Geriatrics - Discussion with Dan Thomas

[Music] Hello and welcome to the Society for Occupied Medicine's podcast. Here we discuss topics, kisses and if anything new and upcoming in the world of acute medicine. This is our view on tick. Remember to always do your own reading around the topics we discuss. Enjoy! Hello everybody and welcome to an episode of Sound the Podcast. This episode we are dedicating to the older person so it's a geriatric podcast and I, although I do see my fair share of the older patients on the acute tape, wanted to have an expert with me. So this week I've got Dan Thomas, Dan, do you want to tell everybody who you are and where you work? Hi, my name's Dan Thomas. I'm a consultant of Gerritrition at entry hospital in Liverpool. I work in the frail to unit and I also do care concessions with the major trauma team. So I've got a self-sufficiency interest in older persons, major trauma or silver trauma. The flay, am I suspect or so I know that we're going to be discussing that in a little while. But you work with a lot of trainees and I know you've got an interest in education as well. Do you think people are a bit frightened of seeing the older patient? Do you think people get a bit more nervous or hesitant? I notice when I'm on the take that sometimes people have been skipped over, sometimes it's because it's neurology but a lot of times it's because it's an older patient. What do you think about that? I think there's a couple of reasons aren't older people are generally seeing it's a bit more boring. Sometimes they're not going to be coming in with the exciting stuff and because there's so many of the presentations of older frailer people up to 100% with a spread of the crisis of things like falls to the area and immobility, incontinence and it's an art to try and tease apart all the all the contributing factors lead as that presentation can sometimes be a bit overwhelming. And takes a bit longer as well I guess, doesn't it? So I think I probably wouldn't pick up a number of patients that's been more complex as my last patient just before my shift's about to finish because you need a bit more time. But do you think we should do differently though? So if you were sort of addressing a group of medical registrars that do the take, is there anything that tends to be done in not so well? Would be older person. So I think trying to label their presentation, being down to one problem, western reality with these people they're off to presenting because lots and lots of different things, gradually built up and accumulated and one thing just tips them over the edge, forcing them to present in a in a fraility crisis. I think the other thing to do differently is stop feeling that you have to investigate and treat every abnormality that you find. If you're older and frail with multiple ability, you're going to have a lot of abnormal things, I've got a scanner, abnormal blood tests or abnormal blood pressure, not all of that needs investigating and treat it. So it needs to take more individual sort of holistic approach as the patients. That's the true skill that was narrative working out what bit you do need to pick up on her, just leave that alone and how do we do that other than experience? So I think experience matters, knowing what matters and who the person themselves have the sense of what their priorities are. So you put some might in, lots of things that matters, most to you. People who work with me all know that I have a little look about echoes and I had to do on the wardrobe this morning, it was 95, who's got a systolic burner. And if you look back in 2018, it's had a echo, and he knows for a while he's got severe T.R. and severe M.R. and we had a joke about the fact he wasn't keen on open hearts and he's like, "What's the point in doing that echo?" And it's that kind of stuff, isn't it? It's just what bit is important? And the other thing to think about is there's a skill in knowing what guidelines to ignore. There is a nice guide and it gives you permission to ignore them, so there's a nice frailty and multi-morbidity guideline, which is really the guide I think gives you permission that that individualised approach trumps the other nice guidelines. Because you can imagine you've got someone with multiple abilities that got diabetes, depression, hypertension, post-reheight potential, COPD, osteoporosis, if you follow every single nice guideline that person's going to spend all the time in outpatient appointments or the time having cardiac rehab, pulmonary rehab, falls and balance training. So you just got to get a sense of what really matters to the older person that you're speaking to. And open an honest conversations about what we can fix, what we can't fix, so what probably we don't need to fix. Yeah, and so much of what we do, it's not the individual's of geriatrician, it's sort of a wide range of T and it's that comprehensive geriatric assessment that makes the difference. And I think we might come on to this, but just in case we don't, in terms of medications, there's always something that comes up with the older patient. I mean, sometimes if you ask them, if you actually count how many tablets they're physically expected to take, any sort of guidance of we can't stop, what we can't stop. When I'm thinking about old, I'm thinking of older answers for the more severe end of the frailty spectrum. I've got someone old but robust and I'm probably not treating them the same way. So you know, I'd treat them in a two or the same way. So I would treat a 50-year-old with chronic disease, but when they're when they're frailer end of the frailty spectrum, then that's when I try to focus a bit more on deep prescribing. So there's two, so you can use things like the stop start, stop start, two, so you can look at things like the anti-colon-neurogenic burden scale that will highlight the problematic, the proof of the medications that often frailer people do less well with. It's also something to think about, what's that medication? What are you actually trying to treat? So we make them on time potentially later, but is it thinking about the high potentials of risk factor, it's not a disease, it's a right hypercastralemia, it's a risk factor, it's not a disease in its in its own right. So you don't want to be prioritising preventative medicine in someone who's approaching the end of the life. Some of the look