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CDHB

Older Persons Health Specialist Service

OPHSS Department Information

The Older Persons Health Specialist Service (OPHSS) is based at The Princess Margaret Hospital. It is responsible primarily for the assessment, treatment, and rehabilitation of elderly people with physical and mental health problems and associated disabilities. There is a strong emphasis on a patient-focused multi-disciplinary approach that is provided in the location most appropriate to the patient, be it as an inpatient, outpatient, or in the person's normal residence.

Consultant Physicians

• Dr John Elliot, Dr Val Fletcher, Dr John Geddes, Dr Nigel Gilchrist, Dr Carl Hanger, Dr Sarah Hurring, Dr Hamish Jamieson, Dr Julie Kidd, Dr Anne Roche, Dr Andrew Sidwell, Dr John Thwaites, Dr Joyce Wan, Prof Tim Wilkinson

Consultant Psychiatrists

• Dr Chris Collins, Dr Matthew Croucher, Dr Brian Deavoll, Dr Dominic Lim, Dr Colin Peebles, Dr Jo Reeves

Medical Officers

• Dr Michele Dhanak, Dr Angela Harding, Dr Gerald Johnstone

Primary Care Liaison Team

• Dr Michael Thwaites (GP), Robyn Bayly (Physiotherapist), Ginny Brailsford (Pharmacist), Donna Rados (Registered Nurse)

Consultation and On-call Service

• There is a duty Physician on call at all times for the OPHSS, contactable through The Princess Margaret Hospital operator. Every clinical area in the CDHB has a nominated OPHSS Physician. Do not hesitate to use this person's expertise. Please phone the Consultant Physician directly or fax referrals to the Admissions Coordinator on 66914.
• There is a psychiatrist available Monday - Friday via the PSE (Psychiatric Services for the Elderly) Community Team. At the weekends, a psychiatric clinician is available. After-hours assistance is available through the Psychiatric Emergency Service. PSE referrals, including Delirium Team and Consultation-Liaison referrals, should be made as follows:
  • 0830-1630 weekdays: single point of entry (SPOE) for OPHSS 66371, fax 67998.
  • 0830-1630 weekends: 337 7899 and ask for the PSE Duty Clinician.
  • All other times: 364 0640 and ask for the Psychiatric Emergency Service.

Consultation Guidelines

Refer to an OPHSS Physician or Psychiatrist for:

• Specialist medical or psychiatric opinion about an elderly patient.
• Assessment for rehabilitation and for ongoing management by Older Persons Health Specialist Service.
• Assessment for entry to residential care - rest home, hospital, or dementia-care facility.
• Please refer to the Guidelines for Referral (OPHSS 0116, OPHSS 0117) and use the OPHSS Referral form (QMR0050). Search for "OPHSS" on the CDHB intranet.

Points to Remember

• The best value is obtained by referring for a consultative service rather than a "takeaway" service, and by referring early, outlining the specific clinical questions to be addressed.
• Rehabilitation and discharge planning can occur in any hospital setting, and should never be put on hold pending review by an OPHSS representative.

Philosophy

As a person ages, there is often a decline in the resources that keep them healthy and independent. These may be internal (e.g., physical health and cognitive functioning) and external (e.g., dwindling social networks and negative attitudes towards ageing). OPHSS specializes in the recognition and management of these issues, both before and as they arise, to maximize the health and independence of elderly people.

Department Guidelines

Refer to the OPHSS Guidelines - search for "OPHSS" on the CDHB intranet.

Attitudes

Elderly patients make up a significant component of hospital practice and, with an ageing population, the size of this component will increase. It is therefore important that all doctors are competent and confident when dealing with older patients.

Poor staff attitudes to older people can adversely influence the standard of care they receive. It is important that older people are not considered an imposition or an inappropriate admission. In particular, labels such as 'social admissions' should not be used as they have a high morbidity and mortality, much of which can be avoided by accurate diagnosis and prompt treatment. Terms such as "acopia" must never be used; the term "threatened independence" is much more useful for describing when an older person is having difficulties maintaining their normal level of functioning in the community. The reasons for threatened independence must be addressed.

Do not be over-familiar with elderly patients. For example, avoid calling them by their first names unless invited to do so. Treat them respectfully and handle them gently when performing the physical examination.

