‘Water, water everywhere’; dehydration in the older population

Janet Gordon & Marie Henson both work for Birmingham Community Healthcare NHS Foundation Trust. Janet Gordon is a dietitian working in Nutrition Support and is team leader for the adult Nutrition Support Team which is part of Birmingham Community Nutrition. At the time of the study Marie Henson was a Community Nurse team leader in the Kings Heath area of Birmingham, which is where the study took place. This study was presented as a poster at BAPEN Conference 2016 and was published here.

The prevalence of dehydration in older people in the UK has not been widely studied. The UK DRIE Study found 20% of residents in UK long term care were dehydrated. The prevalence in those living at home has not been determined. Dehydration in older people is linked to associated morbidities such as increased falls, confusion, and infections and is a frequent cause of hospitalisation. Clear signs of early dehydration in older people are yet to be determined, but there is a need to identify those at risk of dehydration and intervene early. Systems for recognising those with inadequate fluid intakes, and helping them to drink more, are already in place in many UK hospitals where a red jug scheme identifies those requiring assistance to drink.

Using a frailty index in the Emergency Department

Dr Audrey-Anne Brousseau is the first fellow in geriatric emergency medicine in Canada. She was recently appointed as assistant professor at the Université de Sherbrooke in Quebec. Her work focuses on developing best practices for older adults in the emergency department.

EDs are often the safety net of the health care system where the mission is to (rapidly) evaluate, intervene and organize transitions of care. With the aging of the population and the growing presence of older adults in EDs, this mission represents a significant challenge because older adults are complex on multiple levels.

How do we determine whether a patient is fit to go back home — or not?  Needs admission —  or not? Would benefit from rehabilitation, additional community services, further assessment — or not?  A comprehensive geriatric assessment will provide this answer, but is rarely readily available in most EDs. Moreover, human and material resources are often limited in public health care system preventing all older adults ED patients to get a geriatric assessment and appropriate interventions.

Blue Ribbon Patient: Do Not Transfer

Rick Strang RN is Emergency Care Improvement Lead at Isle of Wight NHS Trust in England. When not involved in all types of emergency care Rick is usually finding innovative ways to avoid household chores.

Most of us across acute care have been involved in late night bed pressures that call for that dreaded decision to need to move some patients around between wards. Typically we see the only beds available to be surgical ones whilst the demand is for acute medical beds. Moving acute medical patients directly to these outlying beds from the emergency department (ED) may present too much of a risk. Lower acuity patients from acute wards are therefore often sought out to be transferred into these surgical beds thus making way for the more acute ED demand. End of Life (EoL) patients seem particularly at risk of being moved, which can be very distressing for families, friends, the patient and the care teams.

‘We don’t need no education…’ Teaching about delirium in medical schools

Dr Claire Copeland is a Consultant Physician in Care of the Elderly and Stroke Medicine at Forth Valley Royal Hospital. Her paper Development of an international undergraduate curriculum for delirium using a modified Delphi process has recently been published in Age and Ageing. She tweets at @Sparklystar55

Back in 2015 a workshop at the European Delirium Association (EDA) conference was held to bring together a group of delirium experts. Its purpose? To develop a consensus agreement on a delirium curriculum for medical undergraduates.

Most of you reading this I’m sure will be familiar with delirium. It’s technically been around for centuries. However there are many working in healthcare who still do not know about it. Or if they do, they refer to it by every other name except delirium.

Depression among older people living in care homes – a call for good practice examples

Caroline Cooke is Policy Manager at British Geriatrics Society. Caroline is currently supporting a joint project being carried out by BGS and the Old Age Faculty at the Royal College of Psychiatry. Here she explains the aim of the project and how you can help to make it a success. 

In the UK 405,000 older people (65+) currently live in care homes. Older people living in care homes have complex health needs and most residents have multiple long-term conditions, significant disability and frailty which affect both their physical and mental health. Dementia affects the majority of residents in care homes to some degree and depression is common. Integrated provision is required to meet the needs of care home residents who require co-ordinated input from generalists and specialists in multiple disciplines, and partnerships are essential to integration. 

Elvis is alive and based in Malta

Dr Simon Conroy is a geriatrician at University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal. 

Have you ever been to Malta? It’s a beautiful country with a warm Mediterranean climate and an enthusiastic team of clinicians engaged in improving the care of frail older people.

Along with Professor Tash Masud from Nottingham, I was privileged to be invited to speak at their inaugural geriatric medicine conference in May 2015.

The Power of Language

Philly Hare leads the Joseph Rowntree Foundation’s major research and demonstration programme Dementia without Walls, which supports the collective voice of people with dementia through a growing national network of influencing groups. Philly has worked in the NHS, in local authorities and in the third sector, and holds an MSc in Applied Social Studies from the University of Oxford. She is currently a member of the Prime Minister’s Dementia Challenge Champions Group and tweets from @philly_hare

“Words are very powerful – they can build you up or put you down. When you are speaking about dementia remember this.”

This message comes from Agnes Houston, a former practice manager who is now living with dementia and is Vice-Chair of the European Working Group of People with Dementia. It is endorsed by many other people with dementia and their groups, as well as by key research such as the World Alzheimer Report 2012: Overcoming the stigma of dementia.

