Getting older people home safely
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Tips for how to plan discharge, and some Do's and Don't's for older people
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Getting older people home safely
- 1. Getting older people home safely Rehab,respiteor release? Shane O’Hanlon, Consultant Geriatrician StVincent’s/Loughlinstown Dublin, Ireland
- 2. Case 1 Mary is a 78 year old lady Admitted with pneumonia B/G MCI, COPD, DM, Anxiety, OA knees & hips Baseline: Independent ADLs, walks to shops with a stick By day 5 of admission, medically fit for d/c Nurse mentions that she needs assistance to the bathroom, “legs are still weak” Her daughter asks you for “2 weeks of respite”
- 3. What does Mary need? Sli.do Event code #GIM19 “Polls” A. Respite B. Convalescence C. Rehabilitation D. Discharge straight home E. Something else
- 4. Illness in older people Causes decompensation From Clegg,A
- 5. Illness in older people Causes decompensation Examples: sudden change in function or mobility, acute delirium From Clegg,A Fit Frail
- 6. Illness in older people Causes decompensation Examples: sudden change in function or mobility, acute delirium From Clegg,A Fit Frail
- 7. How do you get older people back to baseline? TREATTHE ILLNESS
- 8. How do you get older people back to baseline? TREATTHE ILLNESS REHABILITATION
- 9. What is rehabilitation? A process that aims to restore or maximise functional ability
- 14. What is wrong with this model? TREATTHE ILLNESS REHABILITATION
- 15. Deconditioning During acute illness there is active deterioration of function and mobility
- 16. Deconditioning During acute illness there is active deterioration of function and mobility Don’t wait for illness to be treated to start reversing deconditioning
- 18. How rehab should be Choong, PICU-acquired complications: the new marker of the quality of care
- 19. How rehab should be Choong, PICU-acquired complications: the new marker of the quality of care
- 20. Rehab: Should start on admission (or earlier) Clearly will depend on medical issues Should be goal directed But actual trajectory can be unclear
- 21. What does Mary need? A. Respite B. Convalescence C. Rehabilitation D. Discharge straight home E. Something else Should have started rehab on admission!
- 23. What is rehabilitation? Here is an example Otago Home Exercise Programme
- 24. Who does rehabilitation? Domestic staff, porters, radiographers... Doctor, PT, OT, MSW, SLT, clinical psychologist, nurse Family, carers Person
- 25. Where does rehab take place? Emergency departments Acute hospitals Rehab hospitals Community hospitals Day hospitals Home Nursing homes
- 26. Rehabilitation: evidence Bachmann, 2010. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials An overall benefit in outcomes at discharge Odds ratio 1.75 (95% confidence interval 1.31 to 2.35) for function relative risk 0.64 (0.51 to 0.81) for nursing home admission relative risk 0.72 (0.55 to 0.95) for mortality
- 27. PREhabilitation
- 28. How do you get older people home safely? Rehab Respite Convalescence “Release”
- 29. Respite “a short period of rest or relief from something difficult or unpleasant”
- 30. Respite There are many people living at home who rely on informal care (family, friends, neighbours…) 1 in 10 people are informal caregivers This can be a 24/7/365 job
- 31. Caregiving The UK State of Caring Report 2018 72% of respondents reported mental ill-health and 61% reported physical ill-health as a result of their role. The De-Stress study surveyed 200 spousal carers of people with dementia in Ireland, 37% reported clinically significant depressive symptoms (Brennan 2017).
- 32. Respite for older people Usually in a nursing home, 1-2 weeks Admission from the community, not from hospital Every few months A chance for the carer to recharge their batteries
- 33. Respite for older people Helps to alleviate carer burden Very costly, but saves state money by supporting (unpaid) informal caregivers Evidence of benefit is inconclusive
- 34. Respite for older people: evidence Willoughby et al 2017 - A greater risk of premature death in residential respite care: a national cohort study Residential respite residents were twice as likely to die from falls/injury than permanent residents A large proportion of respite residents transferred to hospital Deaths from injury-related causes during residential respite care do occur and is an issue that requires greater attention
- 35. Respite for older people: evidence(2) Low et al 2019 - In‐hospital morbidity and mortality among patients from residential respite care Respite patients presenting to ED were more likely to die in the ED than NH patients Patients who present from respite have significantly higher in-hospital mortality than NH patients, and significantly more in-hospital delirium, falls and longer LOS than matched controls
- 36. Respite for older people has risks Unfamiliar environment Transitions of care fraught with hazards Maybe we’re not doing it right; should it be a separate unit from LTC?
- 37. How do you get older people home safely? Rehab Respite Convalescence “Release”
- 38. Convalescence “time spent recovering from an illness or medical treatment; recuperation.” "a period of convalescence"
- 39. Convalescence
- 40. Convalescence: DON’T do it Functional status
- 41. Convalescence We don’t send people to go and sit in a nursing home for 2 weeks after an acute illness Rest is NOT good for you Exercise IS good for you Only indication for convalescence – await recovery, e.g. tibial fracture, needs 3 months of non weight bearing
- 42. How do you get older people home safely? Rehab Respite Convalescence “Release” – a safe discharge
- 43. Planning a safe discharge Your ideas Sli.do Event code #GIM19 “Audience Q&A”
- 44. Planning a safe discharge SHOULD BEGIN AT ADMISSION – SETA PDD COMMUNICATEANY CHANGESTO PDDTO WHOLETEAM ASSESSCARE NEEDS PLANANY RESOURCES NEEDED DAILY BOARD ROUND TO DISCUSS PROGRESS STARTTHE DISCHARGE LETTER EARLY & INVOLVE MDT
- 45. Rehab vs “Discharge to Assess” D2A model based on principle that people should be supported to go home as early as possible Initial assessment, with plan of rehabilitation goals in an inpatient setting. Once a patient is medically stable, they can move either to their own home, or a community rehabilitation setting, where a better understanding of their rehabilitation needs can be established.
- 46. Don’t forget Home visits really useful, especially if concerns Safety vs self-determination Mental capacity Advance care planning – do they want to come back?
- 47. Should we even admit? Hospitals are risky places
- 48. Tips Ask them about their goals Check if they are at functional baseline Minimise transitions of care Nobody should ever be “waiting for rehab” Know where to point people to for support