A free open access series of podcasts for all healthcare professionals working with older adults. We are passionate about looking after older adults and believe it is important for all healthcare professionals to have the skills to look after older adults wherever they may present to the healthcare system.
To recall the evidence base and lack thereof around artificial feeding.
To recall the pros and cons of NG feeding
To understand the ethical and legal frameworks within which decisions should be made.
To recognise when the provision or withdrawal of CANH may pose an ethical or legal dilemma.
To positively engage families in conversation about the potential benefits, and harms, of CANH.
To consider when CANH may not be in a person’s best interest
CANH is a medical treatment and refers to all forms of tube feeding, examples include nasogastric tube, percutaneous endoscopic gastrostomy (PEG) and parenteral nutrition.
We will discuss
The common scenarios encountered around CANH in older adults, pros, cons and common myths
The evidence base, or lack thereof, around this from a research perspective
The legal and ethical framework for decision making, including some recent court cases and a summary of the BMA/RCP guidance.
During this episode we will not be discussing:
TPN (Total Parenteral Nutrition) which is nutrition via a large vein, usually used for non-functioning gut.
Hydration specifically: principles behind feeding decisions are similar but there are often more complexities with hydration and this really needs it’s own discussion [episode 1.8]
Risk feeding in any great detail: again, worthy of its own episode
We will be discussing primarily decisions around NG use, because much of the approach can be applied to decision making around PEG use as well. The major difference being, in simple terms, short term and long term use. We will discuss PEGs later in the episode but for the beginning, when we say NG, you can think about PEG at the same time and consider what the differences might be.
Scenarios in which artificial nutrition is often considered
Acute medical decompensation
NG: Often used in short term while fact finding e.g. PD
PEG: decision would ideally be made in advance
Deterioration in oral intake with reversible cause. Could include too drowsy to eat and drink.
to maintain nutritional intake
we’ll explore some evidence around this later
Prevention of loss of nutritional status
Reduction in risk of oropharyngeal aspiration
Facilitates aspiration free period for swallow rehabilitation
Delivery of medication: nod to PD
Bridging acute decompensation to support recovery of function
Risks associated with NG insertion
eg. pneumothorax, lung collapse
Practicalities e.g. multiple x-rays
Aspiration of feed
Refeeding (but this may happen with oral feeding too)
Implications for quality of life – tube feeding and absence of oral intake
Invasive / may worsen delirium
May require restraint to deliver safely (i.e. keep in place) e.g. mittens
Can distract from decisions around longer term feeding: may provide false hope
Myth 1: Feeding via NG (or PEG) removes risk of aspiration
Severe dysphagia: secretions still aspirated
Aspiration of feed through reflux / regurgitation
Myth 2: People can’t eat if they have an NG or PEG
Myth 3: Enteral feeding causes diarrhoea
Myth 4: NG = PEG
Myth 5: That will improve appetite
Myth 6: That if you NG feed someone, that it will restore their previous baseline (functional, swallow, nutritional etc).
Evidence base and Gaps
Much of the evidence includes patients with various stages of cognitive impairment and using predominantly PEG to evaluate longer term benefits, because of the potential confounding with studying NG use in the acute setting – there are some though. So, we need to extrapolate that evidence to our decision making for NGs as well.
Seldom effective in improving nutrition, maintaining skin integrity, preventing aspiration pneumonia, improving functional status, extending life (RCP 2010)
Teno et al 2012: Pressure ulcers and healing – Grade 2 PEG and non-PEG. Matched Cohort Study
Those with PEGs were more likely to develop pressure ulcers, less likely to have healed at 30 days.
Mortality: no difference at 30 days, higher in PEG group at one year
Acute placement of PEG could contribute to mortality – need to wait 1-2 months
Mortality Rate post PEG insertion
Advanced Dementia %
Teno 2012: PEG vs no PEG
1,957 had a feeding tube inserted within 1 year of developing eating problems.
No difference was found in survival between the two groups – adjusted hazard ratio (AHR) = 1.03, 95% confidence interval (CI) = 0.94–1.13
Ticinesi et al 2016: Prospective Observational Cohort
Adjusted for age, dementia type and stage and discharge setting
Longer survival in those without PEG P<0.0001
‘Quality of life rather than length of life should be prioritised’ (Alzheimer’s society)
Interplay with delirium
Dementia: Cochrane Review 2009: Artificial Feeding in Advanced Dementia
There is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention.
Only 7 trials
4 of which looked at NGT as their study group
Of the 3 trials looking at PEG feeding all have sampling/control issues.
Only looking at advanced dementia
Less severe dementia
Recommend tube feeding for a limited period of time to overcome a crisis situation in mild-moderate dementia with markedly insufficient oral intake if low nutritional intake is predominantly caused by a potentially reversible condition.
NICE/SCIE Dementia Clinical Guidelines (2007) state CANH ‘should not commence if disinclination to eat or inability to swallow is considered part of the disease, and will not change in the future’
CANH should always be in line with meeting therapeutic goals i.e. prolonging life without prolonging suffering or discomfort at the end of life
ESPEN (European Society for Parenteral Nutrition) (2015): guidelines on nutrition in Dementia
Durations of feeding and bounce back (compare with ITU)
Ethics and Legalities
In line with the Human Rights Act (1998) doctors must be aware of how human rights will impact on their decision-making. The courts have confirmed that decisions to withdraw CANH are compliant with human rights law if they are made appropriately.
The MCA does not identify a particular individual as having legal responsibility for decision-making, instead taking a collaborative approach and following the principles of the MCA, which requires all attempts to be made to involve the patient, to consult with anyone named by the person to be consulted with, the family and anyone who expresses and interest in the person welfare i.e. professionals involved. In practice, this will fall to the individual with overall clinical responsibility for the patient’s care, as part of their duty of care to ensure that the care being provided is in the person’s best interests. For example in hospital this is likely to be the consultant, in the community the GP.
Lady Hale, Aintree v James “In considering the best interests of this particular patient at this particular time, decision-makers must look at his welfare in the widest sense, not just medical but social and psychological; they must consider the nature of the medical treatment in question, what it involves and its prospects of success; they must consider what the outcome of that treatment for the patient is likely to be; they must try and put themselves in the place of the individual patient and ask what his attitude to the treatment is or would be likely to be; and they must consult others who are looking after him or interested in his welfare, in particular for their view of what his attitude would be.”
It is important that a ‘balance sheet’ approach is taken identify benefits and risks, a view supported by the BMA and the supreme court who in Aintree v James. identified that even for patients in a permanent VS, the benefits side of the balance sheet needs to be considered. For example, they may have expressed a strong view with respects to the sanctity of life and the intrinsic value in being alive. This should be taken into consideration in making a best interests decision on whether to provide treatment aimed at prolonging his or her life. In all cases the decision should be about what is in the best interests of that individual, and not a blanket approach to particular categories or groups of patients.
Where the person lacks capacity and there is a dispute about what is in the person’s best interests in relation to the withdrawal of fluids or nutrition then the ultimate decision maker is the court of protection
Legal cases: 2018 NG feeding
The Supreme Court (in Aintree v James) reiterated that treatment (including CANH) should only be provided where it is in the patient’s best interests and that the correct question should be whether it is appropriate to provide or continue to provide treatment, rather than whether it is appropriate to withdraw it.
In July 2018 the supreme court confirmed that there is no requirement, for patients in a permanent vegetative state (VS) or minimally conscious state (MCS), to seek approval from the Court of Protection in any cases where there is agreement as to what is in the best interests of the patient, and where both the Mental Capacity Act 2005 and good practice guidance have been followed.
And this can be extrapolated into the more routine cases that we see in neurodegenerative conditions.
Lady Black, An NHS Trust v Y
The case identified a number of significant points on how decisions are to be made, which need to be reflected in decision-making:
– reinforced the message from Aintree v James that the correct question to ask is appropriate to provide or continue to provide treatment.
– an increasing emphasis on patient-centred decisions. The courts emphasising ‘the very strong presumption in favour of the preservation of life’, but that this can be mitigated against by the principle of self-determination – clear evidence that the individual would not want CANH provided under the circumstances
– an unequivocal statement that a patient’s best interests incorporate not just their medical interests, but their welfare in the widest sense – medical, social, and psychological.
Legal Case April 2018 – Long term NG use in End Stage Dementia PW vs Chelsea & Westminster NHS Trust
RW had been cared for by his sons at home until September 2017, when he was admitted to a hospital and was acutely ill. A nasogastric (NG) tube to provide clinically assisted nutrition and hydration (CANH) was inserted as part of his treatment. By late November he [still had the NG] but was ready for discharge as he was clinically stable and had no active infection, but disagreement between the trust and his sons prevented it. It was agreed that RW could be discharged into his sons’ care, had he not needed a NG tube. But the Clinical Commissioning Group (CCG) said it could not provide care in respect of CANH or the NG tube. The issue was solely whether, as the trust contended, he should be discharged home for palliative care and oral comfort feeding only, having had the NG tube removed before discharge, or with the tube in place, as the sons contended.
In April 2018 a Court of Protection judge, having heard evidence from RW’s treating clinician, his family, the CCG, the Official Solicitor and an independent medical expert, decided that it was in RW’s best interests to have the NG tube removed and return home for palliative care only. She took into account the fact that if RW were to be discharged with an NG tube in place, as the sons wished, it would become regularly dislodged requiring his regular return to hospital for its replacement, which would be “highly burdensome” to him. Being discharged home with an NG tube was therefore not an “acceptable or appropriate treatment course for RW”.
The applicant (one of the sons) submitted, in relation to the best interests decision, that the judge had erred in her appraisal of the evidence and the weight she had given to some of the factors, particularly RW’s wishes. These were, contrary to the judge’s findings, ascertainable; they pointed to the fact that he was a “fighter”, to the value he ascribed to life and to his desire to “hold fast to it” no matter how “poor” or “vestigial” in nature it was.
The independent medical expert told the court that offering potentially life lengthening treatment in the form of CANH is no different ethically in this scenario than offering other forms of treatment.
The Court of Appeal refused to interfere with the Court of Protection’s decision that it was not in the best interests of a 77-year-old man with end stage dementia to be discharged home with a nasogastric tube inserted for feeding purposes. The COP judge said that she was not bound to continue life. The sanctity of life is not absolute.” Palliative care “would make [the patient] as comfortable as possible and ensure his dignity and comfort. He will pass away with palliation in a dignified way.”
Ethics of life prolonging vs life enhancing. Do no harm: quantify and clarify the harms to the individual.
There is no statutory right for health professionals to claim a conscientious objection to participating in the withdrawal of CANH. Nevertheless, it is in nobody’s interests for health professionals to be forced to participate in making or implementing such decisions (or to simply avoid making them) and it would be appropriate to involve a doctor who is willing to make a best interests decision for the patient. If there is a conflict of interests then the healthcare professional should declare this early on.
Withdrawal of feeding
Need to establish if there is a valid and applicable ADRT in place that cites to CANH and if yes it must be respected. When a person lacks capacity it must be assumed they had capacity when they made the ADRT unless you have grounds to question this. The fact that the patient who now lacks capacity appears content, or even happy, with their quality of life does not mean that their ADRT is invalid.
If there is a valid and registered LPA for health and welfare then they are the lawful decision maker and their view should be respected.However it is important to remember they do not have the power to insist on treatment that is not clinically indicated.
