Older people in hospital

The Hospital Environment Audit Tool (HEAT) encourages the user to consider the ways the environment, including the model of care and policy framework, affects an older person’s mobility, independence and wellbeing during a hospital stay, and provides practical strategies that can be implemented to optimise the environment.

The HEAT is divided into five sections:

• Patient bedside orientation
• On the ward – limited resources
• On the ward
• Facility audits
• Policy and procedure

Patient bedside orientation is designed to be completed in 5 to 10 minutes and should be used with every patient on admission or after transfer to the ward.

The other sections include multiple modules, each of which are designed to take from 15 minutes to 35 minutes to complete. Staff can complete all sections or simply the section or module which is most relevant at the time. Options are provided for where there is a small budget and short timeframe available, and alternatively for where there is some budget and a longer timeframe available. It is not designed to be used for major refurbishments or new builds.

The HEAT is designed to be completed online, however printable versions of each module have also been provided. An action plan template that can be printed and completed has also been provided for you to document the progress of any changes suggested by the audits.

This section of the Hospital Environment Audit Tool (HEAT) contains modules that look at how the environment in the ward spaces of a hospital meet older people’s needs and enable them to participate in their care.

There are four modules in this section:

• Rooms and bed bays
• Bathroom
• Communal spaces
• Lighting, signage and wayfinding

These audit modules are designed to be used when you have a limited budget and short timeframe. Interventions suggested are able to be undertaken with a small amount of money (if any) and in a short space of time. Please note – there are separate ward audit modules that are more comprehensive and suggest interventions that require a larger budget and a longer timeframe. They can be found in the section: On the ward.

The Communal spaces module contains some suggestions would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget.

The modules in this section are each expected to take between 15 minutes and 20 minutes to complete. The audit modules may be completed individually or as part of a broader audit of the ward or other parts of the facility. The modules are not designed to be used for major refurbishments or new builds.

Rooms and bed bays

This audit module is designed to look at patient rooms or bed bays.

The audit module is designed to be used when you have a limited budget and short timeframe. Interventions suggested are able to be undertaken with a small amount of money (if any) and in a short space of time. Please note – there is a separate ward audit module for rooms and bed bays that is more comprehensive and suggests interventions that require a larger budget and a longer timeframe. Neither are intended for major refurbishments or new builds.

You may use this audit module on its own or as part of an audit of other parts of the ward.

This audit module contains 16 questions and will take approximately 15 – 20 minutes to complete. It contains questions about orientation, safety and comfort.

Start the rooms and bed bays audit.

Bathrooms

This audit module is designed to look at bathrooms in a ward. It can be used for bathrooms with both a toilet and shower, or one or the other.

The audit module is designed to be used when you have a limited budget and short timeframe. The interventions suggested are able to be undertaken with a small amount of money (if any) and in a short space of time. Please note - there is a separate bathroom audit module that is more comprehensive and suggests interventions that require a larger budget and a longer timeframe. Neither are intended for major refurbishments or new builds.

You may use this audit module on its own or as part of an audit of other parts of the ward.

This audit module contains 16 questions and will take approximately 15-20 minutes to complete all sections. It contains 7 general questions, plus an additional 5 questions for a toilet and additional 4 questions for a shower.

Start the bathroom audit.

Communal spaces

This audit module is designed to look at the communal spaces of a ward - the ward entrance, hallway areas, any shared spaces and wayfinding around the ward.

Some suggestions would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of a broader audit of other parts of the ward.

This audit module contains 16 questions and will take approximately 20-30 minutes to complete.

Start the communal spaces audit.

Lighting, signage and wayfinding

This audit module is designed to audit ward lighting, signage and wayfinding.

Wayfinding refers to all the ways in which people orientate themselves in a space and navigate their way from place to place. Older people need more wayfinding aids to assist orientation in a space and they need to be more obvious.