as though it's a drug interaction, so are they on medications that can keep you can't track each other, so we'll often see someone on a the circled nest raise inhibitor like to mepazil for Alzheimer's dementia, but they're also on an anti-colon-neurgic medication, or they may be on a direct, like, freezer-mind together to deem it, but they're also on future cortisone, which of course is fluid to accumulate. So you'll see this pattern of medications and diseases that can't match each other, and then the other thing you do is look for prescription cascade, so when you see a pattern of medications that have been prescribed to counteract a symptom of another medication that's been started, but no one realises that they're treating a side effect, and other tablets are rather than stopping the tablet, they prescribe something else to counteract the side effect. Yes, that I'm not a pain-fathered by throughs and I think that's a lot of pain-fathered by throughs and I think that's really helpful isn't it, just having a little think about medications and what actually matters. You mentioned hypertension, we've got a great podcast on hypertension, so people haven't listened to it, I would recommend going back, but one of the things they talk about on that is actually fiddling around people's blood pressure as an inpatient, often it's more deleterious to their health than just leaving it alone. Obviously if you've got some of the outcomes in and you start, it gives them all their regular medications, their blood pressure is certainly 80, it's a bit of a clue as to what their compliance is like. I'm just going to quickly reflect on the sunbur data, so this just gives us a quick overview of what happens in our sort of population, so 5% of people on sunbur data in 2023 came from a care home and a quarter were over 80, it always makes me sad that 15% people are arriving overnight and that's always a bit of shame because when patients arrive overnight we know that you're more likely to get admitted and you're less likely to be sort of plugged into a sort of aesthetic pathways, but if you look at aesthetic pathways, we were talking about this in one of the conferences recently, you're much less likely to be seen in S-Deck if you're older and that one might before we start press the big record, but we were talking about whether that's because some people are going directly to frailty, but we think still that people are just using, well they're old and frail, they can't possibly go to S-Deck and actually that's the complete opposite of what I'd like to see because it's so much more important to get patients to S-Deck if we can avoid an admission at the older patient, is that something you sort of agree with? You know, more than the frailty, you know, but I can't go that. I always agree, because you don't want to just be taken to people to S-Deck, you're going to be given home regardless of whether you saw them or not, and you don't want to be deprived of the people who are more likely to have the longest length of stay, the chance of being quickly turned around. And I think it's just that thing about just looking a bit bigger than just what somebody looks like in their age and general ability, is actually this is somebody that has actually come in with the sever lightest we can get them out, they need to be in hospital we should do. Because if you're going to start excluding people with frailty or multi-mobility from certain extent, you're saying she's different than one. You're just, yeah, you see people that should be in minus, I'll stop talking about that because I get on my high horse. So we'll start with a case then. So we've got, I've done my very best geriatrician review here, so obviously in 82 you're o fforddau y teideau. Gyddych chi'n dweud o'r apesoddol i'n gwaith, o'r apesoddol i'r apesoddol i'r apesoddol i'r apesoddol i'r apesoddol i'r apesoddol i'r apesoddol, mae'n gwaith ymwyd yn gweld ar gyfer, mae'r apesoddol i'r apesoddol i'r apesoddol i'r apesoddol i'r apesoddol i'r apesoddol, mae'n gwaith ar gyfer. uno o'r senddoedd gwnoedd yn yw yn g DAH. Efallo enjoy byw, sy'n gwneud eich a ynfaithio iefinydgu o'r ganyll pw copy goblie an hon my 시� y flwydd yönu rhywun sどol o my mae'nchi tasty ar yr hyn yn'n relyd infected chocolate i'n gweld yn fer wherem Yongfe di gallganionμοch a Glamor i wedi Maen nhw fanachan nhrydaw hwn sefynandol este wedi unic e lot Caso Pope fel ag rhan gywch ar wedi Angy bronybrion yn clyfog sut ac cyximo fel fel wedi 'wodf fel ael eich markaud o fel ei cawch Iffalo o na gwasiaeth y cyfle i siortace a rawn i ychyd bro Starquins o 'Fouls'? Ond poco o'n gwhold o reisach o titull a mae'r 'P Cannoncellus a roku-ンニd cal a'r beth weru— nie שbur�� i chi reisaithod o'n letos gyfour'n' dylai rom,ugi'r ar Old Time. Or… a Jason Barley yn cael ddyfnod hmpl uncertain y repositaeth ric orotau y bynod hap werrewahir. On wedi episol aion i gwasiaeth ddidd. Mae'r ysbytru'r adlybh, mae'r ysbytru'r adlybh yn ysbytru'r adlybh yn ffawr. Mae'r ysbytru'r adlybh yn ffawr. Is there anything else you'd look forward to medications? You've got your medications for lower your birth pressure, but they're only going to cause falls. If your falls are from due to orthostatic postural apetantian, that medication list that I mentioned earlier around to medication anti-colonidric, but anything, sedatives, things like soft pick loan, manzo deausapines, and the problem with sedatives of medications is to have those two effects that increase your chances of falling, but they also increase your chance of having an injurious fall. So when you compare people who fall on sedation, there's people who fall on sedation, those who fall taking medications out of the azopines as soft pick loan, and more likely to have serious injuries as a result of the fall. So is it, I don't think we look at that. I think everybody's all-lands are on a big page, but I don't think anybody really thinks about the other stuff, and the anti-colonidric bundle, they're don't even. That's something that I think I came to quite late in my medical career. I think I only started looking at that as a consultant, so I haven't made any thoughts about it before. So I wanted to just have my home at that point in time. So is there anything else on your list of falls questions? No, I think just, just, just as being important to watching people walk. There's so much information about the