Organizing Geriatric Services

Using geriatric services

Geriatric services have developed rapidly since the inception of the specialty in the 1950s. They have different forms, depending on local resources, experts, and enthusiasts. Every district will offer different services, each with a different spectrum of options. There are some broader national differences within the UK; services in Scotland and Northern Ireland lean more towards rehabilitation and long-term care than those in England and Wales. The following is intended as a generic guide to utilizing geriatric services in the UK. Diversity will limit applicability.

Services for acute problems

Urgent assessment of the acutely unwell patient, where the disease process is new and severe (eg acute MI, stroke) or the deterioration is rapid (eg delirium).

Examples:

General practitioner (GP) emergency services (see ‘Primary care’, p.46)
Emergency departments (EDs; see ‘Acute services for older people’, p.16)
Acute medical admission service
Rapid Access (admission avoidance) services (see ‘Admission avoidance schemes’, p.20)
Urgent domiciliary visits (see ‘HOW TO … Do a domiciliary visit’, p.33)

Choosing which is most appropriate will depend on patient characteristics (eg if unstable, then an ambulance to an ED is appropriate; if no change is expected over a few days then urgent outpatient assessment may be used) and local service characteristics (availability of urgent clinic slots etc).

Services for sub-acute problems

Assessment of a patient with a progressive disease process (eg increasing falls, worsening Parkinson’s in a frail patient) or unexplained potentially serious problems (eg iron deficiency anaemia, weight loss) or for diagnosis and management plan (eg cardiac failure).

Examples:

Routine outpatients
Speciality clinics (see ‘Specialty clinics’, p.24)
Day hospital (see ‘Day hospitals’, p.22)
Intermediate care facilities (see ‘Intermediate care’, p.26)
Elective admission (to acute hospital, rehabilitation wards or community hospital)
Domiciliary visits (see ‘HOW TO … Do a domiciliary visit’, p.33)

Again, choice of service will depend on patient factors. Single organ problems can be referred to specialist clinics, less well-defined medical problems to a geriatric outpatients, and problems suggesting the need of multidisciplinary input to the day hospital. Local availability, waiting times and consultant interests will also affect choice—while most cardiologists have chest pain clinics, not all will run heart failure services, which may be provided by general physicians or geriatricians.

Services for chronic problems

This includes active, elective management of slowly progressive conditions by GPs, community teams, specialist nurses, and secondary care physicians (see

‘Chronic disease management’, p.44) and the provision of care for established need.

Care may be provided by a number of means:

Informal carers (see ‘Informal carers’, p.40)
Home care and care agencies (see ‘Home care’, p.38)
Day centres (see ‘Other services’, p.42)
Respite care (in care homes or hospitals) (see Box 2.1)
Care homes (see ‘Care homes’, p.34)

Allocation of these usually long-term services is generally after an assessment of need and financial status by a care manager.

Most patients will pass through many aspects of this care spectrum with time, and a flexible, reactive service with good communication between providers is essential. The flow diagram (Fig. 2.1) schematically represents possible patient flows through the system.

Fig. 2.1 An example of a comprehensive geriatric service.

Acute services for older people

Since older people present atypically, and are at high risk of serious sequelae of illness, high-quality acute services that fully meet their needs are essential. In any setting, older people have special needs. Their needs, and the consequences of not meeting them, are amplified in the setting of acute illness. Specific areas meriting attention include pressure area care, prevention and treatment of delirium, and optimal nutrition and hydration. Accurate early and comprehensive diagnosis(es) is essential.

An acutely unwell older person may present to one of several services depending on:

Local service provision
The individual’s understanding of the system
Advice from others (eg relatives, health professionals, NHS Direct)

Any service aiming to diagnose acute illness in older people must have access to immediate plain radiography, electrocardiography (ECG), and ‘basic’ blood tests (including prompt results). Specialist clinical assessment (geriatrician, urologist, neurologist, etc.) and more advanced diagnostics (eg ultrasound, computed tomography (CT), magnetic resonance imaging (MRI)) must be available on a prompt referral basis, although may be on another site.

Emergency department (accident and emergency)

Older people present commonly to the ED with falls, fractures, fits, and faints, as well as a broad range of acute surgical and medical problems traditionally referred directly by GPs to surgical or medical teams. Direct referrals of such patients to ED are increasing, as a result of changes in GP out-of-hours services, advice by agencies such as NHS Direct, and changing public behaviour.

▶The ED is potentially inhospitable and dangerous for older people. The environment may be cold, uncomfortable, disorientating, and lacking dignity and privacy. There is a risk of pressure sores developing due to long waits on hard chairs and trolleys. Provision and administration of food and fluid may be neglected, or inappropriately prohibited on medical grounds. A medical model of care may presume serious illness, prioritizing immobility, invasive monitoring and treatments, at the expense of a more holistic approach that appreciates the downside of these interventions. Staff may be experts in emergency medical management, but their expertise in geriatric medicine and nursing is variable. Deadlines and targets that minimize time spent in ED on trolleys (eg the 4hr wait rule) may well benefit older ED users.