The audit module is designed to be used when you have a limited budget and short timeframe. Interventions suggested are able to be undertaken with a small amount of money (if any) and in a short space of time. Please note – there is a separate ward audit module for lighting, signage and wayfinding that is more comprehensive and suggests interventions that require a larger budget and a longer timeframe. Neither are intended for major refurbishments or new builds.

There is a separate audit module available for wayfinding in the ‘Facility audits’ section. You may also find some questions about lighting, signage and wayfinding in the other facility audit modules and the module ‘On the ward - communal spaces’.

You may utilise this audit module on its own or as part of a broader audit of other parts of the ward.

This audit module contains 12 questions and will take approximately 15 – 20 minutes to complete.

Start the wayfinding audit.

This section of the Hospital Environmental Audit Tool (HEAT) contains modules that look at how the environment in the ward spaces of a hospital meet older people’s needs and enable them to participate in their care.

There are five modules in this section:

• Rooms and bed bays
• Bathroom
• Communal spaces
• Lighting, signage and wayfinding
• Furniture, equipment and handrails

Most suggestions arising from these audits would take some budget and/or timeframe to implement. Several modules have a version that contains ideas that can be implemented with little or no budget and a short timeframe. These can be found in the section: On the ward - limited resources.

The modules in this section are each expected to take between 20 minutes and 30 minutes to complete. The audit modules may be completed individually or as part of a broader audit of the ward or other parts of the facility. The modules are not designed to be used for major refurbishments or new builds.

Rooms and bed bays

This audit module is designed to look at patient rooms or bed bays.

The audit module is designed to be used when you have some resources available. Most suggestions would take some budget and/or timeframe to implement. Please note – there is a separate rooms/bed bays audit module designed to be used when you have a small budget and short timeframe. Neither are intended for major refurbishments or new builds.

You may use this audit module on its own or as part of an audit of other parts of the ward.

This audit module contains 24 questions and will take approximately 25 – 30 minutes to complete. It contains questions about orientation, safety and comfort.

Start the rooms and bed bays audit.

Bathroom

This audit module is designed to look at bathrooms in a ward. It can be used for bathrooms with both a toilet and shower, or one of the other.

The audit module is designed to be used when you have some budget and timeframe. Most suggestions would take some budget and/or timeframe to implement. Please note – there is a separate bathroom audit module designed to be used when you have a small budget and short timeframe. Neither are intended for major refurbishments or new builds.

You may use this audit module on its own or as part of an audit of other parts of the ward.

This audit module contains 26 questions and will take approximately 25-30 minutes to complete all sections. It contains 14 general questions, plus an additional 6 questions for a toilet and additional 6 questions for a shower.

Start the bathroom audit.

Communal spaces

This audit module is designed to look at the communal spaces of a ward - the ward entrance, hallway areas, any shared spaces and wayfinding around the ward.

Some suggestions would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of a broader audit of other parts of the ward.

This audit module contains 16 questions and will take approximately 20-30 minutes to complete.

Start the communal spaces audit.

Lighting, signage and wayfinding

This audit module is designed to look at lighting, signage and wayfinding in a ward.

Wayfinding refers to all the ways in which people orientate themselves in a space and navigate their way from place to place. Older people need more wayfinding aids to assist orientation in a space and they need to be more obvious.

The audit module is designed to be used when you have some resources available. Most suggestions would take some budget and/or timeframe to implement. Please note – there is a separate lighting, signage and wayfinding audit module designed to be used when you have a small budget and short timeframe. Neither are intended for major refurbishments or new builds.

There are separate audit modules available for wayfinding throughout the whole hospital facility. You may also find some questions regarding signage and wayfinding in the ward module on communal spaces.

You may use this audit module on its own or as part of a broader audit of other parts of the ward or hospital.

This audit module contains 19 questions. It will take approximately 20 - 30 minutes to complete.

Start the wayfinding audit.

Furniture, equipment and handrails

This audit is designed to look at furniture, equipment and handrails in a ward area.

