More than 40% of hospital inpatients in Scotland are 75 years or older and many of these patients are frail and have multiple comorbid illnesses.1 They may be unable to see, hear or understand. They are likely to be taking large numbers of medications with very little idea of the names of these drugs, what they do or what side effects they might have. They may be worried and confused. They are also unlikely to have a single diagnosis. For well over a third, admission marks the beginning of the last year of their lives.1 This challenging area of medicine requires great patience and is littered with pitfalls for the unwary. It can also be one of the most rewarding with traditional clinical skills such as establishing a clear history, examining well and making mature clinical judgements all key to success.2


Using the telephone
The often quoted aphorism ‘Listen to your patient, they are telling you the diagnosis’ might be reworded ‘Speak to the relatives...’ when assessing older patients. More often than not the key to a proper history is the telephone and for some older patients it is the only way to obtain any form of history. Telephoning a relative, usually a daughter or a son, and obtaining a history in this way has the added advantages of letting the family know if you are worried and of reassuring them if not. If the frail older patient cannot give a history and has no relatives, then telephone the GP, the carer or the residential home.

 


Assessment
The unprecedented rise in emergency medical admissions can only be accommodated with the same or a lower number of hospital beds if the number of occupied bed days falls. If this is to happen then it follows that the process of ensuring a safe discharge should begin at the time of the receiving call and not 24–48 hours later. The need to free up beds should not, however, override clinical common sense as hasty decisions taken when frail older adults are acutely unwell can lead to an overestimate of care or even a premature move to a care home.

 

Case History: The first part

An 84-year-old retired sheep farmer, living in a care home, has been sent in by the out-of-hours doctor following reports from his care home of poor oral intake and increasing agitation. U&E show mild acute kidney injury with blood urea 14.6mmol/l and serum creatinine 117umol/l (baseline creatinine 89umol/l) and a modestly raised CRP of 17.

The ward doctor phoned the care home and established that the patient had advanced dementia, doesn’t speak, doesn’t like being touched and becomes easily agitated. He spends most days curled up in bed. His wife used to visit regularly, but was unwell for six weeks and died five days ago. The patient has not been told. Her funeral is tomorrow.

We spoke with the patient’s son and daughter and learned that when their mother went to visit he would always hold her hand but would never speak. They told us he had become doubly incontinent; that he required to be hoisted from bed to chair; that he didn’t always recognise them; that he was now completely dependent on his carers for all aspects of personal care; and that he had been in his care home for two months after spending six weeks in the local cottage hospital.

 
Compile a problem list and write a plan
A well constructed problem list helps concentrate the mind and will invariably inform the investigation and management plan. It is essential to identify the main problem or problems rather than focus on medical incidentals and miss the ‘elephant in the room’. Students are usually taught to create lists of differential diagnoses and problems separately, whereas the two can usefully be combined and used as a single list. Review of previous notes together with comments from the care home and our own observations allowed us to construct the following problem list for the 84-year-old patient in the case study:
  • Frail older adult
  • Advanced dementia
  • Not eating and drinking
  • Mild acute kidney injury
  • Raised CRP—query urosepsis
  • Atrial fibrillation—not on warfarin
  • Previous bladder cancer
  • Wife died five days ago—funeral today.
Our investigation and management plan was determined by the problem list. It recommended excluding urinary infection if possible, drug review, intravenous fluids and most important of all—speaking to a family already devastated by the loss of their mother only five days previously.

Know how to recognise frailty
Frailty refers to the gradual loss of in-built reserves that occurs with age, as a result of which apparently minor events, such as infection or new medication, may trigger dramatic deterioration in physical and mental wellbeing.3 It is not an inevitable part of ageing and is not the same as comorbidity or disability, though frailty, comorbidity and disability frequently coexist. Broadly speaking there are five frailty syndromes, presentation with any one of which should lead the doctor to suspect that the patient may be frail (table 1). By any one of these criteria our patient was frail. The British Geriatric Society and The Royal College of Physicians describe approaches to frailty in The Silver Book4 and The Acute Care Toolkit5 respectively.

