The Acute Medical Unit (AMU) is an area with a high turnover of patients who undergo rapid assessment to decide on who needs hospital admission. The quality of patient care in the AMU will reflect improved outcomes and prevent unnecessary use of health services.
Such rapid assessments, however, might not improve the outcome of older adults patients, and the Comprehensive Geriatric Assessment (CGA) is essential for better care and favourable outcome.1 This article will use two case scenarios to discuss the most important mental and physical health needs of older adults in the AMU.
First case scenario
Mrs KJ is a 90-year-old woman who was brought to the emergency department by her daughter. The patient was ambulatory upon hospital admission. She has a history of cough, fever, and loss of appetite. She was diagnosed with pneumonia by the acute medical team and admitted to the hospital for intravenous antibiotics and further management. She had obesity, diabetes, and hypertension. She lived with her daughter and has a son who has not come to see for many years. She has many good friends who regularly visit her.
The patient’s pneumonia was treated successfully with antibiotics in the hospital. However, her hospital stay was complicated with catheter-induced urinary tract infection. The nosocomial infection improved after the removal of urinary catheter and with another course of antibiotics. Upon hospital discharge, she was weak and unable to walk; her condition was attributed to her age.
Her daughter was not familiar with geriatric home care and the patient was bedbound. The patient had frequent crying spells and requested to see her son. Later, she developed bedsores in both trochanteric areas that required hospital admission for debridement and intravenous antibiotics. After hospital discharge, the daughter was advised to take her for regular dressing at the local health centre. After a few months, she died of an infected bedsore complicated with severe sepsis.
Severe outcomes can be expected when a disease-centred approach is practiced instead of a patient-centred approach. Older adults are at higher risk for functional decline after hospitalisation.2-5 Some manifestations of functional decline is avoidable if care service is customised to their needs.5
The patient's inability to walk after hospitalisation is most probably due to deconditioning. Older adults with deconditioning often have impaired coordination and balance that render them at risk for falls and might affect their ability to be independent.6 As suggested by Falvey et al7 hospital associated deconditioning (HAD) is comparable to physical frailty. The only difference is that frailty develops over months while HAD can develop in a few days after hospitalisation.
Both conditions increase the risk of death, institutionalisation, and disabilities. The presence of both conditions worsens the patient’s condition.7 The severity depends on their pre-admission functional ability. More severely affected individuals will have difficulty in bed mobility, transfer, and activity of daily living. They may also have imbalance and orthostatic hypotension that will increase the risk of falls.8
One study described post hospital syndrome as a state after hospital discharge where the patients have minimal physiological reserve that increases their risk for deterioration with new stress and may require another hospitalisation.6 It argued that this typically happens in the early 30-days post discharge and advocated for proper optimisation of the physical and mental health of patients before discharge in order to help them to go through this critical period safely.
Another study introduced two new concepts, namely,(1) iatrogenic disability defined as the “functional decline that results from one or several iatrogenic adverse events occurring during hospitalisation” and (2) hospital associated disability defined as “a loss of 0.5 points or more on the total Katz ADL score between admission and discharge”.
The authors conducted a prospective cohort study of 503 older adults aged 75 years and above who were admitted due to acute illness or for scheduled admission in medical and surgical units a teaching hospital in in France. They found that 18% of the subjects had decreased ADL scores between admission and discharge, and 10% of them had preventable iatrogenic disability.
They suggested that functional decline during hospitalisation could be attributed to two main reasons. The first reason is patient-related such as physical frailty, severe illness, depression, and low cognition. The second reason healthcare system related such as insufficient recognition of patient-related factors, excessive bed rest, no referral to physiotherapist for assessment and intervention, no encouragement for self-dressing and bathing and overuse of diaper and urinary catheterisation.9
Having a disability might lead to anxiety and depression.10 A physician needs to recognise it in order to be able to adequately treat it. Ideally, these patients should be referred to a rehabilitation unit for proper rehabilitation program to maximise their functional recovery. In the absence of a rehabilitation centre, the attending physician has an important role in coordinating with the physiotherapy department in order to create an integrated plan that suits the patient’s needs to help their recover to their baseline activity.
Second case scenario
An 85-year-old woman was admitted to hospital for the management of pneumonia. She had bilateral visual loss due to cataract, impaired hearing, and knee osteoarthritis. She lost weight and complained of weakness. In recent months, she stopped going outside the home and calling her family. She took flurazepam hydrochloride to induce sleep, cimetidine for epigastric pain, naproxen, and aspirin for knee pain, and timolol drops for glaucoma. She lived alone. She had two daughters who lived close to hear. She had no friends.