The audit is designed to be used when you have some resources available. Most suggestions would take some budget and/or timeframe to implement. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of an audit of other parts of the ward.

This audit contains 16 questions and will take approximately 20-25 minutes to complete.

Start the furniture, equipment and handrails audit.

This section of the Hospital Environment Audit Tool (HEAT) contains five modules:

• Model of care
• Food and mealtimes
• Equipment maintenance
• Sensory and thermal environment
• Cleaning

These modules consider how systems, policies, procedures and processes in a hospital setting can be built upon to ensure the environment supports the care of older people and enables them to participate in their care.

The modules in this section are designed to take from 15 minutes to 30 minutes to complete. The audit modules may be completed individually or as part of a broader audit of the facility. Some questions in these audit modules may need to be checked with other staff or departments in your facility.

Your facility may have some services provided by external contractors, for example cleaning, and this may mean that your ability to alter policies and procedures may be limited or indirect. In these case, you are still encouraged to undertake the audits and consider way you might implement any suggested changes.

Model of care

This audit module is designed to be used when you want to determine how your systems, policies, procedures and processes support best practice in the care of older people.

It looks at how the policies and procedures regarding your ward’s model of care optimise an older patient’s participation in their care and encourage their family and carer to be included as part of the care team.

You may use this audit module on its own or as part of an audit of other aspects of policy and procedure, or of the physical space.

We recommend that this audit module be used in conjunction with the ‘Bedside orientation’ audit module. The ‘Bedside orientation’ audit module is designed to be used with every patient, on admission or after a transfer. Consider incorporating the use of the ‘Bedside orientation’ audit module into your hospital or ward policies and procedures.

This audit module contains 15 questions and will take approximately 20-30 minutes to complete.

Start the model of care audit.

Food and mealtimes

This audit module is designed to be used when you want to determine how your systems, policies, procedures and processes support the provision of food and drink during and between mealtimes.

It also looks at how the policies and procedures regarding your ward’s day to day operation enable an older patient’s participation in their care and encourage their family and carer to be included as part of the care team.

You may use this audit module on its own or as part of an audit of other aspects of policy and procedure, or of the physical space.

This audit module contains 12 questions and will take approximately 15-20 minutes to complete.

Start the food and mealtimes audit.

Equipment maintenance

This audit module is designed to be used when you want to determine how your systems, procedures and processes support the maintenance of equipment.

It looks at how the policies and procedures regarding your ward’s equipment maintenance schedule enables an older patient’s participation in their care.

You may use this audit module on its own or as part of an audit of other aspects of policy and procedure, or of the physical space.

This audit module contains 6 questions and will take approximately 20-30 minutes to complete.

Start the equipment maintenance audit.

Sensory and thermal environment

This audit module is designed to be used when you want to determine how your systems, policies, procedures and processes can help optimise the sensory and thermal environment experienced by patients.

It looks at how light, noise, smells, textures and temperature influence an older patient’s participation in their care.

You may use this audit module on its own or as part of an audit of other aspects of policy and procedure, or of the physical space.

This audit module contains 11 questions and will take approximately 20-30 minutes to complete.

Start the sensory and thermal environment audit.

Cleaning

This audit module is designed to be used when you want to determine how your systems, policies, procedures and processes support the maintenance of a clean environment.

It looks at how the policies and procedures regarding your ward’s cleaning schedule optimise an older patient’s care, noting that cleaning may be a service that is outsourced by the health service, therefore the ability to alter cleaning policies and procedures may be indirect.

You may use this audit module on its own or as part of an audit of other aspects of policy and procedure, or of the physical space.

This audit module contains 8 questions and will take approximately 20-30 minutes to complete.

Start the cleaning audit.

This section of the Hospital Environment Audit Tool (HEAT) contains modules that consider how the general areas of the hospital environment support the needs of older people and increase their participation in their care.