Does not cover decisions about CANH in situations when
Death is expected in the following hours or days
Starting or continuing CANH is not clinically indicated
A decision to start, or to stop providing, CANH is part of a broader decision about life-sustaining treatment
[There is a valid ADRT in place]
In these circumstances: individual clinical decision making.
Part 1: General guidance
Capacity assessment – general principles of MCA and Best Interests
Clinical assessment of benefits of CANH in relation to level of recovery that can be expected
Part 2: Next 3 sections cover common scenarios
Neurodegenerative conditions including Dementia
Multiple comorbidities or frailty who suffer brain injury e.g. Stroke
Previously healthy in Vegetative State or Minimally Conscious States
Neurodegenerative Conditions – includes PD, Huntington’s, Dementia – described as
“Conditions which are likely, eventually, to result in the patient being unable to take sufficient nutrition orally. “
It states that, particularly with respect to Dementia
“CANH is not usually indicated where inadequate nutrition is related to the advancing disease itself… May be indicated for a relatively short period for a potentially reversible co-morbidity such as acute infection”
“In the limited circumstances in which CANH is clinically indicated and where a decision is needed about whether to continue CANH that has already started.”
Advocates use of second opinions: “When it is proposed to stop or not start CANH and the person is not within hours or days of death”
Use of second opinions is advocated strongly in the guidance, suggesting a proportionate approach taking into account
Potential for future recovery or deterioration
Expected survival time
The level of certainty with which this can be predicted.
The impact of making the wrong decision resulting in either CANH
Being withdrawn too soon – thus depriving the opportunity to live a life they would value or
Of it being continued for too long – forcing the individual to continue a life that they would not have wanted.
For those with progressive neurological condition including dementia – Does not need to be from a separate department but may be advisable if prognosis is several years
For those with multiple comorbidities or frailty who suffer brain injury – External to the treating department
For those previously healthy in Vegetative State or Minimally Conscious States – Expert specialising in Prolonged Disorders of Consciousness (PDOC), external to organisation if possible and previously uninvolved in care.
A case to discuss
Jim is a 74 year old gentleman with moderate dementia – he lives with his partner and has no formal care. He attends a day centre twice a week. He has been admitted to the acute medical unit with a right basal pneumonia. He is having periods of both hyperactive and hypoactive delirium. His nurse reports that he is too unsteady to transfer to the chair with assistance of 2, he needs prompting and assistance to eat or drink but seems to have very little appetite and after having a cup of tea is coughing and his voice is wet.
Functional baseline: walks with a stick most of the time, independent transfers, needs prompting but not assistance to wash and dress. Partner cooks meals
Swallowing baseline: Avoids very solid foods like steak but otherwise no issues. Never seen SLT before.
We are going to talk about this but NOT talk about the ethics of treatment rationing for older people. The article that the quote comes from does this well – the link is in the show notes!
We have seen in the flow episode that a small number of ‘slower moving’ patients lead to a great decrease in the productivity of the system – an argument then comes about that by preventing these more complex patients coming to hospital (and the high cost that entails) then the overall system will work better, have more money and be more rosey.
Unfortunately life is not always that simple and whilst we know that hospitals are risky places for older people sometimes though they are the places that older people just need to be for a while.
“Undignified care of older people does not happen in a vacuum; it is rooted in the discrimination and neglect evident towards older people in British society. Age discrimination is the most common form of discrimination in the UK. Increased life expectancy is a positive development, but our view of older people focuses almost exclusively on biological decline, and we tend to discuss older people as a problem for health and social care services, a ‘demographic time-bomb’ or a crisis we cannot afford. In contrast, the economic and social contribution offered by older people – for instance in employment, volunteering, or caring for partners, children and other family members – is rarely acknowledged.”
Recording team to briefly discuss this – bias is often to talk about the strain of older people and not the benefits..
A survey of more than 1,000 experts in ageing and ageing in health care from across Europe for the Economist showed that 80 per cent were concerned about the standard of their own care when older and 51 per cent felt that older people were far less likely than younger people to have adequate assessment and treatment in their countries.
There is also evidence that reducing ageism will not only have a monetary benefit for society, but also have a health benefit for older persons. The cost in the USA was calculated in this article as: 1 in every 7 dollars spent on the top 8 health conditions (15.4%)!
Hospitals have to ensure that discrimination is prevented under the Public Sector Equality Duty therefore trusts and services must consider those with protected characteristics when planning and carrying out public duties or services.
All patients have a right to the following
access to health service
good quality of care
being treated by appropriately qualified and experienced staff
making decisions about medications and treatments
being protected from abuse and neglect
respect and confidentiality
complaining if you aren’t happy or things go wrong.
In 2012 it became illegal to discriminate against adults due to age. This is unless the practice is covered by an exception from the ban or good reason can be shown for the differential treatment (objective justification).
Exceptions under the order are
Age based concessions
Age related holidays
Clubs and association concessions
Residential park homes
In addition the following exceptions apply
General exceptions already allowed by the act
Positive action measures
“There are no specific exemptions to the ban on age discrimination for health or social care services. This means that any age-based practices by the NHS and social care organisations need to be objectively justified, if challenged.”
The NHS constitution backs this up by stating that is it a :‘comprehensive service to all, irrespective of age, a duty to respect human rights, access based only on clinical need,’
An audit by the Healthcare Commission (2006) found that explicit age discrimination in policy has declined since the National Service Framework for Older People was introduced in 2001.
One of the most explicit forms of age discrimination in healthcare in the NHS is the upper age limit on some screening programmes by invitation, not indicated by disease prevalence or other clinical indicator. Upper age limits currently exist of 69 for breast and bowel cancer screening and 64 for cervical screening by routine invitation.
Another example (of indirect discrimination) would be the reduction in GP home visits over the last few years. Now people of any age can have a home visit – but it was a service used in the majority by older people. The but back from 22% in 1971 to 4% in 2006 will affect older poeple the most.
Clinical trials… we have talked before about this – so won’t again other than to say it’s a thing… a big thing!
Teams: Geriatrics vs general medical teams – automatically there is an age bias there. But it is there to aim to deliver a better quality healthcare for older people – so isn’t that a good thing? Is age adjusted care ok? but age discrimination not ok?
It however goes both ways:
Age based care can be a good thing though and makes perfect sense in some situations- the older patient with complex healthcare needs for example – we know does better with a team dedicated to looking after them. But does this deny them access to say a cardiologist and therefore say the most up to date specialist treatment (TAVI, Dual chamber PPM etc etc) ? There is no blanket rule that can be applied to these things.
There is a transition of care in psychiatry services at 65… and many areas do not have well defined transition protocols…. but the 65 is often set in stone – regardless of the length of time a patient has been with the younger persons unit / team.
We have come along way though – for example there is no longer a situation there no NOFs can be on ITU for example or ITU will not accept patients over an arbitrary age cut off. Using more physiological based measures will be important here and I (iain) would argue that that is going to be frailty’s greatest give to geriatric medicine – the ability to quantify the physiology and turn age to just what it is… a number.
Either way there is an important step for all of us to not make older people ‘other’ and to resist any labelling of us vs them… this is destined only to drive a wedge between services and make this more difficult. This is something we can all roll model but also needs to be reflected in the way out public services are designed.
Public services should be designed with the aim of promoting equality between people of different ages, addressing the current and future needs of an ageing and diverse population, and eliminating discrimination against older people. We need to be alive to trends that appear to exacerbate age segregation, and we need to seek initiatives that can bring different generations together around issues of shared interest and importance.
3. To inform a senior person – if it is about an individual their line manager or colleague, if it is about a service as a whole then the manager of that service in the first instance.
How to design services that are not discriminatory?
Just short section here:
Essentially use co-construction with your patients and involve them in the service.
Good example I hear of recently was the Isle of Man PD service who have regular service improvement meetings – with any patients that wish to come along also. This way the patients drive the agenda and ensure that over time the service becomes more and more of the service that they need.
The key thing is to talk to your patient and deliver a healthcare service that is focused on their needs and when developing your services to focus on a service designed in conjunction with the service users you are trying to serve.
This episode covers the following areas (n.b not all areas are covered in detail in this single episode):
NHS Knowledge Skills Framework
Core Dimension 3: Health, Safety And Security – Level 2
Core Dimension 6: Equality And Diversity – Level 3
1. Acts professionally
3. Behaves in accordance with ethical and legal requirements
Core Medical Training
Principles of quality and safety improvement
Managing long term conditions and promoting patient self-care
Management and NHS structure
2.01 The GP Consultation in Practice – Core Competence: Maintaining an ethical approach
3.05 Care of Older Adults – Core Competence: Clinical management
Geriatric Medicine Training Curriculum
3.2.5 Rehabilitation in Older Persons
9. Principles of Quality and Safety Improvement
25. Management and NHS Structure
26. Evaluating Performance and Developing and Leading Services (with Special Reference to Services for Older People)
Understand cultural aspects of ageing in relation to ethnicity in particular
Recall conditions and situations in which culture needs to be actively considered as part of a care plan
To feel more confident with being able to anticipate and discuss cultural considerations, different to your own with your patients.
To be able to adapt care plans to the individual
To consider cultural competence as a core component of person centred care.
Main Show Notes
Culture difference is increasingly seen as a crucial factor to consider when undertaking health and social care assessments, planning intervention and support.
Culture refers to a group or community who share common experiences, beliefs, traditions, history, language, which shapes the way its members understand the world. It includes groups we are born into, such as race, national origin, gender, class, or religion or groups we choose to join. Culture will be a strong part of people’s lives, influencing their views, values, hopes, worries and fears and impacting on the way they behave.
Cultural knowledge: what you know about characteristics, history, values, beliefs, and behaviours of another ethnic or cultural group
To develop cultural awareness, one needs to understand self and own biases, to ensure they are not impacting on the way you interact with a person from another culture, this self-awareness enables a person to become;
Culturally sensitive – by being curious, showing empathy and respect, and not making value judgments.
The following questions can help you determine your level of sensitivity.
How accepting are you of people from a different cultural background?
What stereotypes and prejudices do you associate with the ethnic group you identify with?
How are your beliefs, values and outlook on life, different from people of other backgrounds?
What is your attitude toward older people who are difficult to understand because of an accent or difficulty speaking English?
How do I overcome my prejudices?
With respects to cultural identity it is important to consider the following:
everyone has a cultural identity, regardless of whether they recognised or defined it themselves. Sometimes, culture is seen simply as “just the way we do things”;
culture and cultural identity are dynamic and constantly changing;
people may be influenced by and identify with more than one culture or cultural group;
it is the choice of the individual as to which culture they identify with regardless of their cultural background;
Though religion can influence cultural beliefs, often people separate their culture from their religion;
A person’s culture can affect their health. As culture may have a bearing on the choices a person makes when managing their health. An example of this include Punjabi patients who believe eating Karela (Bitter melon/gourd) will treat their hypertension rather than tablets.
Essentially synonymous with person centred care.
In this episode we are going to concentrate predominantly on ethnicity, accepting that there are many more ways to look at this and we are likely to do further episodes in the future focusing on religion and other subcultures.
The structure of this episode will be Thinking about definitions of culture and influence of these on ageing in a wider sense than just healthcare More practical application of the healthcare system and adaptations / considerations to make more inclusive.
Key Points from Discussion
Culture Applied to Ageing
Examples of cultural aspects of ageing include:
Native Americans prize the virtue of wisdom, younger members seeking the wisdom of Tribal elders to help explore their current problems.
In Vietnam, elders have a strong influence in family decision-making and are regularly looked to for their advice.