The patient’s pneumonia was successfully treated with antibiotics in the hospital. However, she was unable to stand alone or move out of bed. She refused oral feeding, so a nasogastric feeding tube was inserted for hydration and nutrition. At night, she became agitated and confused. Her daughters decided to take her to a nursing home. Fortunately, as part of the hospital policy, the patient had to be reviewed by a multidisciplinary geriatrics team before referral to a nursing home facility.
The geriatric team carried out comprehensive geriatric assessment (CGA). The recommendations were: (1) to reduce the number of tablets that she was taking; (2) to consult an ophthalmologist for the reassessment of her glaucoma and the possibility of discontinuing timolol; and (3) to consult an audiometric team and an orthopaedic team.
A psychiatric team was consulted as well, and she was diagnosed with depression. Her nasogastric tube feeding was increased, followed by a gradual restart of her oral feeding. A social worker visited her home, and changes were recommended to her daughter to prevent falls. There was other interventions to improve her mobility and independence. She was discharged home successfully. She was ambulatory and independent on follow up after one year.11
The second scenario showed the impact of well-developed services specialised in the care of older adults in improving outcomes and patient satisfaction.
In the 1930s in the UK, three physicians noted that frail older adults were at high risk for institutionalisation. Medical, psychological, or social support were rarely given to them despite having easily identifiable medical conditions. They proposed that a multidimensional treatment approach could improve patient outcomes. Their success in proving this led to the approval of the geriatric specialty within the National Health Service in the UK in 1948.11
Caring for older adults can be challenging as they not only have atypical presentation of an illness, but they could also have other comorbidities. These include impaired vision, impaired hearing, speech difficulties, undiagnosed depression, delirium or dementia. These all could contribute to the inaccurate diagnosis and improper management that they may face during hospitalisation. The attending physician may depend on the acute health complaint that brought them to the hospital and ignore the interaction with the existing comorbidities.13-15
The diagnosis of an acute illness, such as pneumonia should be made in the context of appropriate exploration of undiagnosed co-existing health issues, prescription of evidence-based medications, education about adverse drugs events, prevention of hospital-acquired infection and decreasing the risk for venous thromboembolism and pressure ulcers.16 The social part of history taking should be covered extensively. For example, they should be asked about the caretaker of their pet or their plant at home when they are ill, and who is looking after spouse or children when they are away.14
Neglecting the social aspect may leads to a psychological stress that might impact their overall outcome. Therefore, a Comprehensive Geriatric Assessment (CGA) is the best way to take care of older adults holistically.
The importance of Comprehensive Geriatric Assessment
The CGA is a multidimensional, interdisciplinary diagnostic process directed at determining the medical, psychosocial, and functional capabilities and limitations of older adults in order to develop an overall plan for treatment and long-term follow-up.12,15
CGA helps deliver an optimal care for vulnerable older adults. This process requires regular review and optimisation to achieve the goals of care.16 It is interdisciplinary, as it takes inputs from doctors, nurses and allied health professionals. It is multidimensional, as it takes patient health holistically and formulates a problem and a well-organised plan to solve the patient’s problems. There is an overall plan for treatment support, rehabilitation, and long-term care that is communicated effectively to the caregiver and other healthcare professionals who take care of the patient outside the AMU. The assessment is done objectively using standard measurement scales and tools to determine the deficit in each domain. An integrated care plan is also created to complete the deficiency.
The main domains of health in CGA as shown in figure 1 are medical/physical, mental, social, functional, and environmental.16-18 It uses validated tools and scales to quantify the functional, psychological, and social health of older adults. However, physical health issues are identified through history and examination, laboratory data, and disease-specific rating scales.12,17
Figure 1: Different domains of CGA and the team responsible for each domain
The core team members of the CGA are trained physicians, nurses and social workers. Other team members, such as occupational therapists, clinical pharmacists, psychologists, podiatrists, dentists, and dieticians can be consulted or added to the core team depending on the resources and individual case needs.16-18
There are many published evidences for the effectiveness of CGA, and it is considered as gold standard of care for older adults. In their Cochrane review of 29 studies with 13,766 participants, Ellis and his colleagues compared CGA to routine care for hospitalised older adults. Almost all studies that they included in the review involved consultant geriatricians and trained nurses in their CGA team. The majority had social workers.