History and Examination

• The case history should follow the normal format. In cases where the patient is unable to give the required information, collateral history from family, friends, carers, GP, neighbours, etc. is essential.
• Social history should not be limited to smoking and alcohol use. Of equal or greater importance in the elderly patient is to know their circumstances prior to admission. Ask about:
  • Place of domicile.
  • Usual (premorbid) level of functioning, including ability to perform Activities of Daily Living (ADLs) such as personal cares and mobility.
  • Use of aids such as walking aids and hearing aids.
  • What support is provided and by whom.
  • How carers (usually family members) are coping. Remember that "carer stress" is becoming increasingly recognized.
• Medications: Older persons are at greater risk of being harmed by medication than any other group. It is therefore crucial to ensure that you have an accurate record of your patient's drug regimen; this may necessitate checking with their GP or pharmacist. Review and rationalization of an elderly person's medications should take place at each admission, particularly with regard to dose adjustment, potential interactions, and side effects. Always ask if they are using over-the-counter (OTC) medications, particularly eye drops, laxatives, hypnotics, and complementary and/or alternative medicines.
• Systems review: as well as the standard systems examination, the following checklist should be completed:
  • Bladder and bowels: Ask about urgency, incontinence, use of continence aids, prostatic symptoms, altered bowel habit, constipation.
  • Eyes and ears: Ask about problems with vision and hearing. Does the person wear spectacles or use a hearing aid? Does the hearing aid work (suspect battery failure if not) and can the patient use it? Have spectacles and hearing aid been brought into hospital?
  • Mouth and nutrition: enquire about dentures and whether they fit. Has there been recent weight loss? Are there obstacles to good nutritional intake, e.g., swallowing problems, availability of food, excessive alcohol intake?
  • Postural stability: have there been any recent falls?
  • Cognition: are there memory problems? Ask about unpaid bills, leaving the oven or element on, burned cooking and other accidents in the home, and getting lost outside.
• Examination: in addition to the standard examination, pay particular attention to the following:
  • Visual acuity: Test short and long distance vision.
  • Hearing: Impacted wax in ears.
  • Nutrition: e.g., evidence of weight loss, angular stomatitis, myopathy, cramps, etc.
  • Evidence of poorly fitting dentures.
  • Cognitive function. Perform Mini Mental State Examination (MMSE) or Montreal Cognitive Assessment Test (MOCA) if cognitive impairment is suspected, and consult Confusion Assessment Method (CAM) to help decide whether or not delirium is a likely cause.
  • Is the bladder palpable?
  • Rectal examination for prostatic disease and constipation.
  • Is vaginal examination required?
  • Rectal temperature if peripheral temperature is low.
  • Joints. Look for arthritis and changes of gout.
  • Feet. Look for lesions such as corns, uncut nails etc., requiring attention. Is there evidence of impaired vascular supply or peripheral neuropathy? Is footwear safe?
  • Gait. Is there instability? Look for signs of pain and neurological or joint disease. Are walking aids appropriate?
• Summary
  • List the problems, starting with those that are in most urgent need of attention.
  • Remember that multiple morbidities often co-exist in elderly people, and that the interaction between these may be contributing to the patient's presentation.

Altered Presentation

Altered or abnormal presentation is the rule rather than the exception in the elderly. Falls, delirium (acute confusional state), lost or threatened independence, and reduced mobility ("gone off legs") are common non-specific presentations. These patients need meticulous examination and work up as there is almost always an underlying medical condition that has contributed to their decompensation.

Beware painless myocardial infarction and sepsis with normal temperature.

Always consider medication as a cause or contributor of the acute presentation.

Management of the Confused Elderly Patient

Accurate diagnosis is the key to management. It is essential to find out the duration of the patient's confusion and distinguish between acute confusional state (delirium) and chronic cognitive impairment (dementia). Collateral history from a family member or carer is invaluable.

Note: These patients are at very high risk. Delirium affects 25% of elderly patients admitted to hospital and is associated with a 1 month mortality of 33%. Remember, too, that cognitive impairment is often missed by medical staff.

• Remember the predisposing factors for delirium, including advanced age, pre-existing dementia, sensory impairment, and Parkinson's disease.
• Use the MMSE or MOCA routinely (all inpatients should be screened on admission unless it is clear that they are not cognitively impaired) and the CAM Screen to help identify delirium.
• Try to make an accurate diagnosis.
• Treat any underlying cause (infection, dehydration, faecal impaction, polypharmacy etc), but remember that the absence of a clear medical trigger for delirium does not mean delirium is not present.
• Consider stopping or reducing medication that may be contributing but do not suddenly cease longstanding medications except in an emergency, and be careful about permanently stopping longstanding medications that were being used to prevent relapse of a recurring condition.
• Consider benzodiazepine and alcohol withdrawal as potential precipitants.
• To treat significant distress arising from agitation or psychotic symptoms, use haloperidol 0.25 - 0.5 mg BD PO (not in patients with cerebral Lewy body disease or Parkinson's disease - see below). Regular dosing is preferred to PRN. Titrate up or down according to the response and withdraw as soon as possible.
• Use lorazepam 0.25-0.5 mg BD PO for patients with Parkinson's disease or dementia with Lewy bodies; quetiapine 12.5 - 25 mg BD PO is another option (Consultant endorsement recommended).
• Avoid using intramuscular injections, except in emergency situations (refer to Psychotropic medication).
• Avoid using sedation unless absolutely required.
• Avoid using "cocktails" of several drugs.
• Aid orientation by providing visual and verbal cues - attend to spectacles and hearing aid if necessary, helpful communication and reassurance from staff and friends/carers, adapt surroundings, e.g., clock, familiar photographs, and other objects from home.
• Avoid using bed rails if agitated or mobile. Consider nursing on a mattress near to or on the floor if there is a risk of falling.
• Use a soft night-light.
• Minimize changes of staff members. Using relatives to stay with the patient may be helpful.
• In complex cases, further advice can be obtained through the Delirium Service ( 66788, fax 66998).
• Consent: It is important to gain appropriate consent for medical interventions. However, treatments which are restrictive or invasive are sometimes used without a patient’s consent when they have an illness that causes impairment to their insight and judgement to a degree that there is a significant threat to their interests, their safety, or the safety of others. In this case the treatments are given within a legal and ethical framework that recognises the importance of maximising a patient’s potential for autonomous decision making and promotes their best interests. This framework and advice regarding ‘best practice’ can be found in the guideline of the Older Persons Health Specialist Service: OPHSS Guidelines for Applying Coercive Treatments.

