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Acute care toolkit 3: Acute medical care for frail older people

All staff working in acute medical units (AMUs) will be familiar with the increasing number of frail older people requiring access to acute care. The AMU provides a key role in identifying the urgent and important issues which, if addressed accurately and comprehensively, will improve patient outcomes. Accordingly, acute medical teams need to possess the knowledge and skills, and demonstrate the appropriate behaviours, for managing frail older people.

Key recommendations

  • Configure services such that they can deliver early comprehensive geriatric assessment (CGA) for frail older people.
  • Consider rotating staff through community services or having ‘staff swaps’ to promote a better understanding of the role of each sector and its pressures.
  • Engage with GP commissioners about whole systems initiatives to tackle urgent care; for frail older people, social care and community services will be key partners.
  • Align emergency, acute medical and geriatric services to deliver high-quality care for older people at the earliest possible time following contact with the acute sector.
  • Ambulatory emergency pathways with access to multidisciplinary teams should be available, with a response time of less than four hours (14 hours overnight) for older people who do not require admission but need ongoing treatment.
  • Older people coming into contact with any healthcare provider or services following a fall – with or without a fragility fracture – should be assessed for immediately reversible causes and subsequently referred for a falls and bone health assessment using locally agreed pathways.
  • An acute crisis in a frail older person should prompt a structured medication review.
  • When suspecting lower urinary tract infections in patients with communication barriers, urine dipstick testing should only be considered in patients with unexplained systemic sepsis (which may manifest as delirium) as it adds little to managing patients with lower urinary tract symptoms, and can be misleading in other patient groups.
  • Older people should not be routinely catheterised unless there is evidence of urinary retention.
  • Acute medical units should have ready access to time-critical medication used commonly by older people, such as L-Dopa.
  • Intra- and inter-hospital transfers of older people at night should be minimised. They can increase the risk of delirium.
  • All older people who self-harm should be offered a psychosocial assessment to determine ongoing risk of self-harm, and to detect and initiate management for any mental health problems.
  • Crises beget crises – consider whether advance care planning might be appropriate to prevent future unwanted admissions.

One of the challenges is that of non-specific presentations, such as delirium, that can mask serious underlying pathology. Delivering a holistic assessment in the AMU is difficult for acute teams, with large numbers of patients to see quickly. Geriatric liaison teams, which have the skills and time to focus on frail older people, can be helpful.

Better integration between primary care, emergency departments, AMUs and geriatric services, all working towards achieving high standards of urgent care, should reduce duplication and improve outcomes.

This toolkit recommends procedures for both initial assessment on admission and later comprehensive geriatric assessment (CGA).