Category: Learning

RCEM – Frailty in the ED

As we all know frailty and care of older patients is becoming a more and more important in the ED. The elderly population is growing rapidly and as you age your health costs shoot up.

The study day not only highlighted several import areas of care within ED, but also how relatively small interventions/conversations can make significant differences.

  1. Think Home First:
    • What is stopping them going home?
    • What tests will guide your decision making? (don’t just investigate because you can)
    • Get them up (you don’t need to wait for physios)
  2. Do the easy stuff: Feed, Water, Toilet, Communicate
  3. DON’T create barriers: e.g. catheters, exessive testing
  4. Ask for help: Local service are your friend

Topics

Population & Costs

Increasing aging population:

Costs as we age:

Life Expectancy

Life Expectancy:

Average life expectancies are often longer than you imagine and after 100yrs life expectancy increases!

  • 80yr woman – 10yr
  • 85yr woman – 7yr
  • 90yr woman – 5yr
  • 99yr woman – 2yr

However, Clinical frailty score is often more predictive.

 

Frailty Trajectory and Life Expectancy

Study shows that the rate of change in frailty has a significant impact on life expectancy. People with “Stable” growth in frailty score remaining at their base line but the faster the CFS changes more impact that has. 

So its worth asking how things have changed over the last year.

Trauma

Frailty has a significant influence on recovery and mortality in relation to both “MINOR” and “MAJOR” trauma. 

 

Rib injury is probably more important than most of us realise – suggesting 15% increase in mortality for every rib a frail person fractures.  JRCALC have since updated guidance to recommend “rib spring” rather than “gentle palpation” in examination.

Silver Trauma Review Clinic:

Mater hospital Dublin have introduced a review clinic for patients following significant traumas.

Mater hospital – Adult only ED

  • 90’000 attendances/yr
  • 10.5WTE ED consultants
  • Major Trauma Centre

Silver Trauma Review Clinic

  • Weekly clinic sees 10 patients/week
  • Follows up: trauma patients discharged with non-operative management or post admission
  • Team: EM, Geris, Frailty ACP, Physio
  • Main work: Thoracic, Spinal, humeral, pelvic injuries
  • Requires access to DEXA and MRI (they MRI all spinal injury through clinic not only to age but also find other diagnosis)
  • Reduced admissions.
  • EMJ
Syncope

A really common presentation elderly patients that can be tricky with a higher baseline probability of cardiac causes.

80% is on the history:

  • However, both memory of events & prodromal symptoms are often reduced in older patients
  • Look for causes “What was different that day”
  • Witnesses are really important – the elderly will tend to down play and may confabulate if memory is an issue

Investigation:

sBP takes longer to improve after standing as you get older. Recovery in <45s tends to be good.
  • Heart sounds – Murmurs
  • Neurological 
  • LSBP
  • Bloods inc BM
  • ECG
  • Get up and Go – to look at gate etc.

Get up and Go test

Causes – the frail often have more than 1

  • Orthostatic Hypotension
    • Drugs, Drugs, DRUGS
    • Volume
    • Autonomic failure: Diabetes, Amyloid, PD, Adrenal insuf etc..
    • Alcohol

 

 

  • Reflex (neurally mediated)
    •  
    • Vasovagal
    • Situational – cough, micturition, post exercise, eating
    • Carotid sinus Syndrom
  • Cardiac Arrhythmia
    • Sinus node, AV conduction, Tachy, device malfunction, inherited
    • ALWAYS interrogate devices if they have one
  • Structural Heart Disease
    • Is there a murmur?

Syncope Pathway – Reduces LoS

Delirium

4AT = NEWS for the Brain

 We miss Delirium in 50% of cases & when we do miss it we are 70-80% confident that we were right – so use 4AT 

 

Then PINCH-ME

We often over test look for the simple things first they are the most common.

Parkinson’s

Link to pdmedcalc.co.uk

 

End of Life

“Wasting a dying persons remaining time is WRONG”

Most patients would prioritise time with love ones rather than fruitless time with us.

Recognise

  • History: CFS, co-morbidities, exersize tolerance, ADL’s Residential status
  • Trends/Trajectories: what has happened since arrival and what has happened ob=ver the last few months?
  • Differential diagnosis: what is the prognosis and are the treatments desirable?

Outcomes

Emergency Laparotomy: CFS is more predictive than age

 

Covid:

 

In-hospital CPR: frailty can predict outcome in UK trial

 

Do Not Resuscitate Decisions  

Ombudsman states: End of Life

  • “Decisions about not resuscitating a patient, or about putting a DNACPR notice on a patient’s record, are made by doctors and do not need patient consent. This can be an immediate clinical decision made when a patient is seriously unwell, or a decision that goes on a patient’s records in advance and affects treatment at a later stage. But it is a legal requirement for doctors to consult with a patient about a DNACPR decision if they have capacity, and with their next of kin otherwise.”

But our communication needs to be clear to patients and families, not just saying “they are sick” but how sick. And not just what we are not going to do but what we are going to do for the patient.

Preparation:

  • Ensure Anticipatory Medication prescribed
  • End of Life trolly (Dandilion trolly – QLD)
    • Syringe driver kit
    • Paperwork
    • Black towels – to hide blood loss (reduces distress)
    • Taste for pleasure – mouth care with things people actually like (families can bring)