In Asian cultures, (i.e. Japan and China) senior members of the family are treasured and it’s the norm for elders to live with and be cared for by younger generations.
In Korea, special festivities honour advanced birthdays. A hwan-gap, or 60th birthday, is a time when children celebrate their parents’ passage into old age (impact of advances in health have impacted life expectancy). At 70, there’s another celebration known as a kohCui which means “old and rare.”
Aboriginal communities: believe specific foods are only for older member of the community, for example Aboriginal people believe wildcat and kangaroo are to be reserved for elders and will cause physical harm if eaten by younger people.
In Hindi culture the suffix “-ji” is added to names to show deference and respect and demonstrate an appreciation of the older persons place in society
In the Philippines, elders are honoured with a symbolic gesture called the mano po, in which the younger person takes the hand of the older person and touches the back of the older person’s hand to the younger person’s forehead.
Different cultures have their own rules about body language and interpretations of hand gestures, for example some cultures point with the entire hand, because pointing with a finger is extremely rude behaviour, in other cultures direct eye contact is considered disrespectful
It is important to remember that cultural competence is not just in relation to ethnicity but also a person’s sexuality, disability or socio-economic status.
Weaver (1999) identified the following factors as important for developing cultural competence:
critically reﬂecting upon and identifying one’s own beliefs and bias;
recognising the impact of colonial histories;
increasing knowledge and awareness of differing cultural groups;
understanding and valuing the notion of diversity;
recognising the level of historical or contemporary distrust between various groups;
appreciating the signiﬁcance of difference in the helping relationship, including the impact of power dynamics. (Weaver, 1999, p. 218)
Yu (2009) identifies two false assumptions implicit in cultural competence: that the way in which people interact with health and social care is inevitably shaped by their culture, which does not allow for an individual view of the impact of their culture; that all members of a group conform to the same cultural practices with the same intensity.
In addition, Wills et al (2017) identify how prioritising cultural identity can have the potential to ignore or minimise the importance of other aspects of an older person’s identify such as sexuality/gender. This reductionist view having the potential to attribute the reason for a person’s behaviour to culture alone rather than any other reason (Williams & Soydan, 2005)
Maidment et al (2016) research found that the following were, in some cases, more important than understanding a particular cultural background, although they acknowledge that understanding culture is helpful:
giving time/being patient especially if communication is difficult and time consuming;
showing tolerance and acceptance of difference, which aids in establishing a meaningful connection with the individual;
However, despite having access to training on working with culture and diverse, the literature demonstrates that white practitioners still experience anxieties, for example in Gunaratnam (1997) study of hospice work, staff expressed fears that they would offend service users and their families at a sensitive time. They were also afraid of being viewed as racist if they asked questions about culturally specific practices.
Gunartanum, Y. Culture is not enough: a critique of multi-culturalism in palliative care. In Field, D. Hockey, Small, N (Eds). Death, gender and ethnicity. Routledge, London or Gunartanum, Y. 2007.
Proctor and Davis (1994) discuss how practitioners fear that admitting to a lack of cultural knowledge makes them appear professionally incompetent. This barrier to asking questions having the potential that the practitioners could end up providing inappropriate care without meaning to. This fear of acknowledging difference likely to stem from a ‘colour-blind approach’, with practitioners feeling that they should not ‘notice’ ethnicity in order to treat everyone equally, ignoring cultural difference with respect to food, hygiene for example (cited in Willis et al, 2017. p. 693).
There is little research that considers the older person from different cultural backgrounds and the impact of ageing within a predominately white, British culture.
In 1928 Robert Parks discussed the concept of the ‘marginal man’ a person who lives in two separate cultures, not fully integrated into either culture, which has the potential to significant impact on their identity and personal consequence.
An area of practical implementation of this is in caregiving and the role of family versus formal carers in different cultural backgrounds
Sung & Dunkle (2009) states that it is a traditionally held believe that Asian societies are more respectful towards their elders than western society due, in part, to a strong link to Confucianism, which sees the family and filial piety (respect for father, elders and ancestors) as fundamentally important. Huang-Hei (2003) suggesting there are two forms of filial piety; reciprocal, which sees care being provided due to love and a wish to repay parents for the sacrifices they have made; and authoritarian, which encourages obedience and compliance and could be considered a means of social control.
More commonly filial piety is defined as a set of attitudes and behaviours, which demonstrate love, respect and care towards parents, which can lead to elderly parents having strong expectations of their children.
Laidlaw et al (2010) research compared three different cultural groups; two were based in the UK and comprised a sample of older adult Chinese immigrants and UK born older adults. The third group were older Chinese adults living in Beijing. They wished to exam whether older people in Eastern and Western societies have similar expectations for filial support and whether the ageing process influenced this expectation. They found:
The two Chinese groups had similar attitudes to filial piety;
The Chinese immigrants and UK participants had similar attitudes to ageing;
Chinese older people living in China have a more negative experience of ageing;
The concept of filial piety remains strong in emigrants despite becoming part of a new culture over time;
Psychosocial loss contributes to an expectation of filial piety – linked to a negative expectation or experience of ageing (loss/being de-creped), which engenders a feeling of helplessness.
This compares to Western societies who tend not to have a philosophy of care, which encourage sacrifice and care for the older generation. Instead older people can be viewed as a burden or a drain on resources (World Health Organisation, 2002).
How culture influences healthcare in the ageing patient:. Most healthcare services stem from what already exists. As most migration of people from minority ethnic groups happened from the 1960s there have been fewer older people from those communities. Hence, healthcare issues which arise with advanced age tend to match the needs of the English Caucasian community, but do not necessarily match the needs of people from other cultures. However, nationally there is a drive to develop services so they match the need of people from all cultural backgrounds. This is especially important now as the population of older people in the black and minority ethnic communities is growing rapidly.
Older patients from all backgrounds may not seek medical support when they require it. The older generation tend to be more stoic, especially those that have lived through years of hardship. The older generation often have respect for healthcare staff. Advice given is often received well and taken. There may be times where older patients may not agree with the advice and treatment plan given, this is usually because they do not understand the advice given or the advice given is against their cultural beliefs.
Understanding information is usually a problem when the patient’s first language is not English. Conversations about fertility, sexuality and contraception can particularly be difficult, and are often influenced by cultural beliefs.
Common medical issues in older patients affected by culture:
End of life care
DNACPR/EOLC – potential challenges
May not be part of their culture or against their cultural beliefs. IT may not ‘exist’ in the countries they have come from (South Asian Communities).
#hey believe in treatment ‘till the end’ (Middle Eastern and South Asian Communities).
Palliative care and DNACPR is seen as withdrawal of treatment and care and viewed as being unethical and unkind.
Health care staff need to be aware of their patients’ cultures and religions in order to tackle such situations. Being aware will make holding discussions with patients and their family members on DNACPR/EOLC much easier.
In certain cultures there are community ‘leader’, religious figures, family ‘elders’ or other key family members whose presence in such meetings can be beneficial. Ask early if this is the case.
Using an interpreter where the patient’s first language is not English is very important.
When a patient dies cultural/religious beliefs can have a bearing on how the body should be treated and how quickly the funeral should happen.
In some cultures the idea of passing urine and stool is perceived as being a ‘dirty’ act. In some Indian communities living in India, toilets are not kept at home and people will defecate and pass urine in communal toilets, away from their own homes. One of the hand’s is used for the action of cleaning oneself after defecation, the hand used (though washed) is recognised as the ‘dirty’ hand, while the other hand is perceived as being ‘clean’ and is used to eat and drink with.
Being incontinent of urine or faeces regardless of your background is difficult for a person. It can affect their social life, their sex life and their home life. Often people will not seek advice to help them with their incontinence.
In certain cultures incontinence is accepted as part of ageing and the loved ones of the sufferer support them in helping them wash and clean. In these communities sufferers may not seek support/help from healthcare services, it is believed incontinence is part of the ageing process. Research undertaken by Doshani et al (2007) identifies the following areas can support women to seek help access to a female GP and if possible a GP with a similar ethnic background
They would prefer to see an allied professional i.e. nurse, physiotherapist, the research indicating that they assumed they would be female.
Some cultures still do not recognise dementia/cognitive impairment as a medical problem. Some cultures believe patients who suffer from cognitive impairment have become unwell due to ‘black magic’/’witchcraft’/’voodoo’, ghosts or spiritual beings.
Some cultures will believe it is part of ‘normal’ ageing and will not seek help.
In some cultures cognitive impairment in family members is not noticed, as family elders are taken care of by their younger family members. As their function reduces other family members help/support them. These patients only get diagnosed or seek further help when they become acutely unwell and are seen in hospital or by their general practitioner.
How can healthcare staff improve their knowledge about different cultures?
Reach out to your local communities and meet with them to learn about their healthcare needs and concerns. Use local community leaders and staff (from the same culture as the audience you wish to support) to reach those communities. Work with local and national charities to hold health screening and education events. Review your local services and strategies regularly in order to match your local communities cultural needs. Make use of interpreters e.g. language line or face to face.
Using an interpreter: When working with people where English is not their first language it is important to ask what their language of preference is and to consider using an interpreter, the dilemma being whether this is a paid interpreter or a family member (ethical considerations) – concerns expressed that the questions asked or responses are not always fully translated.
A UK study of nursing care found that nurses believed they were unable to provide the ‘total patient care’ that they would normally provide, because they could not discuss it with patients
Murphy & Macleod Clarke, 1993, p. 448 cited in Willis et al 2017. p.687).
Be aware of major festivals/celebrations of the various communities you wish to support. This is important as this is usually the time when they can become unwell or need more support. For example there is often a spike of admissions from the South other family members help/support them.
Mr Jones is a 85 year old man who has been struggling over the last 4 years with worsening shortness of breath and diabetic control. He has been in and out of hospital a few times with exacerbations of his symptoms. His mood had reduced and he has recently been diagnosed with depression.
He lives at home alone with a small care package (help with his shopping and his washing etc).
He becomes more breathless and calls his gp:
What model of care is there for him?
What should be done?
A ‘model of care’ broadly defines the way health services are delivered. It outlines best practice care and services for a person, population group or patient cohort as they progress through the stages of a condition, injury or event. It aims to ensure people get the right care, at the right time, and in the right place.
Practical DefinitionSo why talk about healthcare models?
Our current health systems were designed and implemented in the 1940s, in a post war world when life expectancy for men was 66 years and women 71 years.
Now – we are living longer with more complex healthcare needs. Life expectancy is now 79 for men and 82 for women and increasing by 5 hours per day!
It costs 5 times more to look after an eighty year old than it does a 30 year old and so we must consider different models of care to address our changing healthcare needs.
Links to previous podcast on multiple morbidity (3.1) and influence of one disease on another, which influences treatment.
This ageing population puts an increasing dependency on health and social care which has led to the importance of a shift from a problem-based, disease oriented model of care to a goal-orientated integrated model. A proactive, empowering model in which goals are set with the individual.
This shift set against a background of financial difficulties and the importance of providing quality health and social care support, which has led to a move away from medicalised approaches to an emphasis on a holistic, multi-disciplinary and person-centred approaches to care.
If we initially consider overall healthcare systems.(covers funding and macro level dynamics).
There are four basic models of care that are used worldwide on which healthcare services are built.. The Beveridge Model, from which the NHS is structured, The Bismarck Model, The National Health insurance Model and The Out-Of-Pocket Model.
