Transcript Mrs D. – aged 71yrs

So what exactly do you do Duncan?
Dr Duncan Forsyth
Consultant Geriatrician
Segmenting the Population
Assessment Level
Service Response
Comprehensive
Overview
Registration
Complex
Needs
Specialist, disciplinary
Early Problems,
Single Conditions
General Population
Primary Health
and Social Care with
Specialist Support
Partnerships
for Health and
Wellbeing
The right
way may
not always
be obvious
So, we must
learn from
the patient
journey.
Occhum’s razor
The simplest explanation is the right one!
NOT NECESSARILY!
Framework for Quality
• Outcomes
• Safety
• Experience
• Value for Money
In Lay Terms
• Will I feel better?
• Will I be safe?
• Will staff be caring?
• Will I get value for (taxpayer’s) money?
Outcomes for Older People
• Independence
• Wellbeing
• Not being a burden
Safety
• Falls and Fractures
• Hospital Acquired Infections
• Medicines Safety
Experience (Dignity in Care)
•
Abuse
•
Privacy in care
•
Involvement in decision-making
•
Nutritional needs met
•
End of life care
So what does this all mean
on a day to day basis?
Mrs D. – aged 71yrs
• Daughter concerned when visits mum and asks for home visit
– Daughter lives 120 miles away
• 3 days increasing difficulty looking after herself
• Reduced appetite
• Hardly mobile in flat (normally ‘free-range’)
• Cough with green phlegm & dyspnoeic
• Febrile (38.6oC)
• Lives in sheltered housing complex
• No care package
• No medication
What will you do?
Mrs D. – aged 71yrs
• Admitted to community hospital bed
– Oral antibiotics
• 36hrs later
– Delirious
– Refusing all oral fluids and medication
– Immobile
What will you do?
Mrs D. – aged 71yrs
• Transferred to acute hospital bed
– IV antibiotics
– LMWH
– MMSE
20/30
– CLOX1
8/16
– CAM
positive
– IQCODE
2.1
Cognitive screening algorithm
Is there cognitive impairment? MMSE, CLOX1
Duration of cognitive impairment?
Delirium
Ix and Rx
Delirium and chronic
impairment (?dementia)
CAM, IQCODE
Chronic impairment
(?dementia)
Assess for severity, consider
depression, hypothyroidism,
etc.
?REFERRAL
‘draw me a clock that
says 1:45. Set the
hands and numbers
on the face so that a
child could read
them.’
Organisational elements
Point value
Does figure resemble a clock?
1
Outer circle present?
1
Diameter >1 inch?
1
All numbers inside the circle?
1
12, 6, 3 and 9 placed first?
1
Spacing intact? (symmetry on either side of the 12–6 axis)
If yes, skip next.
2
If spacing errors are present, are there signs of correction or erasure?
1
Only Arabic numerals?
1
Only numbers 1–12 among the Arabic numerals?
1
Sequence 1–12 intact? No omissions or intrusions.
1
Only two hands present?
1
All hands represented as arrows?
1
Hour hand between 1 and 2 o’clock?
1
Minute hand longer than hour?
1
None of the following:
1) hand pointing to 4 or 5 o’clock?
2) ‘1:45’ present?
3) intrusions from ‘hand’ or ‘face’ present?
4) any letters, words or pictures?
5) any intrusion from circle below?
1
CLOX1
Confusion Assessment Method (CAM)
•
•
•
•
1.
Acute onset and fluctuating course
– Is there evidence of an acute change in mental status from the
patient’s baseline? Did the (abnormal) behaviour fluctuate during
the day, that is, tend to come and go, or increase or decrease in
severity?
2.
Inattention
– Did the patient have difficulty focusing attention, for example being
easily distractible or having difficulty keeping track of what was
being said?
3.
Disorganized thinking
– Was the patient’s thinking disorganised or incoherent, such as
rambling or irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching from subject to subject?’
4.
Altered level of consciousness
– Overall, how would you rate this patient’s level of consciousness?
• Alert (normal)
• Vigilant (hyperalert)
• Lethargic (drowsy, easily aroused)
• Stupor (difficult to arouse)
• Coma (unarousable)
Inouye SK. The dilemma of delirium. Am J Med. 1994; 97: 278-285.