The use of negative and sensationalist language and images in describing dementia is still widespread. ‘Tsunami’, ‘time bomb’, and ‘crisis’, are common in media headlines, and military terminology, such as ‘onslaught’ and ‘battle’, are often used, even by dementia advocates and charities. Individuals are described as dementia ‘victims’, ‘patients’, ‘sufferers’ or even ‘cases’; as ‘dementing’, ‘fading away’ or in a ‘living death’; and as a ‘burden’ to family and society. Images of helpless people hiding their heads in their hands or cowering in a corner frequently accompany media articles, web pages or reports.

Yet this kind of representation is known to be harmful – it reinforces negative attitudes, bringing fear of old age to all of us, and has a very direct impact on people with dementia themselves through internalisation. This causes denial and reluctance to seek help – which leads to later diagnosis and poorer outcomes, social exclusion and isolation… and can result in hopelessness, frustration, poor self-esteem and depression. Dehumanising the individual can also lead to poor care, and to lack of support for carer and family.

At recent events organised by the UK wide DEEP network, people with dementia called for words that are more accurate, balanced and respectful. They also identified some ‘curl up and die words’ including ‘demented’, ‘sufferer’, ‘senile’ and ‘living death’. These words, that are negatively attached to the person rather than the condition, make people physically flinch when they hear them and create inaccurate stereotypes.

This is not a question of nit-picky semantics or political correctness. In her recent blog, former young carer Beth Britton points out: “If people with dementia didn’t find words like ‘sufferer’ or ‘burden’ offensive this wouldn’t be an issue, but many – not all – clearly do, and this is an incredibly easy change we can all make in how we write and talk about dementia… Our use of language is one really quick and easy way to help make a positive contribution.”

Medics have a very specific role here. They may particularly wish to reassess their use of the term ‘dementia patient’ or, worse, ‘dementia case’. In a health setting the former at least may, arguably, be appropriate, but if used generically to refer to all people who are living with dementia, these words trap them into a passive, medically-defined box which ignores their many other roles. If a doctor tells a person at diagnosis that they are ‘suffering’ from dementia, that sends an instant message of despair. Think how different is the message conveyed in the words “You have dementia, but it is possible to live well with it.”

DEEP recognises that it is going to take collective action to fundamentally change the choice of words that are used to describe dementia and its day to day experiences. Through the national Dementia Action Alliance, they have launched a Call to Action, asking others to join them to address the use of language associated with dementia, and commit to the three ‘C’s:

• Check words and descriptions used in your printed materials against the DEEP Guide
  
• Change any words and descriptions that people with dementia have identified as ones to avoid
• Challenge words which you recognise as our ‘curl up and die’ words whenever you see or hear them – in newspapers, on TV, on websites and in conferences and meetings. And pass on the challenge to others to take forward in their own settings.

This week is Dementia Awareness Week. We hope that you and your organisation will consider signing up to the ‘Dementia Words Matter’ Call to Action, and most importantly of all, embedding the principles requested of signatories.

Follow the conversation around Dementia Awareness Week on Twitter: #dementiaawarenessweek / #DAW2015

Better care for older people

Niall Dickson is Chief Executive of the General Medical Council, sets out how the professional regulator is responding to the needs of doctors when treating older patients. Follow the GMC at @gmcuk

Healthcare is very largely a business for the treatment and care of older people. This is a reality to which not many of us have really woken up.

While there is much talk of long-term conditions and co-morbidities, much of health service delivery and the public’s perception of what an effective healthcare system should be doing remains focused on heroic interventions, lives saved, and patients cured.

We bear some responsibility for this, as the regulator with responsibility for setting educational and professional standards. We have certainly overseen practice which has struggled to adapt to the different needs of a different generation of older people. All too often older people fall through the cracks of organisational and professional silos. We will always need specialist care but we also need to reinvent the generalist physician with the status and authority to co-ordinate care and treatment, and ensure that sufficient attention is given to patients’ mental health and well-being alongside their physical health.

What actually is frailty?

Chris Beech is a Nurse Consultant at NHS Forth Valley, Falkirk. She is member of the BGS Specialist Nurse and Allied Health Professionals Special Interest Group.

Frailty is all around us, especially when you take a quick peek at the recent literature on working with older people. It is important that nurses working with older people in all care settings are aware of what frailty is, what the implications are if someone is identified as living with frailty and what, if anything, can be done about it.

We all have a picture in our head of a frail person, the problem is that there is a big chance that this picture is a different image to the one the person sitting next to you is thinking of. It is important therefore to have the ability to put an objective view point into play.

The Future Hospital Commission: An opportunity to develop best practice around multiple morbidity?

Amit Arora is a consultant physician in care of older people and Chair of the England Council of the BGS.

The Future Hospital Commission report from the RCP has made many recommendations. It recognizes that most patients who attend hospitals do not just have a single medical condition. It highlights the need for some specialists but also more generalists. It also specifically mentions the benefits of Comprehensive Geriatric Assessment  and the need for continued care in the community.