Twenty (One) Tips for junior doctors working with older people

  1. Be good to older people. Many of your patients will be frail and vulnerable. Much of society may view them as a burden. You should not. These are mothers, fathers, husbands and wives. They have been
    on this planet two or three times as long as you have and many of them will have rich tales to tell. It is your job to look after them as well as you can, with empathy and kindness.
  2. Be part of the team. Physiotherapists, occupational therapists, other allied health professionals and experienced nurses will know things that you don’t know – both day to day information, and nuggets of clinical wisdom. Introduce yourself to them, ask about progress, and feed back relevant information. You are now working in a multidisciplinary team.
  3. Older people are really complicated. Acute coronary syndrome (to give just one example) will rarely be treated in a standardised fashion on an elderly ward. Some patients may be suitable for all the drugs on an ‘ACS protocol’. Others may not be suitable for more than one (or even none). Far more will be in between. Look at what your seniors are doing, and ask them why. Remember there is very little black and white in geriatric medicine and different doctors may do different things. Think about their reasoning and decide what kind of doctor you will be. The AGS guidelines on multimorbidity provide a great insight into the reasoning of a thoughtful and knowledgable geriatrician
  4. Because they are complicated, it may be helpful to write summary lists of problems (active, and inactive). It is also useful to consider nutrition, mobility, continence, and mood – document these periodically so that you record the progress of the patient in the notes. If you do this, you are well on your way to performing a comprehensive geriatric assessment! https://www.bgs.org.uk/resources/2-cga-in-primary-care-settings-the-elements-of-the-cga-process
  5. Review the medications – polypharmacy and adverse side effects are common in the elderly. And what benefit is there really for drugs like statins for frail older people in their last few years of life? This document from NHS Scotland is very helpful. https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf
  6. Take time to talk to relatives. In fact, offer to do so. Even if it’s just a quick “Hello, my name is…( http://drkategranger.wordpress.com/2013/09/04/hellomynameis/) I’ve been looking after your mum/dad/grandparent.” You could quickly summarise their progress (with the patients consent). You can also use it as an opportunity for some collateral history. I appreciate that you are very busy and can’t have in depth conversations with all relatives. But imagine you are a relative of a patient, with little idea of what is going on. You can provide much reassurance. And unless you need to spend a long time speaking to relatives, I think it’s perfectly acceptable to convey what you need to and say “Sorry, but I must get on..” It’s important that you show a willingness to engage with relatives. You will soon find that many relatives are grateful, and you find your job more rewarding.
  7. Speaking of collateral history – always get one! If you are ever clerking an elderly patient with cognitive impairment who cannot provide a full history, pick up the telephone and speak to a relative/care home worker/ neighbour. If a patient arrives on your ward and no-one has taken a collateral history, please do so.
  8. If the relatives are unable to visit the ward, or only able to visit when you’re not there e.g. weekends or evenings, then (with the patient’s consent), give them a telephone call and offer to inform them of progress. Otherwise families may feel as if they are in the dark, or that nothing is happening.
  9. Understand what frailty means. http://www.clinmed.rcpjournal.org/content/11/1/72.full. In particular, the understanding that relatively minor stressors can result in significant decline in overall health is important to the assessment of the frail older patient.
  10. Be excellent at diagnosing and managing delirium. https://www.bgs.org.uk/resources/14-cga-in-primary-care-settings-patients-presenting-with-confusion-and-deliriumTreat infection (if it’s there), but don’t just treat infection. Reorientation and early mobilisation are important. Carefully review the medications. Treat pain, dehydration and electrolyte abnormalities. Look for constipation (which is often present) and urinary retention, but use urinary catheters for as short a time as possible. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842841/table/t2-1820465/
  11. Pain can easily go unrecognised among older people. Is your patient agitated and distressed? Consider prescribing analgesia. Co-prescribe laxatives with opioid analgesia.
  12. Monitor the patients bowels. Constipation can contribute to delirium, poor appetite, immobility and urinary retention.
  13. Monitor the patient’s bladder. Consider the possibility of urinary retention (another cause for agitation and distress) and learn how to use your ward bladder scanner.
  14. Don’t perform urine dipsticks for older people. https://www.sign.ac.uk/assets/sign88_algorithm_older.pdf. The positive predictive value is so disappointing that you might as well toss a coin. Asymptomatic bacteriuria is common in older people. Give antibiotics for UTI if patients have acute urinary symptoms, or have bacteriuria and evidence of systemic inflammation (fever/raised inflammatory markers) without another more likely source of infection.
  15. UTI is commonly overdiagnosed in older people, partly because of excess weight given to features such as the character of urine and urine dipstick results. Remember the smell doesn’t tell! Don’t assume a UTI every time your patient becomes unwell but instead, perform a thorough clinical evaluation. We wrote this article on how to diagnose urinary tract infection in older people http://www.bmj.com/content/349/bmj.g4070.
  16. Be excellent at managing falls. https://www.bgs.org.uk/resources/12-cga-in-primary-care-settings-patients-at-risk-of-falls-and-fractures. A ‘mechanical fall’ is a rare event. Most elderly people admitted to hospital will have acute illness and/or recurrent falls that may be multifactorial in nature. Often I find junior doctors will talk about patients with “mechanical” falls being admitted for “social” reasons and in their next sentence mention the pneumonia, acute kidney injury or urinary retention. Make the link – if a patient has recently started falling more frequently or “gone off legs” there will be a reason! Treat acute illness e.g. infection, constipation, renal failure, but don’t give antibiotics if there is no evidence of infection (that seems like an obvious statement, but often people reflexly reach towards trimethoprim!). Remember to also do a thorough review to identify risk factors for falls, and treat appropriately. The falls may be ‘multifactorial ‘– but what are the factors? And how will you address them?
  17. When you are doing tasks at the bedside e.g. venepuncture, cannulation, take the opportunity to find out a little bit more about your patients. Ask them where they live, what their hobbies are, how long the have been married for etc. You will have a much richer picture of your patient as a person, and most of your patients will appreciate you for talking to them.
  18. If your patient is hard of hearing, get their hearing aids, refer them for hearing aids or use an electronic amplifier. Some wards have one, but if they don’t you can buy one as an app for your smartphone which you can then connect to headphones.
  19. You will often get asked: “Do they have capacity?” Capacity is decision and time specific. A patient may have capacity to choose what they want for lunch but not to consent for endoscopy. Read https://www.bgs.org.uk/resources/15-cga-in-primary-care-settings-mental-capacity-issues for more details of capacity assessment.
  20. If a patient “sounds chesty” frequently and has recurrent pneumonia, consider the possibility of recurrent aspiration. A SALT review and modified diet may reduce their risk of further aspiration.
  21. Never diagnose a patient as “acopic.” Patients who are labelled with this offensive term usually have several co-morbidities, often have evidence of an acute illness, and always deserve a thorough assessment. http://www.ncbi.nlm.nih.gov/pubmed/24098878