To explain these in more detail:
The Beveridge Model
Named after William Beveridge who designed the NHS. Healthcare is provided and financed by the government through tax payments
Found: UK, Spain, Scandinavia, New Zealand, Cuba
The Bismarck Model
Named after Counsellor Otto von Bismarck, this was the healthcare system which was put in place in unified Germany. Similar to the american system in that it uses an insurance system, usually funded via payroll deduction from employer and employee, but in this system everyone must be covered and the insurers don’t make a profit.
Found: Germany, France, Belgium, The Netherlands, Switzerland, Japan
The National Health insurance Model
This uses elements of the previous two systems. It uses private healthcare providers but payment comes from a government run insurance programme that all citizens pay into.
Found: Canada, Taiwan, South Korea
The Out-Of-Pocket Model
Only about 20% of the worlds nations have an established healthcare system. Those who don’t, generally have to pay to see a healthcare professional each time they’re needed with millions not seeing anyone throughout their lifetime
3 areas, in hospital, in community and the interface of these two.
Within hospitals these include (we will focus more on the ‘downstream services’:
Hospital-wide (Hospitalist (USA) vs primary care vs specialists)
Mr Jones admitted to hospital – his own doctor directs his care vs hospitalist vs acute medicine vs geriatric team
Mr Jones Sees an ED specialist how has not met him to decide to admit or nothing
Acute Geriatric Units
Evidence for CGA in episode 1.1 location based services work.
Mr Jones admitted to a DME ward etc
Comprehensive geriatric assessment of acute admissions to hospital
There is no clear evidence of benefit for CGA interventions in frail older people being discharged from emergency departments or acute medical units. However, few such trials have been carried out and their overall quality was poor. Further well designed trials are justified.
Community / hospital interface (will talk more about this later)
Models of care at the interface are variously labelled, most commonly as transition care or intermediate care. Most of the evidence has come from the care in the postacute phase
Methods: a pre-post cohort study of the impact of embedding CGA within a large ED in the East Midlands, UK. The primary outcome was admission avoidance from the ED, with readmissions, length of stay and bed-day use as secondary outcomes.
Results: attendances to ED increased in older people over the study period, whereas the ED conversion rate fell from 69.6 to 61.2% in people aged 85+, and readmission rates in this group fell from 26.0% at 90 days to 19.9%. In-patient bed-day use increased slightly, as did the mean length of stay.
Discussion: it is possible to embed CGA within EDs, which is associated with improvements in operational outcomes.
Mr Jones – seen in ED by geriatrician – ? admit or not… early CGA there in ED or soon on d/c
prevent unnecessary acute hospital admissions and premature admissions to long-term care;
support timely discharge from hospital; and
maximise independent living.
Intermediate care services are usually delivered for no longer than 6 weeks and often for as little as 1 to 2 weeks.
Mr Jones admitted in ‘step up’ fashion to intermediate care bed
Originated in the United Kingdom in the 1950s
Dedicated outpatient service providing specialized, interdisciplinary, ambulatory, and usually rapid access geriatric medical, nursing, and rehabilitation care to community-dwelling older patients.
Day Hospitals represented an evolution in primary and secondary level ambulatory care models for older people with complex needs. Those attending Day Hospitals receive and benefit from CGA, individualized multi-domain assessment by a multidisciplinary team using validated scales and interventions that reduce adverse outcomes, hospital admission, and length of hospitalization
The most recent change in Day Hospitals is a shift toward specialty services, clinics, and ambulatory investigations. Paralleling this change, the relatively new construct of frailty has begun to replace historical models of geriatric care and is increasingly being used in Day Hospitals to select and risk-stratify attendees.
This is a really good report published by NHS Scotland:
Despite the recent drive for further integration of services for an individual patient there is still a degree of silo working and no clear linked up pathways..
Historically medical care has focused on single episodes of illness, which does not meet the needs of our older patients with complex needs (Street, 2004. cited in Peek et al, 2007).
There has been much emphasis on the importance of a range of services being formally integrated into multidisciplinary teams to enable them to successfully:
Screen older people
Provide appropriate interventions
Assure continuity of care
A collaborative approach is often seen as the best way to provide different models of care. However there is a general lack of agreement amongst professionals of the elements that make up a collaborative approach.
Integrated care: aims to improve patient experience and achieve greater efficiency and value from health and social care delivery systems.
It aims to address fragmentation in patient services, reducing confusion, repetition, duplication, gaps and delay in service provision leading to better coordinated and continuous care for the individual.
It tries to achieve this by:
Supporting the coordination of services, with a particular focus on those at risk of developing acute illness and being hospitalised
Providing more care in the community including in a person’s home, in partnership with social care, and the voluntary and community sector
Ensuring a greater focus on population health and preventing ill health
Allowing systems (i.e. health and social care) to take collective responsibility for how they best use resources to improve health results and the quality of care being received, thus avoiding trips to A&E.
NHS England: Vanguards
In 2015 NHS england set up a series of collaboratives to trial new care models.
Initially in 3 areas:
integrated primary and acute care systems (joining up GP, hospital, community and mental health services)
enhanced care in care homes (offering older people better, joined up health, care and rehabilitation services)
multispecialty community providers ( better integration of various strands of community services such as GPs, community nursing, mental health and social care, moving specialist care out of hospitals and into the community).
The programme has since been extended to 50 vanguards and plays an integral part in the NHS Five year Forward Plan.
Data shows these programmes have had a direct affect on acute admissions:
Growth of emergency admissions in areas with the integrated primary and acute care systems of 1.1% and multispecialty community providers of 1.9%
compared with non vanguard areas where it was 3.2%.
A report from the National Audit office in July 2018 has shown that the funding needed to continue these initiatives is often being redirected to relieve short-term financial short falls and therefore not always finding its intended target.
In addition; in 2012, the NHS Commissioning Board commissioned National Voices to develop a narrative for the benefits of integration utilising the experiences of patients, service users, carers and organisations which lead to the creation of “I statements” example being:
I work with my team to agree a care and support plan.
I know what is in my care and support plan.
I know what to do if things change or go wrong.
I have as much control of planning my care and support as I want.
I can decide the kind of support I need and how to receive it.
My care plan is clearly entered on my record.
I have regular reviews of my care and treatment, and of my care and support plan.
I have regular, comprehensive reviews of my medicines.
When something is planned, it happens.
I can plan ahead and stay in control in emergencies.
I have systems in place to get help at an early stage to avoid a crisis.
People with urgent medical needs getting same-day appointments at centres, which bring relevant care professionals together under one roof.
People over 60 with two or more long-term conditions referred by their GP to an ‘extensivist’ team with a range of clinical and support skills to develop a personalised care plan.
A ‘virtual ward’ which helps keep older people out of hospital. Doctors, nurses, social care staff, physios and others discuss patients who are put on a rolling ‘virtual’ list each week if thought to be at risk of hospital admission.
Person-centred models of care for older people in an acute care setting – boundary blurring:
Models which take a more holistic, person-centred approach, recognising the centrality of the person, are now considered the gold standard internationally gives patients more empowerment in their healthcare.
There is a recognition that this requires trust to be developed between the person and the practitioner.
Focus of episode: to explore the reasons that a person may need to be admitted following a fall. In the main this means admission to an acute trust but may mean ‘admission away from home’ i.e. a community bed.
The decision between the two, versus staying at home depends on the availability of certain treatments and members of staff for management and as such will vary depending on your local provision. For example, some community hospitals will do intravenous infusions, others may not, some hospital at home services may be able to provide this. So there are no hard and fasts but we’ll explore the main principles to help you be able to make informed decisions with your patient.
The prevalence of gait disorders increases from 10 % in people aged 60-69 years to more than 60 % in community dwelling subjects aged over 80 years.
Gait disorders in adults and the elderly – A clinical guide by Pirker & Katzenschlager in The Central European Journal of Medicine 2016
Human gait depends on a complex interplay of major parts of the nervous, musculoskeletal and cardiorespiratory systems.
The individual gait pattern is influenced by age, personality, mood and sociocultural factors.
With advancing age the proportion of patients with multiple causes or combinations of neurological and non-neurological gait disorders increases.
People can be thought of as complex biological symptoms, well functioning systems can handle a variety of different stressors without breaking down. Older people who are frail can be thought of as a complex system that struggles to adjust to many small stressors which people who are not frail would find innocuous. A fall can be thought of as a manifestation of a system that is struggling to optimally function, a fall is often then the first presentation of a frailty crisis as walking is a complex activity requiring coordination between multiple different body systems.
We are going to structure this episode by using a head to toe approach to the causes of falls, looking at acute and chronic causes of falls at each stage. Bearing in mind that in older adults, the likelihood of multifactorial causes for falls increases.
Vision & Vestibular
Afferent nerves from the visual, vestibular and proprioceptive systems provide essential information on the position of the body and its parts. Disturbances in one of these systems, e. g. proprioception, may be partially compensated by other sensory systems, such as vision.
More likely to be a long term issue than acute. Examples of acute visual disturbance:
Occipital or retinal stroke: needs acute assessment as inpatient
GCA: needs acute assessment but often ambulated after initial assessment
Will cause reduction in visual field / depth perception eg. as well as potential decompensation of above.
Chronic causes can be exacerbated by concomitant delirium
Cataracts: signpost to GP if not already known – surgery reduces risk of falling
Macular degeneration – if rapid consider wet AMD
Will often have compensated their environments and routines over time.
Vestibular system particularly prone to dysfunction in older adults (ep 1.09 – Dizziness) both chronic and acute.
BPPV: Epley manoeuvre and OPD management – ability to function at home will be the determinant here (as below).
Acute labyrinthitis: OPD management usually.
Cerebellar or brainstem stroke affecting eye movements or cerebellar function: acute inpatient management.
Chronic causes of dizziness are more likely to be due to a combination of disruption at a number of points on the pathway between visual, vestibular, proprioceptive and central, processing and psychological: unlikely that acute admission will alter this but seemingly small triggers may make it seem unmanageable at home. From a medical perspective, unless there is a treatable trigger, it is unlikely that admission will improve things. However, physiotherapy to improve confidence and look at functional support is often helpful but early assessment is needed to determine this.
Brain / CNS
Afferent information from visual, vestibular and proprioceptive systems are received in the brain, interpreted and processed to provide signals to the body to move.
This involves many areas of the brain including
Frontal cortex – important for executive function e.g. task planning, motor cortex is here
Basal ganglia – control of movement
Brainstem – reflexes
Cerebellum – control of coordination
Safe walking requires intact cognition and executive control. Acute onset of a gait disorder may indicate a cerebrovascular or other acute lesion in the nervous system but also systemic diseases or adverse effects of medication, in particular sedatives.
Parkinsonism and frontal gait disorders due to subcortical vascular disease or disorders associated with dementia are among the most common neurological causes.
Stroke in any of those areas: will be associated with other focal signs
Delirium often disrupts these complex pathways in a variety of ways: decision re admission then related to both whether the underlying precipitant can be treated outside of hospital as well as whether support for the consequences on mobility and cognition can be.
Fear of falling, anxiety, low mood e.g. motivation, pain.
Moving further down the pathway from brain to limbs: the efferent system comprises descending pathways including the pyramidal tract, peripheral nerves, neuromuscular end plate and muscles.
Pyramidal tract (motor pathways) signs might be seen in stroke (new or old), spinal cord compression.
