When is a geriatric consultation needed?
There are many reasons to ask for a Geriatric Medicine consultation on a patient in hospital. For example: Margaret, an 87-year-old lady, developed diverticulitis and was admitted to the surgical ward, requiring intravenous fluids and antibiotics for a few days, during which time she was not out of bed. When it is time to be discharged back to her retirement home, the physiotherapy team finds that her walking is dangerously unsteady, even with a walker, and she is very weak. Margaret has a moderate dementia and is unable to give a reliable account of how she ambulated prior to coming to hospital.
The Wrinkle Can Help
For more information on what a geriatrician is watch Dr. Didyk's GERI-Minute episode What is a Geriatrician?
What does a geriatrician do?
The geriatrician is asked whether she is a candidate for rehab, or if there is some medical reason to explain this sudden change. Margaret’s discharge from hospital was delayed until the Geriatrician was available to attend and provide an opinion, adding expense to the system and inconvenience or even suffering to Margaret, who was otherwise ready to go home.
Margaret was able to be discharged from hospital as soon as the Geriatrician attended and weighed in. You are probably asking yourself: “How did this wise doctor find a way to slice through the Gordian knot of complex medical and social problems to allow this frail individual to return home?” “What sorcery is at work here?”
It’s no magic, although I feel like a rock star at times when I can come along and provide clarity to a situation, using a combination of curiosity, tenacity and myth-busting that seems obvious to me, but if everyone else figured out my tricks I may well be out of a job.
All about that base (line)
A person’s baseline is vital information, especially when planning a discharge.
The baseline can include a description of the person’s usual function, mood, use of services, routine, and so on. The baseline may change after a stress like an illness, or a hospitalization, but we rarely expect anyone to improve relative to a long established baseline.
It’s like the old joke:
Patient: “Doctor, will I be able to play the piano after this operation?”
Doctor: “Yes, that should be no problem.”
Patient: “Great! I never could before!”
How did I make the discharge decision?
Curiosity: The Geriatrician is possibly the nosiest physician on the planet. I ask innumerable questions: When did you move to the retirement home? Why? Why that particular retirement home? How is it going there? Where did you live before? How do you spend your day? What time do you usually go to bed? Wake up? Take your pills? And so on. I not only ask the patient but, with permission, also the care partner, family member, director of care at the retirement home, neighbour, daughter in law, pretty much anyone who has information to provide. Columbo has nothing on me. I’m incredibly nosy but there’s a reason. For example, on further questioning, we found out from Margaret’s retirement home that she hasn’t walked with a walker in 2 years and in fact uses a wheelchair to ambulate. Margaret was at her usual baseline and no further time in hospital was going to alter that fact.
Tenacity: The Geriatrician never gives up in the quest for information. If the government was to come up with a comprehensive electronic data base that contained all a person’s medical information, I could well be without a job! We Geriatricians are known to spend one to two hours in direct contact with patients during an assessment, but we also spend a lot of time digging up information. For example, I sift through up to seven data sources as part of my assessment: both local hospital databases for information about previous hospitalizations, the provincial database (for any investigations or assessments that were done outside of hospital), the home and community care database (to find out what is going on with community services, including long term care planning), the database used by the Specialized Geriatric Services teams, along with the package of information sent by the family or referring physician, or the current hospital chart. Then we call a family member, friend or community caregiver to get more information about the baseline.
Myth-busting: There’s a joke about the 98-year-old man who visits his doctor to complain about a pain in his left knee. The doctor says: “What do you expect? That left knee has been carrying you for 98 years!” The older gentleman replies: “So has my right knee, but it’s not sore!” Many of us assume that it is part of the normal aging process to become frail and dependent, but that is not so. Most nonagenarians in Canada are living at home with a partner. Of all of those over 65, less than 5% are in a special care home for seniors. Yet, I meet many people who think that it’s normal for seniors to stop banking, cooking and shovelling, and start napping, falling and forgetting. As a result, many family members will assume that the changes they observe in a senior are typical, even normal, and not a cause for further investigation or intervention. The Geriatrician’s role can be to clarify how a senior’s trajectory may have deviated from that of usual aging, and what to expect for the future.
I often ask myself, when doing my “deep digging” for information in preparation for an assessment, why others have not put this information together and drawn the same conclusions as I. I suppose that is the “magic” of what a Geriatrician can do – gather and synthesize relevant data to develop a diagnosis and plan. I should be thankful that no one else seems to be up to the task. At least I still have a job.
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