 

Table 1. frailty syndromes

Falls: collapse, legs gave way, found lying on the floor
Immobility: gone off legs, stuck on toilet
Delirium: acute confusion, muddled, sudden worsening of confusion in someone with previous dementia or known memory loss
Incontinence: new onset or worsening of urine or faecal incontinence
Sensitivity to drugs eg. confusion with codeine, hypotension with antidepressants

 

 
Comprehensive Geriatric Assessment
The gold standard for the assessment and management of frailty in older adults is a process of care known as Comprehensive Geriatric Assessment (CGA).3 CGA has been defined as a ‘multidimensional and usually interdisciplinary diagnostic process designed to determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances’.6 Acute Medical Units that have adopted CGA will usually have a care of the elderly team comprising a physician, physiotherapist, occupational therapist, pharmacist and social worker. A detailed review of CGA is beyond the scope of this paper, but will include everything we have discussed so far, namely early contact with the family, creation of problem lists and discharge planning from the day of admission. CGA increases a patient’s likelihood of being alive and in their own homes after an emergency admission to hospital7 and has also been shown to reduce occupied bed days.8 The British Geriatric Society review CGA in their recent Consensus Practice Guidelines.3

CARDS
The acronym CARDS stands for Continence, Ambulant, Rational, Daily Living and Social Support. It can facilitate a safe discharge if a patient only goes home ‘when their CARDS are right’. No assessment of the frail older adult is complete without documenting visual acuity and hearing, both of which can be included in an expanded CARDS acronym where A stands for ambulant and acuity and D for daily living and deafness. CARDS is not a substitute for formal functional assessment9 but can be used as a rapid and efficient way of obtaining important personal, functional and social history about frail patients when speaking to their families.

 

Table 2. CARDS

C: Continence including use of pads or catheter

A: Ambulant including use of walking aids and tendency to fall

R: Rational, ie. whether muddled and if so how muddled

D: Daily living, ie. the ability to wash, dress and feed self

S: Social support including who does the housework, meals and shopping

 

Sensitivity to drugs
The use of multiple medications and/or the administration of more medications than are clinically indicated is common among frail older adults10 and no assessment of an older person admitted to hospital as a medical emergency is complete without a detailed review of their medications. Adults change physiologically as they age and this must be taken into account when prescribing. Drugs particularly associated with adverse outcomes in frail older adults include antimuscarinics in cognitive impairment; long acting benzodiazepines and some sulphonylureas, other sedatives and hypnotics that increase falls risk; some opiate based analgesics that increase risk of confusion or delirium; and NSAIDs, ACE inhibitors and angiotensin receptor blockers that can cause acute kidney injury when dehydrated.3 Evidence is also emerging that it may be harmful to lower blood pressure in frail older care home residents to targets designed with younger fitter adults in mind.11 Prescribers should, therefore, take responsibility for knowing what frail adults can expect as a benefit or harm from medications before recommending they start or continue on them. Guidelines exist to help doctors as well as patients through this process.12

Delirium
“Confused and off legs” is an all too common presentation in frail older patients, but not a diagnosis. Delirium is a dangerous condition that increases morbidity, mortality and length of stay. 
 
It is also identifiable and treatable. As doctors we have been slow to recognise the importance of delirium though the introduction of the 4AT has raised awareness13 The 4AT is easy to perform and, as an essential factor, requires collateral history from a relative or GP. The Single Question in Delirium (SQiD) screening tool is even simpler to administer: does the relative or friend think the patient has been more confused recently?14 In most instances of delirium there is underlying cognitive impairment. Our patient’s recent increase in agitation (confirmed by collateral history) meant that he met the criteria for delirium. The management of delirium and agitation at the end of life has been reviewed recently.15

How to make a diagnosis of urinary tract infection
Infection is an important trigger for delirium and the urinary tract one of its most common sources. The challenge for the clinician is to diagnose correctly when present and exclude with confidence when absent. “Urosepsis?” is a frequent immediate discharge diagnosis in a frail older patient, usually to the dismay of the doctor to whom the task falls of compiling a formal summary when he or she discovers that a urine sample was requested, but not sent or sent but only after an antibiotic had been started.

To complicate matters further, confused older men and women are unlikely to be able to collect urine aseptically while positive urinalysis and positive urine cultures in the elderly may indicate colonisation rather than infection. An in-out catheter can be considered if it is difficult to obtain a sample, but would usually be inappropriate in the context of delirium. Ninan et al have addressed the investigation of suspected urinary tract infection in older people recently and advice is summarised in Table 3.16

 

 Table 3. urinary incontinence

1. Do not use urine dipstick tests to diagnose urinary tract infection in older people; if they are performed at all, only a negative result should be considered useful in excluding a urinary tract infection.

