Drug burden in older people approaching end of life

Dr. Denis Curtin is a specialist registrar in Geriatric Medicine in Cork University Hospital, Ireland. His paper Drug consumption and futile medication prescribing in the last year of life: an observational study was recently published the Age and Ageing journal.

The vast majority of older adults are admitted to hospital in their last year of life. For many of these people, hospitalizations are frequent and prolonged.

We reviewed the medical records of 410 older adults who were admitted to our hospital in the year prior to death. The median number of days spent in hospital was 32. While in hospital, patients consumed an average of 24 different medications. One-in-six patients consumed 35 or more individual medications. When discharged home from hospital, patients were prescribed an average of 2 unnecessary or inappropriate medications.

New institutionalisation following an acute hospital admission

Jenni Harrison is a Clinical Research Fellow in Geriatric Medicine funded by the Alzheimer Scotland Dementia Research Centre and the Centre for Cognitive Ageing and Cognitive Epidemiology at the University of Edinburgh. Here she discusses her recently published paper in Age and Ageing. She tweets @JenniKHarrison.

New care home admission (also termed new institutionalisation) following an acute hospital admission occurs commonly in the UK. However, national policy documents argue the practice should generally be avoided. Furthermore it is known to be an area of six-fold variation in practice

However, research to understand new care home admission has been limited and little is known about those who experience this extremely important transition. Our interdisciplinary research study evaluated one hundred people admitted from home to a single hospital who were newly admitted to institutional care at the time of discharge.

Benchmarking Older People’s Care in Acute Settings

Lindsey Ashley is the Communications Manager for the NHS Benchmarking Network and is a strong advocate for benchmarking our NHS services.

It is recognised in the NHS and the media that older people are a major service user cohort for health and social care services, both in hospital (the acute setting) and in the community. It is well described that the population is ageing, as people are living longer, and as a result, there are more older people as a proportion of the overall population. Whilst overall life expectancy is rising, there are also significant inequalities across the country in terms of life expectancy.

What happens to patients with abnormal cognition picked up by in-hospital dementia screening – Results from GP questionnaires

Sarah Pendlebury is Associate Professor in the NIHR Oxford Biomedical Research Centre and the Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford and Consultant Physician and Clinical Lead for Dementia and Delirium at the Oxford University Hospitals NHS Foundation Trust. Research and audit interests include cognitive impairment associated with cerebrovascular disease and the interactions between vascular disease, neurodegeneration, co-morbidity and delirium and in the use of short pragmatic cognitive tests in patients with stroke and acute illness. Here she reports on an audit of the actions undertaken by GPs in response to letters informing them of in-hospital identification of cognitive impairment in their patient, which will be presented at the upcoming BGS Spring Meeting in Liverpool.

Dementia and delirium are prevalent in older patients with unplanned admission to hospital and are associated with death and increased dependency, but many confused patients do not have a dementia diagnosis prior to admission. Routine dementia screening for older people (>75 years) hospitalised as an emergency is mandatory in England with onward referral for specialist assessment in those identified as at-risk (dementia CQUIN).

Keeping or increasing function in frail older people after a hospital admission

Hugh Senior is an epidemiologist at the University of Queensland, Australia, and Matthew Parsons is a gerontologist at the University of Auckland, New Zealand. Their paper Promoting independence in frail older people: a randomised controlled trial of a restorative care service in New Zealand has recently been published in Age and Ageing journal.

Many older people will experience a decline in their level of physical function during the period of developing an acute illness that requires hospitalisation and discharge from hospital. A third will be discharged from hospital having not recovered the level of function that they had prior to becoming unwell. The loss of physical function includes losses in key areas required for independent living such as dressing, bathing, getting out of bed or a chair, toileting, eating and walking across a room. As such, this has an impact on the older person’s ability to live independently and safely at home, and increases both the likelihood that the older person will need to reside at a residential care facility and the likelihood of death. A possible intervention to help older people with hospital associated disability is to provide restorative rehabilitation after discharge from hospital, for those who may benefit, with an aim to return to a level of independence where they can return to their own home.