gay pattern, about the balance, about whether they've got any features, or sort of parking synisons, and then the other thing that I'll do is walk and talk with them at the same time, and you'll notice with a particular, with frailer people. It's like, if you've got an old computer, like any NHS computer, try and have two tabs up at the same time. It doesn't compute. It doesn't compute. So you'll notice some of the older frailer people have a problem with them, because it's going to do tasks against them. They just can't walk at all at the same time. So if you're walking with them, you'll talk to them, they have to stop. So again, that's just hinting at maybe there's something that all the systems on quite work, as well as they showed. A question for you, because I think sadly over the years, my practice is changing from what I do, Dean, accepts what to do at the corridor and not. So we were having a discussion to do the day about whether we do deer niles in the corridor and initiatives. Absolutely not, but when somebody in the corridor for 18 to 20 hours, sometimes you're waiting. You've got two, what's your approach to walking somebody in the corridor? So getting off the trolley? So I think it depends on the trolley's, doesn't it? Yeah. So some of the trolley's are just too high. So you can't get people, you can't get people off the trolley to walk them, because they're having to drop to the floor. I don't think I have done it, but not in an older trailer person. I've not got quite to that stage yet, but we might be having this discussion who knows in a few months about whether we walk them out of the ambulance. Okay, I'm going to give you a little bit more information about Bob, but this is my heart sink, this is where I need some help. So we do a line in standing and we discover that he doesn't drop, in fact, drops the pressure. So he's lying, the pressure is 195, if over 95. But when he stands, he drops it by 60. So it's 135, if over 85. He's on a culprit medication, which is Rammagrel. I tend to run the rums, he's also on a bit, I'm waddepean, and he's also on that former Prist-I-BT's. This is the stage where I go, I'm on Earth, what I do, because he's got a partial hypertension. I want to stop the Rammagrel, but he's got a baseline, the pressure 195. So help, what do I do? So we're saying this man seems not frail, don't we? So he's saying he's proud of it, so it's less a soup, he's not frail. In which case, I'm probably going to want to aim for reasonable blood pressure control within. Because he's got risk factors for kidney disease. heart disease, heart disease, stroke, it hasn't a, what I've been important notice is it's symptomatic, postural hypertension, because a lot of people will have a postural deficit, but if it's not symptomatic, it's not cause many problems then, I don't tend to worry as much about that, and then when you come and think about his medications that he's armed, it'd be about thinking, which medications, well that's most likely to stop seeing mentioned around the cradle, but think of it if he's got type 2 diabetes and they are sort of approaching we at them, that might be when you want to continue, and he might decide to stop the ammoderping in-stead. Okay. I think it's slightly different, that's assuming he's fit, robust, has symptomatic postural hypertension, he's still long-twin for type 2 blood pressure, control of him. Sometimes switching the medications to nighttime can help, and there's recent evidence that controlling nocturnal blood pressure improves all the outcomes over controlling daytime blood pressure. So I'd always worry about if you put them at nighttime, does that not make a nighttime form more likely? How is that? Does the evidence match it? No, I think it depends on how, on the age and your, who use it and how, how, how quickly it takes to have them affect, but managing that generally speaking, if we put Bob to inside, managing hypopostral hypertension, or for sense of hypertension with essential hypertension, really tricky, and the way to think about it is, we can't group them as two separate diseases, but the really the same thing, you've got someone who has a problem with their blood pressure physiology, so that physiological mechanisms for controlling the blood pressure don't just don't work. So it's a bit of a client blood pressure, but when they stand up, it drops, they're not two separate conditions, they're sort of two sides of the same guy. And there's quite a few different approaches that you can do in that situation. I mean, one of them, we've spoken about already, so switching medications to nighttime, and then using something short or acting, some fancy being recommended, and then there's lots of non-medical approaches you can use, which I'll be honest, the evidence base for anything working in isolation is pretty weak, but sometimes we still tend to give it a go, so you can ask people to sleep with their band as a bit of an angle, so things like 10, 20 degree angle, which you know, it's okay in hospital bed, isn't it? But most people don't have a band. Not that cool at just seeing it. That's meant to help. You get people to try and take a really cold glass of water before they stand or when they get up in the morning, and the thought is that's meant to dive the blood from all sorts of that digestive splung check, I can never say it. Splung check, splung check circulation to maintain cerebral perfusion. You can encourage people to generally drink more or eat more salt. And then sometimes compression garments will get used, the problem with compression garments is you'll see people put on sit-tends stock kittens, but the amount of volume you've got on your calves is tiny, you're not going to slightly increase the pressure on your calves, isn't going to cause a dramatic rise in blood pressure. So what you really need is that your impression like long johns or corsets, but then you reach that problem is, you know, if they're old and frail, lots of people just can't manage them. Often, you know, if they're old, they'll just decide, I'm not going to treat the hypertension because I think like I said, at the beginning of the podcast, you don't be prioritized in a risk factor over an actual symptom that's causing the person to have a poor quality of life. So you're here with me now. One of the things that we had this case very recently and some people thought, "Oh, for