Hospitals, healthcare, dementia and frailty
Frail older people in hospital can be the source of a lot of frustration: to families, to the hospital system, and to patients themselves. Everything seems too slow. The various parts of the health and social are system don’t seem to work well together. And the experience of being in hospital is often challenging: noisy, busy and not well-adapted to the particular needs of those who are frail, forgetful, or approaching the end of their lives.
Ill-health and disease has changed over the years. In hospital, it is increasingly rare to deal with a single problem in someone who is otherwise fit and well. Two-thirds of hospital admissions are of someone over the age of 70. One-third of all emergency admissions are of a confused older person. At the root is usually some sort of crisis: medical illness, problems such as poor mobility or falling, distress or difficult behaviour. What hospitals deal with nowadays is complicated: people with multiple diseases and problems, various disabilities, often with dementia or mental health problems. This may be compounded by fragile social circumstances, such as an elderly spouse who is also frail, or families with multiple other responsibilities.
The speciality of geriatric medicine, which goes by many more palatable names, such as ‘healthcare for older people’, developed in the UK in the second half of the 20th Century. It is the UK’s biggest medical specialty, but is not always well-known about. It is found in all hospitals, and also provides advice or visits patients at home or in care homes. Geriatricians are doctors who specialise in the care of older people, and work with teams of nurses and therapists, to assess and manage this complex mix of problems.
This means identifying and treating medical illnesses, and starting (or, often, stopping) drug treatments. It also means attention to walking, safety, daily activities, and how to adapt the home environment to make life easier. Some problems cannot be cured, but usually symptoms can be relieved, abilities restored or adaptations suggested, patients and families informed about what is going on, and helped to make decisions for the future, for example about how to manage at home, or whether a move to a care home is needed.
Dementia is an increasing challenge. Dementia causes forgetfulness, and other problems in thinking like communication, reasoning and planning. It becomes increasingly common with advanced age, affecting 20% of those in their 80s and up to half of those in their 90s. People with dementia are very prone to another condition called delirium; a worsening of confusion due to physical illness. Dementia makes recovery slower, and planning more complicated. Families have a particularly important role in providing background information, and helping with decision-making and planning future care. At Nottingham University Hospitals we have pioneered approaches that make hospital wards better places for people with delirium and dementia, to give them a better experience of care.
Some people admitted to hospital will be approaching the end of life. For people with conditions such as dementia, or severe heart, chest or kidney problems, identifying this time can be difficult. Ill people often look like they could be dying, but may recover if treatment is successful. But as diseases reach their more advanced stages, frailty and disabilities worsen, appetite and swallowing may fail, infections or hospital admission become more frequent, and it can become clear that the end is not far off. At that point priorities change: relief of distress and preserving abilities becomes more important than trying to prolong life. We often try to give people the chance to die at home, although the practicalities of this can be challenging, and many older people put a high priority on not being a burden to their families.
Episodes in hospital are but brief interludes in a life: in the UK we have a long history of providing care in the community: at home, or in care homes. This includes rehabilitation services, home care, and work with GPs and community specialist nurses. We hope that anyone with a reasonable chance of regaining their abilities will be able to do so, and most people who want to continue to live at home can do so. This can become very difficult, however, when people with dementia live alone: safety worries, including the risk of falling, abilities to foresee problems or call for help in a crisis can ultimately make this impossible, despite help from home care services. Where this is the case, or where people prefer the company and opportunities for organised activities that can be possible in care home, this can be a positive choice.
Older people’s abilities and problems vary greatly, as do their resources and relationships, their wishes and values. Those of us who work with older people aim to help them navigate a complex system, face difficult choices, and live well to the end of their lives.