Published by sean9n

Geriatric Medicine Consultant Leeds Likes football, disco and onitsuka tigers. Talks about old people on here

36 thoughts on “Twenty (One) Tips for junior doctors working with older people

  1. Brilliant piece!
    I’d add a couple:
    – Don’t shout to them or talk to them as if they were children. Most of them are not deaf and most of them don’t have cognitive impairment. Find out first and for goodness sake…..talk to them, address them. too many people turn around and talk to the relatives instead.
    – Know when to stop. A frail, 95 year old with severe alzheimers might have never wanted to have his pneumoniae treated (would you?)

    Fantastic, well done!

  2. I love this, thank you. Might I share and see how to adapt for nurses and others? Has anyone from NHS Enland or CQC seen this?

      1. This has just come across my desk. I am the Education Coordinator for the Division of Geriatric medicine and we were wondering if you would mind if we reproduce this as a poster to be posted in the Team Rooms for our residents to refer to on a regular basis?

  3. Excellent. As the son of a geriatric patient that has been into hospital five times in 2013 and twice in 2014 already I can assure you that a good many of these don’t happen as a matter of course. I was going down the list and starting at 4 I thought I’d mention 4, 5, 6 specifically, but as I continued it became clear it would be easier though pointless to say which tips were routinely followed: not many.

    My mother had a persistent UTI which went undetected for a few A&E visits and a too short a stay in one hospital. Only after persistently stressing my concerns did one consultant take notice, and on one stay implemented some of the ‘communicating with relatives’ tips. But even then, on the ward, I often found that I was telling the doctors an nurses what the problems were.