1
Remembering things about family and friends, eg occupations, birthdays, addresses
2
Remembering things that have happened recently
3
Recalling conversations a few days later
4
Remembering her/his address and telephone number
5
Remembering what day and month it is
6
Remembering where things are usually kept
7
Remembering where to find things which have been put in a different place from usual
8
Knowing how to work familiar machines around the house
9
Learning to use a new gadget or machine around the house
10
Learning new things in general
11
Following a story in a book or on TV
12
Making decisions on everyday matters
13
Handling money for shopping
14
Handling financial matters, eg the pension, dealing with the bank
15
Handling other everyday arithmetic problems, eg knowing how much food to buy, knowing how long between visits from family or friends
16
Using his/her intelligence to understand what’s going on and to reason things through
Now we want you to remember what your friend or relative was like 10
years ago and to compare it with what he/she is like now.
Scoring the test
1 = Much improved
2 = A bit improved
3 = Not much change
4 = A bit worse
5 = Much worse
Cognitive screening algorithm
 The algorithm is as brief as possible, while allowing for
acceptable sensitivity:
– MMSE4 + CLOX15 = 12 minutes3
Patients below
cut-off points
– CAM6 + IQCODE7 = 10–15 minutes
50% of patients will
be above cut-off
points and exit the
algorithm
Quantifies the
level of delirium
and chronic
impairment
Causes of delirium (precipitants)
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•
•
•
•
•
•
•
D
E
M
E
N
T
I
A
rugs
ndocrine
etabolic
nvironmental
eoplasm
rauma
nfection
poplexy (stroke)
• D rugs:
• CNS active drugs particularly
anticholinergics, polypharmacy,
withdrawal
(antidepressants,
alcohol and benzodiazepines)
• I nfection & Intracranial
• pneumonia, urinary tract, skin
• Stroke, subdural, epilepsy
• M etabolic
• glucose, calcium, ammonia,
hypoxia, low cardiac perfusion
• E lectrolytes
• sodium, dehydration
All may be associated with immobility – remember restraining
Risk factors for delirium (predisposing factors)
• Severe physical comorbidity – especially renal impairment,
infection, dehydration (also frailty)
• Urinary retention
• New environment and stress also increase the risk of
delirium
• Dementia or previous Delirium
• Older age (delirium more likely with increasing age)
• Writhing in pain
• Neuro psychiatric illness previously
• Ears & eyes - deficits in hearing or vision (strongly associated
with delirium, Odds Ratio 12.6)
• Rx, (chronic anticholinergic drug use, polypharmacy)
• Sleep deprivation Surgery
Mrs D. – aged 71yrs
• Next day on PTWR
– Afebrile
– Recalls multiple moves
– Recounts problems with sleeping since being ill & says
she thinks this may be relevant
– Eating and drinking
– Wants to know when she might go home
What should we do with the community bed?
Mrs D. – aged 71yrs
What should we do with the community bed?
• Send her back now
• Give it to someone else
• Hold it for a further 48hrs pending progress
Mrs D. – aged 71yrs
• Full recovery over next 48hrs
• Returned to own flat without care package.
Value for Money
• Avoiding hospital admission
• Reducing length of stay
• Reducing long-term institutional care needs
Avoiding Hospital Admission
What works:
– Targeted prevention
– Disease Management
– Secondary prevention
of falls and fractures
Avoiding Hospital Admission
What doesn’t work:
– Unselected preventive home visits
– Nurse-led care coordination (Evercare)
Reducing Length of Stay
What works:
– Streaming to
specialist care
– Early supported
discharge
Reducing Length of Stay
What doesn’t work:
– Trying to sort
everything out in
hospital
– Step-down hospital
care
Reducing Long-term Institutional Care Needs
What works:
– Multidisciplinary assessment in the
community
– Early intervention and care in dementia
– Improved Housing
Reducing Long-term Care Needs
What doesn’t work:
– Hospital-based assessment
BUT
– The world may have changed!
5 key ingredients for
service redesign
5 Key Ingredients
Early Intervention in Old Age Conditions
Old Age Conditions
• Falls
• Vision
• Mobility
• Hearing
• Confusion
• Feet
• Continence
• Oral Health
5 Key Ingredients
•
Early Intervention in Old Age Conditions
•
Streaming to Specialist Care in Crisis
Streaming to specialist care in crisis
• Confusion
• Off legs
5 Key Ingredients
•
Early Intervention in Old Age Conditions
•
Streaming to Specialist Care in Crisis
•
Early Supported Discharge
Early Supported Discharge
In the person’s home,
whenever possible.
5 Key Ingredients
•
Early Intervention in Old Age Conditions
•
Streaming to Specialist Care in Crisis
•
Early Supported Discharge
•
Multidisciplinary Assessment prior to Placement
Multidisciplinary Assessment
Reduces long-term residential
placement by up to a third.
