Take time to talk! The importance of an informant history

Adam Dyer is a Final Year Medical Student in Trinity College Dublin. Dr. Sean Kennelly (MB PhD FRCPI) is a Consultant Physician in Geriatric and Stroke Medicine in Tallaght Hospital (Dublin, Ireland) and a Clinical Senior Lecturer in Medical Gerontology at Trinity College Dublin (TCD). The following work was presented as a platform presentation at the 64th Irish Gerontological Society Meeting in Killarney, Ireland (October, 2016).

Imagine you’re seeing a consult or you’re on a post-take ward round. How often do we examine a patient and identify cognitive deficits, see that the CT brain scan report and the MMSE score are readily on hand, but then ask staff about the patient’s premorbid cognition and function and are met with blank expressions?

An important factor which complicates the presentation of older people to acute hospitals is the presence of impaired cognitive status (either in the form of dementia, delirium or both). Continue reading

Identifying frailty in hospital

Professor Kenneth Rockwood has published more than 300 peer-reviewed scientific publications and seven books, including the seventh edition of the Brocklehurst’s Textbook of Geriatric Medicine & Gerontology. He is the Kathryn Allen Weldon Professor of Alzheimer research at Dalhousie University, and a staff internist and geriatrician at the Capital District Health Authority in Halifax in Canada. 

Last autumn, at a meeting of the Acute Frailty Network in London, I sat in on a discussion group about identifying frailty in acutely ill older people who come to hospital. Although some participants noted objections about such screening in some quarters, with this audience, there was no need to discuss why it makes sense to identify people at greater risk than their age peers of being harmed by usual hospital care.

Before moving on, let’s consider for a moment why anyone might object to screening for baseline frailty in patients who presented to A&E.  For those who see it as reasonable to screen for frailty it almost seems that those who don’t believe that it somehow encourages frail patients unnecessarily to seek hospital care.  Continue reading

Time to Up our Game (TUG) in the management of falls!

Debra Eagles is a Resident in Emergency Medicine at The Ottawa Hospital in Canada. Here she discusses her recent Age & Ageing paper.

970Your medical student reviews a case with you.  It is a 78 year old woman who presents with right knee pain subsequent to a recent fall.  The student has taken a comprehensive falls history and physical examination.  After reviewing the knee x-ray, the student summarizes the case by stating the patient suffered a mechanical fall, luckily without evidence of fracture and can be discharged home.  But wait, you say, can she safely mobilize?  The medical student smiles triumphantly, yes, she was able to use her walker to ambulate a short distance.  Excellent, you say, she can be discharged home.  But you wonder, is there anything further you can do to determine what her risk of negative outcomes associated with falling is. Continue reading

Choosing the right care for people from nursing homes: Hobson’s Choice, Morton’s Fork or Buridan’s Ass?

Glenn Arendts is Associate Professor in Emergency Medicine at the University of Western Australia and Chair of the Geriatric Special Interest Group of the Australasian College for Emergency Medicine. He writes about his Age & Age paper. 

donkeyHobson’s Choice: A choice where there is really only one option
Morton’s fork: A choice between two equally unpleasant alternatives
Buridan’s Ass: A hungry donkey placed equal distance from two identical bales of hay cannot use reason to choose between them, and so dies of hunger

Take a straw poll of hospital emergency department (ED) staff and you will find majority support for the following statement: “too many people from nursing homes are sent to the ED”. That your poll results may say something about the views of some hospital staff toward nursing home (NH) residents is immaterial. Acute medical care of dependent people with life limiting illness is an area of legitimate concern, and the prevailing orthodoxy is that ED is a less than ideal place to deliver it. For decades, health services have invested in a variety of programs and interventions to reduce the transfer from NH to ED. Continue reading

Paramedics; Frailty detection and admission avoidance

Dr Amy Heskett works as a Speciality Doctor within the West Kent Urgent Care Home Treatment Service. This team aims to prevent hospital admissions by working alongside GPs, nurses, carers and paramedics to provide a holistic management plan. She writes a blog about her experiences on her blog communitydoctoramy.wordpress.com and can be found on twitter @mrsapea

paramedics-photoThe West Kent Home Treatment Service provides home-based medical treatments to avoid hospital admissions when appropriate. Referrals come from GPs, Community Nurses and Paramedics; but more importantly our team widens as soon as we start to work with patients, their family and carers.

