Published on April 3, 2014
What are we really trying to achieve? Dr Jane Tolman Transitional Care Conference, Sydney, May 30, 2013
Australia 1901 (blue), 2001 (grey) and 2021 (pink) 1,000 800 600 400 200 0 200 400 600 800 1,000 0- 4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Numbers ('000s) Males Females Age Projected Total fertility rate = 1.75, annual net migration = 110,000.
The Epidemiological Transition 19th Century 20th Century 21st Century Infectious Systemic Neurodegenerative _________________________________________________________ Cholera Cancers Neurodegenerative: Smallpox Vascular diseases: Dementias Tuberculosis strokes and cardiac Parkinson’s Typhoid Hypertension Gait slowing Diabetes Vascular Lung diseases
Australian Statistics 10 Causes of Death - Rates since 1920 (Age Standardised) 7 Systemic causes falling - 2 Brain causes rising • Infectious diseases • Accidents • Circulatory Diseases incl. Stroke • Respiratory Diseases • Gastro-intestinal diseases • Genito-urinary diseases • Neoplasms/Cancer • Endocrine/Metabolic diseases • Neurological diseases - at 75+ only • Mental Health diseases - at 85+ only
Systemic disorders of aging: Projections from SOPS data (n=522, Age trends: * p < 0.05; ** p< 0.01) 0 0.5 1 1.5 2 2.5 75 78 81 84 87 90 93 Age Prevalencerate Other Systemic Peripheral Vascular Disease Chronic Lung Disease* Stroke Obesity Heart Disease Arthritis
Brain disorders of aging: Projections from SOPS data 0 0.5 1 1.5 2 2.5 3 3.5 75 78 81 84 87 90 93 Age Parkinsonism** Dementia** Gait Slowing ** Cognitive Impairment ** Vision** Ataxia**
The Age March 15, 2008 • There are twice as many Australians dying with dementia now, compared with a decade ago • Heart disease and cancer are the biggest killers (ABS, 2006)
Relative deaths 1997 Strokes: 12,400 Heart disease: 29,000 Dementia 3,384 2006 Strokes: 11,465 (~1,000 fewer) Heart disease: 22,983 (6,500 fewer) Dementia: 6,542 (3,156 more)
Neurodegenerative Disease • Alzheimer’s disease • Dementia with Lewy bodies • Parkinson’s disease • Fronto-temporal dementia • Motor Neuron disease • Age-related macular degeneration • Vascular brain disease • Progressive supranuclear palsy • Corticobasal degeneration • Spinocerebellar atrophy
Prevalence of neurodegenerative disease In the > 75 year olds: • Gait ataxia 50% • Visual impairment 38% • Cognitive impairment 38% • Gait slowing 19% • Dementia 17% • Parkinson’s disease 5%
Neurodegenerative disease: functional consequences • Is the major cause of disability in personal care, domestic care and mobility Among the >85 year olds: • 80% need assistance with domestic care • 30% require personal care • 70% are cognitively impaired (high delirium risk) • 70% are mobility impaired (high falls risk)
Dementia • Incidence is about 2% at 65 years of age • Incidence doubles every 5 years from 65 to 90 years
Dementia and hospital admission • Of hospitalised elderly Australians with dementia, 37% are not discharged to their usual residence Karmel, Hales and Lloyd, AIHW Bulletin 53 2007
Delirium Incidence • 17% of patients on a medical ward, at some time during the admission (Cameron, 1997) • 40-50% of those recovering from a hip fracture (Kaplan, 1998) • One third of hospitalised dementia patients (Levkoff, 1992)
Delirium and Dementia • Delirium may represent the result of an attack on a frail brain i.e. delirium unmasks dementia • Delirium may permanently damage the brain
Delirium Prognosis • Mortality is 25–33 % within one month of onset ( Weddington, 1982)
Length of Stay Data (AIHW 2007)
Length of stay for all persons with stay of at least one day • Mean is 8.6 days
For those with a diagnosis of dementia • Mean LOS is 19.6 days
For those whose principal diagnosis is dementia • Mean LOS is 30.1 days
Mental Disorders in Old Age Disorder Community General Hospital Dementia 5% (>65) 20% (>80) 22-61% Delirium < 1% 15-48% Depression 8-13% 23-45% Anxiety 5-15% 4-11% Alcohol 2-3% 2-13% Psychotic disorder 1% 2%