5 Key Ingredients
•
Early Intervention in Old Age Conditions
•
Streaming to Specialist Care in Crisis
•
Early Supported Discharge
•
Multidisciplinary Assessment prior to Placement
•
Partnership
Partnership
• Integrated teams
• User-held records
• Joint planning and
commissioning
A Recipe for Care
For every complex problem there is a
simple solution…
but it doesn’t work!
A Recipe for Care
It’s not rocket science…
it’s much more complicated!
Let’s change the subject
Mrs JD - 1
• 78 year old woman
• 2 week history of shortness of breath
• 4 week history of general lethargy and swelling of the
lower limbs
• No past medical history
• No medications or allergies
• No family history
• Non smoker
Mrs JD - 2
•
•
•
•
•
Gross peripheral oedema to the umbilicus
Tense and swollen abdomen with ascites
Markedly raised jugular venous pressure
Bibasal inspiratory crepitations
Alk Phos 458, ALT 65, Bili 34
Mrs JD - 3
Mrs JD - 4
Mrs JD - 5
Mrs JD - 6
What would you do next?
Mrs JD - 7
• Diagnosis explained to patient and family
• Patient complained of increasing shortness of
breath, abdominal discomfort and poor sleep
• Diamorphine prescribed as required
• Resuscitation status discussed with the family
• Rapid deterioration and death within 48 hours
Mr WA - 1
• 90 year old man
• Presented with a 2 day history of increasing
shortness of breath
• Discharged a week previously after a 2 week
admission with congestive cardiac failure and
renal impairment
• Aspirin, digoxin, furosemide and ACE-I
• Living at home with qds care and a high degree
of family support
Mr WA - 2
• Fit independent man until 4 years ago
• 2003 seen in DME clinic & diagnosed CCF + AF
– Treated with diuretics, ACE-I and digoxin.
•
•
•
•
Improved with intensive clinic follow up & discharged
Stable until late 2005 when admitted with CCF
Over the next 18 months admitted with CCF 3x
After each admission care needed increasing
Mr WA - 3
O/E
• Short of breath at rest, with bibasal crepitations
• Peripheral oedema to the sacrum
• Raised jugular venous pressure
• Creatinine 213, (132 when recently discharged)
• ECG poor R wave progression and AF
• CXR congestive cardiac failure
Mr WA - 4
• What will you do?
• What are your expectations?
Mr WA - 5
•
•
•
•
•
•
Treated with diuretics
Patient failed to respond
Creatinine increased to over 500
Shortness of breath and oedema worsened
Patient became unresponsive and distressed
Started on a diamorphine pump and died
peacefully
Mrs GD - 1
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•
•
•
•
•
95 year old woman
Admitted from a nursing home
Refusing all food and drink
Advanced dementia
Bed bound
Not obviously dehydrated
Mrs GD - 2
• Retired teacher, widowed 12 years ago
• Living independently until 7 years ago when presented to GP with
cognitive impairment
• Managed at home with increasing amounts of social services help
• 5 years ago admitted to a residential home due to her dementia
• 2 years ago transferred to a nursing home
• Several admissions over the preceding 5 years with several different
problems: UTIs, falls and PMR
• 2006 admitted with a similar presentation, treated for depression
and subsequently started eating again
Mrs GD - 3
What would you do next?
Mrs GD - 4
•
•
•
•
Medications simplified
Continued to be offered antidepressants
Continued to be offered food and drink
With family agreement, the decision was taken
that artificial feeding was not in her best interests
• Painful investigations stopped
• Became acutely distressed
• Started on a diamorphine pump and died
peacefully
Illness trajectories
1. Previously fit lady, high level of
function. Rapid deterioration
after a diagnosis of cancer
2. Gradual decline in function due
to organ failure punctuated by
episodes of acute admission
with marked functional decline.
Sudden “unexpected” death
3. Chronic steady decline in
function over a longer period of
time
Causes of death in UK (ONS 2003)
@ 530,000 deaths p.a.
84% (448,307) aged 65 and over
Cancer
25%
Heart disease
19%
Respiratory disease
14%
Stroke and related disease
11%
Other
31%
1% rule
• percentage of population dying each year
• percentage of population in the last year of life
Palliative Care for older people
• 75% people in Europe and US would prefer to die at
home
• 18-32% have that option
• Chief causes of death in old age are chronic illnesses
(cardiac, stroke, respiratory)
• @25% deaths due to cancer yet in UK 95% hospice
places occupied by cancer sufferers
www.parliament.uk/parliamentary_committees/health_committee.cfm
» www.euro.who.int
Three triggers for supportive/palliative care
To identify patients for supportive and/or palliative care, any of the
following can be used: (from the Prognostic Indicator Guidance Paper
10)
The surprise question
‘Would you be surprised if this patient were to die within the next
6-12 months?’ an intuitive question integrating co-morbidity, social
and other factors
Patient choice/need
the patient with advanced disease makes a choice for comfort
care only, not curative treatment, or is in special need of
supportive/palliative care
Clinical indicators
specific indicators of advanced disease for each of the three main
end of life patient groups (cancer, organ failure, elderly
frail/dementia)
Care for people wanting to die at home
• In UK 56% terminally ill would prefer to die at home
• Only 20% do!
