Geriatric medicine in Hull: a comprehensive service

Continuing care of Old People—A Medical Viewpoint

Provision for old people who are in need of continuing care requires close co-operation between informal carers and different agencies and disciplines providing health and social care. In the United Kingdom, the present system of care has evolved from earlier patterns of care centred on the asylums and the poor law with its workhouse institutions. It lacks cohesion. Despite the designation of old people as a priority group, resources are still inadequate to provide a good quality of care. Organisational differences between health and social services can lead to inefficient use of existing resources. More specialised medical, psychiatric and social services for old people enhance the possibilities for co-operation even though they may appear to lead to greater fragmentation. The history of the development of these services in the UK, including the recent expansion of private sector care, is reviewed, with special attention from the medical perspective to the phenomenon of ‘bed blocking’. The recently published Griffiths Report on community care is briefly considered, and some principles for future developments are laid down.

Age-Related Geriatric Medicine: Relevance of Special Skills of Geriatric Medicine to Elderly People Admitted to Hospital as Medical Emergencies

This study was carried out to find out how many patients aged 75 and over admitted to hospital as medical emergencies had features appropriate to care by physicians in geriatric medicine and to examine the extent of use of specialist facilities by these patients. The purpose was to examine criticisms of age-related admission policies which have focussed on misplacement of patients with single diagnoses and lack of access to specialist care. An analysis was made of admission, process and discharge characteristics relevant to the special skills of geriatric medicine, multiple pathology and use of specialist services by 554 patients aged 75 and over. These were collected prospectively, consecutively admitted as medical emergencies via the accident and emergency department of a large district general hospital with an age-related (75 and over) medical admissions policy. 84 patients (15%) had single pathology and no characteristics suggesting the need for specialist geriatric care. 177 (32%) had single pathology and one or more specialized characteristics. 66 (12%) had multiple pathology alone. 227 (41%) had multiple pathology and specialized characteristics. There were 142 specialist referrals in 121 patients (22% of the whole sample). We concluded that the special skills of general physicians specializing in the medical and associated community problems of elderly people are highly relevant to patients aged 75 and over presenting as medical emergencies. There was no evidence of lack of involvement of specialists in their care.

Differences between "geriatric" and "medical" patients aged 75 and over

We analysed the characteristics of patients aged 75 and over admitted to the geriatric and general medical wards over a three month period in a teaching hospital. Patients admitted to the geriatric wards were slightly older, were more often female, more likely to be admitted during the day and during a week day, more likely to have been seen by their own general practitioner, had more chronic and multiple illness with non-specific presentations, and stayed longer in hospital. Referring doctors seem to discriminate between patients needing geriatric care and those more suitable for general medical care, but there is an overlap in the characteristics of the two groups.

Prevalence of Clostridium difficile on a mixed-function ward for the elderly

We studied the prevalence of Clostridium difficile over a period of 2 months on a mixed-function geriatric ward. Seven (14%) of the 49 patients were long-stay but the remainder were in hospital for acute illness or required a short period of active rehabilitation. Although 69% patients had recently received antibiotics, from only two (4%) was C. difficile isolated from their faeces. Our results show that C. difficile is not endemic in patients on all geriatric wards as has been previously suggested.

Effect on a geriatric service of opening a 25-bed ward on the district general hospital site: an audit

Notes and discharge summaries of 2,560 patients were analysed in a pre-planned study to determine how the establishment of a 25-bed assessment ward on the district general hospital (DGH) site affected the work of a geriatric unit that had previously had no DGH beds. Throughput, changes in referrals and practice, and changes in outcome were measured using a computerised programme which examined the work of the unit for a year before and a year after the opening of the assessment ward. There were no changes in overall bed numbers or staffing, so changes were likely to be the direct result of establishing the DGH beds. The second year of the study showed a 33% increased throughput, with increased referrals from the accident and emergency department and evidence of more active investigation and treatment and a tendency towards a shorter length of stay. There was an increased number of transfers from all departments to the geriatric department for rehabilitation and a shortened time interval to transfer. Admissions to the general medical unit for patients aged 65-74 and 75+ did not change.

Benefits of effective hospital services for elderly people

An age related hospital service for elderly people was set up in Waltham Forest Health Authority to provide acute medical care when needed. Despite a reduction in the allocation of funds over the years 1982-4 the health authority increased the number of district general hospital beds available for elderly patients and improved home nursing services. The outcomes of the changes made were assessed against the aims of the service by using data from the Hospital Activity Analysis, SH3 returns, government population estimates, and yearly figures collected in our department. It is concluded that introducing an age related service in our health authority has benefited people aged over 65.

Elderly patients in acute medical wards: factors predicting length of stay in hospital

A prospective study of 419 patients aged 70 and over admitted to acute medical wards was carried out by medical staff from a geriatric unit. Data, including presenting problem, housing, social support, mental state, continence, and degree of independence before and after admission, were recorded. Of the 419 patients, 143 remained in hospital after 14 days and 65 after 28 days. The major factors associated with prolonged stay in hospital included advanced age, stroke, confusion and falls as reasons for admission to hospital, incontinence, and loss of independence for everyday activities. Social circumstances did not predict length of stay. Although these factors are interrelated, the most important influence on length of stay was the medical reason for admission. Early contact with the geriatric medical unit in these patients may speed up the recovery or result in more appropriate placement.

