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.
History
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?
Presenting complaints
• 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.
Examination
General examination
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.
Cardiorespiratory examination
Look for valvular disease
and heart failure. Postural hypotension is common and should be excluded in
every patient.
Neurological examination
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.
Investigations
Bedside investigations
•
Blood glucose.
•
ECG.
•
Urine dipstick.
•
Lying and standing blood pressure.
Laboratory investigations
•
FBC and U+E.
•
Creatine kinase for any patient ‘found on floor’.
Imaging
•
Chest X-ray.
•
CT head if risk of subdural haematoma, or if stroke is suspected.
Management
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.