you to course." So the problem with that is it puts your blood pressure up, isn't it? So it's just going to cause your blood pressure to be even higher. You've got to start to think outside the box, but they're very helpful tips. And actually, I haven't told you about, are they actually symptomatic? So as soon as we find it, we try and sort it, but actually if it's not making symptomatic, does it matter? Yeah, and the other thing just to go back to sort of that, we do tend to not measure line sun blood pressure and when we book the age of 60, I think it comes into hospital is, that's got limited value in someone who's, if they've come in because they're hypervalemic or they're septic or they're anemic, they may well have a postural deficit, that doesn't mean they've got, they've got an orthostatic hypertension that's the baseline. Yeah, if you see the transient problem. Yeah, if you see a patient who's been stuck in at home or in your mum's department for one or two days, not put out that, not proud to break the auto-eater drink, that their blood pressure's like to drop on this band. So line sun blood pressure is a really useful thing to do in people who fall. It's just about interpreting the contact of everything else that's going on with that person. And that would be mean for a second and say, we've always stopped as unlawful pain and moved things around a little bit, but it's still hyper-attensive. In fact, it's got worse. Let's say we send in home and we see them in clinic and it's blood pressure's now 210, but it's still got this working egg drop. And he is symptomatic, but apart from the stuff we've mentioned, does there anything else that we can do? They would be the people who have been referring on to a difficult hypertension clinic. Assuming again, this man, he's pretty fit, pretty well. A fees. Because you do see this problem in younger patients, especially with diabetes, when there's a lot of auto-emitting, the rapid-theat-folder. It is a tricky problem. So you'd be enlisting a support of health. And I guess I was with a physiognomy of the day who was just can't swim in the mouth. Like you've just said about this. It's practical. Our sex is suddenly up slowly, and which is all well-e Good, until you really need a wee area. Yeah, and there's all sorts of things of actually a clenching, your fists clenching, your veins, squeezing your calves. And then, is it, I do, before the start of the day? Is it worth getting a physiognomy to speak to them, do you think? Well, sometimes just we can explain. We can do it. We can do it. We can do it. I'm going to move on to another case. And so we've got Maureen now, who's 79. So Maureen lives alone and works three days a week at the local charity shop. So, yeah, again, we've got another robust, fit healthy, 79-year-old. She's completely independent. She lives at the house alone, and she's got no carers, managers, the stairs, obviously fine. She's got history of CKD3 and osteoporosis. It's never smoked. And she was crossing the road yesterday. She's very, very disgruntful, because of youthful, one of those scooter things crashed into her. And she was a hit, and she bounced off a parked car. She's got multiple refractures. Four on the left, three on the right. Multiple bruises and no other fractures. But this is where I get a bit grumpy. So we see in her age, and straight away, refer to the lyrics. That's hospital policy, we're told. You go into research to see this lady, out of it, and this is based on a case that I've seen fairly recently. So she got sets of 89 on two metres. And an ABG showed she was retaining CO2 with a mild osodosis. She got pinpoint pupils in her respiratory six. She's had a big slug, 20 nm of ibionolfin about 15 minutes ago. When you examine her, she's flinching, but she's only responding when you do either shout at her and allow voice or when you're an examineer and inducing pain. Lots to discuss here, and you'll be expert at this on this. So I guess the first question for me when I saw this lady is, where is she's best managed? Because I fully accept I may not be right here, but when I looked at her, I felt like she needed this difficult combination of pain control. But at the same time, we were given enough pain control to make it comfortable, but they were knocking off a respiratory rate. I felt like, on a trauma ward, they might be more adept at dealing with this, but maybe I'm wrong. No, I think you're right. I always always agree with that. And I think the first thing I would say is, how many root fractures do you say to yourself? Just get a four on one side and three on it. So I'm going to say, I don't think you would know that. So the fifth is a plain chest X-ray. So you can assume this is diagnosed. So I think she got a CT-pant-gum. OK, fine. Because she was part of the trauma court. But immediately her age, she's medical. The first thing I was going to say is, it gets very weak, bad, and diagnosed in root fractures. So if you've got someone that you've got pain, that's a suspicion of root fractures, because they're in a lot of pain, they fall on the liver, the hypersic. Then you've been into doing a CT chest, because that will tell you the number of root fractures and give you all the information you need about those fractures. And any related injuries, every fractures, chest full injuries in old patients carry a really high mortality. About one in three will get pneumonia. And much more likely to die when you're over the age of 65 with root fractures than a younger person. So why do you think that is? The purely that they're frail, or is this thing he has going on? I think there's a couple of things going on, isn't there? So you've got people who are full, who have fractured their ribs from falls, from standing height, they will have osteoporosis. That's not the case in someone who's been involved in a road. A road-trafficking condition. Terrible. It's just normal physiological changes that happen when you age, you're more prone to hypoxia, you're more prone to hypercampsia. particularly when you've, if you've got the cathode system from previous electrical factors for other reasons then you've got the restrictive lung defect and more likely to retain the retain carb dioxide. You just generally have a bit less compliant, so not a bit less elastic, so you're more likely to get pulmonary contusions and again there's another reason to do a