They also showed that those who received CGA had a higher chance of survival and living in their home after hospital discharge. The risk ratio (RR) was 1.05 with a 95% confidence interval (95%CI) of 1.01-1.10. However, there was weak evidence to support the beneficial effect of length of stay or cost effectiveness due to heterogeneity and missing data.19
Kocman et al20 conducted a study in a perioperative surgical department to determine whether CGA can be delivered without a geriatrician. The health care professionals who participated in their study were interested and enthusiastic about caring for older adults. However, their study concluded that a geriatrician or clinician with adequate geriatric background is a must.
The possible reason for the findings of Kocman et al could be the inappropriate setting of the study instead of the lack of a geriatrician in the team. One of the study participants stated that there was insufficient time for the interventions, and there was a conflict between the aims of the surgical team and the interdisciplinary team. For example, surgery must be performed within three weeks, but physiotherapists need four weeks to reach the target outcome. Moreover, one anaesthetist who participated in this study stated that the approach was not part of his training and perspective. If the same was applied in the AMU, the findings and conclusions might be totally different because most internists get geriatric exposure during their training.
In order to implement geriatric services in a hospital without geriatric support, the AMU is a good place to start as this team take care of admitted older adults in medical units, and are usually consulted to see older adults in ED, surgical units, orthopaedics and other units in hospitals where they can disseminate the change to the better care. The acute medical team could then organise the delivery of these geriatric services to other departments in the hospital.
Physical needs of older adults in non-geriatric medical unit
Older adults have many physical needs, such as such as skin care and pressure ulcer prevention, need for medication optimisation, and the need for bladder and bowel care. However, identification of physical frailty is by far the most important physical need.
Frailty is a reversible clinical syndrome in which a person is susceptible to acute stress due to the deterioration of the physiological reserves of one or more of body system that may result in gradual functional decline. Early recognition of frail patients in the acute care unit is important for improving care.22 It commonly manifests as functional decline and disability that leads to falls and deterioration of the activity of daily living (ADL) and instrumental activity of daily living (IADL). It is also associated with premature mortality.23 Frailty is key to identifying those who will benefit from the holistic management plan of CGA, hence saving time and resources for those who really need them.24 CGA is not for older people with good physical health or severely frail adults with terminal illness.12
There are several-aspects of frailty: physical, social, and psychological. Many tools have been validated for use in hospital setting to diagnose frailty.25-29
Four most commonly used scales will be discussed here.
Clinical Frailty Scale30,31
It is a visual and clinical tool. It uses variables readily observed without specialist training, such as the use of walking aids, and the abilities to eat and dress. Frailty is diagnosed if the score is more than five. It tells about the baseline health status, two weeks before the acute illness, and helps to decide regarding resources allocation and decision for aggressive treatment or comfort care.
This scale depends on five physical characteristics:
- Unintentional weight loss (>10 pounds)
- Self report of exhaustion (identified by two questions from the Centre for Epidemiologic Studies – Depression (CES–D)
- Slow walking speed (based on time to walk 15 feet, adjusting for gender and standing height)
- Low physical activity (based on amount of kilocalories expended per week)
- Grip strength (adjusted for gender and body mass index).
Frailty is diagnosed if there are three out of the five criteria. This scale is easy and simple to use, especially if used to identify those who will benefit from CGA.33 There are certain disadvantages of this tool. First, it cannot be used to identify physical frailty among those with the following conditions: depression, stroke, low cognition, Parkinson’s disease as all these conditions were excluded from the original study. Eighty-five per cent of the study population were Caucasians; therefore, applicability of this scale to other ethnicities has to be verified. Finally, the hand grip meter is difficult to find outside of the research model.
This index is calculated as the following: the number of deficit that a person has, including their symptoms, signs, laboratory result, and disabilities, divided by the total number of deficit that a person may have. This score ranges from 0 – 1, and frailty is diagnosed when the score is >0.25. It is a comprehensive scale that includes different aspects of frailty and can be applied to individuals with disabilities33 The disadvantage of this scale is that it is time consuming. The other problem is that the total deficits are calculated based on study in four developed countries, some of the deficiencies might not be applicable in other countries.
Edmonton Frailty Scale36
It assesses ten variables, namely: cognition assessed by clock test, balance, and mobility through a timed get up and go test, general health, functional independence, social support, medication use, nutrition, mood, and continence. The variables are assessed by simple questions all given a score of 0, 1 or 2. A score of 7 and above is diagnostic for frailty. There is no need for special training in geriatric medicine to use this tool.
Early recognition of frail older adults in the AMU would help in the identification of those who will benefit from CGA. Strategies may be initiated to improve or maintain their physical health instead of rapid deterioration during admission and after discharge from the hospital.