Transitional Care For those with: • multiple co-morbidities • high care needs • complex social situations in the immediate post hospital discharge period
Transitional Care Aims: • Minimising or avoiding lengthy hospital stay • Enhancing recovery • Optimising function • Reducing hospital readmission rate • Supporting carers • Reducing early and inappropriate RACF placement
TCP: the evidence Coordinated discharge planning and provision of post acute care services with additional case management: • improves QOL and • reduces hospital bed day use Lim, Lambert and Gray, MJA. 2003; 178 (6); 262-6
...the evidence Integration of acute care and long term care services has been shown: • To reduce institutionalisation • Be cost effective when well set up Johri, Beland and Bergman, Int J Geriatric Psychiatry. 2003; 18 (3): 222-35.
...the evidence After hospital admission or recurrent hospital admissions, multifactorial interventions can: • Improve QOL • Reduce emergency health care usage • Improve ADL performance • Reduce falls and improve mobility Courtney, Edwards. Chang, et al , J Am Geriatric Soc. 2009; 57 (3): 395-402 Melin, Wieland, Harker and Bygren, J Am Geriatric Society, 1995; 43 (3): 301-7 Stott, Buttery et al. Age and Ageing. 2006; 35 (5): 487-91.
...the evidence Meta-analysis demonstrates that input of varying durations and intensities from a wide range of health care disciplines can: • Reduce falls • Reduce hospital and residential aged care admissions • Improve physical function But: • the margins of benefit were small • High readmission rates can be expected (32%) Menzies and Hanger, NZ Med J. 2011; 124 (1341): 29-37
... the evidence Intermediate care utilising a care management approach reduced the risk of death and permanent institutionalisation for frail elderly by 31% Parsons, Senior et al, Age and Ageing, 2012; 41 (6), 722-8
Essential elements 1. Single entry point 2. Case management 3. Geriatric assessment 4. Multidisciplinary team involvement
What happens In 2010-2011 there were 17,441 discharges from TCP: • Nearly half returned to the community • Nearly a quarter returned to hospital • 19% went into residential aged care
• A case from a general surgery ward: • Mr AF, aged 79 Case 1
resident of high care nursing home • Admitted to hospital in October 2010 with a small bowel obstruction • Complex medical background with extensive multisystem disease
Background – Resident of nursing home for 4 years – Initial move to NH was for compromise due to severe chronic obstructive lung disease – Limited family contact in recent years – Most of his time spent in bed or a chair watching television – Little social contact with other residents or visitors – Mobility restricted to 10 metres with wheeling frame
Gastrointestinal – Ulcerative Colitis – Open cholecystectomy • Sub-diaphragmatic abscess • Chronic pain
Respiratory Severe COPD 110 pack year smoking history Domiciliary oxygen Multiple admissions with exacerbations Cor pulmonale Multiple pulmonary nodules
... background • Long term high dose prednisolone – 37.5mg for a decade • Cardiac: – Ischaemic heart disease • AMI 2007 – Paroxysmal atrial fibrillation – Pulmonary hypertension • Renal: – Ureteric lymphoid folliculitis
...background • Haematological: – Pernicious anaemia • Psychiatric: – Depression • Endocrine: – Type 2 Diabetes • Poor control • Oral hypoglycaemics • Bilateral cataracts • Vascular disease • Cognition: – MMSE 21/30 in 2007 – Short term memory declining, but no diagnosis of dementia made
Progress ◦ Initial management conservative ◦ Day 3, deteriorated: laparotomy (small bowel resection and division of adhesions) ◦ Managed in ICU postoperatively ◦ Ventilated for 36 hours post op ◦ TPN commenced
Progress Day 6 discharged to the ward Day 10 faeculent peritonitis ◦ MET call ◦ laparotomy ◦ ileostomy ◦ abdominal wound left open ICU post operatively ◦ Intubated and ventilated for 10 days Day 17 surgical note that “chance of definitive repair is low”
