Hospital care failing elderly patients

A study by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has highlighted major flaws in a number of key areas of hospital care for elderly patients, following surgery.1 The report, An Age Old Problem: a review of the care received by elderly patients undergoing surgery, revealed that poor nutrition and serious associated illness were extremely common; clinically significant delays occurred between admission and surgery in many cases; and, in over two-thirds of cases, patients were not reviewed by specialists in “Medicine for the Care of Older People (MCOP)”. The study examined the cases of more than 800 patients over the age of 80, who died in hospital within 30 days of undergoing surgery, and found that just over one in three (38%) received good care, 44% received care that could have been improved and 6% received care that was less than satisfactory. Report author and NCEPOD clinical co-ordinator in surgery, Ian Martin, commented: “Most patients were admitted as emergencies by very junior doctors without timely input by senior care of the elderly clinicians. There is still a long way to go to ensure good practice and appropriate care – this is despite our advice in 1999 and recommendations in the 2001 National Service Framework (NSF), calling for specialists to be involved at every stage of elderly care.” Professor Mike Gough, report author and NCEPOD clinical co-ordinator in surgery, added that greater vigilance is required when elderly patients attend the emergency department with nonspecific abdominal symptoms such as, diarrhoea and vomiting, or signs of infection. He commented: “These patients should be assessed by a doctor with sufficient experience and training. If these patients do not receive appropriate multidisciplinary care, including assessment by a surgeon, their underlying needs may not be appreciated and this is often associated with greater delays in performing surgery.” A summary of the report findings is provided below:

Pre-operative care

Risk assessment: Risk assessment can be particularly difficult in the elderly surgical population and should include input from senior surgeons, anaesthetists and MCOP clinicians. However, in over two-thirds of cases (67.7%), patients were not reviewed by MCOP specialists – despite the recommendations included in the National Service Framework for the Elderly. NCEPOD chairman, Bertie Leigh, commented: “Questions should be asked about the wisdom of performing surgery on the elderly at sites where these clinical teams are not available. Even patients whose problems appear straightforward to the team under whom they are admitted, may have more complex needs than are recognised.” In elderly patients needing urgent surgery, careful attention should be given to improving fluid status, reducing unnecessary drug treatment, anticipating nutritional support, and assessing mental capacity. Unfortunately, mechanisms for the assessment of nutrition and mental capacity were found to be absent in a number of sites. Thirty sites did not have written policies or protocols for assessing the nutritional status of patients and 98/277 sites did not have a nutrition team, while documentation of mental capacity in this sample was also poor (395/701). Acute kidney injury at the time of admission was also an important cause of comorbidity in this elderly population (186/765) before surgery. Furthermore, some patients in the study were receiving a large variety of medicines (463/740), with a serious risk of drug interactions. The authors concluded that comorbidity, disability and frailty need to be clearly recognised and seen as independent markers of risk in the elderly. Moreover, this requires skill and multidisciplinary input – including early involvement of MCOP clinicians. They recommended that: