Age and Ageing 2001; 30: 441±443
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2001, British Geriatrics Society
COMMENTARY
Can we manage more acutely ill elderly patients in the community? Doctors, health economists and politicians in the United Kingdom continue to debate alternative strategies for the management of acute medical admissions to National Health Service hospitals. Several factors would suggest that such a debate is necessary. The rise in acute admissions
The demand for acute medical admission has risen incessantly over the past 30 years [1, 2]. Systems for acute medical receiving, initially staffed by general physicians, were tailored to the needs of a patient population much younger than that which now presents. For example, in Scotland in 1980 those aged over 80 years of age accounted for 10% of admissionsÐcurrently the ®gure is 20%, and elderly people represent the fastest growing section of the admitted population. The reasons for this rise are complex, poorly researched, incompletely understood and, importantly, not solely attributable to demographic shift [3]. If these elderly patients presented with similar clinical problems to those seen in younger patients, then little change in systems of acute care might be necessary. The needs and problems of older patients are, however, substantially different. The management of acute illness or sudden functional decline in older age is challenging and complex. Atypical and non-speci®c presentations of serious disease, including sudden functional or cognitive decline, can make diagnosis dif®cult [4±6]. As a result, uncertainty often surrounds diagnosis and predictions of prognosis. Comorbidity and polypharmacy [7] complicate prescribing. Relatively minor physical illness may be accompanied by major functional decline. Complications, including death, occur more frequently [8±11], and functional and medical recovery times are often prolonged [11]. To deal with this group of patients, attending doctors require time, thought, training, experience, judgement and care. In addition, the expectations of older patients are, not unreasonably, changing. Patients, and their carers, may have widely varying views on the intensity of medical investigation and treatment that they wish to receive or will accept. An 80-year-old with chest pain may not wish to be admitted to hospital for care in a coronary care unit, resuscitation or thrombolysis. On the other hand, they may. It is unreasonable to assume either [12].
The need for change
Given these changes in the characteristics of patients requiring acute admission it would seem likely that new systems of care would be necessary if quality is not to suffer. Indeed, concerns about quality of acute hospital care for elderly patients have been frequently expressed [13]. Equally, there is increasing concern about equity of access to specialist services for older patients [14], with both the UK government and Scottish Executive apparently committed to addressing such inequity. The central aim of system change must, therefore, be the improvement of quality and equity of care. However, the rise in demand for acute admissions has been accompanied, over a similar time period, by a decline in the number of acute hospital beds [2]. More patients must be treated in less time. Shortened length of stay and the twin imperatives of early discharge and complete avoidance of admission have therefore come to dominate strategic thought: considerations of quality and equity seem secondary. Older patients, with their complex needs and prolonged medical and functional recovery times, are now perceived as a major problem within a system desperate to maintain or reduce total bed days. Cost-effective use of resources must be considered in the modern National Health Service, and few would disagree that average length of stay can be shortened further, but just how far can the strategy of avoidance of admission be taken without compromising the principles that the specialty of geriatric medicine endeavours to represent? Are acute admissions currently appropriate?
It is stated that 20% of hospital inpatient days for elderly patients are ``inappropriate'' [2]. It is, however, incorrect to infer that 20% of acute admissions are also inappropriate. Indeed, the limited literature regarding acute hospital admission suggests that the vast majority of acute hospital admissions are appropriate [15, 16]. In other words, the admitted patients require the facilities and expertise of an acute unit, irrespective of their age. Importantly, in accident and emergency departments, older people are much more likely to be sicker and in need of hospital admission than younger patients [17]. A few older patients are admitted inappropriately. Their needs are diverse [15]. Some are recognized to
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A. T. Elder have terminal disease and might be more appropriately admitted direct to a hospice bed, were it available. Some have no acute medical needsÐalthough this can only be apparent after adequate medical assessmentÐand little potential for rehabilitation. Their admission may be precipitated by family, primary care or social services recognizing that they cannot be supported in their current environment. They require longer-term functional support or institutional placement, and time in hospitalÐwhich is often lengthyÐis primarily used to organize that support or placement. Faster access to, and simpli®ed funding of, co-ordinated multidisciplinary assessment and support in the community, ideally through a single point of access that links health and social services, could usefully prevent many such admissions. Other patients with chronic conditions such as heart failure often experience multiple readmissions to hospital Ðimproved discharge planning and follow-up has been shown to reduce the need for hospitalization [18]. Most of the older patients currently admitted have acute or sub-acute medical and functional problems, either alone or in combination. Comprehensive geriatric assessment, in the community or in hospital [19], provides an evidence-based model for the provision of the co-ordinated multidisciplinary care that they may need [20]. Any system of acute care for elderly patients must recognize their diversity of need: six basic requirements for any such system are suggested in Table 1. There can be little disagreement that current UK acute hospital care for older people does not ful®l such requirements, but what alternative strategiesÐother than simply attempting to improve acute hospital careÐare proposed? Alternatives to hospital admission