CT thorac rather than a chest attack trick, because they just work to show on chest x-ray as well as the dual CT. And then I guess there's the things that we give these patients as well, like you said with this person there's they've been given OPI, telling you know, the older you are, the more sensitive you are to the adverse effects of that, but there's so much more inflammation I've want to know about the rip fractures. I've made it in this case like she's got seven I guess that first of all and there's that many in my head I need to be phoning somebody about whether we need to do something and as long as that what you're only do to whether they get fixed or not necessarily fixed, but he has been managed on somewhere where they're familiar with looking at some sort of a rip with fracture path, which is normally going to be a trauma ward and the problem with rip, any other fracture you can immobilise, you can't immobilise your ribs, they move at the time, so when I'm assessing these patients in A&E or on the trauma ward I sort of want to know how many ribs are broken, is it unilateral, bilateral, where are they broken, what's the position, is it posterior, anterior, lateral, are they displaced rip fractures, are the displaced rip fractures, which ribs are actually broken because depending on which ribs are broken will give you other cleavage, so ribs are one to two, that's takes quite a lot of energy, so normally that would be so that could be associated with other injuries, so if it not had to happen, scan a hand scan and then sometimes you'll see some external fractures of those people and then ribs tend to 12 lower ribs might get spleen spenic injuries, liver injuries, kidney injuries and also is there a flail, so it's talked about radiological flail, so three or more ribs broken in two places and then you've got a clinical flail which that's a paradoxical chest wall movement and then also you'll want to know what other injuries have they got, is there pulmonary contusions, is there a hemothorax, is there a hemothorax, is there any other trauma on the pan scan, so there's a whole lot of things to be thinking about when you're assessing someone with with rib fractures, when do you sort of think about surgical intervention, so I've come onto surgical intervention shortly because the evidence of ACE for it is extremely weakened, so very controversial area, what I really want to get a sense of is what I've read a set about the rib fractures, you know the actual characteristics of them, but then the individual themselves, so we can use various scorn systems to predict that for the outcomes, so the one that that we would use, that I'm familiar with is called the battle, the battle score, and is that based on pre-packaged? Very easy stuff to, sorry not pre-act them, but based so you're looking at age, the number of rib fractures, whether they've got any respiratory illness, whether they've got quite a lot of the, whether or not you're quite glint, a lot of the sats are now, and the higher the score is, and the stumbles, the stumbles, smash battle, that will then guide your analgesic options, most of these patients when they've got a lot of injuries going to be some form of regional anesthesia. Because the problem here is to give her enough, we've already knocked her up, yeah, and she's going to get in the vein, isn't she? And then you use that regional anesthesia both because it's a good source of pain relief, but also to be open to sparing, because your treatment for these people is just to try and reduce, this gets pain under control, so they can breathe effectively so they don't get any bone yet. That's all you're trying to do. And you just not feel appropriate. And there's all sorts of regionalesthetic approaches that can be used depending, again, on the characteristics of the fractures, but yeah, if they've got a high stumble score, then they're likely to need to regionalise these in, not all of them, but all of them. And here, we've got a trauma team and a trauma ward, not everywhere has that. So hopefully, if this happens in the community, an ambulance would take its patient to somewhere with a trauma centre. But sometimes these patients end up being wheeled in or carried in by their relatives, and they end up in hospitals that don't have a trauma, sort of, a central trauma ward. So she'd been seen in resource and then referred to medics, but there isn't a trauma team. What could the team and medical regi do? Is it an orthopedic ward that she would do? Should she be transferred to a trauma centre? So I guess when we work as the regional trauma centre isn't it, but every hospital will have a trauma unit. So everywhere, everyone should have a trauma unit, which has normally run by orthopedics with general surgery. And that's what she really needs to do. And I guess what you'd aim for is they looked after someone like her, be looked after by a team with close things, sort of, their downstairs, your pain team colleagues, and then sort of have a frail team in between, and if they're injured, and if they're injured, they're from an older, and if they're an older frailer person. And it's certainly the medical ward isn't the right place for someone like her. And because you've again, you mentioned fixation, didn't you, and when? When you're out of the offered. It's a controversial area, and I guess with any sort of controversial decision, studies get done, and then people will complain, so that's not the patient I'm doing at all, you know, with the right patient selection, we think it works. But it's a rough rule, the evidence base for it, improving outcomes in anyone who isn't ventilated, and who doesn't have a frail chest is not that great. But there are times when surgical, when we would consider surgical fixations, and often involved in those NTT discussions, so you want to be doing it as early as possible, so at least in the first couple of days, it's only really going to work if there's something to fix, so the more displaced they are, I guess the more likely they are to benefit from fixation. You want it to be the pain's not being controlled with the region as these, you're all there, to tear it from a spiritual onto you, you get to the managing well, then you're not going to consider operating. And part of the power dot's I find is the people that may benefit, also the people that are highest risk surgery, so you're