Loss Of Function And Independence
Caring for patients with multiple long-term conditions, frailty, and functional or cognitive impairment is an increasing challenge for families and health and social services. These patients often present to the Emergency Department with a relatively minor functional decline, but one that renders the patient ‘off their legs’, ‘bedbound’ or ‘acopic’ (unable to cope).
The Emergency Department can offer a rapid, thorough, medical and social assessment, with the aim of making an early decision as to whether the patient should be:
• Discharged home ± increased nursing/social support.
• Transferred to a rehabilitation bed.
• Admitted to a medical bed.
Such decisions require the range of skills of many different health professionals to be integrated, but can provide safe and effective care and avoid unnecessary acute hospital admissions.
An early part of the history and examination of these patients should be their Abbreviated Mental Test (AMT4) score. If this suggests impairment (score less than 4), the rest of the history may need cautious interpretation. It is always useful to corroborate the history from at least one other source (carer, relative).
Key questions are:
• Why is the patient here now?
• Is there a (reversible) reason for a loss of function?
• Precipitants: ask in detail about any recent symptoms, specifically adequacy of oral intake, loss of weight, bowel or urinary symptoms, and symptoms of infection.
• Falls: falls are common and a careful history is necessary to work out the aetiology. Ask about the frequency and pattern of falls, possible precipitants such as problems with gait and balance, and syncope/pre-syncope.
• Medications: an accurate list of medications and doses, including recent changes, provides insight into the current medical conditions being managed and possible drug interactions and side effects, both of which are common in the elderly. Assess likely compliance with medication.
• Cognition: what is the current level of function, cognitive and mental status, vs the usual level? Ask about alcohol consumption and mood disturbance. Many patients successfully conceal high alcohol consumption: use the CAGE questions.
Ask about family and social supports, and if external services are currently in place to support the patient with their Activities of Daily Living (ADLs) at their home.
Look for evidence of infection, chest and urine being the most common. Minor trauma may cause occult hip and pelvic fractures in an osteoporotic patient.
Look for valvular disease and heart failure. Postural hypotension is common and should be excluded in every patient.
Assess speech, gait and cerebellar function. Look for weakness or changes in reflexes that would indicate stroke. Full sensory examination of limbs is not practical in the Emergency Department, but pinprick and vibration should be performed to search for evidence of peripheral neuropathy (diabetes, vitamin B12/folate/thiamine deficiency).
The rare but treatable condition of normal pressure hydrocephalus occurs in elderly patients and presents as ataxia, incontinence and confusion. CT confirms the diagnosis.
• Blood glucose.
• Urine dipstick.
• Lying and standing blood pressure.
• FBC and U+E.
• Creatine kinase for any patient ‘found on floor’.
• Chest X-ray.
• CT head if risk of subdural haematoma, or if stroke is suspected.
Identify medically reversible reasons for a loss of function. This might include treatment of urinary tract infection, constipation, or stopping a recently commenced medication. Beware occult fractures of neck of femur and neck. CT or MRI may be necessary in cases where there is pain but an equivocal plain X-ray examination.
Patients may require new equipment (e.g. a walking aid), a home hazards assessment, or additional home or community services. These may be combined with a rehabilitation programme involving exercise and physical therapy.
Disposal: who can go home?
Patients at risk of falls require a formal falls risk assessment before discharge, and either admission or early referral to a falls clinic. Reversible medical conditions identified and treated within the Emergency Department (e.g. UTI, mild hyponatraemia, polypharmacy) do not necessitate hospital admission.
Discharge patients who appear well, in whom serious pathology has been excluded and who are safe to return to their normal home environment after screening by the multidisciplinary team.