Continence Problems

Urinary Incontinence

• Attempt to ascertain whether the patient has stress or urge incontinence.
• Consider medication as possible contributor, especially cholinergic agents.
• Check MSU.
• Perform abdominal, rectal, and vaginal examinations to exclude faecal impaction, prostatism, urinary retention, atrophic vaginitis, etc.
• Measure bladder residual volume by portable ultrasound scan.
• Use an incontinence chart to identify any problem times or pattern of the incontinence.
• A trial of an anticholinergic (e.g., oxybutynin) may be worthwhile if detrusor overactivity is suspected and no contraindications exist. Remember that cognitive impairment may be worsened by anticholinergics.
• Referral for urodynamic studies may be required in a small number of cases.

Faecal Incontinence

• Faecal impaction with overflow is the leading cause in older people.
• Perform abdominal and rectal examinations (± abdominal X-ray) to exclude faecal impaction, painful rectal and anal conditions.
• Check the medication list for contributors, e.g., opioids, aperients.
• Consider the use of bulking agents.
• Do not use constipating agents until you are certain that high faecal impaction is excluded.
• Use commonsense measures such as encouraging the patient to use the toilet after a meal.

Loss of Functional Abilities/Deconditioning

Older people can lose function/abilities as a result of their acute illness or the treatment they are given or simply by being in hospital. It is important to optimize their recovery by combining medical treatment with measures to maintain independence as much as possible. Specific rehabilitation may also be required. Ensure that the older person has their normal aids (e.g., spectacles, hearing aid, walking aid, comfortable shoes) and gets dressed in day clothes (where appropriate) to facilitate recovery of function.

Falls in Older People

Falls are common, have serious health causes, and are a major cause of injury and subsequent disability.

Falls in hospital

In hospital, major risk factors for falls are the effects of acute illness (delirium, muscle weakness, dependency on staff for basic ADLs), medications affecting blood pressure or alertness, and unfamiliar environment (e.g., slippery floors, toilet is far away, unstable furniture, usual walking aid is not available). These often manifest themselves when the older person wants to get up to go to the toilet.

Risk factors for falling

Intrinsic risk factors (pertaining to the individual) include:

• Musculoskeletal: leg muscle weakness, osteoarthritic knees, impaired balance (reactions)
• Poor vision
• Impaired cognition (poor insight, judgement, and decision making)
• Medications: benzodiazepines and other psychotropics, diuretics, polypharmacy
• Postural hypotension (often via illness or medications)
• Acute illness causing muscle weakness, delirium, or dehydration

Extrinsic risk factors (relating to the environment) include:

• Slippery, unstable, or uneven surfaces (wet floor, loose rugs, ice)
• Poor lighting
• Unstable activities (climbing)

Most falls in older people are due to intrinsic factors, many of which can be modified.

Assessment

It is vital to obtain a clear history of each fall, including collateral history from family or another witness. Ask:

• What were you doing just before the fall, and then what happened?
• How had you been feeling over the last few days before the fall?
• Were you able to get up off the floor and how long before you could get up?
• Did you have any injuries? Did you feel back to normal?

Notes:

• Try to avoid the term "mechanical fall" - it is non-discriminatory. Instead describe what happened.
• Most patients have more than one cause for falls.
• If patients say "I must have tripped", seek alternative causes.
• Syncope and loss of consciousness raise possibilities of significant cardiac or neurological disorders and should be investigated accordingly.

Examine for orthostatic hypotension, gait abnormalities, muscle weakness, joint pain as well as injuries sustained in the fall.

Prevention or treatment options

• Strength and balance training reduces falls risk:
  • Programmes include the Otago Exercise Programme, Tai-Chi groups, or individualized strength and balance training with a physiotherapist.
• Medication review, with particular emphasis on reducing or stopping medications with sedative CNS activity (benzodiazepines, psychotropics, and antidepressants), or those with hypotensive actions.

  Note: Medication review must take a holistic view, including ongoing indications, and not just risk of falls. Gradual planned withdrawal, together with discussion with the general practitioner, is usually needed, particularly for centrally acting medication such as benzodiazepines or antidepressants.

• Environmental assessment, such as a home visit, is particularly important for those with visual impairment.
• Prevention of deconditioning with acute illness or immobility - it is important to maintain mobility and activity during acute illness or hospitalization.
• Hip protectors may be used to reduce the risk of hip fractures.

Topic Code: 1548