able to frame a person with COPD, might be the person you think will end up doing badly with their displaced group fractures, they may be the person I consider speaking to surgeons about fixing, but also other people that you're at least likely to want to put under a general nervous, fever and operating, the issue with people like this patient is, I guess what I especially think is it's all the trauma, it's these patients will end up in a step, it's frail to you, it's medical assessment units because their injuries aren't necessarily picked up because often the mechanisms of injury are such a low energy, and this person wasn't being able to be, if they're all from a standard height, so someone who's found at the bottom of the stairs, but no one's of taking the leap of imagination to think, could they actually fall down those stairs, so they end up in the medical back base? I think this one, although I say that, I think that's fairly obvious to me that this is a trauma, and should be true to it as a trauma, I did a lot of fighting to get this particular patient not to be on the AMU, I guess the other ones that were probably more likely to come up with us are when there's only one or two group fractures, which I suspect, I don't know if you're certain you'll tell me in a minute, I'm sure it's still associated with the mortality, can we comfortably manage those on an AMU, and what sort of thing should we be looking at on for? Yeah, so I think if you're someone here having you who's multiple rip fractures, being not so places, bilaterally, that's completely different to someone with one or two broken ribs, which are very common and often in these patients, at least when I was doing an A&E job, I was always telling you, can't X-ray to exclude or to simple rip fractures because all you're going to be doing is giving them an energy to incentive them on the way. So I think there's one or two rip fractures in there, they're fine, I think that's okay to be looked after on a medical. And what should we be looking out for, you know, they're all right, but what sort of. So I think if they've got just one or two rip fractures, I'll probably stay all right as well. I think you know, highpox, a good way of something that I do is I just ask people to have, can you hold your breath for three seconds? It's got to be a good long sort of one, two, three Mississippi, three seconds, and see if they're able to do that. And if they can do that, and they're not going to need discomfort and you know, they're saturating well on their arms and normally then they're probably going to be absolutely fine. When I see these patients on an A&U, I tend to sort of want to see that they can take a deep breath, so I wouldn't really if they can't, so I'm like, well, that's whether pneumonia has started to creep in older, frailer patients, let's say everybody who's really quite frail. sometimes come along and they're on QDS, there are a season one on QDS, Kodi, maybe they're a bit vulnerable thrown in if they need your PLN. First of all, I know it's me if they can't actually ask 'cause they're very frail, I won't ask. Bit of tip on analogies over these people. I think I know what I do, but I'm not as serious. - Yeah, I think everyone's got the road approach to everyone's got a painkiller that they think is a ridiculous painkiller to use when you find one of your colleagues is their favourite painkiller. So I think, you know, my approach is regular Parasatomal and then normally I use oxycodone, a smile painkiller of choice, but other approaches are acceptable. I think you don't want to have people on a mismatch of lots of things that counteract each other. You know, lots of different types of opioids being given by a different routes. You'll to try and choose one and up a tight rate. - I can't imagine being constipated with fractured ribs as much as them. - No, no. - Make sure that they've got a benefit of onboard. - Very, very rarely you sometimes get permission to use a lighter cane patch. - I don't like that today, 'cause it's the expense. - I think it's the probably an expensive placebo. (laughing) - So yeah. - I would sometimes - Feels like a decenter to change your mind. - Lovely, anything else that we should think about. So I think I haven't got any more on trauma per se. So we've talked a bit about rib fractures. Anything else you want to say about trauma, given that you've a lady sort of expert on it. I think pain control is always my sort of thing that we need to get right. Rib fractures are ones that I must confess to you, worry me. And low thresholds are a pH-extract, and it's deteriorating to measure that. They'll look a few years later. - Yeah. - And low threshold for CT. - Yeah. - To characterize all those things I spoke about at the beginning. - Lovely. So we're gonna move on to our last case then, which is heater, 92-year-old, and multiple past medical history. So it's got CKD, triple A, or disavailance, type 2 diabetes, hypertension, had an MI, the age of 65, which was probably followed by a cabbage. It's got prostate cancer, but there seems to be well-controlled on insolid X injections. And two years, Gary E. is a family that was paying close attention that his memory was done to deteriorate a little bit. So he's now got diagnosis of dementia. Usually, recognize his close-funding friends, but gets a bit disorientated time and place at times. But most of the time, he's, you know, continent, he can go to the toilet himself, just needs a bit of help getting there. So he lives in a care home, where he requires supervision and prompting with his ADLs. His care is called 999 that morning, because it was found confused. And then my favourite phrase, not, "Smelt strongly over your head." So he's come to ED, and he's diagnosed with a UTI, after a dipstick was positive, because they rubbed it onto the pad and it was positive for everything. I'm just throwing in all my headaches. Patients, I see. Right, so he's got a Y count of 13. He medlovings a little bit on the low side at 120, CLP's 50. His chest sexual is a very poor film, because it's brutal, but he can't see anything massive on that. And the rest of the physical exam is largely normal. Medical registrar comes along and gets very angry at the point that we've caught this at UTI. And they say this is a delirium, whitely secondary to endocryphalitis, because he's drowsy. So he started on