Why it gets harder to prevent falls when older people leave hospital

Chiara Naseri is a physiotherapist and is currently completing her PhD at Western Australia’s Curtin University School of Physiotherapy and Exercise Science. She has recently published a review in Age and Ageing entitled “Reducing falls in older adults recently discharged from hospital: A systematic review and meta-analysis.”

The paper reveals the complexity of the discharge process for older people and that more support is required than is currently widely recognised. Her team found that falls prevention strategies, known to reduce falls for older people in general, were not as effective for older people following hospital discharge.

Evidence has shown 30% of the population of older people who live in the community fall at least once per year, 10% of these falls result in a serious injury. Whereas 40% of the population of older people who have recently been discharged home from hospital fall within 6 months of discharge, most of these falls occur in the first month and 54% result in a serious injury, particularly hip fractures.

Delirium awareness is not just for hashtags, it’s for life

Dr Shibley Rahman is an academic physician interested mainly in dementia and frailty. He tweets at @dr_shibley

My most recent experience of delirium was truly terrifying, to the point that, as a care partner of a close relative with dementia experiencing delirium, I felt I needed counselling about this admission to a London teaching hospital.

I have now witnessed delirium ‘around the clock’ for half a month so far.

Delirium research is not taken as seriously as it should be.

Where for example is the research which explains the neural substrates of hypoactive and hyperactive delirium? How long do ‘sleep episodes’ last for? Is it a good idea to wake someone up while he is sleeping? Are there are any neuroprotective agents which prevent long term deterioration after delirium? How much of the delirium will the person experiencing it actually remember?

Ward rounds – are they safe and effective for patients and doctors?

Dr Tarun Solanki is a Consultant Physician and Geriatrician at Taunton and Somerset NHS Foundation Trust.

Geriatricians are, in many hospitals, now responsible for looking after more than 50% of medical in-patients and are frequently required to look after outliers on non-medical wards. A recent article in the BMJ suggests that doctors’ way of working would not be accepted by businesses making decisions with far less impact and suggests that the old concept of the ward round is broken and needs to change^[i].

Since we, as geriatricians are providing a substantial element of acute inpatient care, should we not be at the forefront of improving the ward round so that it is not only effective and safe for patients but also to ensure geriatricians do not suffer from undue work pressures and risk burn-out?

LOST: Sense of humour

Bridget Leach has been a nurse for over 30 years. She currently work in falls prevention but was also a ward nurse and ward sister for many years.

LOST: Sense of humour OWNER: NHS Reward for return: happier, healthy & retainable workforce.

The above may seem flippant but a simple google of the term ‘Do hospital managers have a sense of humour?’ returned a myriad of articles including academic research.

Some of the articles were what I would consider odd; for example; a member of hospital staff doing tricks with disappearing scarves while …”the surgeons began cutting away dead flesh …” to a ‘humour cart’ containing, amongst other things, ‘funny props’; I know plenty of hospital staff who, in certain circumstances, would consider a bedpan on the head and a proctoscope a funny prop so who knows?

Predicting who will be admitted to a care home from hospital?

Jenni Burton 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 the results of two linked systematic reviews of predictors of care home admission from hospital. She tweets @JenniKBurton.

Care home admission from hospital has long been recognised as an area of significant variation in practice (Oliver D et al. 2014. Making our health and care systems fit for an ageing population) and one which remains a strategic target to reduce across the UK. However, more than half of care home admissions each year in Scotland come directly from hospital settings. It is therefore important to explore the predictors of this life-changing transition to help inform prognostication, communication with individuals and their families, service planning and the extent to which we can intervene to prevent or modify this outcome. 

Catch a falling star

Dr Kawa Amin is a consultant Geriatrician, Consultant Lead for the Falls Service and Geriatrics Departmental Lead for Safety & Quality at Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT). He also represents the BGS on the advisory group for the National Audit of Inpatient Falls (NAIF). Deborah Watkins is a Physiotherapist and the Falls Lead at BHRUT.