The mental health needs of older adults in the AMU
Identification of delirium is one of the fundamental mental needs of older adults in the AMU. It has a tremendous effect on general well-being and survival. It is diagnosed clinically; therefore, history from caregiver is very important to identify the changes in the patient’s clinical status.
Delirium is known as acute confusional state. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-V) diagnostic criteria for delirium (Edition 2013) are as follows:
- A- Disturbance in attention and awareness of the environment.
- B- Acute onset, usually hours to days, and fluctuates in severity during the day.
- C-Impaired cognition (e.g.: disorientation, memory deficit)
- D- Both A and cannot be explained by pre-existing neurocognitive disorders, and there is no severe reduction in the level of consciousness, such as coma.
- E- The disturbance is due to a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or multiple aetiologies proven by evidence from history, physical examination and laboratory findings.
According to the DSM-V, delirium is divided into three main types based on activity: (a) hyperactive characterised by agitation and inappropriate behaviour, (b) hypoactive type characterised by lethargy and withdrawal, and (c) mixed level of activity that includes features of both hyperactive and hypoactive delirium. Table 1 illustrates the most common predisposing and precipitating factors of delirium during hospitalisation.
Dementia or cognitive impairment
Use of physical restrain
Severity of the disease
Age > 70 years old
Vision or hearing impairment
Medications with anticholinergic effect
History of stroke
Anaemia or blood transfusion
Table 1: Predisposing and precipitating factors for delirium37
The prevalence of delirium in a medical ward is reported to be 18%– 35%, and older adults who develop delirium are at high risk for death a year after discharge.38,39 A metanalysis of 42 studies showed that delirium increases the risk of death (odd ration [OR] of 1.71, 95% CI: 1.27-2.23) and institutionalisation (OR 2.41; 95% CI: 1.77-3.29) irrespective of age, sex, severity of illness and comorbidities.40 One study argues that delirium is missed in 72 % of older adults admitted to the AMU.
However, they considered the diagnosis of delirium is missed if it is not documented in the patient’s clinical notes. This could explain the percentage of missed diagnosis in 72% of older adults.
Several factors are identified as contributors to the misdiagnosis of delirium:41
- Lack of awareness of the medical staff that delirium could be the sole manifestation of an underlying acute illness
- Many healthcare professionals expect delirious patients to present with hyperactive form. However, the hypoactive form is more common in older adults
- Delirium tends to fluctuate, so medical staff may fail to recognise that lucid interval is part of it.
One of the most widely used tool to detect delirium in older adults during hospitalisation is the 4As Test:42
It has four parameters:
- Abbreviated Mental Test - 4. (AMT-4)
- Attention test
- Acute change or fluctuating course.
It scored from 0 to 12. A score of 0 indicates delirium and/or moderate to severe cognitive impairment is unlikely, Scores between 1 and 3: suggest cognitive impairment and that a more detailed cognitive test is recommended. A score of 4 or above suggests possible delirium. This tool is simple and easy to use. It is designed for non-specialist and there is no need for training to use it. Its website contains full guide how to use it with case examples.
The treatment of delirium is directed towards finding the underlying cause through history-taking, physical examination, and laboratory data. Possible triggers should also be avoided. Some physician may prescribe antipsychotic or sedative medication to manage agitated patients. However, these medications may turn hyperactive delirium into a hypoactive form and prolong the delirium state. Hence, non-pharmacological strategies should be the first line of management.
Examples of these strategies are keeping the patient in a quiet, well-lit room, ensuring a safe environment, encouraging the presence of a family member, correcting sensory impairment, and bladder and bowel care.
Older adults in non-geriatric facilities may face many challenges and unmet needs. However, there are easy and simple interventions that can be carried out to improve their condition. Incorporation of CGA as part of the care of older adults in these units, as well as early recognition of frailty and delirium are simple steps that should be started in AMUs. Training the medical team in this evolving field is mandatory, in response to the steady increase in the number of older adults. Services must be adapted to meet their needs to ensure better patient care and good outcomes.
Upon encounter of older patients with acute condition in your units, ask about other common problems, such as urinary incontinence, mood, activity of daily living and social support. Assess them for frailty and delirium and then modify your treatment plan accordingly. Make sure to involve physiotherapist early to assess mobility of an older adult and provide necessary help to preserve or improve their degree of mobility. One does not need to be geriatrician to do these simple things. A good understanding of what should be done, proper implementation, and regular evaluation of service are essential to see the difference.
Majdah AL Rushaidi, Trust Doctor at James Cook University Hospital, Department: Old Person Medicine (OPM)
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