Key facts:
Author: Andrew Stein
Top Tip: You can die of a social disease
Key Differential Diagnoses
- 'More medical > social' admission - ie predominantly medical (with some social issues)
- 'Medical only' admission
- Psychiatric admission
Key Investigations
It's important not to miss a more medical admission. So, run a investigative screen:
- FBC, CRP, ESR
- U+E, LFTs, Bone, glucose
- ECG, CXR
Key Treatment
- Meet the family ASAP, and stress importance of helping them to help the patient
Key Management Decision
- Intermediate care (social worker, physio, OT etc)
Background
The true 'pure' social admission is rare. This 'more social > medical' admission is common
Introduction
- The frail elderly constitute most 'more social' admisions. Most acute medical units have abandoned the concept of an age-related admission process. This is partly for political reasons (related to targets); and partly, because of a desire to make the admission process 'fair'. In other words, we want to make sure that patients of all ages, get the highest quality of care.
- The 'pure' social admission is rare ie the patient has no active medical issues, and their home circumstance has broken down
- To discover the other medical issues, take the opportunity of admission to carry out a full clinical assessment and investigative screen. It is particularly important to review all medications. Ring GP if necessary. Polypharmacy is a major problem in the frail elderly. Eg - look for falls induced by postural hypotension (caused by drugs)
- Medical issues can be the cause of their 'social' admission - ie by falling over they are no longer suitable for their current level of home care. By correcting the problem, you solve the 'social issue' and return them to their previous level of social care. And a nursing home is not necessary
- Remember an 'atypical presentation' of a medical component in a 'more social' admission, is not atypical at all. It is normal, in the frail elderly for a pneumonia (silent) or MI (silent) to present as a fall, or a 'more social admission'
- (Incorrectly) labelling a 'more social' admission as 'social-only' does them a disservice, and closes the brain of the health professionals that follow. It is the complex interaction between social (personal, family, carer), financial and medical issues that has lead to the 'pure social' and 'more social' admission. Therefore all issues will have to be sorted, to return the patient to a stable home circumstance; whether it be their own home, or a residential or nursing home
- The term 'social admission' is not helpful; it is similar to 'acopia' or 'off legs and unable to cope'. They all emphasise the unwelcome nature of the admission. More importantly and deeply, they are not a recognised diagnoses. Furthermore, phrases such as 'GOMER', 'bedblocker' and 'crumble' are frankly insulting. Do not use them, and rethink your humanism if you think them. You will get old one day - ie this will be YOU. If you cannot imagine that, imagine your grandparents
- Rather .. ask 'Why?' (And what are you going to do about it?)
Definition
- An admission that is mainly for social reasons - ie, patient (family or carers) cannot cope with current social setting
Epidemiology
- 10-15% of acute medical admissions are now > 80 yrs
- Patients over 65, mostly with multiple long-term conditions (and many with frailty and functional or cognitive impairment), account for around 60% of admissions and 70% of bed days in NHS hospitals
- The proportion of these that are 'more social' is unknown
The Old Crock (from 'The Way we Age Now')
- "The Old Crock is deaf. The Old Crock has poor vision. The Old Crock’s memory might be somewhat impaired. With the Old Crock, you have to slow down, because he asks you to repeat what you are saying or asking. And the Old Crock doesn’t just have a chief complaint – the Old Crock has fifteen chief complaints. How in the world are you going to cope with all of them? You’re overwhelmed. Besides, he’s had a number of these things for fifty years or so. You’re not going to cure something he’s had for fifty years. He has high blood pressure. He has diabetes. He has arthritis. There’s nothing glamorous about taking care of any of those things" (Gawande A, Rockwood K. ‘The way we age now’. The New Yorker, 30 April 2006)
Symptoms
- Variable and multiple
- Make sure you have obtained an uptodate drug list. If necessary, ring the GP. Look at previous medical history on computer
Note: an accurate social history is vital. The key question is 'what is their normal level of dependence?'. Write this down
Key questions
- "Who looks after you at home? (ie what is their normal level of dependence). You may have to find this out from other sources
- "How are you feeling?"
- "What are your worst symptoms?" (then focus on them)
- "Why do you think you have been admitted?"
- "Shall we talk to your family?"
Signs
- Variable and multiple
- Do a full examination, and make sure you have looked at all of patient's body. Don't forget to look for causes of a 'more medical' admission (eg, CVA, pneumonia) and the effects (eg, pressure sores, #NOF). Tap the spine looking for crush fractures
- What's the BP? Postural drop?