Neuromuscular disease is usually chronic and reasonably rare e.g. MND, polymyositis: management for most of these occur as an outpatient even though they are serious conditions so again, comes down to functional ability
Hip and knee osteoarthritis are common non-neurological causes of gait disorders.
Usually long term vs injury – directly related to sarcopenia plus OA and other chronic conditions. Pain is most likely to be the limiting factor in chronic joint conditions and may require admission to optimise e.g. steroid for RA, analgesia to facilitate weight bearing. If sudden onset and related to a fall, may need to assess for fracture or ligament damage.
Poor strength and muscle mass, relation to nutrition: have they the support to get nutrition?
Growing evidence that you can build muscle mass plus 70 – exercise is the single thing that can be improved and impact on falls prevention
Breathlessness due to either may limit exercise tolerance and therefore enter a cycle of decline through deconditioning.
low oxygenation as cause of breathlessness
Suspected arrhythmia as cause of fall (sudden, unprecipitated collapse) – will need usually 24 hours cardiac monitoring: fix is a pacemaker / medication.
Postural hypotension with symptoms: 1 in 5 community dwelling older adults have a postural drop so symptoms are the important factor here – if it is acute onset, it will usually be associated with symptoms. Not all need admitting though – function and safety the determinants (ep 6.02)
Continence impacts falls and falls (mobility) impact continence.
If urinary incontinence is new then consider if it might be a UTI – note new PHE guidance on not using dipsticks. Outpatient management unless sepsis, dehydration needing iv fluids, or functionally affected.
New faecal incontinence: check for overflow (common cause), check for associated neurology to suggest spinal lesion. Latter needs inpatient management, former does not.
Sensory ataxia due to polyneuropathy, alongside higher cognitive function disorders are one of the commonest causes of impaired walking.
Peripheral neuropathy: long term usually. effects balance due to lack of sensation, may be associated with pain or ulcers.
Feet: long term usually! Need for OPD podiatry and chiropody – one solution is training staff to cut nails to resolve immediate impact on pain and stability.
Few foot causes will require admission but pro-active management will reduce risk of falling.
Wider issues surrounding that person e.g. environmental e.g. home, social support, psychological support, including loneliness.
Injury vs confidence preventing walking – importance of pain control for injuries and access to supportive rehabilitation
Medications review will often find contributing medications e.g. sedation, postural stability, continence.
Long Term High Risk
Long term high risk: management strategies (including that RH doesn’t take away falls risk). high low bed/ sensors/ POC/ pendant again patient choice and capacity
To admit or not to admit?
How to risk stratify for admission: needs acute hospital admission for the thing that is wrong rather than the fall itself.
What is causing the fall – does the medical management need to be as an inpatient? Falls is not a diagnosis – admit for reason for fall if appropriate
What needs to be in place at home for this person to have an acceptable level of risk vs safety.
Are there short term goals for optimisation that could be helped by rehabilitation? multiple things that can be optimised together might indicate rehabilitation potential. Night time needs is a key consideration for bedded rehabilitation
What does the person want? Shared decision making and autonomy
Would I send this person to hospital for this vs should I admit? Cognitive bias of where seen: OPD vs ED, community teams often more comfortable with managing risk than hospital based teams
What interventions are people being admitted for?
medical: monitoring / investigation / management only available in hospital
nursing: care needs unable to be met at home e.g. wound care, delirious, medication administration, supervision of mobility
physiotherapy + OT: functional ability requires aids not available elsewhere / intensity of therapy unavailable elsewhere, rehabilitation and assessment
Community services available influences decision
rapid response teams
voluntary sector e.g. red cross
times of day available
intensity of review required
This episode covers the following areas (n.b not all areas are covered in detail in this single episode):
NHS Knowledge Skills Framework
HWB3 Protection of health and wellbeing – Level 2
HWB6 Assessment and treatment planning – Level 3
HWB7 Interventions and treatments – Level 2
G2 Development and innovation – Level 2
G7 Capacity and capability – Level 2
Foundation Curriculum (2016)
7. Works effectively as a team member – Interaction with colleagues
9. Recognises, assesses and initiates management of the acutely ill patient
10. Recognises, assesses and manages patients with long term conditions
11. Obtains history, performs clinical examination, formulates differential diagnosis and management plan
Faculty: Dr Jo Preston, Dr Iain Wilkinson, Sarah Smith, Alison Fitzgerald, Tracy Szekely
Release date: 9th April 2019
Care integration doesn’t happen by itself. Strong leadership, clear planning & good cross sector communication to build trust are key ingredients of success. Impressive work being led from a hospital starting point in Shropshire. https://t.co/fxuAdN4Tsg— Martin Vernon (@runnermandoc) March 7, 2019
To understand the role of Geriatrics teams in acute ‘front door’ settings in hospital
To recognise when acute Geriatrics teams may be helpful
To appreciate how you might work alongside an acute Geriatrics team
Main Show Notes
Front door Geriatrics can mean different things in different localities. Generally speaking, they are MDTs specialising in the care of older adults, working in settings such as ED, CDU, AMUs or Frailty Units.
Key Points from Discussion
ED attendances are increasingly characterised, not by life-threatening medical emergencies, but by non-emergency situations, for example, relapses in chronic conditions, the consequences of a fall, a breakdown in social care or functional difficulties including a decrease in mobility. Safe discharges back to the community often require an assessment of needs and setting up support systems, in addition to treating medical symptoms.
Recognition of this shift in focus led to the Silver Book by BGS in 2012 and provides guidance on the urgent care needs of older adults in the first 24 hours of an acute care episode, both in the community and in hospital. BGS set up a special interest group for ‘Frailty in urgent care settings’ in 2017.
Front door Geriatrics teams focus on a broader MDT input early in admission rather than focusing on solely the medical issues early on and addressing the wider context later in admission ‘if get complex’, when this could have been predicted earlier on.
Front door geriatrics are usually MDTs which similar to those found on normal wards for older adults but getting involved earlier during admission with the aim being to
Implement early CGA to identify issues to be addressed
Identify which need hospital management
Involve community services for longer term issues to be addressed
Through these, prevent avoidable admission
Effective, early triage to Geriatric specialty wards.
Maintain mobility and function through early intervention
Managing expectations early for complex and frail older adults
management plans e.g. rehabilitation goals, discharge destination, ceiling of treatment
issues to be addressed during admission vs at home
advance care planning
For any good front door service to work, there needs to be access to information regarding the patient’s normal circumstances, care provision and support network.
Early = relatives more likely to be available for collateral
Access to community documentation and information systems. (community ep 3.02)
The teams may involve doctors, nurses, physiotherapists, OTs, pharmacists, social workers etc. Given the setting they work in, they require skills in both acute medicine and Geriatrics and more often work across disciplinary boundaries.
Many different models of care exist across the country. National picture is very mixed and currently no evidence to suggest what model is best for patient and system, maybe that different models are required depending on demographic and type of hospital.
Bedded Frailty Units
Patients usually ‘owned’ by team and have more traditional team structures
Key is clear pathways for preventing unnecessary admission and work best when integrated with social services e.g. those with multiple councils / CCGs may not work so well
Well defined criteria for admission
Need to avoid being ‘just more beds’
Liaison into Acute Areas
Patients usually ‘joint care’ or remain under admitting team
Less traditional interdisciplinary working which is often more flexible.
ED / CDU: Evidence suggests that the presence of therapists in the ED facilitates early discharge and prevents admission however ED may not be the best place for this to occur, nor doing CGA: v. busy, distracting, with time limits before patient moved.
Focus is on good, early, quality of care for older adults but inevitably system metrics are of interest
Decreased LOS through preventing avoidable admissions needs to be balanced against readmissions rates.
Decreased early LOS, can lead to increased LOS in downstream wards as those admitted have high needs comparatively. This is dependent on how the bedbase and data is measured though.
Similarly decreased LOS in downstream wards may be seen due to early information gathering which helps plan discharge and anticipate issues earlier on in admission – impact on ‘stranded’ patients.
Communication is key in forming and maintaining relationships between individuals in any walk of life. In particular, a therapeutic relationship between a health or social care worker and the person they are working with, requires open and clear communication in both directions. We need to be aware of the position of power afforded us in our roles often, and this often means that extra effort is required on our end.
Key Points from Discussion
In this episode we are going to concentrate mainly on the topic of communicating with relatives. Many of the principles will apply to talking to patients themselves. The reason for this focus is that we are assuming that communicating directly with a person about their condition or situation is second nature to many of us, and it is in those situations where they may not be able to speak for themselves that some of the most difficult situations can occur. Multiple opinions and agendas may come to the fore.
Legal and ethical principles
As with everything in medicine, we are bound by law to meet certain requirements to protect our patients, and guided by certain ethical principles to act in their best interests.
Two laws are key here
Common law duty of confidentiality 1
Mental Capacity Act 2005
There are other laws relevant to patient confidentiality and disclosure of confidential information in specific situations, which GMC provides guidance on.
Before you disclose any information to a patient’s relatives, you need the patient’s consent.
Best practise is to ask your patient for their consent before each disclosure. If there are things that they don’t want to be disclosed to relatives, then this must be respected.
Often in practise we see HCPs assuming that patients consent for relatives to be included in discussion, for example where a patient attends A+E with a relative who remains present throughout the assessment, without the patient’s objection, and that’s okay, as per common law. This is implicit consent.
However if there is any doubt, or where sensitive information is being discussed it is really important to have the patient’s consent before disclosing this to relatives. Failing to gain consent could compromise the patient’s trust in that HCP, or in all HCPs, and their subsequent interactions with the health service.
Mental Capacity Act
When patients are unwell in hospital, it’s common for them to be unable to give consent, whether because they are unconscious or drowsy, delirious or have a long-standing cognitive impairment, or because they lack capacity for some other reason. That’s where the Mental Capacity Act becomes relevant. Remember that capacity is decision-specific, and that a patient should be assumed to have capacity until proven otherwise.
If a patient can’t give their consent for an HCP to disclose information to their relatives, then as HCPs it is our responsibility to decide whether this would be in their best interests. If a relative has Power of Attorney for Health and Welfare, then legally we can disclose relevant information to that person to allow them to make decisions regarding the patient’s treatment. Remember you need to see it.
Ethical dilemmas are not uncommon when deciding whether to disclose information to relatives. For example, when a patient has previous expressed that they do not wish for their relative to be informed of some clinical details of their case, and then they lose capacity and we wish to involve the relatives in decision making. Often there is not a clear right answer. What is important, as per the Mental Capacity Act, is that we act in the patient’s best interests and that we choose the least restrictive option. This may mean, for example, disclosing the minimum amount of information possible to the relatives to allow them to be involved in the decision making process, while respecting the patient’s previously expressed wishes to withhold certain information from them. It may mean asking for advocates to be involved or for second opinions from colleagues or ethics committees.
Common Clinical Situations where Communication with Relatives (and/or patients) can be difficult
In each of these scenarios you can see that the balance of power can feel unsettled and this may be what is making the exchange challenging.
Where there is clinical uncertainty
Upsetting or potentially upsetting topics
Breaking bad news
Where a patient’s care is transitioning from active to palliative
Discussions about escalation and resuscitation, particularly where the relative’s opinions differ from those of the responsible clinician
Where patient or relatives are angry, upset, or have a complaint
Where a mistake has occurred which has caused harm or potential harm
Where there has been a breakdown in communication between relatives and staff
Where the relative’s opinions relating to discharge planning differ from the those of the MDT
The SAGE & THYME model framework:
Setting: If you notice concern, think of the setting, create some privacy,
Ask: Can I ask what you are concerned about?