Strategies to optimize care for older people in ED might include:

Close liaison with geriatric medical and nursing specialists
Medical and nursing rotation between ED and geriatric medical wards
Focus on optimizing food and fluid provision and pressure care
Provision of alternative modes of admission and assessment, eg Rapid Access Clinic, direct admission to geriatric ward
Provision of specialist geriatric assessment unit
Occupational therapist, physiotherapist, and social worker with expertise in older people based in ED

The older patient in intensive care

With the aging population and a reduction in overt and covert ageism, a greater proportion of intensive care unit (ITU) and high dependence units (HDU) beds are occupied by older patients. However, they remain a rarity with <3% of most ITU admissions in the UK for patients aged >85.

▶Age alone is a weak predictor of outcome and should not be used as the sole reason to deny ITU/HDU care. Frailty scores provide more accurate prognostic information. Patients with multiorgan failure especially in the context of frailty will not do well on ITU.

Older patients with the following should be considered for ITU/HDU:

Postoperative
Septicaemia
Post cardiac arrest/life-threatening arrhythmia
Acute drug effects or overdose
Intensive monitoring eg acute MI or stroke thrombolysis
Ventilatory support, eg pneumonia or pulmonary oedema

If in doubt discuss your case with ITU physicians. Even where patients are unsuitable for admission to ITU, the intensive care specialists and their outreach team may be able to offer advice. The use of early warning scores (EWS) (which are designed to detect patients in pre or periarrest situations) in parallel with escalation/trigger systems (to prompt timely management decisions) is growing. This trend may well increase the involvement of intensivists in the management of critically unwell frail elderly people.

▶Remember that older, frailer patients are more likely to refuse intensive treatment so always enquire, from the patient if possible, or the relatives about any advanced refusal of intensive treatment (see

‘Advance directives’, p.664).

The great integration debate

There has been a longstanding debate among UK geriatricians about the best model of care for older people in hospital. Historically, age-related care grew out of workhouse facilities and the advent of care provided in mainstream institutions was a major step against ageism. The provision of age-related services on the same site and with equal facilities to facilities developed. This defied the label of ageism and professed other advantages. Traditionally care has been divided into either ‘age-related’ or ‘integrated’ but there are many shades of grey in between these two extremes, usually developing locally in response to manpower restraints, ward availability, and the enthusiasm of individuals. The two ‘pure’ systems may be described as follows:

Age-related care. A separate team of admitting doctors to deal with all patients over a certain age (varies—commonly around 75 years) who then care for these patients on designated geriatric wards
Integrated care, In truly integrated care, specialists will all maintain additional generalist skills. These generalists will admit all medical patients regardless of age and continue looking after them on general medical wards, in parallel with specialist clinical commitments

(See Table 2.1 for advantages and disadvantages of each system.)

The debate has never been fuelled by any evidence (there are no studies comparing systems) and it has become less fevered recently as the reduction in junior doctors’ working hours has made it impractical in many hospitals to run two entirely separate teams. As a result various hybrid systems have grown up, managing patients pragmatically and sampling the best aspects of both the systems.

A common compromise is that there is integrated acute assessment, with a single admitting team, but rapid dispersal to the most appropriate service—gastroenterology for a patient with acute gastrointestinal bleed, cardiology for acute MI, and acute geriatric medicine for a confused elderly patient etc. This dispersal may be done at a variety of levels and times, again depending on local service strengths and constraints. Models include triage of need (‘needs’ or ‘function’ related segregation) by an appropriate person immediately after admission (admitting specialist registrar (SpR), experienced nurse, bed-manager, etc.), dispersal by a ward allocation system after removal from the admitting ward or over a period of a few days (by inter-speciality referral) as the special needs become apparent.

As individual systems evolve, the debate recedes and energies are invested into providing the best possible care for all patients through innovation and flexibility within a certain hospital structure, rather than in drawing boundaries and maintaining rigid definitions. Vigilance against ageism in these evolving systems remains essential.

Table 2.1 Comparison of age-related and integrated care

*Age-related care*
Advantages	Potential drawbacks
All old people seen by doctors with a special interest in their care	Possibility of a two-tier standard of medical care developing, with patients in geriatric medicine settings having lower priority and access to acute investigation and management facilities
All old people looked after on wards where there is a multi-disciplinary team	Less specialist knowledge in those doctors providing day-to-day care
Even apparently straightforward problems in older patients are likely to have social ramifications that are proactively managed	May be stigmatizing for all patients of a certain age to be defined as ‘geriatric’
	May be less kudos and respect for geriatric medicine practitioners
*Integrated care*
Advantages	Potential drawbacks
As the majority of patients coming to the hospital are elderly, it maintains an appropriate skill base and joint responsibility for their care	Many generalists will not be skilled in the management of older patients, so those under their care may not fare as well
There is equal access to all acute investigative and maintenance facilities, as older patients are not labelled as a separate group	Specialist commitments are likely to take priority over the care of older patients
Trainees from all medical specialties will have exposure to and training in geriatric medicine assessment	The multidisciplinary team input is harder to coordinate effectively where the patients are widely dispersed
Sharing of specialist knowledge is more collaborative and informal	Management of the social consequences of disease tends to be reactive (to crisis) rather than proactive

Admission avoidance schemes

Admission avoidance schemes (AAS) are very variable in content and name. Schemes may be divided into those that do and do not offer specialist geriatric assessment (provided by a geriatrician, a GP with a special interest, or a geriatric specialist nurse).