    Once her atonic bladder had been diagnosed and a long term catheter fitted she had to go into hospital again for a bowel problem. During that stay the catheter came out and some nurse decided to leave it out as “she was doing fine without it.” Sure enough another infection came along a floored her once more, with all the typical symptoms of confusion and delirium. On that same stay, once she recovered, she was due for discharge. We’d had a crazy time with discharge meds provision on a previous visit, so I went to great lengths to tell doctors and nurses that she wasn’t going home until the meds were checked. I was assured everything was fine. I arrived to collect her only to find that someone had decided that she didn’t need the catheter again; and some of the meds were missing again. Of course mistakes happen. They happen all the time. In the last three years she has not had one stay in hospital that hasn’t suffered for lack of tips like these in this post being followed.

    A number of times I’ve asked if the nurse or doctor if they are aware of some significant co-morbid condition that they should consider, only to see the nurse or doctor hurriedly rummage through the case notes, look for colleagues that might know more but cannot find them, scratch their heads. I am totally baffled by the fact that summary notes are not at the front of case files. Even in complex cases such as my mother’s it doesn’t need much more than a single A4 summary page, maybe two, and not in fine print. It really isn’t difficult. The patient medical passport I read about very recently, that has been trialled in some areas, is a great idea. Rather than wait for it to be adopted I’ve started to build my own. It’s going to go with her everywhere.

    These tips would should not be mere tips but mandatory reading, at least once a month as a part of a regular protocol for preparing to treat patients. And staff new to elderly patients should be drilled on them. More than once I’ve had the response from nurses, “I’m not familiar with dealing with elderly patients.” Seriously? I’d have thought that in an age of ageing patients that would be a primary part of the training.

    Another tip: if you have some elderly patients on your ward, find out who isn’t familiar with this work and make them do it. But keep an eye on them, because they will screw up, and elderly patients are either unwilling or unable to complain.

  4. Thanks this is really good.
    I have got background in healthcare but it is my mother’s experience that your checklist is so pertinent to.
    She was frail 84 year old lady with early dementia who had been living at home with help, admitted to hospital with acute shortness of breath related to end stage heart failure. She was actively treated for just over 2 weeks with no improvement but there was dramatic decline in her general condition.
    This prompted me and my sister at one stage to ask a doctor to put down my Mum’s charts etc and stand at the bottom of her bed and look at her. What did they see? What we saw someone who was nearing the end of her life who was emaciated, frightened, confused and at times extremely distressed. It was us who invited the palliative care team to be involved and thanks to them Mum died peacefully 5 days later just before Christmas.
    Your checklist would certainly have helped the junior medical staff and nursing staff who cared for Mum.

    1. Thank you

      Someone else commented on twitter that I hadn’t mentioned end of life care which is a significant part of geriatric medicine.

      Recognising when to stop unnecessary interventions is a key skill in geriatric medicine and hard to put into a neat tip. Indeed, it is a decision that should be made by a senior doctor. But if junior doctors are as kind and thorough with their dying patients as ones that they are treating “aggressively” then that is a good start.

      There are lots of other “tips” that I could have mentioned but omitted for brevity. Might do a part two at some point

  5. This is a great list. Thank you for posting it. Would you mind if I used it in our junior staff induction handbook? (I would credit you of course.)

    Eve

      1. Thank you! I’m a specialty doctor in Medicine for the Elderly at Monklands Hospital in Airdrie.

  6. I came to this excellent piece through twitter. I would add when thinking of getting more information from relatives also consider ringing the GP who may well know what “normal” is for this patient.

  7. Hi Sean really enjoyed your presenation on acute trimethoprim deficiency at the BGS and think thes tips are fab!. Will incopporate them in our induction.
    Best wishes

    Sue Poulton
    Consultant Orthogeriatrician

  8. Sean, we have used this in our induction booklet and I realised that we hadn’t asked your permission! Can we get forgiveness and belated permission please? All credit given.
    Also can we possibly hand out for a G4J event in Glasgow??

  9. I totally agree with #6! It’s so important to connect with those who are close to your patient as they’ll feel more involved with what’s going on with their parents. And they’ll be more likely to visit more often if you are able to establish a relationship with them which, alternately, benefits their parents significantly!

    I made this quick video of an elderly lady learning to put on her socks. She’s very funny (she isn’t an actor!). Tell me, what do you think? https://goo.gl/a9r54M

  10. Great list Sean. I am a geriatrician in Canada and would like your permission to share with not only our residents but also the administration. We ound also like to post in our physician newsletter and want to credit you properly. Can you provide your info?

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