Progress Complications in ICU included ◦ Addisonian crisis ◦ anaemia ◦ hyperglycaemia ◦ hypotension requiring inotropes ◦ sepsis ◦ electrolyte abnormalities ◦ hypoalbuminaemia ◦ cholestatic LFTs Day 20 discharged to the ward Multiple returns to theatre for perforations, collections, fistula and dressings
Progress Day 28 MMSE by liaison psychiatry ◦ Score 10/30
Summary ◦ 19 trips to theatre ◦ 18 units packed cells ◦ 7 MET calls ◦ 3 ICU admissions ◦ 12 days intubated ◦ 75 days on TPN ◦ 450 pathology reports ◦ 6 CT scans ◦ 30 X-Rays ◦ 1 nuclear med scan ◦ 2 ultrasounds No limit to his resuscitation documented till day 136 Died in Palliative Care Ward day 145
Case 2: Mr RG • 75 year old man admitted from home with infection • Previously functioning independently, but some slowing • Day 6 seen by Aged Care team more unwell, transferred to Acute Aged Care Ward • Paracetamol overdose diagnosed (iatragenic); transferred to ICU
...Mr RG • Discharged home day 14 from ward • Five weeks after discharge admitted with multiple problems: SOB (COPD and CCF), declining mobility, functional decline, acute on chronic renal failure • Family angry with hospital • How is this man going to do?
...Mr RG • Day 5 of this admission, has BP of 85/68, bilateral pleural effusions, peripheral oedema and established renal failure • Day 6 team decides needs TCP and transferred Day 7
...Mr RG • Day 5 of TCP: develops atrial fibrillation and sacral pressure area noted • Day 7: oedematous rash on legs with blisters and seepage through skin • Day 8: BP 80/51; low oxygen saturations, gouty ulcers (contributing to poor mobility), needing prompts for ADLs, often confused, fatigued +++
...Mr RG • Day 14 transferred back to acute ward for further management • Dies that night
Case 3 Mrs BM 84 year old neurosurgery patient Past history: Right THR TKR Hypertension Osteoporosis Social history: independent with most ADLs walked with aids for 3 years since hip surgery
Day 1 Fall while turning in car park with daughter in regional centre GCS at time of accident 15/15 GCS reduced to 3/15 in hospital Intubated in ED CT showed right fronto-parietal SDH, 25mm x15mm Discussion with RHH geriatrician: “not appropriate for surgery” Right fronto-parietal SDH evacuated in regional hospital by general surgeon Attempted ventricular ICP monitor; unsuccessful
Day 2 Transferred to ICU Talk with daughter, GP. Daughter angry with orthopaedic surgeon (from 3 years ago)
Days 2 to 5: -pupils 3mm reactive -sedation ceased -GCS after 48 hours between 6-8 -ICU assessment “Poor prognosis” -“Chances of regaining independence remote”, -“Best outcome NH with significant disability” Day 6: - family meeting: daughter, ICU consultant, neurosurgeon - explained poor outcome - not for met calls, CPR, ICU, intubation, inotropes -suggest palliative care input at some stage -plans to extubate next day
Day 33: multi organism UTI started Tazocin ? arrange PEG Day 34: patient responsive but requiring full assistance to roll Day 30: transferred to regional hospital on TCP Day 52: discharged to nursing home Day 62: readmitted to hospital with aspiration pneumonia Day 67: died
Summary • Number of operations: 2 • Number of hospital days: 67 • Number of team changes: 6 • Number of naso-gastric tubes: 3 • Number of episodes of aspiration pneumonia: 3 • Prognosis at all times: poor
Case 4: Mr GQ • 91 year old man presents to ED with a fall 2/52 ago and ongoing neck pain • Lives with 95 year old wife, daughter next door • Cognitively OK • Frail physically • CT shows extensive cervical spine damage
Cervical Spine • Unstable displaced type 2 dens fracture of C2 vertebral body. • Bilateral atlantoaxial complete dislocation. • Tiny fractures through the C1 lateral masses bilaterally. • Suspicious old C1 anterior arc fracture. • Significant central canal stenosis at the level of the C2 fracture • Extensive degenerative disease of the spine.
