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It is generally accepted that elderly people fare best when care is provided in their own homes. However, some conditions require more intensive management than can be provided in the community. The admission of elderly patients to hospital, their treatment and subsequent discharge can prove challenging. Whilst self-sufficiency depends a lot on the underlying condition, delivering a package of care to an acceptable standard can make the difference between an individual who is a self-sufficient functioning member of the community and one who is disabled and dependent.
The Department of Health (DH) recognised the importance of providing quality care to the elderly and produced a raft of guidelines outlining the sort of issues which need to be considered when planning services. Many of these were enshrined in the National Service Framework for Older People in 2001. A White Paper addressing the social aspects of elderly care, 'Our health, our care, our say: a new direction for community services', was published in 2006.More recently, guidance has been issued by NHS England to commissioners of elderly care. The focus is very much on integrated care, with planning starting from the basis of individuals in the community. The frail elderly need to be identified and services commissioned according to their needs.
Concerns have been expressed about the standard of nutrition which elderly patients have received in hospital. As a result of a campaign run by Age UK, an independent group called the Hospital Food Panel was established by the DH. Their report recommends that all NHS hospitals should develop a food and drink strategy and identifies key standards that should become required practice.
Patients should be treated according to clinical need rather than age. This might seem self-evident but may present pragmatic difficulties. Some clinicians might balk at the idea of referring an 85-year-old patient for coronary artery bypass surgery but, if the patient is otherwise fit for surgery and wants the operation, they should be offered the chance to have it. A report, 'Achieving Age Equality in Health and Social Care', was published in 2009 containing various recommendations supporting the concept of equality in healthcare for the elderly.This culminated in the Equality Act 2010 which included provisions that banned age discrimination against adults in the provision of services and public functions.There have been some improvements but the NHS and social care still have some way to go in this respect.
Patients should be treated as individuals and empowered to make choices about their own care. This involves providing information in a form that patients can understand and listening to their views and the views of their carers. Preserving dignity in a hospital setting is a major objective and includes separate toilet and washing facilities, single-sex wards and safe care for patients with mental disorders. The Government announced that it would end the indignity of mixed-sex wards by the end of 2010.Since the introduction of financial penalties, unjustified admissions to mixed-sex wards are rare but still occur.
The aim here is to relieve pressure on acute hospital beds and provide care in a more community-based setting. The principles are the same whether care is provided by intermediate care teams in the patient's own home or in an intermediate care facility. The goal is to restore the patient to full function and avoid the need for long-term care by providing integrated rehabilitative support.
The National Intermediate Care Audit Report 2013 found that crisis response teams and home-based services appear to be well integrated into the wider health and social care systems with referrals received from primary, secondary, community and social care sources. However, more work needed to be done to integrate mental health services (including dementia care) and enabling services.
Specialist care whilst in hospital
With the change in demography in the UK, a significant proportion of people in hospital are now aged over 65 and secondary care needs to provide services tailored to the needs of its elderly population. The emphasis has been on improving access to care and the last few years have seen a significant increase in the number of elderly patients being admitted for cataract surgery, hip or knee replacements and interventional cardiac surgery. In addition to traditional geratologists and consultants in care of the elderly, many hospitals have set up specialist multidisciplinary teams focusing on the needs of the elderly whilst in hospital and on discharge. The Royal College of Physicians of London recommends that acute medical units should be staffed by a multidisciplinary clinical team delivering a consistently high-quality service. Such teams should include specialist nurses, physiotherapists, occupational therapists, intermediate care, pharmacists, social care and specialist discharge teams.
Evidence suggests that stroke patients fare best when admitted to specialised stroke units. The aim is to provide rapid access to diagnostic services, care provided in stroke units led by specialised physicians and multidisciplinary intervention to enable early discharge, rehabilitation and secondary prevention. The release of the National Institute for Health and Care Excellence (NICE) guidelines on stroke in 2008 has helped to standardise care across the UK.Building upon this, hyperacute stroke units (HASUs) have been piloted in London and the resulting reduction in mortality has motivated NHS England to consider a roll-out programme across the rest of the country.
Management of falls
See also separate article Prevention of Falls in the Elderly.
Falls are the leading cause of mortality in the over-75 age group. All patients who have had a fall should be offered a multifactorial risk assessment and multifactorial interventions. NICE recommends the following:
Multifactorial risk assessment
- Older people who present for medical attention because of a fall, or report recurrent falls in the preceding year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial fall risk assessment. This assessment should be performed by healthcare professionals with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. Multifactorial assessment may include the following:
- Identification of the history of the falls.
