general older pat ients have bene \201 ted from the systematic approach to secondary prevention however, thi s may not always be appropriate in the frailer elderly who may, for example, get postural s ymptoms with ACE inhibition. There is the chance to \200\230opt out \200\231 in an individ ual because it is \200\230not clinically appropriate \200\231 or the medi- cation is not t olerated, but these standards discourage the individual tailoring of therapy that is essent ial in geriatric practice. Documenting evidence consumes large amounts of GP time, which co uld otherwise be spent seeing patients. In addition, diseases that are NOT covered by the s tandards may suffer. These include conditions such as Parkinson \200\231s disease, depressi on, and osteoarthritis, which are very common in older people. Out of hours \200 No longer a requirement to provide out-of-hours services to patients (in fact may be dif \201 cult to opt to do so) Mostly now provided by centralized PCT services \200 Most GPs experienced improved qualit y of life, and recruitment to this career has improved Patients are unlikely to be seen by a doctor who knows them, increasing the rate of referral to hospital Patients are asked to attend a central assessment point, and if they are unable to (eg immobile), they are likely to be seen by a paramedic or taken to hos pital via the 999 system 48 CHAPTER 2 Organizing geriatric services Careers in UK geriatric medicine Consultant career pathway \200 After quali \201 cation foundation level 1 and 2 jobs are undertaken \200\224 most include some time in geriatric medicine. Core medical training (usually 2 years) comes next and most doctors will obtain M RCP at this stage Application for a SpR post may follow a period of research, but commonly this is done directly after CT2 posts Specialty training in geriatrics takes only 4 years but is almost always paired with another specialty, eg general internal medicine, rehabilitation medicine , stroke medicine. Dual accreditation will take 5 or more years Triple accreditation in geriatric medicine, general internal medicine, and stroke medicine is an increasingly popular career path Non-consultant career grade pathway \200 Includes staff grades, clinical assistants and a ssociate specialists \200 Responsibilities of the post-holder vary considerably from equi valent to SpR (staff grades) to consultant (associate specialists) The main difference from a consultant post is that they do not hold overall clinical respon sibility and have variable responsibility for management, administration, and training There is a pathway to convert to constant grade but it is time consuming and expensive Primary care physicians \200 GPs may wish to sub-specialize in geriatric medicine \200 This often leads to clinical assistant sessions in geriatric medicine services (either acut e, rehabilitation, or community settings) \200 Such GPs often have signi \201 cant exper ience in geriatric medicine during their vocational training scheme, and may obtain the diploma in geriatric medicine Non-European overseas doctors \200 Many overseas doctors wish to work in the UK for a per iod of time, and it can be dif \201 cult and expensive to get a \200\230foot in the door \200\231 \200 Most overseas doctors begin with clinical attachments, which are unpaid observer posts, but enable the doctor to become familiar with the UK healthcare syst em Doctors trained in the European Union may apply for any job in the UK but excellent English language skills and some familiarity with the UK healthcare systems will be an advantage Since 2008 non-EU trained doctors are legally only able to be employed in training grade posts which cannot be \201 lled by an EU applicant It is essential for non-EU trained doctors to take the PLAB examination ( M www.gmc-uk.org/doctors/plab.asp ) Obtaining MRCP and the diploma in geriatric medicine help to de \201 ne an interest and will assist with subsequent appointments DIPLOMA IN GERIATRIC MEDICINE (DGM) 49 Diploma in Geriatric Medicine (DGM) Quali \201 cation awarded by the Royal College of Phys icians (UK) to \200\230give recognition of competence in the provision of care of older pe ople \200\231. Candidates Candidates must be 2 years post medical quali \201 cation, and have held posts in geriatric medicine. Usually taken by GPs with an interest in ger- iatrics (often trainee s) or doctors working in (or applying for) geriatric posts (trust grades, staff grades, ass ociate specialists, etc.). Sometimes will count towards other geriatric quali \201 cations (eg master \200\231s courses) so may also be done by specialist registrars, although it is not primarily