IRI-TAS, IQV, IB-TANS, and Plan for LAPI. So this is something that I am seeing much more of these days. We can talk about the UTI diagnosis as well, but what's troubling me is the endocryphalitis diagnosis, because in the frail patients who are confused, I find it really difficult to say this definitely isn't, but there's absolutely no way I really want to start LPN these patients. Where do I start with this one? Yeah, I mean, it's really, really difficult, isn't it? I mean, my experience is I'm in catholitis, and I think of my colleagues, it's just catholitis, the people that you think have got it, never-ender, haven't it? And you've been misstituted and the people who have got it seems to be very overdiased, but also very good. Yeah, but it's not. It's a moment to appear, anyway, is it? So if you think about all the CTPs we do, our most really fit-well people that are put into a shopping trolley, we've got about chest pain, and none of them have got a PE. And then it's the people that you do find it at post-mortem that have massive people that we've been able to talk about. So it's one of those, isn't it? But the problem is that we're probably getting more patients that have had it that we've missed. And therefore we're now twitched about it. So we're thinking about it and everyone. Is there any good tips from this? Well, think that in catholitis, it's very broad, isn't it? Even if you can say, violent catholitis, there's still quite a lot of different viruses that can cause in catholitis. But generally speaking, if in catholitis is a catch-all term, then it can present the fluctuating, cognition and confusion. So it's not so unreasonable, it's a differential diagnosis in this person. But often there's other features, aren't there? So you know, seizures, focal, neurological deficits, or factory hallucinations, that there may be other clues pointing towards in catholitis. But you're like with this person, can we definitively move on in catholitis? That's now a PE. No, but are there other things that we can consider? Yes. Do you do the LP? There's a lot of these patients there. You'd have to sedate them to get an LP, first of all. So I tend to find that when I come along for the post-ate war round, they've started on all the treatment and planned for an LP. I don't think anyone would do an LP and there's so many other things this could be. And in some cases, a lot of the time patients announce they're going to get better. So again, I can't say that it's not the IVA cyclovere or whatever else, but it's more likely that they're delirium is settling because it was something much more common. So what's your approach to that? So I think with this man, you've got someone who's got a vulnerable brain for delirium, haven't you? He's already got conscious impairment. We know he's frail because he's living in a car home. It's going to take a very non-major insult to make him delirious. So I tend to put people in here, who are the people who have a very low threshold for delirium, be someone like him, in which case, for me, there's probably much more like them in catholitis. I've got someone who's fit and robust with no history of quantum impairment, no history of delirium that coming in with a new change in cognition and there's no more likely alternative course than maybe the ones I'd be thinking more about in the catholitis in. Because with this man, life is in a very beginning with people frailty. It's, with someone like him, who's in the central delirium, he's got a vulnerable brain, he's got a pre-disposed infactor, the precipitating factors for him are going to be lots and lots of little things, which may be minor in themselves and sort of immetriable, you know, a mildly low sodium, a slight infection somewhere. His battery's from his hearing aids have changed. He's missed a dose of a medication so he's not been started on any medication. His care is, who look after him, have changed on that day. And he's in, you know, he's moving his care home. So often it's lots of these tiny, tiny little things build up and then one tiny thing takes them over the edge and sort of the straw that broke the candles back and trying to tease apart all those things can be difficult. I mean, as a referral, if you've only found one cause of delirium in these people, you've just not been looking hard enough. And also, you know, probably about the third of patients, even when you're using that sort of pinch me, an amonic to look for the common precipitating factors, you don't find a cause anyway. But I'm much less worried about the people who I already know that brain's not working well. Yeah, so I think lots to pick up from that. So I forgot to say this at the beginning when you were talking behind us a problem list. And I find that even more so in an older frailer patient, because if I write the problem list out, as I'm going through the notes and then speak into the patient, then when I'm writing my plan, I can look back at the problem list, because like you say, there's always so many little bits and pieces. And then the other one, as you mentioned, the pinch me anew on it. So definitely want to flag that as a brilliant tool. But again, I've only come across like this there recently, but it is on a busy wardrobe. And you've got some of the delirium, we talked about time precious and sometimes finding the sort of heart, they think they've got complex patients in front of you. If you've got a couple of pneumonics, obviously, it can make it easy to remember all the things you need to do. It's helpful. So pinch me, test me now. We should say it's Friday afternoon. Just to put this in context, so pinch me through pain, infection, nutrition, constipation, hydration, medications, environment. So like medications, metabolic, and I would say about the constipation, and I might get thrown up the British Geo-Aptia Society. This could be very good for me. I might become a provider, but I think sometimes I worry a little bit that constipation is the util of the geriatrician. So we get fat at all people getting laid with us, uti-alty, but too often we reach the constipation as being the cause of the delirium. That's not to say constipation is never court was I'm certainly liking to be contributing factor. I'm probably going to want to have that satisfaction of just saying, isn't there a founder give laxatives move on? Because with most people the learian that tends to