- Assessment of gait, balance and mobility and muscle weakness.
- Assessment of osteoporosis risk.
- Assessment of the older person's perceived functional ability and fear relating to falling.
- Assessment of visual impairment.
- Assessment of cognitive impairment and neurological examination.
- Assessment of urinary incontinence.
- Assessment of home hazards.
- Cardiovascular examination and medication review.
- All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention.
- In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):
- Strength and balance training.
- Home hazard assessment and intervention.
- Vision assessment and referral.
- Medication review with modification/withdrawal.
Elderly patients may have a different pattern of disease and different response to treatment than younger patients.
The symptoms resulting in hospital admission may be caused by a combination of several disease processes and it is important to identify which is contributing to the current difficulties (eg, cataracts and arthritis resulting in falls). Multiple causes may need to be treated in order to relieve the presenting problem.
Older patients may develop incontinence, immobility, instability, and acute delirium or confusion in response to virtually any disease. NICE recommends that patients should be assessed for risk factors for delirium on admission to hospital. If there is an increased risk, a tailored multi-component intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention.
Myocardial infarction may occur without chest pain and chest infection may present without cough or sputum.
Lack of physiological reserve
This phenomenon of older people results in rapid onset of illness, delayed recovery rate and increased incidence of complications compared with younger patients.
A reduction in excretion and impaired metabolism of drugs may require a reduction of dosage. There may be less tolerance to side-effects and the problems presented by polypharmacy may also be an issue.
A significant proportion of patients who experience delayed discharge are elderly. Poor hospital bed management and a failure of communication between health and social care are the principal contributing factors. Features of good discharge planning and post-discharge support include:
- Involvement of the patient and their family in decisions about their care.
- Hospital multidisciplinary teams associated with acute admission facilities working in an integrated manner.
- Adequate and timely transfer of information between services.
- Timely provision of discharge and support packages.
- Adequate information to patients and families about voluntary organisations, re-enablement services, and financial and social support.
End of life care
Doctors are continually being reminded of the importance of obtaining consent for treatment and of involving patients in decisions about their care. However, difficulties can arise when patients are unable to understand decisions or give informed consent. In such situations, clinicians should take into account the following:
- The existence of an Advanced Directive or Living Will.
- Power of Attorney - this can be used for decisions about care as well as financial issues.
- Independent Mental Capacity advocates - advocates should be appointed to represent people who lack capacity and face serious decisions with no one to be an advocate for them.
Another raft of guidance involves the provision of end of life care and, whilst this may be of more relevance to community and palliative care services, it also impacts on community hospitals.[18, 19]
Further reading and references
Welikala J; Respect, dignity and compassion to become mandatory for NHS training posts, Health Service Journal, 2014
Older people: independence and mental wellbeing; NICE Guidance (December 2015)
Our health, our care, our say: a new direction for community services; Dept of Health, 2008
Safe, compassionate care for frail older people using an integrated care pathway: practical guidance for commissioners, providers and nursing, medical and allied health professional leaders; NHS England, 2014
Age equality in health and social care; Dept of Health, 2009
Equality Act 2010; The National Archives, legislation.gov.uk
Ageism in Health and Social Care; Age UK, 2014
Mixed-sex wards to be eliminated this year; Nursing Times (requires registration), August 2010
New Cross Hospital trust fined £1.7k for mixed ward breach; Express and Star, 2014
Stroke and transient ischaemic attack in over 16s: diagnosis and initial management; NICE Clinical Guideline (July 2008)
Factsheet: Establishment of hyper-acute stroke services; NHS England, 2014
Falls: assessment and prevention of falls in older people; NICE Clinical Guideline (June 2013)
The Older Person in the Accident & Emergency Department; British Geriatrics Society - Best Practice Guide 3.2 (May 2008)
Lawson P, Richmond C; 13 emergency problems in older people. Emerg Med J. 2005 May22(5):370-4.
Delirium; NICE Clinical Guideline (July 2010)
Mangoni AA, Jackson SH; Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2004 Jan57(1):6-14.
One chance to get it right; Report of the Leadership Alliance for the Care of Dying People, June 2014
Care in the last days of life; NHS Improvement Programmes, 2014
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