There are five modules in this section:

• External areas and parking
• Entrance, foyer and reception
• Stairs, lifts and paths - internal areas
• Outpatient and waiting areas
• Wayfinding, signage and use of colour

Some suggestions for improvement would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

The modules in this section are designed to take from 15 minutes to 35 minutes to complete. You may use these audit modules individually or as part of a broader audit of other parts of the facility. The modules are not designed to be used for major refurbishments or new builds.

External areas and parking

This audit module is designed to look at the external areas of a facility, including parking areas, external pathways and garden areas.

Some suggestions for improvement would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of a broader audit of other parts of the facility. We suggest completing it with the other facility audits to enhance your understanding of how to improve the environment for older people.

This audit module contains 17 questions and will take approximately 15-20 minutes to complete.

Start the external areas and parking audit

Entrance foyer and reception

This audit module is designed to look at the entrance, foyer and reception areas of a facility.

Some suggestions for improvement would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of a broader audit of other parts of the facility. We suggest completing it with the other facility audits to enhance your understanding of how to improve the environment for older people.

This audit module contains 15 questions and will take approximately 15-20 minutes to complete.

Start the entrance, foyer and reception area audit

Outpatient and waiting areas

This audit module is designed to look at outpatient and other designated patient waiting areas.

Some suggestions for improvement would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of a broader audit of other parts of the facility. We suggest completing it with the other facility audits to enhance your understanding of how to improve the environment for older people.

This audit module contains 13 questions and will take approximately 15-20 minutes to complete.

Start the outpatient and waiting areas audit

Stairs, lifts and paths - internal areas

This audit module is designed to assess internal stairs, lifts, paths and the ramps and handrails used to facilitate access to general or public areas of a facility.

Some suggestions for improvement would take some budget and/or timeframe to implement, while some may be able to be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of a broader audit of other parts of the facility. We suggest completing it with the other facility audits to enhance your understanding of how to improve the environment for older people.

This audit module contains 23 questions and will take approximately 25-35 minutes to complete all sections. It contains 11 general questions on paths, handrails and ramps, plus an additional 8 questions on lifts and an additional 4 questions on stairs.

Start the stairs, lifts and paths - internal areas audit

Wayfinding, signage and use of colour

This audit module is designed to look at wayfinding in the general or public areas of a facility.

Wayfinding refers to all the ways in which people orientate themselves in a space and navigate their way from place to place. Older people need more wayfinding aids to assist orientation in a space and these need to be more obvious.

Some suggestions for improvement would take some budget and/or timeframe to implement, while others can be changed quickly and with minimal budget. It is not intended for major refurbishments or new builds.

You may use this audit module on its own or as part of a broader audit of other parts of the facility. We suggest completing it with the other facility audits to enhance your understanding of how to improve the environment for older people.

This audit module contains 21 questions and will take approximately 25-30 minutes to complete.

Start the wayfinding, signage and use of colour audit

This section of the Hospital Environment Audit Tool (HEAT) contains the module: Patient bedside orientation.

It is designed as a checklist of key questions that will assist clinicians to introduce patients to the hospital environment and orientate them in the ward and is designed to be used with every patient, on admission or after a transfer.

It looks at the immediate bedside environment and orientation to the ward.

This audit module contains 22 questions and will take approximately 5-10 minutes to complete.

Start the patient bedside orientation audit.

These topics provide information and recommend actions that we and our organisations can take to improve care for older patients.

Person-centred practice puts the person at the centre of everything we do.

It recognises that every patient is a unique and complex person. It respects and responds to their needs, preferences and values and the knowledge they bring about their health and healthcare needs with the aim of delivering individualised care that is holistic.

Person-centred practice can minimise the functional decline of older people in hospital and help us tailor care to meet each person’s needs. It can result in decreased mortality, readmission rates and healthcare-acquired infections; improved functional status and increased patient and carer satisfaction.¹

For this reason person centred practice is integral to meeting many of the actions in the National Safety and Quality Health Standards, especially Comprehensive Care and Partnering with Consumers.

