Dr Simon Conroy is Head of Geriatric Medicine, University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal.
Urgent care of frail older people is rapidly becoming the core business of acute hospitals; it is often described as a ‘wicked problem’. This year has been one of the most challenging periods for staff and patients in the NHS in many years. The debrief is on-going, but candidate theories include ‘too many old people’ (sic), lack of primary care, poor ED staffing, and reduced outflow relating to social care cuts. The truth is likely to be a combination of all of these factors, and many others. An important output from the post-mortem is to determine what we can do about it in the future?
Undoubtedly one of the drivers is the ageing demographic, which does mean that hospitals need to expect more older people coming though their doors, many of whom will be frail. Whilst there have been significant improvements over the last few years in the acute care response to older people, there is still a long way to go. There have also been some significant misunderstandings about what is required for older people accessing urgent care. It is not just geriatricians! Rather it is the technology to which geriatricians can usefully contribute to or even coordinate – Comprehensive Geriatric Assessment (CGA). But CGA is not an exclusive club. Every physician involved in managing frail older people should be able to play a useful part in CGA. It’s just that geriatricians are specifically trained to do it, although increasingly other physicians are developing their skills in this area which is key for future-proofing urgent care. Yet we see significant variation in the interpretation of what constitutes CGA. I have taken the liberty here of illustrating some of the key concepts.
Comprehensive Geriatric Assessment is defined as ‘a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up’1.
‘Multidimensional’ – this highlights the importance of taking a holistic overview. In this cohort of patients, it is not sufficient to focus simply on one domain or the main problem of the patient. For example, an approach to chest pain that simply states that the troponin is negative and that a coronary angiogram is not required, but fails to test for and identify the cognitive impairment that led to the individual not taking analgesia for arthritis (the true cause of the pain), is doomed to fail. Equally, a purely functional approach to falls that seeks to provide only rehabilitation and not identify the underlying reasons for a fall (of which there are many, including serious disorders such as aortic stenosis) will not succeed. It is the integrated assessment of all of the domains of CGA that allows an accurate problem list to be generated.
‘Interdisciplinary diagnostic process’ – in a mature CGA service, the hierarchy should be flattened such that all staff should feel empowered to constructively challenge within and without of their particular area of expertise. For example, the option to admit for rehabilitation by a therapist concerned about falls at home might be challenged by pointing out that admission often increases the risk of falls, and that home-based rehabilitation may offer substantial benefits2. Equally therapists will bring useful information to the diagnostic process – for example, the patient who is ‘fit to return home’ that develops new dyspnoea on mobilisation might prompt a re-evaluation of respiratory function and identify potentially new diagnoses such as pulmonary embolus. That this assessment is a process and not a discrete event is also key; the process should continue in an iterative manner over the course of the acute stay and the diagnostic elements should be sensitive to deviations from the anticipated pathway. For example, if the initial treatment plan for an individual with a fall and hip pain but no fracture was to ‘increase analgesia, reduce anti-hypertensives and aim to return home once able to walk 5 metres unaided using a frame’, yet after 14 hours, pain remains a problem, the diagnosis may need to be re-visited and further imaging considered.
‘Frail older people’ – targeting patients who will benefit most from CGA is important. CGA requires time and staffing resource, both of which may be in short supply in a hospital e.g. busy ED environment. The use of accurate and easy to use case-finding or screening tools should be a critical first step. A wide-range of screening tools are available, but none are perfect and none have an Area Under the Curve of greater than 0.7 – so the current tools alone are insufficient to identify the population of interest, although they can be used to reliably screen out those that do not require CGA as their specificity (and hence negative predictive value) tends to be good)3-5. The most common targeting criteria are a combination of age, physical disease, geriatric syndromes, impairment of functional ability and social problems6.
‘Coordinated and integrated plan for treatment’ – reinforces that the team caring for an individual need to know and respect each other’s roles and know and understand what each is doing, and how the medical treatment will impact upon the rehabilitation goals and vice versa. For example, whilst therapists would not need to know the detailed intricacies of the management of acute heart failure, it is important that they know that intravenous diuretics might be required for the first few days that will result in polyuria, and then be able to incorporate continence needs into the rehabilitation plan. Equally, doctors will need to appreciate that just because a patient has grade 5 power on the MRC grading system, that does not necessarily translate into useful functional ability.
‘Follow-up’ – as many older people will have multiple long–term conditions, they will usually require some form of on-going care and support. How this is delivered will vary from country to country, but there is little point in providing excellent acute care if conditions are only going to be allowed to decline because of a lack of on-going support. For example, a two-week admission during which Parkinson’s disease medications are carefully titrated and optimised in conjunction with the multidisciplinary rehabilitation process can easily be reversed if there is no on-going titration of L-Dopa once the patient returns home.
So whilst integrating standard medical diagnostic evaluation, CGA emphasises problem solving, team working and a patient centred approach.
It is incumbent upon geriatric services, which by definition should be specialised in the care of frail older people to lead the way in ensuring that they lead and evidence great clinical care and support other services through education and training in delivering CGA to all frail older people.
The Acute Frailty Network seeks to bring together centres from across the country to share best practice in developing urgent care solutions for frail older people. The focus is on the first 72 hours in acute hospitals, whilst maintaining strong relationships with, and awareness of, the broader system. If you want to know more see the website (above), contact firstname.lastname@example.org or follow us on Twitter: @acutefrailty.
- Rubenstein LZ, Rubenstein LV. Multidimensional assessment of elderly patients. Adv Intern Med 1991a;36:81-108.
- Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, et al. Early discharge hospital at home. Cochrane Database of Systematic Reviews Issue 1, 2009.
- Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills T, Rothman RE, et al. Risk Factors and Screening Instruments to Predict Adverse Outcomes for Undifferentiated Older Emergency Department Patients: A Systematic Review and Meta-analysis. ACADEMIC EMERGENCY MEDICINE 2015;22(1).
- Salvi F, Belluigi A, Cherubini A. Predictive Validity of Different Modified Versions of the Identification of Seniors At Risk. Journal of the American Geriatrics Society 2013;61(3):462-64.
- Di Bari M, Salvi F, Roberts AT, Balzi D, Lorenzetti B, Morichi V, et al. Prognostic stratification of elderly patients in the emergency department: a comparison between the “Identification of Seniors at Risk” and the “Silver Code”. Journals of Gerontology Series A-Biological Sciences & Medical Sciences 2012;67(5):544-50.
- Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients. British medical bulletin 2004;71:45-59.