Falls are a major cause of disability and mortality for older people in the UK and the problem is likely to increase with an ageing population.  The associated mortality and morbidity from a fall is high with individual consequences ranging from distress, pain, physical injury and loss of confidence to complete loss of independence which impacts on relatives and caregivers.  Usually nurses are the first discipline to attend to a patient following a fall.  

Dying with dementia – we need to measure more than the place of death

Katherine Sleeman is an NIHR Clinician Scientist and Honorary Consultant in Palliative Medicine at the Cicely Saunders Institute, King’s College London. In this blog she discusses her paper Predictors of emergency department attendance by people with dementia in their last year of life: Retrospective cohort study using linked clinical and administrative data. She tweets @kesleeman

Over the past decade there has been a strong policy focus in the UK and elsewhere on dying out of hospital as a marker of good quality of end of life care. We have previously shown that, for people with dementia, hospital deaths have fallen over this time period, possibly as a result of these policies.

However, it is increasingly recognised that the place of death is an imperfect proxy for the quality of end of life care, providing little more than a snap shot of where a person was in their last moments.

“Please remember I’m still a person!” A carer’s solution to help hospital staff provide person-centred and holistic care

Zoe Harris cared for her husband at home before his dementia reached a stage where she was unable to cope, and he spent his final months in a care home. As a result of that experience, Zoe developed a range of communication tools to ensure that carers were aware of his needs and preferences, and which have subsequently been adopted by over 1,000 care homes and home care agencies. Her latest project is Mycarematters, an online platform where people, or someone on their behalf, can upload information to help hospital staff treat the whole person and not just their medical condition. @ZoeHarrisCCUK @Mycarematters @Care_Charts_UK

When I look back, I think Geoff had been showing signs of dementia for at least eight years before his diagnosis, and it was only a matter of months after he was finally told that he had what was probably a mix of Alzheimer’s Disease and Lewy Bodies, that his condition took a turn for the worse. I had to admit defeat and he moved first to a dementia assessment ward and, three months later, to a care home for what turned out to be the final 13 months of his life.

We talk a lot about delirium after hip fracture, but what can we do about it?

Dr. Susan Freter is an Associate Professor of Medicine at Dalhousie University, and a staff geriatrician at the Nova Scotia Health Authority in Halifax, Canada.  She has a special interest in delirium prevention and management in orthopaedic patients.  

Geriatricians talk a lot about post-operative delirium.  It is common after surgeries, especially in people with a lot of risk factors (or we could say, especially in the presence of frailty), and even with recovery it makes for a bad experience.  The occurrence of hip fracture, which mostly befalls patients who are older and frail, demonstrates this routinely.  We know that taking extra care with at-risk patients can help to prevent delirium.  Taking extra care can manifest in different forms: educating the caregivers, paying attention to hydration (is the patient actually drinking the cup of water that is plonked down in front of them?), paying attention to constipation (preferably before a week has gone by), making sure hearing aids are in the ears, and using medication doses that are geared for frailty, rather than for strapping 20 year olds. But how can what we talk about be translated into what we do? Does the ‘doing’ actually work in practice?

Cognitive impairment, mortality and discharge from an acute hospital

Carole Fogg is a Senior Lecturer at the University of Portsmouth/Portsmouth Hospitals Trust, (UK). She is a PhD Fellow under the Wessex Collaboration for Leadership in Applied Healthcare and Research, exploring hospital care and outcomes for patients with cognitive impairment and dementia. Her paper “The relationship between cognitive impairment, mortality and discharge characteristics in a large cohort of older adults with unscheduled admissions to an acute hospital: a retrospective observational study” has recently been published in Age and Ageing. She tweets at @Carole_Fogg 

When older people with dementia are admitted to hospital, they are more likely to die or to stay in hospital longer than people without dementia. Many older people have cognitive impairment (CI) (problems with memory and thinking) which is a main feature of dementia, but have not yet been given a diagnosis, or may have CI due to other medical conditions. We investigated how common cognitive impairment is in older patients in hospital, and what the risks are for these patients of staying longer or dying in hospital.