Gather: All concerns – not just the first few – ‘is there something else?’
Empathy: Respond sensitively – ‘you have a lot on your mind’.
Talk: Who do you have to help?
Help: How do they help?
You: What do you think would help?
Me: Is there something you would like me to do?
End: Summarize and close
SBAR works here also I think.
Practical Tips for Communicating with Relatives
Establish who you are speaking to. Don’t make assumptions! Find out what the patient’s support network looks like. Are there other people who should be present for important discussions?
Recognise and acknowledge their emotions. Fear can look like anger, and feeling like they’re not being involved in what’s happening to their sick relative can make people feel frightened. Relatives often feel like they are being kept in the dark, and it may be for as simple a reason as they haven’t known to ask for information. Lack of information can make people really frustrated or angry, and if you make it clear from the start that you are there to inform them and answer their questions, you can diffuse a tense situation very quickly.
Miscommunications and mixed messages from multiple team members can be frustrating, and frightening. Apologise, and try to make sure everyone is on the same page.
Do the relatives want to speak to you with the patient present, or without? (with patient’s consent)
Setting. Assume the unconscious patient can hear you then ask if the relatives would prefer to stay or be elsewhere.
Establish your agenda, and establish their agenda, at the start of the conversation. If there is a lot to discuss, or if time is short, it can help to set it out clearly, like stating the learning objectives at the start of a teaching session, or like a GP might do at the start of an appointment.
Be flexible.. Sometimes you go into a conversation with an agenda and within a few seconds it becomes clear that you are on a completely different page from the person you are talking to. Be willing to be flexible, adapt or abandon your plan. It depends on how much time you have; if a patient is deteriorating quickly then sometimes you have to persevere to try and bring the family onto the same page as quickly as possible; if you have more time, you can take it, and remember that you’re building a relationship for the next days or weeks.
Make sure they know that the decisions being made are not on their shoulders.
Be aware of cultural differences (upcoming episode). Support networks are hugely diverse, and it’s important to approach every patient with an open mind and not to make assumptions before you have gathered information.
Just because you’re comfortable talking about difficult topics, doesn’t mean that relatives are. Relatives get really anxious that patients will find some conversations distressing – sometimes correctly, and sometimes not. It may be helpful to ‘test the waters’ ahead of any conversations with family, with the person directly to establish a) how much they themselves wish to talk about and b) how much they want their family to know / be involved with. Establishing what they know already and what level of information they are comfortable with at the outset can be helpful e.g. are you the sort of person that likes all the details or the headlines? A gentle sentence like ‘I’m worried about how you are doing’, can open the conversation whilst allowing the person themselves control over the pace and content of the subsequent discussion. If relatives then express concern in a meeting, you will be able to talk about what that person wants or does not want to discuss. It also demonstrates that you are capable of having a non-traumatic conversation with the patient on a difficult topic.
Acknowledge that the topic is difficult. Acknowledge their concerns. Point out that just because it’s an upsetting topic doesn’t mean it shouldn’t be discussed, and actually that it’s really, really important that it IS discussed.. Advocate for your patient, point out how it would feel to be kept in the dark e.g. to know something is wrong or that you’re dying but nobody is talking to you about it.
A lot of communication skills with relatives are identical to those for patients –active listening, summarising back, open questions, ICE, ‘any other questions? Anything else you wanted to talk about?’. When will you next speak, and how can they contact you in the meantime? Don’t use jargon!
Feedback important conversations to the rest of your MDT. In a perfect world everyone would read every word in the notes but in reality, people don’t always read the notes and context is often lost. The best way to prevent relatives getting mixed messages is to make sure the MDT is all on the same page.
Particularly Challenging Scenarios
DNACPR and treatment escalation decisions
These can be challenging because of the uneasiness of the situation on both sides. We talked earlier about situations in which patients and relatives can feel uncertain or ‘at sea’ and this can impact on the types of conversations that you will have, including how emotional they become. The same will happen to you and this is why more senior colleagues can have, what seems like the exact same conversation but it go better. It can help to feel best prepared on your side for these conversations. Also, take a moment to reflect before you start: are you tired, stress, hungry? You may not be able to do anything about these at that particular time, but an awareness will help you to recognise whether you need to take a minute to prepare and ‘wind down’. It can also be helpful if you feel yourself getting frustrated in a conversation, to know whether it is partly how you are feeling to begin with. Note episode on psychodynamic approaches to ageing ep 5.01.
As well as the above, remember:
Decisions of this sort are legally medical decisions. A person cannot insist on a futile treatment. An equivalent for therapists would be that a relative cannot insist on bed-based rehabilitation if they will not benefit from it.
PoA means speaking with that person as though they are the person they are advocating for. This still does not give them the right to insist, as the person would not either.
Next of kin, in the absence of PoA technically has no legal standing, although we would all agree that active involvement in decision making should be undertaken. No-one, including the person themselves, nor the PoA can insist on a futile treatment. A judgement call needs to be made on the impact on your therapeutic relationship for other aspects of treatment though, to push through a decision like this.
Joint decision making is likely to be the most successful. Using phrases that allow you find out as early as possible how close to common ground you are can be really helpful. You can then work out how to meet them there. Try things like:
So your mother has been unwell for a few months now, tell me what has been happening – this often allows the person themselves to acknowledge any deterioration leading up to this point.
You mentioned that your mum can’t walk very far – this can then lead to a discussion about physiological reserve in the face of an illness.
Your mum is very unwell right now, have the two of you ever had any conversations about what she would or wouldn’t want to happen in situations like this?
If your mum could hear us talking now, what do you think she would say about it? – this often alleviates the pressure felt by a loved one about how they feel vs what they think their relative would want.
Through the use of clinical vignettes, one study looked at how 3 different levels of shared decision making after a clinical error where interpreted by the American public. Those with brief, but thorough shared decision making, were 80% less likely to report a plan to contact a lawyer than those not exposed to shared decision making (12% and 11% versus 41%; odds ratio 0.2; 95% confidence interval 0.12 to 0.31). Participants exposed to either level of shared decision making reported higher trust, rated their physicians more highly, and were less likely to fault their physicians for the adverse outcome compared with those exposed to the no shared decision making vignette.
The term ‘flow’ describes the progressive movement of people, equipment and information through a sequence of processes. In healthcare, the term generally denotes the flow of patients between staff, departments and organisations along a pathway of care.
Flow is not about the what of clinical care decisions, but about the how, where, when and who of care provision. How services are accessed, when and where assessment and treatment is available, and who it is provided by, can have as significant an impact on the quality of care as the actual clinical care received. The concept of using flow to improve care has received increasing traction within healthcare, especially in relation to reductions in patient waiting times for emergency and elective care. Awareness has been growing of the ideas, first tested in other industries, and results that organisations have generated by applying flow thinking to their organisations.
Definition from staff – Daniel Woosey Physician Associate, Surrey and Sussex Healthcare
It’s the movement of patients from the front door of the hospital through the hospital process until they are discharged home.
Bed crises are now commonplace in our acute hospitals. Patients regularly wait in crowded emergency departments, breaching the four-hour target because of lack of available acute medical inpatient beds. There has been a year on year increase in emergency medical admissions and hospitals have consistently high bed occupancies. A common short-term solution to the problem is to ‘board out’ patients from medical wards to surgical wards or even temporarily to day units to facilitate patients to be transferred out of the emergency department.
Why worry about flow?
A simple guide to congestion
On a free-flowing motorway, typically the right-hand lane will be occupied by cars travelling faster than the left and middle lanes. To travel safely at 70mph, a car needs about 100 metres of road. At slower speeds, less space is needed. The maximum capacity of a kilometre of road, assuming safe distances are maintained, is around 43 cars. The fastest cars will cover a kilometre in 32 seconds.
If more cars join the road, traffic will have to slow down to maintain a safe distance. In the managed motorway example, this allows 51 cars (20% more) to fit in a kilometre of road. The average journey time increases by only 4 seconds but total time for all road users jumps by 32% (28 to 37 minutes) (Transportation Research Board, 2008).
Once more traffic joins the road, speeds must reduce further. At 30mph, all of the lanes travel at the same speed, and three times as many vehicles can fit in a kilometre of road (see Table 1 for a breakdown of this). However, the average time taken to travel 1 km has almost doubled and the total time for all users has increased almost six times.
The fact that more congestion in a confined space means less speed, and less flow once a certain level of occupancy is reached, is well established in modelling of road traffic. Heavy congestion cannot be solved by asking people to drive faster. In fact, speed can only be increased by reducing congestion first.
The flow of patients through beds in a hospital reflects the same dynamics as the flow of traffic on a road. Just as cars moving more quickly require more road, patients who are moving through the hospital system more quickly use more bed space and resources at any one time.
This is because, relative to the amount of time they spend in a bed, more time must be spent preparing the bed for them, preparing it for the next patient, and carrying out processes for admission or transfer. As wards fill, this becomes less feasible. Just as with a full road, the speed of passage becomes limited
Peak occupancy is when the most beds are full. It normally occurs around 8am, after overnight admissions and before patient discharge starts.
Peak flow is when the most patients are being moved in and out of beds. It normally occurs in the late afternoon, as emergency arrivals and elective discharges peak.
Flow needs space: every patient transfer requires sufficient resources for the process to happen without delay. After discharging the previous patient, this includes time for cleaning, patient transfer, handover and communication. Unless each of these is in place, the process will take longer than necessary, potentially leading to poor patient experience as queues build up. Furthermore, increasing amounts of staff time will be wasted waiting for patients and rescheduling work.
When queues build up, work-around solutions such as ‘boarding’ patients on wards or providing care in the emergency department or assessment areas are used, often increasing delays.
The amount of space needed to manage peak flow is dependent on the numbers of admissions and discharges and the time each takes. We estimate that between 2% and 4% of bed capacity is likely to be needed for this activity in most hospitals.
Six principles underpin good non-elective patient flow
Flow is a team sport – patients often visit many different health and social care professionals and departments before, during and after their hospital stay. All organisations, departments and staff groups in and outside hospitals need to collaborate and act together – for example, through shared assessments and interventions to deliver effective and responsive patient care.
Flow needs focus from the top – there should be senior clinical and executive leads for flow who use live data to track flow across the hospital, identify unnecessary variation and troubleshoot where there are bottlenecks.
Flow is seven days a week – attendances and admissions occur relatively consistently through the week and so should reviews, transitions and discharges.
Flow is about case mix – use analytical tools to understand the acuity of patients attending the ED and how this varies across the day and the week. Use this information to match resources to demand.
Flow needs patient input – pathways and individual patient journeys should be regularly reviewed with patients to appreciate where flow is being blocked, see things from their perspective and improve processes and systems.
Flow needs to be maintained at times of pressure – systems will come under significant stress. Tried and tested escalation processes should be implemented when they do, to protect assessment and short stay wards, clinical decision units, ambulatory emergency care and acute assessment services. Escalation should be meaningful and the whole system needs to act to relieve pressure where it occurs.
Poor quality healthcare systems deliver poor results – for patients, staff and taxpayers. Much of the previously experienced growth in NHS funding was predicated on the assumption that more resource and capacity was required to improve the quality of, and access to, healthcare. However, many have observed that these increases did not deliver the proportionate improvements expected.
Only 10% of patients stay in hospital over 7 days, but these patients use 65% of beds and generate 32% of income (Hospital Episode Statistics, 2016). Redesigning this phase of care appears to offer very large system benefits.