be lots of other little things that have gone wrong. So yes they might be constipated, need to truthy constipation and it might even be that it's the sudden constipation that's tipped them over the edge. But if you're just going to diagnose it's delirium, sacrilege constipation and not look at all the other factors in the background that's gradually there. Then you're missing it. Yeah but I do think we should just congratulate me for remembering. Yes well done. I haven't preempted that so that's very proud of myself when I've tried it, definitely. Yeah I think that's important isn't it and it goes back to pointy subject, you know, you should be thinking going at least two of those. So in this patient I would stop the acycobare probably, I probably stopped the ibita as well because it's fairly broad section, depending on how he was clinically. I wouldn't go looking for any chephalitis unless there was something else. And I have to confess to the audio thing I call it done in the corridor about somebody very similar to this saying, what do you do? Because I can't say it isn't and I really try now. I feel much more comfortable with that. This is somebody who's got lots of reasons to do that area so they've got a brain that's wonderful to this. It isn't feeling my cut. It could be and I can't excuse it but let's treat the common stuff first. First is somebody who's 70 and they've passed medical history that's coming to keep the confused and the endrailsy. And then is those patients that you feel much more comfortable doing LPL as well? Yeah. That's helped me no range. Yes it's a struggle with the support. It's that balance between their precipitates and and put disposing factors in someone where they have the guts of vulnerable brain, foot leary and or not. And it's the people with no Christian or conscious issues robust well who suddenly come in with a dramatic change in personality, behavior, consciousness, cognition. But I would tend to be most worried about in catholite to say, but yeah tricky because you can never really exclude it without without sort of image in plus minus a lump of puncture. We haven't really seen a lot of the UTI and I'm hoping for the vast majority of the people that listen to podcasts. We shouldn't have to go because I think that. What you say that this message should have got through but in the last three months I've had referred to me a triple A as a UTI. That's my favourite so far. So abdominal pain and a fever was definitely a UTI but they'd actually got a triple A. I've had quite a few subjoils over the years which have been referred to me as a UTI and an appendicitis. It's like you know don't just, it's a bit of some sort of a delirium isn't it? Don't just stop it or they've got a fever and they've got a bit of white cells in the ear. I mean we shouldn't be dipping the ear in anyway but it just think about it more carefully. I think that message is out there whether people really need practice it or not. I'm not sure. We had an interesting conversation there the day about the value of MSUs in patients. So continent patients who've got symptoms of a UTI. Obviously you don't really wait for MSUs you're just going to treat them anyway. Who do you send MSUs on? Because I've seen, I might have drawn this but I'm sure I've seen some evidence where we should be reducing the number of people who send MSUs on over the age of 85. Okay so I guess I send MSUs on people who are worried to make having UTI just because they're a help guide. And a resistant. They're a guide and a few biotic choice. And if they're not better then you've got MSU in this resistant. Yeah so you're not worried about sending MSUs then. No I'm not aware of the guidelines. I can't be aware of seeing that. I'm sure somebody told me that over the age of 85 it becomes less useful. It doesn't mean I would treat a positive, you know, if they think if they've brought something new and they're asymptomatic I'm not going to. I so as a threat to it. Where that might be coming from is don't send it if they haven't got symptoms always. I'm sure as a consultant you're the same as me you get an awful lot of results to file and suddenly you've got an MSU in front of you and there's nowhere in the notes anywhere that this patient ever had anything. Why was this? And that was positive. But you know you just ignore those words don't you unless it's something that would cause you concern. But as far as this just be a bit more thought for that who we're sending the MSU on. But if you've got somebody who's in infection query because it's part of my infection screen. Yeah and I would send it and the other one is I do dipstick because if the dipstick negative then it's not possible but it's a new to it. That's huge. It just makes it less likely doesn't it. So I'm not going to be bothered about a positive dipstick in someone like that because as we've spoken about they're not that they're not used to talking a negative dipstick. Because if you can sort of decrease the chance of it being huge if it is a negative dipstick. It's with my urine dipstick and constipation in a way that I do worry that you are going to be thrown out of the British or get to society. But there it is. It's about common sense and applying stuff to patients individually isn't it? It's the rule. Okay. I've covered the cases. Is there anything else that you would want to talk about or cover? No I don't think so. I think we've chatted it as it is on pretty quickly and realise we've actually been recorded for that. So it would be a good place to stop. Thank you as ever for listening. I will put some references onto our show notes onto the website as usual. Thank you very much for listening. Thank you all for listening to another episode of the Society for Acute Ments and Podcast. We hope this episode has been interesting and helpful for you all. Please do go to the SAM website www.acutementsen.org.uk for all things Acute Ments and including show notes from today's episode under the Education menu. You will also find more information about Acute Ments and the team and how to contact us individually. Please do get in touch with us via Twitter using @acutemedpod and let us know what you thought as well as topics you'd like us to explore in future episodes or if you want to get involved with Love You To Get involved. Thank you again for listening and we hope you can join us next time. [MUSIC]