Relationship of long-term and acute-care facilities. The problem of patient transfer and continuity of care

Approximately 17% of patients residing in an extended-care facility--which provides close physician-patient contact and strong affiliation with an acute-care hospital, although does not have the capacity for intravenous therapy--required admission to an acute-care hospital during a one-year period. The most common medical problem necessitating transfer to the acute-care hospital was an infectious process. Most infections were correctly diagnosed in the extended-care facility, but due to the inability to administer intravenous therapy, transfer was thought mandatory. The acute-care hospital stay was short, which is thought to reflect partially the close affiliation between the extended-care facility and acute-care hospital. Complications occurred while patients were in the acute-care hospital with 30% demonstrating new pressure sores upon their return to the extended-care facility. Repeated acute-care hospital admissions were not uncommon, usually occurring within a short period after the patient's return to the extended-care facility, and commonly related to the same medical disorder that caused the initial admission. Prognosis was poor in patients who required admission to the acute-care hospital and mortality rate increased to approximately 50% in patients requiring multiple admissions. It is concluded that an extended-care facility that provides a high level of physician-patient contact and a close affiliation with an acute-care hospital is advantageous in providing efficient and continual care for the elderly. Provisions for the administration of intravenous therapy might even increase the efficiency of such a facility.

Who should provide hospital care of elderly people?

Since 1980 Islington Health District has appointed one consultant physician trained in geriatric medicine and three general physicians. The effect of these appointments on health care of the elderly in hospital was studied by means of Hospital Activity Analysis data for 1980-83. There were significant reductions in length of stay and in numbers becoming long stay among elderly patients admitted to the geriatric department. There was little change in these variables for elderly patients in general medical beds. The reduction in length of stay was achieved by the geriatric medicine department despite a lower staff/bed ratio and negative skewing in favour of acute medicine, and without any significant increase in the rates of readmission or mortality within 2 weeks of admission.

Alive and well: geriatric medicine in the U.K. in 1984

The function of the hospital geriatric service in the U.K. is described within the context of the overall support for the frail, disabled, and sick elderly in this country. It plays an important part in the secondary care of the very old, and perhaps an even more important part educating the public and the profession to the needs of this rapidly expanding section of the population. A short account is given of the nature of geriatric medicine and the role of the consultant geriatrician. The history, achievements, and current status of the specialty are briefly reviewed, and some of the directions which future developments may take are indicated. Whether or not a comprehensive separate service on the U.K. model emerges in other countries, it is certain that they will need centres of geriatric expertise to pursue research and to provide education and enlightenment for all concerned with the medical problems of old age.

Benefits of access to on-site acute and critical care for the residential section of a multi-level geriatric center

Of 220 residents living in the residential unit of a multi-level geriatric center, 95 required a total of 131 transfers to other facilities over a one-year period. Fifty-three of these patients were transferred to the associated chronic-care hospital for short-term acute medical investigation or treatment. The average length of stay of 17 days was similar to that of patients of comparable age with comparable medical conditions admitted to an affiliated acute general hospital from the community. In addition to continuity of medical care and the social and psychologic advantages of remaining within the geriatric center, this transfer potential resulted in substantial financial savings. The cost of hospitalization in the general hospital would have been more than twice that of the geriatric unit.

Improved care for patients on a new geriatric evaluation unit

An analysis is presented of a geriatric evaluation unit (GEU) established at the Sepulveda VA Medical Center in 1979 to provide comprehensive interdisciplinary assessment and treatment of geriatric inpatients. The data on 74 patients admitted during the first year show that major improvements can occur in several outcome areas. Placement location was improved over expectations in 48.4 percent of patients, thus permitting a higher level of independence with a lower level of care requirements. Functional status (Katz ADL scale) improved in two-thirds of the patients who could have shown improvement. An average of almost four new treatable disorders not noted by previous physicians were diagnosed per patient. The mean daily number of prescribed drugs was reduced by 32 percent per patient, and the total number of drug doses by 43 percent. Though limited by the unique aspects of the vA situation and by lack of a control group, the findings lend support to the efficacy and value of the GEU concept. (A randomized controlled study is in progress.)

Health and medical care for the elderly and aged population: the state of the evidence

Emerging statistics emphasize the special needs of the elderly for health and medical care services. A variety of services are being recommended to meet these needs, but few of them have been subjected to rigorous study for determining efficacy, effectiveness or cost. Examination of about 1,000 studies of health and medical services for the elderly published between 1967 and 1978 revealed only 7 that met predetermined criteria for well-designed and executed investigations. The varied needs of the elderly are finally being recognized, and undoubtedly pressure will be increased for meeting these needs. In this era of finite monetary resources and budgetary restraints, we need better data upon which to base the selection of medical care services for the aged. Resources needed to provide care of known benefit should not be diverted to provide care of unknown benefit.