Alternatives to acute hospital admission can be broadly divided into those that focus on domiciliary assessment and care, and those that replace acute hospital admission with admission to another facility such as a community hospital, general-practitioner unit or private nursing home [21]. Table 1. Six requirements for a system of care of elderly patients with acute illness or sudden functional decline Provision of rapid, accurate investigation, diagnosis and treatment of medical problems Provision of rapid, accurate assessment and support of functional needs Provision of a period of co-ordinated rehabilitation Equity of access to specialist investigation and treatment Respect for individual patients' and/or carers' preferences regarding style and location of care Ef®cient and effective use of resources
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Most domiciliary care schemes attempt to provide a proportion of the care and assessment in the home and a proportion at hospital. Co-ordinated medical diagnosis and functional assessment can be achieved through rapid-access attendance at a day hospital or, in a recent development, accident and emergency department or acute medical assessment unit [17]. Rapid provision of subsequent support, rehabilitation and medical follow-up at home has however proven more dif®cult to co-ordinate. Indeed, the major challenge in all the domiciliary settings is to provide and co-ordinate equivalent and adequate levels of both medical and functional input. A community initiative, perhaps in the form of a `rapid-response team' that offers nursing care, physiotherapy and functional support to an elderly patient who is confused and `off her legs' totally fails that patient if it fails to identify and treat her underlying pneumonia. Similarly, rapid-access medical outpatient or domiciliary consultation schemes, which may assist with uncertainties in diagnosis and treatment, also fail if they do not address the patient's need for functional support and rehabilitation. Can alternative institutional settings, such as generalpractitioner beds, community hospitals or nursing homes, meet the needs of the acutely unwell older patient? Only if access to medical diagnostic facilities and appropriately trained medical, nursing and rehabilitation staff is greatly improved. Some acute illness in older people can be managed without all the `high-tech' facilities of a large acute hospital, but we do need a clearly de®ned, agreed and accepted de®nition of precisely what constitutes alternative `low-tech' facilities [22]. Is it, for example, reasonable to admit a patient with delirium to a facility without on-site radiography? Is it reasonable to have medical assessment, diagnosis and treatment planned by professionals who may have no special training, aptitude or interest in the care of older people? Is it reasonable that different standards or guidelines of care may be applied, and that the facility lies outwith local National Health Service structures of clinical governance [23]? Currently, in many `intermediate' settings proposed as alternatives to acute hospitals, `low tech' is equivalent to `no tech'. The need for evidence
Clearly, in this era of evidence-based medicine, it would be unwise to accept automatically that any new strategy of care is necessarily more effective, more acceptable to the patient or indeed less expensive, than acute hospital admission. Rigorous evaluation of all alternative community, intermediate, domiciliary or other nonacute hospital schemes must occur, but to date such evaluation has been limited to small-scale, local studies of highly selected patients, which have employed widely varying methodology and provided con¯icting, inconsistent and highly debatable outcomesÐbe they clinical or cost-related [20, 21, 24].
Commentary What do patients and their carers think of the alternatives? Most studies fail to ask. The widely broadcast generalization that `elderly people wish to stay in their own homes for as long as possible' is probably correctly reported, but surely relates to the avoidance of longterm institutionalization rather than the management of episodes of acute intercurrent illness [25]. Despite much uncertainty over patients' views, and the absence of good evidence of ef®cacy, safety, cost reduction or patient satisfaction, the implementation of alternative strategies to deal with acute illness in older people is well underway in many regions of the UK. Our acute admission systems are struggling to cope, not just because there are more patients, but also because those patients are different. The current system was not designed to cope with a high proportion of functionally impaired, complex medical patients with prolonged recovery times. Although change is unequivocally required, the new, and apparently central, strategy of avoidance of acute hospital admission is not predicated on the critical issues of quality, equity or patients' wishes. Pursuing such a strategy amongst a group of individuals who differ from others only in that they happen to be old is prejudicial. Perhaps, in our `New Age', this is our `New Ageism'. ANDREW T. ELDER Department of Acute Medicine for the Elderly, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK Fax: (+44) 131 537 2680 Email:
[email protected]
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