A day of referrals began with a call from a Paramedic who had attended V after she had fallen in her bedroom, but luckily sustained no injury. This was on a background of dementia and the need for daily support from her son to assist with meals, prompt medications and support trips made outside the home. V’s only other medical history was that of hypertension and one fall a year ago. V was normally able to get herself to the toilet and used a stick to mobilise slowly indoors; while carers attended once a day to provide personal care. Continue reading

A Bespoke Blue Light Response to Frail Older Fallers: Makes Complete Sense – But Does It Work?

Spencer Winch is a specialist paramedic in urgent care and a trainee advanced clinical practitioner in emergency care. He has a special interest in falls and care of the frail older patient and his time is currently split between the ambulance service, the local emergency department and a masters degree in advanced clinical practice. @spencerlwinch

Anna Puddy, Kate Ellis, Gill Carlill, Josie Caffrey, Claire Wiggett and Moyra Pugh are all advanced hospital based occupational therapists specialising in emergency, acute and elderly care. @TheRealAnnaPud, @OTMoyra, @CaffreyJosie

South Western Ambulance VX09FYPWith falls in patients over the age of 65 making up 8.5% of the emergency workload locally, paramedics and the ambulance service have found themselves in a prime position to assess, treat and discharge this cohort of patients pre-hospitally. This upholds Keogh’s vision that care and treatment should be delivered closer to home without the need for hospital, and is being achieved by ambulance crews on a daily basis as highlighted in a consultant paramedic colleague’s (NWAmb_Duncan – link to BGS blog) recent blog. Higher education and degree based programmes for the paramedic profession now encourage more thorough assessment of injury and illness and thoughts around causative factors of falls, length of lie and potential for acute kidney injury. Those that are discharged on scene are then flagged to the community falls prevention teams for mobility, functionality and care assessment provided by nurse and therapists. With increasing demand on all NHS healthcare agencies, these assessments are not instantaneous and literature would suggest that those who have fallen, are likely to fall again within 24 hours without immediate intervention. Continue reading

Do pharmacists have a role in reducing emergency admissions?

Alyson Huntley is a Research Fellow at the University of Bristol’s Centre of Academic Primary Care. She has recently published a systematic review of pharmacist-led interventions to reduce unplanned admissions for older people.EmergencyAvoidance

The expansion of the pharmacist’s role as a contributor to patient’s health has been championed over the last couple of decades.  In addition to their traditional role, pharmacists contribute to the care of people with long term conditions by carrying out medication reviews, promoting healthy lifestyles, and supporting self-care.

The older people become, the more medications they are likely to be taking (both prescribed drugs and self-medication) leading to an increased risk of adverse reactions, interaction between drugs and poor adherence. Continue reading

Only a minority of stroke victims are being seen by doctors within the recommended timeframe

Despite the recent FAST awareness campaign, just 8% of high-risk patients surveyed attended clinic within 24 hours of symptom-onsetshutterstock_115549357

In a study, published in Age and Ageing, of over 270 patients newly diagnosed with minor strokes or transient ischaemic attack (TIA), only a minority sought medical help within the timeframe recommended by the Royal College of Physicians. This is despite the high profile FAST campaign, which was taking place at the time that the study was conducted. Continue reading

The traditional Multidisciplinary Meeting: Still the Gold Standard or Losing its Lustre?

Prof David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London. He is President Elect of the British Geriatrics Society.team

Since leaving my role as national clinical director at the end of last year, I have found myself seconded for day a week to the NHS Emergency Care Support Team and to the Kings Fund alongside my clinical day job. In this new capacity, I have gone into a number of busy acute hospitals or health economies to review care pathways for older people. It has been fascinating to meet so many hard-working colleagues and to see the similarities and differences in how older people’s services are delivered. A key focus in these visits is ensuring that – whatever the issues may be with external delays waiting for “step down” community services or social care – we do, as hospital teams whatever we can internally to minimise delays in our own care pathways. Continue reading

Unlocking gridlock in hospitals

Published in the June issue of the BGS Newsletter, we look at some startling results achieved through a couple of simple mechanisms as reported in to reports published by The Health Foundation.shutterstock_7751779 (2)

The reports showcase programmes piloted in Sheffield Teaching Hospitals NHS Trust and South Warwickshire NHS Foundation Trust

The Flow Cost Quality improvement programme was set up to explore the relationship between patient flow, costs and outcomes by examining patient flow through the emergency care pathway and developing ways in which capacity can be better matched to demand. Continue reading