Category: frailty

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)

Acute Behavioural Disturbance / Excited Delirium

Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.

  1. High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
  2. Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
  3. Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
  4. Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC

Refusing treatment = Mental Capacity Assessment [LINK]


OrderDrugRouteTypical Dose (mg)Onset (min)Duration (hr)Warning
First LineLorazepam - AdultIV1mg IM/IV (max dose 4mg/24hrs)2-51-2Respiratory depression, IM unpredictable onset
IM15-30
Lorazepam-ElderlyIV0.5mg IM/IV (max dose 2mg/24hrs)2-5
IM15-30
Second Line - AdultOlanzapine (not within 1hr of IM Lorazepam)IM5mg (max dose 20mg/24hr)15-45>10Arrhythmia Risk: Only if previously used OR ECG
Second Line - ElderlyPromethazineIM10mg15-30>10
Sedation ST4+ involvement requiredKetamineIV1-2mg/kg120-30Theoretical risk of worsening cardiovascular instability
IM2-4mg/kg3-560-90

RCEM -abd

Trust Guide

#NoF – Fractured Neck of Femur

BOAST Guidance

  • #NoF patients (or other fragility fracture) who requiring CT Head (for head injury) also be performed a CT Neck
    • Fragility fractures indicate the patient is at high risk of also sustain C-Spine injury.
    • Also the pain is likely distracting and the patient is often over 65yrs old so Canadian C-Spine rules will not apply.

Hx/Exam

  • Why did They Fall? – was this a collapse?
  • Are they sick? – Co-morbidity/illness is common in this group and must be recognised
  • Anticoagulants? – This affects treatment
    • On Warfarin – If INR >1.5 (or unavailable) Vit-K 5mg
  • Other injuries? – >65’s the most common mechanism of TARN major trauma is fall <2m
  • Typically – Pain hip/buttock, shortened, externally rotated
  • Atypical – Few signs (can they lift their leg & is rotation at the hip painful)

Read more

Silver Trauma

The population is ageing and thus our ‘typical’ trauma patient is also changing. In 2017 the TARN report “Major injury in older people” highlighted the following issues:

  • The typical major trauma patient: has changed from a young and male to being an older patient.
  • Older Major Trauma Patients (ISS>15): A fall of <2m is the commonest mechanism of injury
  • Triage/Recognition of ‘Silver Trauma’ is POOR
    • Pre-hospital: Not identified hence taken to TU’s (Here) not MTC’s (Leeds).
    • The ED: Often seen by Junior Staff and endure significant treatment delays.
    • Hospital: Much less likely to be transferred to specialist care.
    • Outcomes: More likely to die, but those who survive have similar levels of disability to younger people.

Read more

Delirium in the ED

Delirium is one of a number of geriatric syndromes and has significant associated morbidity and mortality.

3 subtypes of delirium

  1. Hyperactive – easies to spot, one we are most familiar with. Characterised by agitation/aggression/hallucinations “the non cooperative patient”
  2. Hypoactive – harder to spot. Characterised by drowsiness, less responsive, vacant, sleeping more at home
  3. Mixed

Remember there is NO SUCH THING AS A “POOR HISTORIAN” !! – Just a poor clinician! If your patient is not cooperating and can’t tell you very much then you need to find out why!!! Read more