It’s a question that I’ve come to think about again as use and abuse of the Clinical Frailty Score proliferates, but now in the context of a pandemic, where there are concerns about the availability of critical care beds, and a need for rationing but an admirable desire not to be ageist.It’s a question that I’ve heard colleagues locally and nationally answer, with varying degrees of confidence and detail.
So, what do you actually do? Aren’t all your patients just dying? What do geriatricians do that other doctors don’t do? Here are questions that get asked to geriatricians, and that we sometimes answer variably with words and phrases like “holistic care,” “whole person,” “general medicine,” and “kindness.”
So, why should someone be admitted under the care of a geriatrician, on a geriatric ward if they are say, 85 years old with a pneumonia? What benefit would they gain compared to being admitted to a geriatric medicine ward then say a respiratory or a general medicine ward?
Well, it depends. Most doctors are pretty good at managing most cases of pneumonia. If on day 3, your patient is not requiring oxygen, fluids or intravenous antibiotics, and is eating and drinking and walking around it is pretty easy to let them go home with some advice.If your patient is not walking around, and needs help washing and dressing, then it depends – on what they are normally like. Actually, for patients who are severely frail and dependent, say normally immobile and living in a nursing home then from a purely discharge point of view, getting a patient home might be quite easy – although there are other benefits from comprehensive geriatric assessment…
For patients who normally live at home, independent, or with varying degrees of frailty then their newfound dependence can cause frustration for some doctors.“Medically fit!”“Needs PT/OT.”“Why are they still here?”So, is there any benefit of a geriatric MDT looking after such patients? What does “The Evidence” show? Well, a Cochrane review of 13,766 patients across 29 trials from 9 countries showed that older people who are admitted to hospital and get access to comprehensive geriatric assessment are more likely to be alive in their own homes at one year. In fact, the number needed to treat is 33.
Surely by now we should be at a point where not providing this evidence based treatment makes you an outlier? There’s a couple of barriers here though. First of all, not all geriatricians are completely convinced by what we do. “It’s just common sense, isn’t it.” And even when we are proud of what we do, which is a lot, sometimes we find it hard to articulate.
So what is “comprehensive geriatric assessment.”Well, it’s led by someone with specialist expertise in looking after older people, usually, but not exclusively a geriatrician. It is multidisciplinary with expert input from therapists and nurses, who want to look after frail older people, and who know how to assess them, how to talk to them and how to provide rehabilitation. It is usually provided in a specialist geriatric ward but also makes use of home based and intermediate care services when this is more appropriate. It is tailored to the individual. Knowing what a patient is normally like, knowing how severe this illness is, knowing how to treat this illness in its broadest sense (see below) and knowing what goals are meaningful and realistic for patient and carer, are key.
It is structured and often covers the following areas:·
- Active problem list·
- Consideration of co-morbidities – how they might interact with acute problems, and how they might impact on each other·
- Cognition assessment – looking for and treating delirium, and identifying memory problems·
- Mood assessment·
- Falls assessment – knowing that a multicomponent treatment plan can reduce risk of further falls·
- Nutrition assessment·
- Medication assessment with particular attention to the problems of polypharmacy and use of the geriatrician’s scalpel – deprescribing·
- Assessment of bladder and bowel function, knowing that constipation, urinary retention and incontinence can be managed and that failure to manage them hinders rehabilitation·
- Assessment of function including not only whether someone is dependent or independent in a binary way, but enough detail at least to assess someone’s [tinyurl.com/CFSRockwood]clinical frailty score. A change in function is important to note here, and is at the heart of acute geriatric medicine·
- A social assessment including formal and informal support services· Occupation, hobbies and interesting facts·
- An environmental assessment·
- Goals and wishes for the future·
- Ceilings of care and advance care planning.
These issues are often grouped into fewer, broader domains – physical/medical, mental, social, environmental and functional assessments but you can see how it can be hard to articulate exactly what comprehensive geriatric assessment is. This problem is further compounded by the ability of many organisations to “tick the boxes” of comprehensive geriatric assessment without necessarily managing the problems identified.