Day of presentation Orthotics review: • Malibu collar Neurosurgical review: • spinal precautions • recommend MRI to demonstrate ligamentous stability • subcutaneous heparin Aged Care review: • Transfer to ward • Meet family and discuss prognosis and goals
Day two of admission • Delirious overnight • Aspirating • Family meeting • Discharged home with support from community nurses and general practitioner
Subsequently • Brief period in nursing home respite with wife • Returned home and currently lives a happy and fulfilled life with wife of 72 years
Case 5: Mrs ED • 77 year old woman from high care facility presents with episode of breathlessness • Saturations 67% in ED • CXR clear • Treated for “flash pulmonary oedema” by medical registrar
History from Nursing Home • RN described clear story of aspiration • 20 year history of Parkinson’s • Anarthric following Deep Brain Stimulator 5 years ago • Placed in NH only 5 weeks previously because of exhaustion in 87 year old husband • Poor mobility • Dependent for all ADLs
Speech therapy review • Aspirates saliva • Swallowing not safe
Progress • Family meetings daily (high power medical family) • NGT for Parkinson’s medications two days (weekend) and NBM • Speech Path review day three: aspirating on saliva • Plan to palliate: comfort care instituted day three • Died peacefully day 8 on continuous subcutaneous medications for comfort
Case 6: Mr MR • 75 year old retired truck driver admitted from home with increasing confusion • History of renal disease: solitary kidney, refused dialysis in the past, GFR 19, anaemia and bone complications • Also: diabetes, gout, HT, asthma, essential tremor • 90 pack year smoking history • >60g alcohol daily till a few months ago
... Mr MR • Family had noted perseverative behaviours, declining language skills, difficulty finding things in the house, not able to work out how to use the razor- over a period of two years • Loss of weight of 19kg in 6 months
...Mr MR • Hyponatraemic, declining liver function • Delirium on background of dementia with low cognitive reserve diagnosed • Treated for pneumonia • Day 7 transferred to TCP, where: confused, impulsive, needing prompts, short of breath, hypertensive. Minor improvements overall • Day 26 of admission, discharged home
...Mr MR • Wife coped poorly • Continuing cognitive and physical decline • Substantial support from family • Referred to Palliative Care by GP six months later • Dies in Palliative Care ward 11 months later
What are we really trying to achieve? Consider the Goals of Care • Cure • Restore • Palliate
Decision making: What we need to do • Get a really good history (much more important than lots of investigations) • The history from previous months is much more useful than the immediate medical history • Speak with families and find out what they are worried about and what they want
What we need to acknowledge • We’re not going to live forever • It’s OK to accept risk • It’s OK to be allowed to die • It’s better to have a managed death • Patients (or their surrogates) have a right to self determination. We would want this for ourselves.
Principles Early intervention is essential • It’s best to avoid hospital presentations/ admissions • Have an early comprehensive assessment by a multidisciplinary team • Decide: is the goal palliation, cure or restoration of function? • Aim to identify dementia and other neurodegenerative conditions: they make things complicated
Mitos y realidades de las sustancias psicoactivas
Mitos y realidades de las sustancias psicoactivas.
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