2. In patients who are able to provide a history, urinary tract infection should be diagnosed only in the presence of a combination of at least three acute urinary symptoms or signs, such as dysuria, urgency, frequency, or suprapubic tenderness.

3. In patients who are unable to provide a history, urinary tract infection should be diagnosed only when evidence exists of acute inflammation (for example, fever/hypothermia or raised white cell count or C reactive protein) associated with bacteriuria on urine culture and no other more likely cause of their acute illness exists.

4. Asymptomatic bacteriuria is common in older people; avoid treating bacteriuria in patients with non specific symptoms that cannot be attributed to urinary tract infection, as this confers no benefit and may cause harm.

 

 Assess mental capacity 
Capacity to consent to treatment must always be assessed and incapacity should never be presumed just because a person has a particular health problem or disability such as dementia. ‘Capacity’ means the ability to use and understand information to make a decision. The four point Mental Capacity test is shown in table 4. If the answer to any of these questions is no then that person does not have capacity. 

 

Table 4. Mental capacity test

1. Can they understand the information given?
2. Can they retain the information given?
3. Can they balance, weigh up or use the information?
4. Can the person communicate their decision?
 

 

As a general rule a person who does not know where he or she is, is likely to have incapacity. All patients judged to have incapacity should have an Adults with Incapacity (Section 47) form completed and filed in their notes. Capacity can of course fluctuate, particularly in delirium, and must be reassessed if the clinical picture changes. Our patient clearly had incapacity, which allowed us to make treatment decisions on his behalf.

DNACPR and ceilings of care
Junior doctors will often treat frail older people actively when they become seriously unwell, particularly at night and particularly, as is so often the case, when there is nothing in the notes to indicate that a treatment ceiling exists. It would be better if the doctor on call was able to consider a spectrum of treatment options ranging from full escalation with all that the NHS can offer (ITU, ventilation, inotropic support and renal replacement therapy) at one end to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and purely symptomatic treatment at the end of life at the other; and also to recognise there is a useful middle ground that people can travel along as the end of life approaches. The trick is in finding a way to raise the question of CPR and ceilings of care with the patient and family in a way that does not lead to a panic response. Focusing on what can be done as well as what will not help and doing this before a patient becomes critically ill can save much emotional and (in terms of intervention) physical pain. 

“Can we talk about some difficult things?”
If the patient has capacity then he or she should be involved in the discussion, but not necessarily before you have spoken to the family. If it can be established that he or she has been failing over the last few weeks or months a useful opening line is ‘Can we talk about some difficult things?’ This frequently prompts the family to volunteer their fears and concerns. It also helps the doctor commit to talk about end of life care. Another approach is to ask the surprise question ‘Would you be surprised if your mother/father was no longer with us in a year’s time?’17 If the response is ‘Yes’ then they might or might not feel that CPR would be appropriate, but will invariably want the patient to be treated actively. If the answer is ‘No’ then it opens the door to discussing palliative care as a treatment option.18,19 Because we knew that their father’s condition had indeed gone downhill in recent months, we were able to ask the surprise question. Neither son nor daughter thought he would survive for a month let alone a year.

Anticipatory care planning
It is possible that our patient’s admission could have been avoided with an Anticipatory Care Plan. Anticipatory Care Planning is a process of discussion between a patient and a professional carer, which sometimes includes family and friends, that allows the patient to express their wishes for care prior to a sudden deterioration in their health.20 To assist this process NHS Scotland has an established national electronic anticipatory care plan called the Key Information Summary that can be accessed by both primary and secondary care.21 Useful information can be added such as contact numbers for relatives or carers and patients views on difficult decisions such as those around CPR.22 All of this can improve the chance that decisions that have often, by necessity, been made at speed are those which the patient would wish and are in keeping with the overall management of their condition. There is evidence that this community-led approach also reduces admissions and length of stay.23 It would be enormously helpful if all frail older adults had a key information summary and some discussion around ‘What should happen if...?’ but still many patients and their families appear not to have considered this possibility when the subject is raised. 

Quality of care
The provision of consistent, reliable and person- centred care for frail older people at or near the end of life is one of the great challenges of medicine today. It takes time and patience, but it can be extremely rewarding and is much appreciated by patients and their families. Delirium is an important diagnosis not to miss. Those nearing the end of their lives who become critically ill require early and in-depth discussion of whether treatment should be active or palliative. Comprehensive Geriatric Assessment, a willingness to pick up a telephone, early contact with family, problem lists, an awareness that drug sensitivity increases with age, the use of CARDS (or equivalent), Anticipatory Care Plans and the confidence to discuss ceilings of care are just some of the ways in which we can ensure frail older people experience the quality of care they deserve.