• 56% die in hospital under generalists
– Current English policy excludes hospice patients from
legislation expediting discharge from acute hospitals
• 14 days palliative care at home costs @ £2500 ($4600,
€3800) cf £4200 for equivalent hospital care
» www.parliament.uk/parliamentary_committees/health_committee.cfm
Gold standards framework
(www.goldstandardsframework.nhs.uk)
• Community based, with local variations
• GP led
• Considers the whole dying experience
Key tasks – the 7 Cs
(Gold Standards Framework)
C1
C2
C3
C4
C5
C6
C7
Communication
Co-ordination
Control of symptoms
Continuity including out of hours
Continued learning
Carer support
Care in the dying phase
Goals of the Gold Standards Framework
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•
•
•
•
Symptom free
– patients’ symptoms are as well controlled as possible
Place of care
– patients are enabled to live well and die well where they choose
Security and support
– better advanced care planning, information, less fear, fewer
crises or admissions to hospital
Carers are supported, informed, enabled and empowered
Staff confidence, team-working, satisfaction, communication are
better
Liverpool care pathway
•
•
•
•
Designed for the final 48 hours of life
Written guidelines, anticipates problems
For use by all hospital staff
Four main sections:
Diagnosis of dying
Initial assessment
Ongoing assessment
Care after death
Criteria for diagnosis of dying in patients
without cancer
• Would you be surprised if this patient died within the next 48hrs?
• All possible reversible causes for current condition have been
considered
• Increasingly rapid deterioration and some of the following:
1. Increasing weakness- often bed-bound, requiring help
with personal care
2. Increasing drowsiness, impaired concentration, difficulty
in maintaining even briefest of conversations
3. Able only to take sips of water, no longer able to take oral
medication.
• Rev Philip Staves, assistant
chaplain
• Bereavement counselling
process unique to Cambridge
Bereavement Care follow up Services
DME
Neurology
Transplant
Oncology
Wards
F3, G3, G4
A3, A4, A5, NCCU
C9
D9
Bereavement Care follow up Services
1. Condolence Card
Sent to nok within a few days of a death.
Blank inside, hand written by ward manager.
2. Follow up Letter
Sent to nok about 5 weeks after a death.
Personalised letter, with reply slip, offering a
follow-up meeting if required.
Bereavement Care Services
DME follow up statistics for 2006
Ward
F3
G3
G4
Tot
Number of deaths
102
98
102
302
Number of responses
to letter
15
12
14
41
14.7%
12.2%
13.7%
13.6%
7
6
5
18
6.9%
6.1%
4.9%
6.0%
Number of follow up meetings
• ‘One of the ways we can measure
ourselves as a society and as a healthcare
system is the way we care for our weakest,
including our dying patients. We must regard
care of the dying therefore, as a measure of
our success and not of our failure, within the
NHS.’
Dr Keri Thomas, NHS National Clinical Lead for Palliative Care.
Gold Standards Framework.
www.goldstandardsframework.nhs.uk
Key points:
 There is growing awareness of the need to improve end of life care
for older people who constitute 86 percent of all deaths.
 The three trajectories of illness illustrate the complex challenges that
face us with end of life care for older people.
 There are significant developments in care, e.g. NHS End of Life
Care Programme, Gold Standards Framework, Gold Standards
Framework in Care Homes, Liverpool Care Pathway for the Dying,
Advance Care Planning and Preferred Place of Care.
 Care of the dying should become a measure of success rather than
of failure in our health system.
Let’s change the subject
Anne isn’t herself - 1
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86yrs female resident in NH
Husband also resident in NH (? Why)
Bed-bound & aphasic after CVA 18m earlier
Fully dependent for all personal care and needs feeding
Long-term urinary catheter
Registered blind – glaucoma & ARMD
Deaf
3 days h/o reducing conscious level
Now not eating or drinking and unable to take medications (aspirin 75mg,
omeprazole 20mg, Sinemet 125 tds)
GP presumed UTI as chest clear and she is febrile (38.2oC)
Anne isn’t herself - 2
• Husband wants her treated & admitted to hospital
• In EAU - dehydrated
– Na 150, K 3.6, Ur 19.3, Creat 59
– CRP 100, Hb 13.4, WCC 11.9
– Alb 28
• NGT inserted but feeding not instigated for 2 days whilst
awaiting Mg & PO4 to assess for risk of refeeding
syndrome
– S0 IVI in interim for rehydration and antibiotics
Should we artificially feed this patient?