You may be part of the problem
- Despite a growing emphasis on holistic care, communication and team-working, there is still a bias in the values of medical training towards the hightech, the novel and the rare – and of course, the well-remunerated
- In one study of Norwegian medical students, junior and senior doctors were asked to rank 33 diagnoses in order of their ‘prestige’. Conditions such as acute coronary syndrome and leukaemia were at the top, with typically geriatric and mental health problems at the bottom
- It is likely that your medical school training has emphasised these disparities; and that has been re-inforced by the attitudes of senior doctors (and nurses) when you start working
Dealing with relatives (and avoiding litigation)
- Many relatives fear that an elderly person may be written off at an early stage, and may therefor be more defensive about their normal level of dependence
- It is also wrong to assume that, just because someone is 85 yrs old, that either the relatives or patient, will feel that they will take a philosophical view about having had a 'good innings'. Some of the most serious allegations of substandard care come from this area. Relatives often assume, that in the chaos of an admission unit, their relative will get low priority. They can be right
- Be sensitive to the family dynamics, particularly in the area of dementia, and chronic dependence
- The admission may be the culmination of many months of major family stress, trying to cope with an increasingly difficult situtaion; frustration with the social services and the GP, and trying to avoid hospital admission - until they really really cannot cope
Investigation
A routine clinical assessment, and investigative screen is worthwhile. After that, don't 'go hunting' for disease
Blood
- FBC, ESR, CRP
- U+E, LFTs, Bone, Glucose
Other
- ECG ('silent MI'?), CXR ('silent pneumonia')
Diagnosis
- Exclusion of major medical disease
Differential Diagnosis
- 'More medical > social' admission - predominantly medical (with some social issues)
- 'Medical only' admission
- Pyschiatric admission
Treatment
Treat hospital-acquired infection quickly
Treatment
- If medical component discovered on routine clinical assessment and investigative screen (above), treat
- Have a low threshold for starting oral METRONIDAZOLE (and sending a stool sample off) if they acquire diarrhoea. They may have picked up C diff from the hospital
'Not for resus'
- Do NOT immediately suggest that patient have a 'not for resus' form filled out. Leave that issue to seniors. If you think, appropriate, you can suggest it to them
Prescribing issues
- Take opportunity of admission to review all medications. Ring GP if necessary. Polypharmacy is a major problem in the frail elderly. Look for postural hypotension (often caused by drugs), and other drug causes of falls
Key management decision
- Intermediate care referral (Has it been made? To right person/team? Has it arrived? Been acted on? When?)
- Writing "Diagnosis: Social, Plan: continue" in the notes everyday demonstrates that you do not know what the patient is waiting for
Admit?
- Usually. Occasionally if the social issues are minor, the patient can be (safely) discharged from the Emergency Dept (or medical admission ward) if there is a dynamic component of the intermediate care team working there
Bed plan
- Appropriate general medical ward
- A medical admission (or observation) ward is inappropriate. Many hospitals now have a short stay ward (often linked to a medical admission ward) where a large 'social package' can be organised more quickly than from a conventional medical ward. They are often staffed by a dynamic component of the intermediate care team. If you have one, use it
Referrals
- Intermediate care
The Rest
Maxim
- 'You can die of a social disease'
Care with the language you use
- The language used – for instance ‘bed-blocker’ and ‘inappropriate admission’ - all reinforce the premise that older people are somehow a ‘problem’, impairing the functioning of the system (from its 'correct purpose') by their very presence
- Remember. The function of a hospital is to save lives, and provide care. It is not for us to judge whether one patient 'deserves' hospital admission, or not. What about the deeper issues? Why, in our culture, we don't have alternative mechanisms for the care of such patients, is also not a medical issue
Complications
- Hospital acquired infection (especially MRSA and C Diff)
Things often missed
- Crush #spine, #NOF, silent MI, silent pneumonia, CVA
Pain
- It can be difficult to separate symptoms (especially pain) from different systems. Remember referred pain as well: eg, band-like chest/adbominal pain, from a collapsed thoracic or lumbar vertebra; shoulder-tip pain, from diaphragmatic pathology (eg, gall bladder); upper abdominal pain from MI or CCF (liver distension); and diffuse abdominal pain from a strangulated femoral hernia, or bowel ischaemia
- Patients often have pre-existing chronic pain in several sites, and make have problems differentiating the new from the old pain. This makes it even harder
Follow-up
- Usually not necessary, except if 'more medical' admission, or develops a hospital acquired problem. Then ask GP to do that, as patient is likely to find a trip to outpatients stressful
Risk stratification
- These patients are in great danger, if you send home, without the home circumstance being sorted
Prognosis
- Unknown (little research) but note comment above. Why don't you do some?
2° Prevention + Health promotion
- Ring GP to prewarn about discharge, to encourage home visit next day
Don't forget
- Record normal level of dependence and drug list in the notes. THIS IS VITAL
- Involve family and intermediate care early
- Atypical presentation of disease in the frail elderly is not atypical at all. It is typical
- Care with your language. Do not use insulting phrases such as 'GOMER' or 'crumble' or 'bed-blocker'. Do not think in that way either. This will be you one day
- GP contact is essential to make discharge safe
Red flags
- Missing 'more medical' or 'medical-only' admission
- Sending home, without necessary safety net in place (food, heat and care)