Non-medically based schemes

These may include emergency provision of carers, district nurse, occupational therapy and physiotherapy, delivering, eg, prompt functional assessment and increased care after a fall. As medical assessment is not a part of the scheme, treatable illness may be missed. As a minimum such schemes should incorporate assessments by healthcare professionals who can recognize the need for specialist geriatric assessment and can access such services promptly.

Schemes with a medical assessment

Variously titled Early Assessment, Rapid Assessment, Emergency or Rapid Access clinics
All aim to provide a prompt response to medical need in older people, with acuity falling somewhere between immediate admission and more elective outpatient services
Few schemes aim to provide same-day assessment, most aiming to see patients within 1 week of referral, and at best the next day
There is an assumption that patients are midway between first symptoms and severe disease, and that early intervention may prevent decline, permit less aggressive or invasive treatment, and permit the patient to remain safely at home
Services are best accessed via telephoned, faxed or electronic referral, with prompt assessment of the content of and response to referrals by an experienced professional

▶There is a risk that acutely unwell older people who need emergency assessment or treatment are referred to AAS rather than admitted immediately. If in doubt, admit to the emergency medical/geriatric medicine team. Delirium is an example of a presentation where admission to hospital from home is usually required.

In practice, most AAS do have to admit a modest proportion of patients to hospital directly. In some cases this represents optimal care, but in others it introduces a dangerous delay to a clinical situation
AAS staffing usually includes senior medical staff (± junior support). Experienced nursing assistance is invaluable, perhaps in the form of a nurse practitioner. Nursing roles are variable but may be very extended, to include history taking and physical and mental state examination
Most commonly, AAS are housed in ‘general’ outpatient facilities. Examples of problems managed here include anaemia or breathlessness
A more comprehensive geriatric response (see ‘Comprehensive geriatric assessment’, p.70) is facilitated when AAS is housed in or adjacent to outpatient multidisciplinary services, eg Day Hospital
AAS should have prompt (ideally same day) access to occupational and physiotherapy services, to support the patient at home whilst the effect of medical interventions become apparent. Patients with complex needs are best managed in this environment, eg Parkinson’s disease with on/off periods

Day hospitals

Day hospitals (DHs) provide services that lie somewhere between outpatients and inpatients. Patients stay for half or a full day and the primary aim is to regain or improve independence for a group of frail elderly people with complex needs.

The case mix and interventions vary widely between units but can include:

Medical—new patient assessments, eg for falls, weight loss, anaemia, as well as chronic disease management, eg heart failure, parkinsonism
Nursing—eg pressure sore and leg ulcer treatment
Physiotherapy—eg following stroke, fracture, surgery
Occupational therapy
Diagnostics—facilities for usual blood tests, radiology, et. and also specific therapeutic trials, eg levodopa
Treatments—eg blood transfusions, intravenous furosemide infusions

A flexible and holistic attitude is required and many DH clients will take advantage of multiple different services in a ‘one-stop-shop’ approach. There is usually a mixture of new patient assessments, rehabilitation, and chronic disease management. Patients may be referred directly from the community or from other outpatient settings or may be booked for a follow-up after an inpatient stay. Some units have designated sessions for specific patient types or services (eg movement disorder clinic, admission avoidance clinic). Multidisciplinary teamwork and comprehensive geriatric assessment (see

‘Comprehensive geriatric assessment’, p.70) and functional goal setting are all important tools.

History and evolution

The first DHs were set up in 1960s. In their heyday many units had collected a huge number of patients who were very frail but had little active intervention and used their visits as social occasions or respite for carers. Unacceptably long waiting lists hindered efficient running in some units. Transport problems often proved to be a weak point, with patients spending lengthy periods of time waiting for, or during transport.

The monitoring/supporting role has now been largely taken over by day centres (see

‘Other services’, p.42) and modern DHs tend to have a high ratio of new:old patients and a rapid turnover. Increasing pressure on acute hospitals has opened up the role of rapid access admission avoidance clinics and early supported discharge schemes. Intermediate services development, following the national service framework (NSF), has sometimes augmented services (eg falls services) and sometimes denuded them (eg where outreach services have taken over).

Cost effectiveness

Pressures to justify the expense of day hospital places led to a flurry of publications looking at effectiveness and cost-effectiveness. While this area remains controversial a systematic review in 2008 found that DH patients did have less functional deterioration, lower rates of institutionalization and hospital admission than control groups receiving no care. However DHs did not prove superior to other comprehensive care services (eg domiciliary rehabilitation). DH care is costly but this may be offset by decreased inpatient bed usage and institutionalization or social care costs. It is very important to ensure this expensive resource is targeted effectively and regularly evaluated to ensure cost-efficiency.