Hi, I am Siri, an NHS doctor from India working as an SHO in General Medicine, and in today's article, I will be giving you a brief introduction to a day in the life of an SHO in Geriatric Medicine.
"Old age is not a disease, it is a strength & survivorship, triumph over all kinds of vicissitudes & disappointments, trials and illnesses" - Maggie Kuhn
What is Geriatric Medicine?
Geriatric Medicine involves patients over the age of 65, who have multiple long-term conditions, and admit to the hospital with various health conditions.
“Geriatric medicine is a “whole person” speciality. Based on a solid infrastructure of general medicine, it involves consideration of psychological, social and spiritual dimensions, together with functional and environmental assessments. A geriatrician needs to be aware of legal aspects - capacity and consent, human rights, guardianship; and ethical conundrums, such as when to investigate or treat.“ - Professor Graham Mulley, Emeritus Professor in Geriatric Medicine, University of Leeds.
Specifics of Geriatric Medicine
Geriatrics was my first rotation as an SHO in NHS, and I found it includes a whole group of medical specialities. Providing healthcare to older adults is very challenging, and I was able to see various medical conditions and learned a comprehensive approach to clinically assessing elderly patients. Most of the job depends on communication skills, as we need to communicate with patients, relatives and carers, physiotherapists, occupational therapists, General practioners, pharmacists and other speciality doctors.
Ward has mixture of patients with various past medical conditions. Most of them get admitted due to falls, delirium secondary to pneumonia/UTI/constipation and dementia. Comprehensive geriatric assessment is a multidimensional approach to the patients, which comprises involving medical, functional and psychosocial elements in planning the treatment and bringing it back to the baseline. The following are five important things you need to know while you are working in Geriatrics Medicine.
1. Collateral history
Most of the patients have cognitive impairment and they can’t provide information related to their basic functions. It will be hard to provide an adequate clinical assessment or plan appropriate management without this knowledge. So comprehensive collateral history is very important in managing elderly care. Collateral history is completely about the baseline function of thr patient. Taking a cognitive and functional history from a carer or relative is an important core clinical skill to practice, and you will get experience by taking as many collateral histories as you can. This includes:
A detailed history of presenting complaint(s) & past medical conditions which includes duration and progression of symptoms.
Mood and behavioural changes
Activities of daily living, mobilizing with any support and carers history
Family history and social history.
MAPLE-V is a pneumonic used for collecting collateral history. This mnemonic will help you to assess patients on main domains of cognition and helps in making the diagnosis of dementia.
Memory and learning - Acute/chronic and duration
Attention - Ability to focus on tasks, e.g. reading books.
Personality - Any changes in mood and behaviour
Language - Difficulty in understanding and communication
Executive function - able to plan and perform complex tasks, e.g. dressing.
Visuospatial perception - changes in recognizing objects, face and hand-eye coordination.
'As an SHO, I felt working in Geriatrics was really challenging as we need to see patients with chronic medical conditions, however, it gives a great opportunity to learn the importance of working as a part of a Multidisciplinary Team, and providing comprehensive medical care for patients considering all the factors.' - Dr Siri
2. Abbreviated Mental Test Score
This test gives a snapshot of someone’s cognitive abilities on admission. It includes orientation to person place and time as well as a few more items to test different things. AMT test is like a questionare, which includes asking about the following questions, and has one point for each question:
What is your age?
What is the time to the nearest hour?
Give the patient an address, and ask him or her to repeat it at the end of the test e.g. 42 West Street
What is the year?
What is the name of the hospital or number of the residence where the patient is situated?
Can the patient recognize two persons (the doctor, nurse, home help, etc.)?
What is your date of birth? (day and month sufficient)
In what year did World War 1 begin?
Name the present monarch/prime minister/president.
Count backwards from 20 down to 1.
A score of 6 or less suggests delirium or dementia, which you need to evaluate with even more investigations. A full history and examination should be done along with CT scan of the head and bloods including B12/folate, TFT’s and CRP. If you suspect any chest infection - do a chest XRAY and for any urine infection - do a urinalysis. You should do a Per rectal examination, to rule out constipation.
3. Mental Capacity Act
The Mental Capacity Act gives guidance on assessing mental capacity which can be used for providing health care and deciding discharge destination. People with dementia do not have mental capacity and become unable to make decisions regarding their care. The Mental Capacity Act is the law in England and Wales that protects people who cannot make a decision. It covers important decision-making about a person’s health, social care and financial conditions. The Mental Capacity Act is based on five key principles:
A person has the right to make decisions for themselves. You must assume that someone can make their own decisions, unless it is shown that they can’t do this.
A person should not be treated as being unable to decide unless they have been given all help and support to make and communicate their own decision.
A person should not be treated as being unable to make a decision just because other people think they have made a bad decision.
If a person lacks capacity, any decisions that other people make for them must be in the person’s best interests.
If a person lacks capacity, the people deciding for them must consider the option that is the least restrictive to the person’s rights and freedoms.
Patients may lack capacity due to medical conditions including an injury, a learning disability, a mental illness, or dementia. Patient is said to have mental capacity if they can:
understand the information that is relevant to the decision they want to make
keep the information in their mind long enough to make the decision
weigh up the information that is available to make the decision
communicate their decision in any way – including talking, using sign language, or through simple muscle movements such as blinking their eyes or squeezing someone’s hand.
4. RESPECT form
ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. The ReSPECT form gives us an idea of patients' recommendations for clinical care in future admissions. We should respect patient preferences regarding attempting CPR or ward based ceiling care. It is used in a wide range of clinical settings and immediate decisions about patients' emergency care and treatment can be easily made by all the healthcare professionals.
Section 1 includes patient's basic details.
Section 2 has a summary of diagnosis, communication needs, preferences reasons, and relevant documents including an advance care plan, advance decisions and wishes about organ donation.
Section 3 includes prorities about sustaining life and comfort care.
Section 4 includes recommendations about emergency care, regarding sustaining life including comfort care and CPR attempts.
Section 5 includes patient's capacity and legal proxy.
Section 6 is about who is involved in making the decision. The doctor who is signing the form should select appropriately and should document names and roles, along with the discussions.
Section 7 includes doctor's signatures and GMC reference numbers.
Section 8 and 9 includes emergency contact numbers and confirmation of validty.
5. End of life care/Palliative Care
End of life care is about patients who are suffering from a terminal illness in the last months or years of their life. It is about providing comfort care and respecting your dignity by managing pain and other distressing symptoms. The people providing your care should ask you about your wishes and preferences to plan your care. It has a holistic approach involving social and psychological support for you and your family or carers. It also doesn’t mean it should be done at end of life, you can receive palliative care earlier in your illness, while you are still receiving other treatment.
Patients with more co-morbidities and those who are not improving despite the treatment are referred to the palliative care team, which involves doctors and nurses who are specialised in palliative care. Doctors should discuss with patients and carers the likely sequence of events in the late stages of illness to anticipate the wishes of patients and carers. Comfort care involves managing pain and breathlessness through anticipatory medications which are given through a syringe driver.
As an SHO, I felt working in Geriatrics was really challenging as we need to see patients with chronic medical conditions, however, it gives a great opportunity to learn the importance of working as a part of a Multidisciplinary Team, and providing comprehensive medical care for patients considering all the factors.
If you have any questions feel free to ask on the TrewLink website, I would be happy to help.
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Good luck,
Dr Siri
Written by Siri
Edited by Julia
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