Patients living with frailty are no different.
From the NHS-I document – Report then links into SAFER and red/green days
Frail patients are identified as soon as they present to the ED or directly to assessment services, and receive specialist, high quality, person-centred care on the non-elective pathway. They are discharged without delay when their acute care is complete, with the right level of support to continue their recovery and rehabilitation in their own home.
Frailty should be identified and measured at the front door using an evidence-based assessment tool (for example, the Rockwood Clinical Frailty Scale).
There should be a multidisciplinary team that is competent to deliver holistic assessment and management of older people (through comprehensive geriatric assessment).
The frailty pathway should be embedded in processes in the ED, AEC, CDUs, AMUs and on specialty wards.
Patients with frailty should be actively involved in their care and the provider able to demonstrate shared decision-making/patient-centred care. Patients should be routinely asked what is most important to them and their responses clearly documented.
Hospitals should be aware of what happens to patients with frailty who leave their service. This is a central part of providing care to these patients.
S – Senior review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions.
A – All patients will have an expected discharge date and clinical criteria for discharge. This is set assuming ideal recovery and assuming no unnecessary waiting.
F – Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10 am.
E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday.
R – Review. A systematic multi-disciplinary team review of patients with extended lengths of stay (>7 days – ‘stranded patients’) with a clear ‘home first’ mindset.
1.34. The NHS and social care will continue to improve performance at getting people home without unnecessary delay when they are ready to leave hospital, reducing risk of harm to patients from physical and cognitive deconditioning complications.
What can the MDT do to help?
NHS I report – AHPs supporting patient flow
Patient flow is a team sport’. Without AHPs there would be no flow. Patients would languish in hospitals, inappropriate admissions would flood in and discharges would grind to a halt. AHPs, the third largest professional group in the NHS, are highly trained autonomous professionals whose collaborative work with medical, nursing and social care colleagues is the engine of patient flow.
This report showcases some good examples of where AHPs working together with other parts of the MDT improve care and improve flow.
All AHPs should:
ask what they need to start, stop or do differently to support patient flow across the system and to gain the most value from AHPs skills
review the 10 clinical standards of the seven day hospital services programme (NHS England, Seven Day Services Clinical Standards, 2017) to ensure AHP services support the ambition for patients, admitted as an emergency, to receive high quality consistent care, whatever day they enter hospital
use the ‘state of readiness for future care’ framework (see Annex) to review utilisation of the workforce: ― are all professions working at the top of their scope of practice? ― what skills are or can be shared to reduce duplication and silo working? ― what can we train others to do and safely delegate?
support cultural change, particularly moving from risk aversion to a culture of embracing positive risk as part of AHPs’ professional duties (Royal College of Occupational Therapists 2018)
evaluate, improve and demonstrate the impact of AHPs’ contribution (Priority 3, AHPs into action)
ensure that AHPs are aware of, support and where appropriate, lead initiatives such as the SAFER patient flow bundle, Red2Green days, ‘end PJ paralysis’ and ‘last 1000 days’ campaigns, recognising the value of their input.
This links into the principle of Kaizen and the small incremental improvements – its the small things that really matter and add up to make bigger changes.
To date, virtually all attempts to improve flow have focused on single organisations or pathways. Hardly any have sought to improve flow across the entire primary, acute and social care spectrum. The task of bridging the entrenched cultural differences between professions and bringing together organisations that have often been governed, funded, inspected and regulated in isolation has been too daunting for most
This study sought to identify common design flaws that limit the impact of flow initiatives.
This qualitative study was conducted a Canadian regional health system in which a number of flow initiatives had yielded no overall improvement in system performance. Interviews with 62 senior, middle and departmental managers, supplemented by ∼700 documents on flow initiatives, were analysed using the constant comparative method.
Findings suggested that smooth flow depends on linking a defined population to appropriate capacity by means of an efficient process; flawed initiatives reflected failure to consider one or more of these essential elements. Many initiatives focused narrowly on process, failing to consider that the intended population was poorly defined or the needed capacity inaccessible; some introduced capacity for an intended population, but offered no process to link the two. Moreover, interveners were unable to respond effectively when a bottleneck moved to another part of the system.
Typically, flawed initiatives focused on too small a segment of the patient journey to properly address the impediments to flow. The proliferation of narrowly focused initiatives, in turn, reflected a decentralised system in which responsibility for flow improvement was fragmented. Thus, initiatives’ specific design flaws may have their roots in a deeper problem: the lack of a coherent system-level strategy.
Reduce the volume of patients by redesigning assessment, diagnosis and short stay care.
Most activity growth is for short-stay patients. Redesigning the ‘front’ of the hospital may improve care, but this is unlikely to be sufficient to solve flow problems. •
Reduce the time spent in hospital by redesigning rehabilitation and discharge processes.
Only 10% of patients stay in hospital over 7 days, but these patients use 65% of beds and generate 32% of income (Hospital Episode Statistics, 2016). Redesigning this phase of care appears to offer very large system benefits. •
Improve control systems to provide real-time workflow information to improve both individual patient care, system management and support process improvement.
Around 90% of patients spend less than 6 days in hospital and use only 35% of hospital space with an average stay of 1.1 days (Hospital Episode Statistics, 2016). Very small changes in length of stay (measured in minutes) and small changes in the time taken to prepare beds can cause significant disruption. Hospitals need systems that reduce non-value-adding time and provide real-time operational data to support real-time decision making and service planning.
A review article published in the BMJ on 31 January. Authored by Terence Quinn, Simon Mooijaart (Moy-yaart), Katie Gallacher, and Jennifer Burton. It’s called “Acute care assessment of older adults living with frailty.” I chose this because in it there’s a simple graphic to guide initial assessment of the frail older person when they present to acute care settings. To give a flavour of what is highlighted under four key domains you find, under history – medications, for physical exam – vision and hearing assessment, for psychiatric exam – a delirium screen, and for functional assessment – gait and balance. And what I liked about this is that around these four domains the authors have highlighted the knowledge about the home environment and caregivers as essential contextual information that should shape management of these individuals.
Major Trauma is defined in the scientific literature using the Injury Severity Score (ISS), which assigns a value to injuries in different parts of the body and totals them to give a figure representing the severity of injury. An ISS greater than 15 is defined as Major Trauma
Major Trauma; “multiple serious injuries that could result in disability or death” – it makes no comment on the mechanism of the injury
The Silver Book, the British Geriatric Society guidelines for the emergency care of the older people, recognises the need for additional special considerations to be integrated with the ATLS approach in managing elderly trauma and endorses the view that geriatricians should receive training in the structured assessment of older people trauma, including hip fractures, head injury and polytrauma
Important to point out here I think that trauma can mean: Neurological injury, chest injury, skeletal injury or internal organ injury. It is not just broken bones. Assessment therefore as we shall see requires a range of professionals. We will not really talk too much about neck of femur fracture care as that is only one part of trauma and I will talk too long!
Key Points from DiscussionWhat is major trauma?
Historically disease of young men and high energy transfer mechanisms of injury
e.g. road traffic collisions, crush injuries, stabbings/shootings etc
1990 biggest major trauma group 0-24 years old (approx 40%)
but…now- mean age of trauma patients is increasing
The UK population is ageing – in the past 70 years ago, life expectancy in the United Kingdom has increased dramatically. Now just over 10% of Britons die before age 65, compared to nearly 50% when the NHS was founded in 1948.
This increase has been greater than that predicted by population data alone, with the percentage of major trauma patients over 70 years old nearly tripling since 2005.
In 1990, the mean age of the Major Trauma patient was 36.1 years, but by 2013 this had increased to 53.8 years
the most common mechanism of injury is fall from standing height (i.e. low transfer mechanism of injury)
Trauma Audit and Research Network (TARN)
In the late 1980s data showed that there was unnecessary mortality due to inadequacies in organisation and delivery of care – led to the development of TARN
national organisation, collects data on trauma in the UK
inputs- type of injury, physiological parameters, predicted survival, compared with actual outcomes
now the largest trauma database in Europe
really good source of lots of useful information/ research on trauma in the UK
Patient are seen initially in the prehospital setting (i.e. ambulance/ air ambulance)
Prehospital practitioners use triage tools, transfer time and clinical judgement in order to decide whether the patient is transferred to a trauma unit or major trauma unit
The major benefits of prehospital care are realized during the second phase of trauma (after the initial impact), when the timely provision of care can limit or halt the cascade of events that otherwise quickly leads to death or lifelong disability.Without prehospital care, many people who might otherwise survive their injuries may die at the scene or en route to the hospital. Most deaths in the first hours after injury are the result of airway compromise, respiratory failure or uncontrolled haemorrhage. All three of these conditions can be readily treated using basic first aid measures.
Triage tools take in to account factors such as vital signs, anatomy of injury and mechanism of injury to guide decision making.
Most tools also include special considerations for special patient groups such as pregnant women, the morbidly obese and older patients
The idea is to get the right patient to the right place at the right time for the right treatment
Current prehospital triage systems are not good at identifying older major trauma patients: just 17% of major patients older than 60 were triaged directly to MTCs by pre-hospital services, compared to 40% of those under 60 years old.
This could be because much of the teaching on trauma triage emphasises the importance of mechanism of injury, aiming to identify high energy transfer mechanisms. However, this does not apply to older people, who can sustain serious injuries from relatively low energy transfer mechanisms.
This lack of early identification means that initial treatment is more likely to be in a lower level Trauma Unit or District General Hospital, and to be undertaken by a more junior doctor.
It also means older patients are less likely to be transferred to specialist care, and have longer times to both investigation and intervention – for instance, TARN has shown the elderly wait longer for a CT head following head injury, and have longer times to surgery across all body areas and categories.
As expected, age has a profound impact on survival from Major Trauma: 12-month mortality in the over 75s is 40%, compared to 10% in the over 60s.
Although older patients are more likely to die, those who survive do not have a larger incidence of disability compared to younger people.
Both these studies have failed to show that increasing Injury Severity Score (ISS) significantly impacts on outcome – but our systems to look after older people with trauma as we shall see are often based around this score.
Good outcomes are possible following Major Trauma in the elderly, and it appears possible to improve outcomes with coordinated and systematic approach, as has happened in neck of femur fractures (mortality has halved thanks to the NHFD)
Surgeons in all specialties and anaesthetists are less reticent to operate on elderly patients than previously as outcomes continue to improve.
For instance, severe open lower limb trauma is a complex injury in patients of all ages, and limb salvage may require free tissue transfer.
Older people are more prone to this type of injury
a recent single-centre study of management of severe open lower limb trauma in the elderly demonstrates positive outcomes: the group report only 7% mortality at 6 months, with the cause of death unrelated to injury in all of these patients.
The study also reported positive patient reported outcome measure results, and clinical outcomes in keeping with and even better than those reported for other age groups (i.e., 1% flap failure rate and 150 days to bony union).
It is vital to point out that this elderly patient group received expedient surgical intervention, indeed they received it as quickly as patients in younger age groups, and in keeping with national guidance.
Khadim MFK, Emam A, Wright TC, Chapman TW, Khan U. A Comparison Between The Major Trauma Centre Management Of Complex Open Lower Limb Fractures In Children And The Elderly. Injury 2019.