designed for this group. May also be of interest to psychogeriatricians. It is of use to all junior doctors doing a geriatric job as it motivates them to study importa nt topics that will recur in MRCGP and MRCP and it gives them something tangible at the end of an attachment. Examination structure Written section \200 2 hr \200\224 60 multiple choice questions C linical examination \200 76min \200\224 4 x 14min stations (incorporating one history ta king, two examination stations, and one communication skills and ethics station) Syllabus \200 Demographic and social factors UK demography \200 Social in \202 uences on ageing Clinical aspects of ageing \200 The ageing process \200 Disease prevention \200 Featu res of atypical presentation of disease \200 Management of common conditions \200 Domic iliary care for the disabled \200 Legal and ethical considerations \200 Terminal care \200 Administrative aspects Knowledge of social services \200 Special geriatric services and facilities such as day c enters, nursing homes, etc. Financial considerations \200 Audit Further reading Royal College of Physicians of London online : M www.rcplondon.ac.uk/educat ion/examinations . This page intentionally left blank 51 Chapter 3 Clinical assessment of older people Consultation skills 52 Multiple pathology and etiology 54 Taking a history 56 Other sources of information 58 Problem lists 60 General physical examination 62 HOW TO Assess gai t in an older person 63 Investigations 66 Common blood test abnormalities 68 Comprehensive geriatric assessment 70 52 CHAPTER 3 Clinical assessment of older people Consultation skills There are certain skills that are key to any consultation, but some are more important with an older patient. Arranging an appointment \200 For older patients, attending hospital may be more of a phy sical and emotional challenge, for which there is a need to feel well. Patients often decid e not to attend clinic appointments because they feel ill \200 Hospital transportation is often used. Morning appointments usually require a patient to be ready by 8:30am \200\224 daunting for someone who takes time to get going in the morning. Offer late morning or aft ernoon appointments, using early slots for patients who travel independently When informing the patient about the appointment, make sure that instructions are clear. Pa tients with dementia should probably have appointments sent to carers who would ideally att end with them; visually impaired patients may need a large print letter or a telephone call \200 Remind the patient to bring both medication and prescription lists to their appoint ment. Muddled medications may indicate self-medication problems. Comparison of drugs and li st helps to assess concordance Establish who has requested the consultation \200\224 eg memory clinic appointments are often in response to family concerns, and the patient may not attend as th ey do not perceive or wish to face the problem \200 DH settings for consultation can be m ore relaxed, allowing the patient to recover over lunch before facing the trip home again Are hospital attendances really necessary? Discuss with the GP, offering to discharge the patient to his/her care, but supported by open telephone access f or advice and a hospital review on request If all else fails, DVs may be useful Rapport \200 Good rapport with the patient makes the interview easier, more productive and more enjoyable Smart dress increases patient con \201 dence, especially in older patients \200 Always i ntroduce yourself \200\224 shake hands if it seems appropriate, and address formally (Mr/Mrs/Miss) unless invited to do otherwise Be friendly but not patronizing or over familiar. Informal chat can break the ice, and show that you have time for and interest in the person \200 Older patients deserve and expect respect from (inevitably) younger doctors, but often have more respect for the medical pro fession \200 Patients are likely to have great faith in a trusted GP than in a young juni or met for the \201 rst time. When asked what is wrong, they may quote the GP diagnosis ( \200\230Dr Brown said I had a stroke \200\231) rather than offering their experiences. Emp hasize that you work as part of a team ( \200\230Your doctor has asked for our opinion, so we need to go over things again. I will let them know what I think. \200\231). After a hosp ital admission, explain changes to prescriptions and that you will inform the GP \200 Ack nowledge and apologize for waiting times and uncomfortable conditions (eg during an emergen cy admission) \200\224 it may not be your fault, but apologizing may defuse frustrations t hat hamper the consultation CONSULTATION