What are the risks?
Should we feed
this patient?
Is feeding possible?
No
Yes
Health?
Prolong Life?
Palliation?
What’s the objective?
Is feeding a medical treatment?
Yes
Can feeding
achieve the
medical
objectives?
No
No
Is feeding basic care
No
Yes
Yes
What are the important values?
No
Is the patient competent?
Yes
Patient decides
Surrogate decision
Feeding not justified
Anne - The Facts
• Provision of food and fluids is a fundamental care-giving
activity
• 15% of the elderly living in the community and upto 60% of
older adults in hospital and long term facilities are
malnourished, requiring supplemental nutrition (Refail at all 1999)
• ‘Hungry to be heard’ – Age Concern 2006
• Dehydration affects the oral mucosa and most of other
bodily systems.
• A weight loss of 5% in a month is regarded as severe and
we need to recognise that oedema and excess body fluid
can mask true weight loss.
Anne - The Facts
• Without hydration & nutrition death will occur on average within 14
days
• With hydration & no nutrition death will occur on average within 60
days
• With minimal hydration & minimal nutrition the agony is prolonged!
• In the latter 2 scenarios the individual will become malnourished
with all its attendant complications
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–
–
–
–
–
altered immune function (infection risk)
delayed wound healing
reduced quality of life
increased care giving burden
thromboembolic disease
mortality
• 3 strands to decisions re feeding older people – scientific principle,
technical feasibility and moral principles.
Anne - Considerations
• NG tubes can be passed quickly at the bed side and one
can give bolus doses.
• NG treatment should not exceed 3-4 weeks due to risk of
mucosal injury. BAPEN suggest PEG should be inserted
after 14 days of NG feed.
• PEGs are reliable for weight gain and thought nicer for
body image than NGs.
• PEGs are difficult to dislodge
• Approximately 125,000 are done annually and formulae
can suit the individual.
• PEGs do have infection control issues and leakage at site
can be uncomfortable.
• Common to have abdominal cramps and diarrhoea from
the formulae
Anne - Considerations
• Gjerdingen’s study (1999)– 95% of cognitively normal
people would not want ANH in the case of severe dementia
• Gillick’s study (2000) indicated NG feeding does not help
pressure areas heal and increases the incidence of
aspiration pneumonia
• Stroud’s study (2003) indicted 30 day mortality rate for 2040 % of patients post PEG (wide range of diagnoses) –
mortality from other studies (just dementia) @60%.
• Rabeneck’s study (1996) showed a mean survival rate of
7.5 months in 7,369 patients after PEG insertion
Re-feeding syndrome
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•
•
•
First described in Far-East POWs
Occurs when previously malnourished individual fed with high carbohydrate load
– Results in hypomagnasaemia & hypophosphataemia
– PO4 < 0.5 mmol/l
In starvation
– ↓ insulin secretion in response to ↓ carbohydrate intake
– Fat & protein catabolism
– Resultant intracellular loss of electrolytes – especially PO4
PO4 normal serum levels
– Intracellular PO4 may be depleted despite
– Within 4 days of feeding the shift back to carbohydrate metabolism, ↑ in insulin
secretion and uptake of PO4 in to cells
Inability to phosphorylate results in:
– Cardiac failure
– Rhabdomyolysis
– Respiratory failure
– Increased risk of infection
– Hypotension
– Arrythythmias
– Seizures
– Coma
– Sudden death
Anne isn’t herself - 3
• Day 4 seen by DME consultant who liaised with nursing
staff on surgical ward (medical outlier)
– SALT
• to advise re: appropriate oral feeding
– Inappropriate to consider PEG
– Consider accepting aspiration risk
– May need to re-discuss with family, GP & NH
withdrawing NGT, end of life care & return to NH
Anne isn’t herself - 4
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Day 6
– no SALT review yet, NG re-sited
Day 7
– SALT advises try pureed diet or alternatively NBM
Day 8
– Dietician’s main concern is to maintain nutritional intake
– seems to have ignored or not read entries by SALT and Geriatrician
– advises bridled NGT awaiting PEG
Day 9
– SALT & dietician communicate with each other and advise bridled NGT
Day 10
– Medical SpR speaks with nephew and GP
– All agree with Geriatrician’s original recommendations & Anne returns to
NH that day
Thank you for your attention
Any questions?