Systematic literature review and meta analysis of older patients with trauma (>65 but compared the >75 group to the 65-75 yrs)
Overall mortality rate among the geriatric population presenting with trauma is higher than among the adult trauma population. Patients older than 74 years experiencing traumatic injuries are at a higher risk for mortality than the younger geriatric group. However, the trauma-related mortality sustains the same rate after the age of 74 years without any further increase. Moreover, severe and extremely severe injuries and low systolic blood pressure at the presentation among geriatric trauma patients are significant risk factors for mortality.
Older people appeared to have poorer postinjury functioning and HRQoL compared with younger adults or preinjury levels
Poor preinjury function, pre-existing conditions and increasing age were associated with poorer outcomes, whereas preinjury-independent living was associated with better outcomes.
but:… The studies were heterogeneous, limiting synthesis. There was a lack of evidence around the impact of injury on older people in terms of paid work and unpaid work. It was unclear if existing injury outcome guidelines are appropriate for older people.
Older people do worse generally, and are often at increased risk of peri-procedural mortality, although this may relate to a more severe initial illness. However older people, who survive major trauma, have similar outcomes to their younger counterparts
There is little seasonal variation in major trauma in older people.
There was little variation in length of hospital stays across the adult age groups
Comorbidity (as measured by the Charlson Comorbidity Index) has an adverse effect on outcome, but it is likely that other factors associated with age have a greater effect. Research is needed to determine the effect of frailty
During the past few decades, research has shown that many injuries can be prevented or their severity reduced through the implementation of simple measures.
Innovative solutions that engage different sectors of society have resulted in cost-effective interventions that can prevent injuries at work, at home and on the street.
Examples include the use of motorcycle helmets and restraining systems, such as seat-belts and child restraints in cars. detectors; and the installation of fencing around hazards such as wells or deep pools of water.
Many of these strategies are highly cost effective.
Motorbike helmets in UK – 1973
Seat belt law in UK Motorbike helmets – 1983
Seat bels in buses – all made after 2001
Health and safety act – 1974
Adult safeguarding – part of care act 2014
Where will we be in 2031?
Systems of care and care pathways in operation or in development Midlands Silver Trauma Group
The Midlands Silver Trauma Group was established in November 2016 by Midlands Critical Care and Trauma Networks to fulfil a number of aims
To respond to issues emerging in management of elderly trauma
To establish workable, evidence-based standards of care
To expand their HECTOR (Heartlands Elderly Care Trauma & Ongoing Recovery) training programme from a regional to national initiative
Their response to the problem of under-triage of elderly trauma patients was to implement a SIlver Trauma alert – a pre-alert issued to the receiving emergency department when an elderly patient was likely to need early intervention or access to imaging, but who may not always need a trauma team response.
Criteria for activation of the Silver Trauma Alert are:
Age 65 or over
SBP <110mmHg with a significant injury
Injury to 2 or more body regions
Suspected shaft of femur fracture
Open fracture proximal to the wrists or ankles
Direct conveyance to Major Trauma Centre if RTC or Pedestrian vs car mechanism
Polypharmacy is when people are taking multiple medications.
As people get older the number of medication they are prescribed can increase as they develop more and more medical conditions (indeed also the as the treatment of these conditions changes with time there may be more medications used – Average number of medications per person has increased by 54% in ten years)
Due to changes in older peoples physiology then polypharmacy can become a problem and actually iatrogenesis is one of Bernard Issacs ‘geriatric giants’
Definition of polypharmacy has changed over the years as the number of medications people take has increased, so more than 4 or 5 medications would have been considered polypharmacy
‘Use an approach to care that takes account of multimorbidity for adults of any age who are prescribed 15 or more regular medicines, because they are likely to be at higher risk of adverse events and drug interactions. Consider an approach to care that takes account of multimorbidity for adults of any age who:
are prescribed 10 to 14 regular medicines
are prescribed fewer than 10 regular medicines but are at particular risk of adverse events.’
But the numerical definition of polypharmacy is not as useful as taking an approach when you decide whether someone has appropriate or inappropriate polypharmacy (often called problematic polypharmacy)
An example of appropriate polypharmacy may be a robust older person who has had a heart attack and now has heart failure, it may be appropriate for him to be on 7 or 8 different medications.
By 2018 3 million people in the UK will have a long-term condition people managed by polypharmacy
The number of people on ten or more medication has increased from 1.9% to 5.6%
A third of people aged 75 years and over are taking at least six medicines.
If people take multiple medications then there may be drug-drug interactions e.g. cholinesterase inhibitors and anti-cholingerics – we discussed this in episode on delirium 1.02.
Drug – disease
There are also drug – disease interactions, when a medication can make the management of another disease more difficult e.g. NSAIDS can make hypertension worse.
It is very easy for people to end up taking multiple medications, especially when single disease guidelines are followed for an individual who has multiple diseases.
With multimorbidity in particular, the number of drug-drug interactions can rapidly escalate.
In one paper 12 single disease NICE guidelines were analysed and they found 133 potentially serious (drug-drug) interactions for the type 2 diabetes guideline, of which 25 (19%) involved one of the four drugs recommended as first line treatments for all or nearly all patients.
and 32 potentially serious drug-disease interactions between drugs recommended in the guideline for type 2 diabetes and the 11 other conditions.
Given that: “adverse drug events cause an estimated 6.5% of unplanned hospital admissions in the United Kingdom, accounting for 4% of hospital bed capacity” It makes it an area we should focus on!
Complying with disease specific guidelines is difficult, a person with three chronic diseases takes six – thirteen different drugs a day, if people have six chronic conditions (COPD, ischaemic heart disease, osteoarthritis, hypertension, diabetes and depression) then the number of medications rose to 18 a day
Something that we commonly see is a prescription cascade, where a medication has been started to treat the side effect of another medication e.g. furosemide is often started to treat the leg swelling (peripheral oedema) that has been caused by a calcium channel blocker such as Amlodipine.
In addition to what has been discussed so far then there are some medications that can commonly cause problems specifically in older frailer people – such as medications with a high anticholinergic burden (discuss later), and medications that have a sedative effect such as diazepam or zopiclone.
Medication most associated with admission due to ADR
The most common medicine groups associated with admission due to ADRs were:
Worth noting that these are recognised adverse effect e.g. easier to recognise when a drug is causing an AKI, drugs that cause people to present with vague symptoms, frailty crisis etc may not be in the above list.
Older people are more sensitive to the adverse effects of polypharmacy due to some physiological changes which occur with ageing. NERD ALERT
Absorption: Increased Gastric pH (sometimes due to medications such as proton pump inhibitors) due to atrophic gastritis. Decrease in gastric emptying.
Distribution: Probably the main physiological change that occurs with ageing that leads to adverse drug reactions.
Increase in body fat and decrease in body water (as a proportion of total body weight).
Volume of distribution of fat soluble drugs increases so medications such as benzodiazepines accumulate due to increased elimination half life, so can still have an effect a long time after the medication has been stopped.
Volume of distribution of water soluble drugs is decreased so water soluble drugs e.g. such as digoxin need a reduced loading dose.
Altered permeability of the blood brain barrier so the brain of an older adult can be exposed to higher levels of medication causing cognitive adverse effects
Reduced hepatic blood flow can reduce clearance of medications that have high hepatic excretion ratio e.g. Amitryptiline.
Relevant to polypharmacy in any age is the number of medications someone takes means it is more likely that they are taking an inducer or inhibitor of Cytochrome P450 increasing the chance of drug-drug interactions.
As people age there is a reduction in renal mass and renal blood flow. eGFR decreases by 0.5% a year after age 20.
Affects clearance of water soluble drugs such as diuretics, digoxin and NSAIDs.
Older people and drug trials
When they are included often they are ‘healthy’ older people
Frailty, multimorbidity, cognitive impairment, care home residents often an exclusion criteria
20-50% of older people prescribed at least one medicine with anti-cholinergic activity.
Dry mouth and eyes, constipation, urinary retention, blurred vision, tachycardia
Sedation, confusion, hallucinations, decline in cognitive and physical function
23% of people with dementia.s prescribed AC drugs.
medicines with anti-cholinergic properties have a significant adverse effect on cognitive and physical function, but limited evidence exists for delirium or mortality outcomes.
“We searched the Medline database from 1966 to 2007 for any study that measured the anticholinergic activities of a drug and evaluated the association between such activities and the cognitive function in older adults. We extracted from each study the method used to determine such activities and the list of medications with anticholinergic activities that were associated with negative cognitive effects, including delirium, MCI,dementia or cognitive decline. This list was presented to an expert interdisciplinary team that included geriatricians, geriatric pharmacists, geriatric psychiatrists, general physicians, geriatric nurses and aging brain researchers. Subsequently, the team categorized the above medications into three classes of mild, moderate and severe cognitive anticholinergic negative effects”
Firstly why do we want to deprescribe, it may be for many older people living with frailty then they are not going to live long enough to benefit from medications that are being used for prevention purposes such as statins or antihypertensives.
Should try and continue medication if it is providing day to day symptomatic relief such as analgesia, antianginals if get angina – broadly follow the principles from the multimorbidity guidelines to help with this:
Should not stop drugs such as antiseizure medication or drugs for parkinsons without very careful consideration and input from the relevant specialist.
Barriers to Medicines optimisation or Deprescribing
Concern from clinicians to discontinue medications started by another provider
Fear of drug-withdrawal side effects
Lack of resources
Resistance from patients or family members
Fear of losing patient-provider relationship
Protocol to Medicines Optimisation or Deprescribing
Ascertain all drugs patient is currently taking and reasons for each one
Need patient (or family member) to bring all drugs (prescribed, complementary and alternative medications and OTC meds)
Clarify how/when/if patient is taking medication
Ask the patient if they have missed any doses recently:
mention a specific time (such as in the past week),o explain why you are asking,
ask about medicine-taking habits,
do not apportion blame.
Use the pharmacist to help! – perform med reconciliation (may involve contacting patient’s pharmacy, employing pill counts, etc)
Consider overall risk of drug-induced harm in individual patients in determining required intensity of deprescribing interventions
Unnecessary polypharmacy, the use of drugs at incorrect doses, and potential drug-drug and drug-disease interactions were significantly lower in the intervention group at discharge (absolute risk reduction 35.7%, number needed to screen to yield improvement = 2.8 (95% confidence interval 2.2-3.8)).
Underutilization of clinically indicated medications was also reduced (absolute risk reduction 21.2%, number needed to screen to yield reduction = 4.7 (95% confidence interval 3.4-7.5)).
Here – created a list of medications suitable for safe prescribing in older people. Started with an 11 member panel.
Updated in 2015
A list of explicit criteria for potentially inappropriate medication (PIM) use in frail older adults with limited life expectancy.
STOPPFrail comprises 27 criteria relating to medications that are potentially inappropriate in frail older patients with limited life expectancy. STOPPFrail may assist physicians in deprescribing medications in these patients.
Has the diagnosis changed? Was long term treatment intended? Is the dose correct?
Solicit the patients opinion and concordance
Tests and monitoring
Are further tests needed?
Evidence and guidelines
Is there a better approach to this illness now? e.g. new guidelines
Consider iatrogenic problems (Side effects, drug interactions)
Risk reduction or prevention
Identify the individual patients risks
Simplification and switches
Simplify the regimen and implement cost effective switches
Consultant Pharmacy Services – Tasmania
Address one of the key problems with the things we just talked about – you have to know something about the condition etc to make a choice with the patient. All well and good if you know everything(!) and understand the context, but for most of us it’s hard. These try to address that by looking at specific groups of medications and have produced an excellent series of factsheets for specific groups of medications.