SKILLS 53 Environment \200 Older patients are more likely to feel helpless and vulnerable in hospital if only partially clothed and on a couch. Interviewing a fully dressed patient sit ting in a chair gives more dignity and respect \200 Good light, quiet, and no interruptio ns will minimize problems from visual and hearing impairment Giving advice \200 Advice is taken more often if rapport has been good during the intervi ew. Appearing knowledgeable and professional increases the chance of agreement to investiga tions and medication changes. For example, some patients refuse to take aspirin, having bee n told years ago by a trusted doctor \200\230never to take aspirin again \200\231 because of an ulcer. Take time to explain that risks and bene \201 ts change with evolving disease and as new therapies develop. Gain understanding and agreement (see b \200\230HOW TO Discuss warfarin for AF \200\231, p.280) \200 Multiple conditions require multiple inve stigations and medications. For example, following a TIA the patient may be well, yet tests can include bloods, ECG, chest radiograph (CXR), brain scan and carotid Doppler, and sever al drugs are often prescribed. Take time to explain the rationale for each, thereby increas ing concordance Write a list of planned investigations and medication changes along with their justi \201 cation. Give the list to the patient. This takes time, but increases the likelihood that advice will be followed Offer to repeat your advice to family members (who may be sitting in the waiting room) or t o telephone someone who is at home. A frail spouse may not be able to attend outpatients, o r a busy daughter may not have time to attend, yet both may be vital to the delivery of eff ective ongoing care \200\224 eg administering medications or organizing appointment diarie s It can sometimes be helpful to send a copy of your GP letter to the patient but providing a second letter with key messages in \200\230lay \200\231 language t o the patient is even better 54 CHAPTER 3 Clinical assessment of older people Multiple pathology and etiology Most diseases become more common in an older population. So me con- ditions such as osteoarthritis are present in the majority (radiographi- cally 70 % of over 70s). By the age of 80, it is very likely that an individual will have at least on e disease. Many will have more than that ( multiple pathology ). As increasing numbers of m edications are advocated in the practice of evidence-based medicine, so polypharmacy and ad verse effects become more common too. Chronic stable conditions The patient may have adapted to the limitations imposed by the di sease (eg not walking as far or as fast because of osteoarthritis knees; reading large prin t books because of failing vision) or medicated to aid symptom control (eg analgesia in art hritis). However, background multiple patholo- gies should be noted for two main reasons: \200 Cumulative chronic disease will cause decline in physiological reserve \200 The old er patient with multiple stable diseases has less resilience to physiological challenge tha n a \201 t young person; a smaller insult is needed to cause illness Non-speci \201 c presentations re \202 ect the complexity of the pathology \200\224 back ground problems interacting with new (perhaps seemingly minor) insults to cause acute decli ne without obvious cause \200 Many patients adapt to impairments, particularly if the fun ctional decline is gradual \200 Assessment and intervention remains helpful, eg failing vision is often accepted as a part of ageing, yet is often amenable to treatment Acute presentations There are several aspects to consider: \200 What is the acute precipi tant? This may be minor, eg medication changes, in \202 uenza, constipation What are the underlying pathologies making the patient more susceptible to the acute precipitant? Note that one acute pathology can lead to another in a vulnerable patient \200\224 eg a be d-bound patient with pneumonia is at high risk for thromboembolic disease So, for any single presentation there are likely to be multiple aetiolo- gies which need to be unraveled. This can be dif \201 cult, but applying a structured logical approach assis ts the process: \200 Use a problem list to help structure the approach (see b \200\230Pr oblem lists \200\231, p.60) Allow time for the acute event to settle, physical and psychological adjustments to occur (much slower than in a younger person), stamina and con \201 dence to build up, care arrangements to be put in place, etc. \200 Involve a multidisciplinary te am to take a holistic look at the patient and 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