What is sarcopenia?
Progressive and generalised muscle disoreder associated with an increased risk of adverse outcomes such as falls and fractures.
Muscle fibres reduce in number and due to this there is a loss of explosive power, needed for functions such as sprinting, standing from a chair and even coughing.
What is frailty?
"A state of increased vulnerability to stressors due to age-related declines in physiologic reserve across neuromuscular, metabolic and immune systems."
It is the effect of systemic ageing and not chronological.
This means that a young patient can be frail, and a chronologically old patient can be fit and well and not frail.
Frailty suggests that a frail person will have much of a more adverse reaction to a simple infection like a UTI compared to a fit and well patient.
Define frailty, multimorbidity and disability.
Frailty = Risk of deterioration when faced with a physiological stressor
Multimorbidity = Involves two or more medical conditions that may or may not interact
Disability = Physical or mental impairment that has a substantial and long-term negative effect on a person's ability to carry out normal daily activities.
How is a fraity score carried out?
The Clinical Frailty Scale
Explain The Clinical Frailty Scale.
Very fit - Robust, energetic, motivated. Among the fittest for their age.
Well - No active disease symptoms. Exercise and are active occasionally
Managing well - Medical problems are well controlled but are not regularly active
Vulnerable - Independent but disease symptoms limit activities.
Mildly frail - More evident slowing. Need help in high-order IADLS such as finances, transport, heavy housework and medications. It can impair shopping and walking outside alone.
Moderately frail - Need help with all outside activities and with keeping house. Problems with stairs and need help with bathing and maybe dressing.
Severely frail - Completely dependent for personal care from whatever cause may it be physical or cognitive. Not of a risk of dying within 6 months.
Very severely frail - Completely dependent, approaching end of life. Typically they could not recover even from a minor illness.
Terminally ill - Approaching end of life. Life expectancy is less than 6 months.
What is comprehensive geriatric assessment (CGA)?
A tool to determine the medical, psychological, and functional capabilities of a frail older person.
This is to develop a coordinated and integrated plan for treatment and long-term follow-up.
It leads to better outcomes, including readmissions, reduced long-term care and greater patient satisfaction and lower costs.
It emphasises QOL, functional status, prognosis and outcome.
What is the typical CGA team?
Domains of the CGA.
Physical symptoms - pain, continence, sensory impairment, MSK problems, multimoribidity management
Mental health symptoms - Mood and cognitive assessment
Functional abilities - Assessment of activities of daily living like washing, dressing, bed transfers etc...
Living environment - Home visit or access visit. This is led by occy health and to assess hazards around home and safety. Stairs, rugs, lighting, flooring etc...
Social support network - Financial asssessment and carer's assessment. Does the individual have family or friends helping out? Any visitors or daytime activities?
Future wishes - Advanced care planning. Nomination of power of attorney, CPR decision and refusal of treatment.
What is polypharmacy?
Often occurs when 6 or more drugs are prescribed at any one time.
This leads to increased drug interactions, drug-drug interactions and drug-disease interactions.
A problem with polypharmacy is not only side-effects but also that concordance might decrease as a result.
Reasons for altered pharmacokinetics in older people.
Drug absorption might be increased due to gastric emtpying slowing etc...
Drug distribution might be higher due to volume distribution.
Drug metabolism might be reduced.
Elimination from kidney can be reduced
How to optimize compliance and concordance of medicine in older people.
Understand what medications are taken and which are not.
Understand the problems around taking that medication.
Simplify the regimens as much as you can.
Review care needs.
Educate on why the medication needs to be taken.
Explain the elements in safe prescribing.
Correct agent for the correct patient with the correct diagnosis.
Correct time and dose.
Check for drug allergies.
Check for potential interactions with other drugs.
Use generic drug names and write the drugs in CAPITALS.
Don't use abbreviations
Dose, frequency, times. Route of adminstration and inclue a start date and review/end date if appropriate.
Be cautious with decimal points, they can be difficult to read. E.g. if 0.5g write 500 mg instead.
Don't use mcg - write micrograms instead.
Write "units" not "U". Latter can be misread as a 0.
Print name as well as signing if on a paper chart.
Write why it is taken.
Always make sure you review medications on a daily basis.
What is STOPP/START tool?
A safe-prescribing tool.
Screening Tool Of Older People's Prescriptions (STOPP)
Screening Tool to Alert to Right Treatment (START)
There are STOPP medications and there are START medications.
In instances of changes in health or for any other reason of an older person those tools come in handy for review.
What does a discharge involve?
Medication to take home
Transport - Family or needed taxi?
Therapy assessment with Occy and Physio
Restarting package of care - if more complex or not in place a section 2 may be involved to arrange it.
District nurse referral if required or palliative care or community lead referral if warranted.
Transfer back letter for residential/nursing home.
What is a section 2?
In most cases a referral is made to Social services to assess funding for example a care home or direct payments, or a package of care.
A social worker is then allocated to the patient/servoce user and will responsible for putting together an appropriate package of care.
Why do discharges fail?
One or more elements of the criteria under any one title hae failed, like obtaining a suitable package of care.
Patient/user health complications.
Communication breakdown between health care professionals and social services.
Decisions around funding.
What is section 5 in discharge?
A section 5 is sent by nursing staff to Social Services, to alert them to the fact that the patient has been declared medically stable for discharge.
Once the section 5 is received the designated social worker is expected to start taking decisive action towards discharge.
Social services incur a financial penalty if they are responsible for delayed discharge.
Reasons for admission of older people.
Self-presentation to A&E
Admission from clinics
Referrals from community services
Referrals from community hospitals
Admissions from residential and nursing homes.
Explain the assessment of capacity.
Problem based approach of palliative care.
Who is involved in the end of life care assessment and initiation of that management?
It's a decision between patient, physician and family.
This is assuming the patient has capacity.
Pain is a major symptom that is needed to be managed in palliative care.
What are the five principes of effective analgesia?
By the mouth - if possible
By the clock - fixed intervals
By the ladder - The WHO analgesic ladder
For the individual - no standard doses of opioids
Attention to detail - communicate, set times carefully and warn of side-effects.
Explain the WHO analgesic ladder.
1 - Non-opioid e.g. paracetamol
2 - Opiod for mild to moderate pain like codeine. Still give paracetamol
3 - Opioid for moderate to severe pain like morphine, diamoprhine and oxycodone. Stop the codeine.
Use laxatives and anti-emetics with strong opioids.
Principles of palliative care.
Important when curative care is no longer possible and care needs to switch to a more holistic approach.
Individualised for each patient and concentrate and focus on their needs.
If patient is conscious and able to swallow they will still enjoy food and drink.
Priority needs to be on comfort and dignity.
When can the end of life or dying phase be recognised?
Bed bound in their disease
Only able to take sips of fluid
Unable to take oral medication
Non-related pain symptoms at end of life.
Nausea and vomiting - Cyclizine or haloperidol
Constipation - fluid intakes and laxatives
Dyspnoea - morphine or midazolam
Agitation - midazolam
Confusion - Haloperidol or levopromazine
Non-pharma prescription in end of life care.
Regular mouth care should be prescribed and given.
Macmillan nurse and palliative care team aid.
In end of life care, how are most medications given?
Anticipatory end of life medications given s/c.
Morphine - pain
Haloperidol - Agitations and N+V
Midazolam - Agitation and anxiety, seizures
Levomepromazine - N+V, anxiety and agitation
Glycopyrronium - troublesome respiratory secretions.
Cyclizine - N+V
Hyoscine butylbromide - Respiratory secretions
What is essential to have in place in end of life care?