 

Case History: The second part

We were unable to obtain a urine specimen for culture. We felt that an in out catheter would have been too invasive given our patient’s agitation and the fact that he kept pulling off his urosheath. 

We were however able to establish by bladder scan that he wasn’t retaining urine. Following a discussion with his son and daughter we agreed not to investigate or treat his AKI or possible urosepsis further and to transfer our patient back to his care home with discretionary medications for pain relief, agitation and secretions.19 We further agreed that he should be kept comfortable in his care home rather than readmitted to hospital in the event of continuing decline in health. He died comfortably three days later.

 
 
Sian Finlay, Consultant Physician, Acute Medical Unit, Dumfries Infirmary, Dumfries
Martin Wilson, Consultant Physician, Department of Care of the Elderly, Raigmore Hospital, Inverness,
Chris Isles, Consultant Physician, Acute Medical Unit, Dumfries Infirmary, Dumfries
 
References

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2. Kurrle SE, Cameron ID, Geeves RB. A quick ward assessment of older patients by junior doctors.  BMJ 2015;350:h607 (published 18 march 2015). 

3. Fit for frailty.  Consensus practice guidelines for the care of older people living with frailty in community and outpatient settings. A report from the British Geriatrics Society, 2014 

4. The Silver Book.  Quality Care for Older People with Urgent and Emergency Care Needs.  British Geriatric Society, 2012 

5. Royal College of Physicians.  Acute Care Toolkit 3.  Acute Medical Care for Frail Older People, March 2012

6. Comprehensive Assessment of the Frail Older Patient: Good Practice Guide.  London, British Geriatric Society, 2010. 

7. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P.  Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials.  BMJ 2011; 343: d6553

8. Silvester KM, Mohammed MA, Harriman P, Girolami A, Downes TW. Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources. Age and Ageing 2013;43:472-477.

9. Quinn TJ, McArthur K, Ellis G, Stott DJ.  Functional assessment in older people.  BMJ 2011; 343:d4681

10. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients.  Am J Geriatric Pharmacotherapy 2007;5:345-51.

11. Benetos A, Labat C, Rossignol P, Fay R, Rolland Y, Valbusa F et al.  Achieved Blood Pressure, and Mortality in Older Nursing Home Residents.  The PARTAGE Study  JAMA InternMed. 2015;175:989-995.

12. The Scottish Government.  NHS Scotland Polypharmacy Guidance. www.polypharmacy.scot.nhs.uk (accessed 7/3/16)

13. Bellelli G, Morandi A, Davis DHJ, Mazzola P, Turco R, Gentile S et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014;43:496-502. 

14. Sands MB, Dantoc BP, Hartshorn A, Ryan CJ, Lujic S.  A single question in delirium (SQiD): testing its efficacy against psychiatrist interview, the confusion assessment method and the memorial delirium assessment scale.  Palliat Med 2010; 24: 561-5

15. Hosker CMG, Bennett MI.  Delirium and agitation at the end of life.  BMJ 2016; 353: doi: 10.1136/bmj.i3085

16. Ninan S and Walton C.  Investigation of suspected urinary tract infection in older people.  BMJ 2014;349:g4070.

17. The Gold Standards Framework Prognostic Indicator Guidance. www.goldstandardsframework.org.uk accessed 15th August 2015

18. Gill TM, Gahbauer EA, Han L, Allore HG.  The roleof intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older people.  BMJ 2015; 350: h2361

19. Ruegger J, Hodgkinson S, Field-Smith A, Ahmedzai SH on behalf of the guideline committee. Care of adults in the last days of life: summary of NICE guidance.  BMJ 2015; 351: h6631 

20. Mullick A, Martin J, Sallnow L.  An introduction to advance care planning in practice.  BMJ 2013; 347: f6064

21. National Information Systems Group. Key Information Summary (KIS).    www.nisg.scot.nhs.uk/why-nisg/our-services/project-management/key-information-summary, accessed 29/2/16 

22. Boyd KJ, Murray SA.  Worsening disability in older people: a trigger for palliative care.  BMJ 2015; 350: h2439 

23. Baker A, Leak P, Ritchie LD, Lee AJ, Fielding S.  Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation.  Br J Gen Pract 2012, DOI: 10.3399/bjgp12X625175