Dr Jane BurnsMedical Director, Acute Division

NHS Lanarkshire

Quality in Pre-Admission Assessment;Facing the ‘Silver Tsunami’

Scottish Government Statistics;

The number of people aged 75 and over is projected to increase by 23% between 2010 and 2020, and by

82% between 2010 and 2035

In the same 25 year period, the number of people aged 60 – 74 is projected to increase by 27%. In 2010,

23% of the population was aged 60 and over. By 2035, this is likely to have increased to 30%

THURSDAY 1 MARCH 2012

Ageing Scotland faces population time bomb

Scotland is facing a demographic time bomb after new figures revealed the country's elderly population is

predicted to rise by more than half a million during the next two decades.

Analysts at the National Records of Scotland office believe the number of pensioners living in the country

will swell by 551,200 by the year 2035.

While most age groups are expected to remain stable, the number of pensioners is due to hit 1.4 million

within 25 years, up from 879,500 today. An extra 21,500 over-65s have been added to the estimates, after

the statistics were revised upwards from the last data released in 2008.

It means that within 23 years the percentage of Scots who are of pensionable age will rise from the current

figure of 16% to almost 25%.

“The Office for National Statistics estimates that the

number of people in Britain over the age of 65 will

increase by 65% over the next 25 years. This

significant shift in demographics will change our

perceptions and expectations of older people, and

healthcare services will need to respond”

October 2012

The ‘Silver Tsunami’

“Instead of a mass movement of water, this tsunami is made up of seniors – a human flow that, without planning, threatens to overwhelm and engulf us”

“It's great news on the longevity front, but not for a health-care system that is unprepared for the repercussions of an aging population.

Alzheimer's disease is one of the challenges for which the nation is not ready.

Today, one in eight has Alzheimer's, and the risk of developing the brain disorder doubles every five years after age 65.

Although most people will not develop Alzheimer's, by 2025—30 percent more than today”.

Cognitive Impairment vs Incapacity:

DEFINITIONS

Cognitive Impairment (CI) is impairment of memory that may result in difficulty with processing the necessary information to make complex decisions, including consent to care and treatment, but may equally have no impact on decision making ability.

Capacity means being able to understand what is being proposed, to weigh up the relevant information, including its benefits, hazards and options, and to use this in reaching a decision being consistent in their views and decision making.

Incapacity manifests itself as problems with decision making because of mental disorder or inability to communicate and can be a result of; • Difficulties with perception, understanding, logical thinking, memory or motivation.• Inability to plan, make judgements or resist undue influence from others• Severely disordered emotions or disordered thought form or content• Problems with communication

Cognitive Impairment; at risk groups

Certain high risk groups or patient populations have a higher incidence of cognitive impairment with or without impaired capacity,

These groups may include but are not limited to adults with;

• Dementia

• Learning difficulties

• Stroke with severe aphasia

• Alcohol related brain injury

• Delirium or acute confusion

• Head injury

• a significantly reduced level of consciousness from any cause

• over 65 years (combination of increased risk with age + acute illness)

• less than 65 years where areas of concern have been raised by the patient, their family / carers, their GP or any member of the multi-disciplinary team

Case Study (Pre-operatively):• 70 male referred by GP for TKR

• Past History; mild COPD, depression, ‘cerebrovascular disease 2007’

• Pre-Admission Assessment

• ADLs; forgetful since TIAs (x3) in 2007, dull of hearing

• PMH: previous uneventful GAs but more than 10 years ago

• Tracheostomy as a child ?diphtheria

• Attends vascular clinic at GP practice annually following TIA’s x3 2007

• Awaiting further investigations for ?Parkinsons.

• Medication = oxybutynin, aspirin, omeprazole, co-codamol, ventolin

Family concerned about patient being in hospital as feels he may become increasingly confused. Recently on holiday and wandered away and was lost for 5 hours.

Patient alert @ PAA but says he became confused as he could not recognise any of his surroundings

Son is psychiatric nurse

Case Study (Peri-operatively):Admitted for TKR following day

Procedure uneventful; Spinal with IT morphine, co-codamol, sc morphine PRN (none given)

Day ♯1 post op; noted to be vague and distressed/tearful at times; physio notes vague – poor participation and at second visit agitated

Day ♯2 post op; as above, daughter in to assist with meal – better in evening

22.35; FY2 review - very confused, been a murder, staff involved, “brandishing walking stick with menace – threw a right hook but was dodged successfully”

Coaxed back to bed; haloperidol PRN and investigate potential causes of delirium (coag –ve staph found in BC and treated)

Continues with confusion hampering recovery and mobilisation, pulling out IVs

Day ♯5 post op; broke window of his door

Day ♯6 post op; smashes a window and hitting staff

Remains in acute care until 25/10 with episodes of very violent aggressive behaviour but general background of confusion, agitation & distress (wandering naked, doubly incontinent)

Day ♯33 post op; rehab facility – made some progress but remained confused with falls risk

6/7 weeks later; Nursing Home

Following month; Deceased

Pre-Admission Assessment

AIM

All patients scheduled for a surgical procedure are optimally prepared for that procedure and its associated peri-operative and post-operative care;

and

To do this in a way that provides the optimum patient experience and makes the best use of available resources.

Cognitive Impairment: Screening

• An initial screening test of cognition is recommended in at risk groups and will help to

inform subsequent interactions at all levels of healthcare

• This initial test is based on the Abbreviated Mental Test 4 (AMT4),

as recommended by NHS Education Scotland (NES).

• Scores of 3 or below should always initiate

further action

• Any assessment of capacity, will generally take a longer period of observation and

interaction with a patient and their family or usual carer, unless the need for an

emergency treatment supersedes this or there is a pre-appointed Welfare Attorney or

Welfare Guardian in place to assist the patient in these matters.

Cognitive Impairment: Further Assessment

• This more detailed assessment is carried out by the multi-disciplinary team and will use

a variety of recognised tools and clinical assessment skills, including, but not limited to;

• AMT 10 (Abbreviated Mental Test)

• MMSE (Mini Mental State Examination)

• ACER (Addenbrooke’s Cognitive Examination).

• Actions following assessment should be agreed with the patient, family and/or carers

and the multi-disciplinary team.

Cognitive Impairment: Pilot in PAA

• All patients over 65 to have AMT4 recorded

• If score is < 3

• Delerium screen if new (FBC, U & E’s, glucose, urinalysis)

• Return appointment to see ACE nurse for more detailed assessment

• Actions following assessment should be agreed with the patient, family and/or carers

and the multi-disciplinary team.

• Severity of CI

• Acuity of illness

• Nature of proposed surgery

• Care plan to support acute admission (day surgery, carer to accompany, surgical and

anaesthetic technique, avoid triggers, agreed escalation)

Cognitive Impairment: Pilot in PAA - Results

• 3 months, all 3 preassessment units, approx 6,000 patients assessed

• AMT4 easy to incorporate

• 5 / 6 patients with score < 3 & referred to ACE nurse for further assessment

Outcomes

• Peri-operative care plans agreed

• Subsequent care forwarded to GP

Impression;

• not a tsunami,

• easy to do,

• patients appreciate it,

• simple patient safety tool

Best Practice in Pre-operative Care

The complex elective patient should never be presented to the clinician at less than 24 hours notice

Traditional working patterns have been designed around what suits clinicians best

Working patterns may have to change to facilitate best care for patients

“One Stop Shop” is not always best