This really is quite difficult to describe, but let me try. A 90 year old lady is admitted to a general ward with a fall. A thorough history is taken but difficult to elicit due to “confusion.” Examination and bloods seem unremarkable. An ECG and troponin appear to have shown evidence of a myocardial infarction so triple antithrombotic therapy is started. A urine dipstick is pleasingly positive for everything and the urine, does indeed smell. Antibiotics are duly administered. The pharmacist reviews several medications, but the ward team ask “GP to review.” Various care plans are filled out and a plan for “PT/OT” is made. Someone, somewhere suggests a rehab bed, or maybe 24 hour care. Both sound good because with this person’s confusion, there is no way that they could possibly manage at home.All boxes have been ticked but no meaningful plan has been formed. Frustration is everywhere.
In an alternative universe the person is seen by a specialist geriatric team who look through the emergency medicine department notes and decipher that the patient appeared to walk into the emergency department with no apparent complaint. She had an ambulance call out the day before with “confusion” but no cause could be found. Whilst in the department, she complained of central chest pain, and indeed had ECG and biomarker changes of a myocardial infarction.
A collateral history is obtained. She used to ramble with her father and remains an avid walker, well known to people in her neighbourhood. Despite significant memory problems, there is no history of getting lost. She has lived in this area for some time, and indeed found her way to the hospital safely. This is at odds with her apparent “wandering” in hospital which seems to be risky until we realise her need to roam, that can be alleviated by a member of staff escorting her to the hospital shop for a newspaper.
She has carers twice a day who help her with personal cares, meals and medications. Her daughter helps with shopping and cooking and cleaning. She remains physically active despite her “end of the bed” frailty and indeed was found chopping wood in the garden with an axe just a couple of weeks ago, something she has always done.
When we assess her bleeding risk, using the CRUSADE score, we judge her at high risk of bleeding, and she prefers to be on fewer medications. Although she had dual antiplatelets for a week, we switch to monotherapy on discharge. Her blood pressure is very low and falls further on standing so we stop antihypertensives and amitryptilline, which no-one can remember the indication for. After discussion with her and her daughter, we decide that the benefits of a statin would be limited.
The physiotherapist has also spoken to the daughter and takes a careful history of cognitive decline for the past year, in keeping with possible dementia where family have provided increasing support, first for finances, and then with meals and shopping. Carers started 6 months ago. She likes walking, as we already noted, but also the music of David Bowie, which is odd because she used to hate Bowie when her teenage daughter was a fan, but now livens up when she hears his music on the ward.
The example above is based upon a couple of real cases I have seen in the last year, and I hope illustrate what we do on geriatric wards. We are inquisitive. We are thorough. We are specialists in frailty and its related syndromes. We de-prescribe, not with abandon, but with careful gleeful consideration. We work with an MDT where we all gather and share information and modify each others plans. We consider the impacts of co-morbidities. We understand the value of methodical assessment of bladder and bowel function, of delirium and falls assessments, and of mood. We consider patients preferences and values, and we lap up their stories to enrich our understanding.
Her preferences are to be at home, and the family note that although she has memory problems, they are not particularly worse in hospital and she has a strong support network of family and friends. The occupational therapist identifies the need for rails to be fitted to the stairs and the front entrance. Although she can walk unsteadily holding onto someone else, she is currently not able to manage the stairs on her own so she is discharged home with the help of the intermediate care team who will move her bed downstairs and provide therapy at home to practice the stairs. She will be followed up in the memory clinic.
We have soft hearts, hard heads and thick skin. We try and stop people dying when this what they want. We restore function when this is possible. We don’t write people off, but we don’t press on at the end of an illness trajectory. We recognise when treatment isn’t working or isn’t in keeping with someone’s values and preferences. We look after frail older people. We do this because we value older people and want to work with them. We like working with uncertainty and competing demands. We like working in teams and allow space for others to contribute, even though we usually lead. We like not just knowing that treatment needs to be different for frail older people, but how this is different, because we have specialist knowledge, expertise and experience.
If Comprehensive Geriatric Assessment was a drug, we would give it everyone. But there are no drug reps here, only specialists in geriatrics.
We need to do what drug companies do: Educate. Lobby. Publicise. Persuade. Preach.
It’s not easy to explain, but explain we must. You can’t bottle this. This is geriatric medicine, and this is what we do.