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Acute medicine and frail older people

Acute medicine and frail older people. Leicester Medical School. Simon Conroy Senior Lecturer/Geriatrician London March 5 th 2010. Outline. How it is – for frail older people What is going wrong? Is it going wrong? Why?. Decompensation. Intercurrent illness. Breakdown of support.

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Acute medicine and frail older people

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  1. Acute medicine and frail older people Leicester Medical School Simon Conroy Senior Lecturer/Geriatrician London March 5th 2010

  2. Outline • How it is – for frail older people • What is going wrong? Is it going wrong? • Why?

  3. Decompensation Intercurrent illness Breakdown of support Primary care Crisis

  4. Acute care starts in primary care • 269,000 admissions (all ages) from 144 general practices in Leicester/Leicestershire • 1 admission per person per 10 years • Practice level predictors of hospital admission • Age>access>deprivation>distance

  5. Decompensation Intercurrent illness Breakdown of support Primary care GP Call for help 999 Crisis Direct to ED/AMU Crisis addressed Intermediate care ED

  6. Frail older people and the ED • The decision to admit to hospital • Increases the risk of complications (falls, urinary catheterisation, delirium, malnutrition, pressure ulcers, deconditioning) • Puts community services on hold (so discharge complicated) • Costs ~£1000-1500 • So is delegated to the most junior doctor in the hospital…

  7. The ‘transfer of care’

  8. Decompensation Intercurrent illness Breakdown of support Primary care GP Call for help 999 Crisis Direct to ED/AMU Crisis addressed Intermediate care ED ED 75% AMU 25% Community

  9. Meta-analysis of consultant level discharge rates (AMU) Older people

  10. ‘Meta-analysis’ of consultant level 30 day readmission rates Older people

  11. Older people

  12. Readmissions – a new geriatric syndrome? • 2007-9, Leicester Royal Infirmary • 10,583 individual patients admitted to LRI AMU aged 70+ • Readmission over ~4 months • 30% complex vs. 22% non-complex older patients readmitted, p<0.001 • Typically 10-13% for ‘all comers’ • No qualitative studies of ‘the readmission’

  13. Any readmission over time Hazard ratio 2.2

  14. And it ain’t just social • Patients discharged from AMU • Mortality 37% complex vs. 12% non-complex, p<0.001 • 30 day mortality 19% vs. 3%, p<0.001 • 90 day mortality 30% vs. 6%, p<0.001

  15. Deaths occurring early on Hazard ratio 4.2 Adjusted (age & gender) 3.6

  16. Decompensation Intercurrent illness Breakdown of support Primary care GP Call for help 999 Crisis Direct to ED/AMU Crisis addressed Intermediate care ED ED 75% AMU Base wards 90% 10% 25% Community Community

  17. Ageism Polypharmacy Cognitive impairment End of life care Non-specific presentations Comorbidities Differential challenge Functional decline Frail older people

  18. Summary • Frail older people poorly served by acute care response • Reverse of Marjory Warren’s era! • Getting acute care right for frail older people requires an integrated whole systems approach

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