Overnight Hospital Discharges

Chris Roseveare is a Consultant Physician in Acute Medicine at University Hospitals Southamption, and is Editor of Acute Medicine Journal. He tweets at @CRoseveare. Here he discusses a recent report from Sky News: Hundreds Discharged From Hospitals Every Night

news.sky.com

It’s 2am on a Sunday in a hospital in the UK, and the duty consultant physician has just been called in. It has been a difficult weekend for the medical team: the Acute Medical Unit (AMU) was already full on Saturday morning following a busy Friday night. Compounding this, the locum agency were unable to fill the SHO vacancy on Saturday and the foundation year 1 called in sick for her night shift. Sunday had started with 15 medical patients waiting to be clerked in the Emergency Department (ED), and the medical team have struggled all day to clear the backlog. Ambulance trolleys are now queued in the corridor in the ED; there are ten patients who have waited more than four hours for a bed in the AMU, two of whom are approaching a twelve hour wait. Beds have been opened – and filled – in the managed care unit as well as the medical ambulatory care area. More than 20 patients have been ‘outlied’ into the surgical division during the course of the weekend, which has necessitated cancellation of a number of elective surgical admissions planned for surgery tomorrow. There no longer seems to be any room for manoeuvre.

In consultation with the on-call executive, the duty manager now has a plan: several patients have been identified across the hospital whose discharge is planned for Monday morning – perhaps if they could be discharged from hospital overnight this could help ease the pressure in the ED….? The medical consultant is on her way into the hospital. This will be a difficult discussion.

A recent report on Sky News suggested that ‘over 300,000 patients’ had been discharged from hospital overnight since 2012, including over 60,000 who were over 75.

Newsflash: Acute Care system fails an older patient, reflections from a relative

Ron Murphy is a software designer, he blogs at ronmurp.net

An older patient presenting acutely to A&E in an unwell and frail state can erroneously be assumed to be at their baseline pre-morbid state, with some additional new complaint like a “UTI” as an over-riding diagnosis. My active and mobile mother was reduced over a period of three months to a delirious crumpled wreck who didn’t know what day it was because of a persisting UTI that had not been dealt with. Her past medical history was complicated: stroke, heart attack, pacemaker, diverticulitis, arthritis, diabetes not well controlled, kidney function not right … you get the picture. But still, before the UTI she was sharp and active.

What follows is a brief account (you don’t want the detailed version) of what happened in A&E on three failed visits.

Streamlining admissions

Dr Sean Ninan is a Specialist Registrar in General (Internal) Medicine and Geriatric Medicine working in the Yorkshire deanery, UK.

When I was 20 I travelled round India, a wonderful beguiling country with some of the worst administration I have ever encountered, much of it unchanged from systems introduced during the Empire.

I have fond memories of the trip but there were many frustrating experiences too. Taking out money from the bank, for example, was particularly painful.

You enter, make your way to reception and explain that you would like to take out some money. They ask you to take a ticket, and you wait in the queue. After some time, patiently waiting you reach the front of the queue.

“Saving, deposit or withdrawal?”

“Admission prevention” and “care closer to home” for older people – between the sceptics and enthusiasts

Prof David Oliver is BGS President-Elect, is a Consultant Geriatrician at the Royal Berkshire Hospital, Visiting Professor of Medicine for Older People at City University London and a Kings Fund Visiting Fellow. He recently stood down from his role as National Clinical Director for Older People at the Department of Health.

This is my first blog since becoming President-Elect of the British Geriatrics Society. Alongside my day job as a busy coalface geriatrician, I have spent the best part of four years seconded to the Department of Health as a senior government advisor in the Civil Service. I resigned at the end of 2012 because I couldn’t reconcile my new role as a BGS officer with the role as National Clinical Director or (as the press would have it) “tsar”.

No longer bound by the Civil Service Code, I am free again to speak my mind. A particular issue I want to discuss here is the thorny subject of “admission prevention”, “admission avoidance”,  “care closer to home”,  “care outside hospital” – take your pick.

Inappropriate referrals

The medical student had come to join me in transient ischaemic attack (TIA) clinic. I had taught him about diagnosis, differential diagnosis, investigations and management. We had just seen an interesting patient with recurrent stereotyped symptoms of tingling down one sided, preceded by a funny feeling in her head and usually accompanied by clouding of consciousness and sleepiness afterwards. I explained to him why I thought these were complex partial seizures.

“It must be so frustrating doing a clinic where half the patients haven’t even had a TIA,” he said. He had previously sat in a respiratory clinic where many breathless patients had been referred who didn’t even have lung disease.