Consultant physicians working with patients - Royal College of ...

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2 Specialties Geriatric medicineGeriatric medicineDr Zoe Wyrko MBChB MMedSci MRCP(London) Consultant geriatrician1 Description of the specialtyGeriatric medicine is the branch of general medicineconcerned with all aspects of health and illness in olderadults. Geriatricians possess the specialist skills neededto diagnose, manage and treat conditions occurring in aphysically and mentally frail section of the population.Additional challenges are provided by the fact that olderpeople have different patterns of disease presentationwhen compared to younger adults, they respond totreatments and therapies in different ways, and theyfrequently have complex social needs that are related totheir chronic medical conditions.The patients are traditionally adults aged over 65 years,but younger people with complex needs can also benefitfrom input by a geriatrician. Those who gain the mostbenefit from specialist geriatrician input are the frailelderly. Frailty often presents as non-specific ill health(the ‘geriatric giants’ of falls, confusion, incontinenceand immobility) but leads to prolonged hospital staysand poorer outcomes. 1,22 Organisation of the service and patternsof referralTo provide integrated holistic care for older people,geriatric medical services should cross the boundarybetween primary and secondary care. Care pathwaysshould consider the physical and psychologicalneeds of normal ageing, together with the crisesand potential deterioration associated with acuteillness.An acutely ill older person should be assessed as soonas possible using appropriate diagnostic and imagingfacilities, usually in an acute district general hospital(DGH) or teaching hospital. It is vital that older peoplearenotdeniedaccesstothebestofdiagnosticserviceson the basis of their age and the organisation ofcommunity and hospital services should be gearedtowards this aim.No clear evidence exists that any one pattern of elderlyadmission system is superior (age-related, needs-relatedor integrated with general medicine), so the formatchosen needs to be appropriate to the facilities andsystems already available. There is increasing interest ininvolving geriatricians in the accident and emergency(A&E) department and medical admissions units tofacilitate the early comprehensive assessment, andappropriate subsequent treatment environment, of frailolder people. Patients admitted urgently to geriatricmedical services might be referred directly by their GP,attend the A&E department and be referred onwards foradmission, or be transferred from other acute areas suchas surgical or psychiatric facilities.The increasing importance of involvement ofgeriatricians with the care of older people in specialtiesother than medicine is becoming apparent, with earlygeriatric assessment routinely taking place in those underthe care of orthopaedic surgeons for fragility fractures.Referrals for rehabilitation are taken from almost allspecialties at a later stage in a patient’s hospital stay.Rehabilitation aims to optimise or maintain physicalfunction and, following patients’ admission to hospital,should start as soon as they are physically able.Geriatrics is the parent specialty for stroke medicine,and both the acute stroke and stroke rehabilitationservices are often led by geriatricians.Community models of careCommunity geriatrics is a growing subspecialty, withsome consultants working exclusively in thecommunity, although the majority have sessionalcommitments to both community work and acutehospitals. A job plan may include time spent incommunity hospitals, as well as supportingintermediate care services, community matrons andcare homes. A wide variety of work patterns arepossible, but it is vital that integrated pathwaysinvolving community services are developed locally,with community geriatricians working closely with GPs,district and specialist nurses, and allied professionals.C○ Royal College of Physicians 2013 119
Consultant physicians working with patientsThe consultants will often lead clinical governanceprocesses and teaching for community services. Theyare specifically required to supervise clinically and tosupport any GPs with a special interest (GPwSIs) inelderly care.Relationship with other services and agenciesMultidisciplinary working necessitates close liaison withmany complementary services (see Table 1), as well asthe mainstream specialties in a DGH.3 Working with patients: patient-centredcareWhat you do with patientsInvolving patients in decisions about theirtreatmentGeriatricians are committed to rooting out ageism inthe delivery of medical care and recognise thatcompetent informed adults have an established right torefuse medical procedures – sometimes in advance.Respect for patient autonomy is at the centre ofpractice, particularly when dealing with advancedirectives and issues relating to nutrition in patients ofadvanced old age. Medico-legal topics such as power ofattorney, Court of Protection and the Mental CapacityAct 2005 are important parts of everyday geriatricmedical practice. Geriatricians regularly seek patients’and carers’ views on end-of-life care, cardiopulmonaryresuscitation, assisted ventilation, artificial feeding andother ethical issues.Patients with chronic conditions and the roleof the carerGeriatricians recognise the importance of involvinginformal carers in decisions about complex treatmentin old age and consider a patient’s quality of lifeand a disability-free life expectancy as important goalsof treatment rather than absolute longevity. Patient andcarer support groups may have a role in the managementof patients with chronic conditions in older life,particularly those with conditions such as stroke,Parkinson’s disease and dementia. In addition, patients’and carers’ views form an important part of the clinicalgovernance process in geriatric medical departments inhospitals – either individually or as part of focus groupsthat look at complaints and the patient experience.Older people should be treated as individuals at all times,be offered a choice of treatment and be involved in thediscussions planning their future care. Services need to beTable 1 Medical and paramedical services supportingthe assessment and rehabilitation of older peopleDomainActivities of dailylivingCare managementCommunicationEliminationPalliative careMental stateNutritionMobilitySpecialist nursesServicesOccupational therapySocial work servicesSpeech and language therapyAudiologyHearing therapyOphthalmologyOptician servicesDental servicesContinence adviserStoma therapistUrological or gynaecological servicesUrodynamic assessmentPersonal laundry servicesSpecialist pain reliefHospice supportPsychiatry of old ageClinical psychologyDietetic adviceEnteral and parenteral feeding servicesincluding percutaneous endoscopicgastrostomy (PEG)Dental servicesVideofluoroscopyPhysiotherapyWheelchair and aid suppliesOrthoticsPodiatryOrthopaedic servicesChiropodyChronic obstructive pulmonary diseaseHeart failureParkinson’s diseaseDiabetesTissue viabilityDementiaFracture or orthogeriatricmade easily accessible, regardless of provider, by involvingolder people and their carers in service planning.There are a number of areas for which all specialistelderly care units should have policies. These include:maintenance of dignity, privacy and humanity in care;end-of-life care/advanced care planning and ‘do notresuscitate’ orders; and provision of written informationfor patients about life in hospital, the choices to bemade, discharge plans and the timescales involved.120 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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