This topic gives an overview of person-centred practice and recommends actions that we and our organisations can take, in addition to health service policy and procedures, to provide quality person-centred care to our older patients.

Person-centred practice and functional decline

Person-centred practice is important because it can improve experiences and outcomes for our patients and improves our own satisfaction and morale.

• Person-centred practice is crucial in reducing functional decline in older people in hospital, for example:
  • if we know what types of foods and drink a patient prefers then we can look at how they access these while in our care so they are less likely to lose weight or become dehydrated in hospital
  • if we know that a patient likes to take a walk every day we should encourage them to keep active while in hospital so they can continue this when they go home
  • if we listen to the family’s concerns about a change in a patient’s level of alertness, we can investigate delirium
  • if we understand how a patient usually takes their medication, we can look to alter how we might administer them.
• Person-centred practice can mean decreased mortality, readmission rates and healthcare-acquired infections; improved functional status; a shorter length of stay in hospital; and increased patient and carer satisfaction.¹
• Person-centred practice improves the patient’s experience, reduces their anxiety and enhances trust – all important in an unfamiliar hospital environment.
• Person-centred practice leads to better outcomes through partnerships and shared decision-making.

‘When you are caring for somebody who is acutely unwell, it is hard to sometimes look at them as a person and not just as a bunch of observations’ – Luke, graduate nurse²

Implementing person-centred practice

Person-centred practice is a natural part of our day-to-day work

We can make person-centred practice a part of our work through our everyday interactions with patients and their family and carers, for example:

• smile and introduce ourselves
• wear a name tag that people can see and read
• explain your role to the patient
• ask the patient how they are feeling today - both physically and emotionally
• see the patient as a person who has a life outside hospital
• treat the patient as an equal partner
• listen to the patient and respect the knowledge they bring about their own health
• listen to their family and carers
• acknowledge that being in hospital can be a frightening and uncertain time for patients and their families
• acknowledge that feeling lonely or isolated in hospital can be a common experience
• make sure the patient has all the information they need to make informed choices.

‘ find that the families and the carers that come along to us, with the patients, have a wealth of knowledge. When the patients can’t tell us what they need, their carers often can.
- Dora, clinical resource nurse²

Person-centred practice must be embedded at an organisational level

Person-centred practice should be embedded in our organisations.³ To achieve this, ‘senior leaders need to unite them around a common sense of common purpose’.⁴

Embedding person-centred practice

The World Health Organization’s framework for creating age friendly communities urges organisations like hospitals to consult with ‘older people on ways to serve them better’ as it ‘contributes to empowering older people and fostering age-friendly respect and social inclusion’.⁴

Ask how your organisation is embedding person-centred care in day-to-day practice:

• Are there policies and procedures for involving patients and carers in their own care?
• Is training provided to staff on person-centred care?
• Do leaders explain and promote the importance of person-centred practice?
• Do we seek and use patients’ and carers’ feedback to improve our practice?
• Do we engage patients in staff education programs?
• Do we have systems to collect and report patient experience data?
• Are person-centred principles part of core business and embedded in organisational and employment documentation and performance review processes?
• Do we have a culture of reflective practice, continuous improvement and lifelong learning?

Achieving person-centred practice

Many Victorian health services are surveying their patients and families to improve their understanding of their patient’s needs and adapt their service to these needs.

As part of the Victorian Department of Health’s Improving care for older people initiative, health services across Victoria undertook to implement person-centred practice in settings involving older people. Some examples include:

• Alfred Health has a Patients Come First plan and has developed an organisation-wide patient experience survey, which has been translated into five different languages. In collaboration with the Department of Health, Alfred Health also produced a DVD resource called Best Care for older people: the patient experience
• Eastern Health implemented performance monitoring strategies including mystery shopper observations and patient interview, leadership walk-rounds, patient experience trackers which capture real-time information, and monthly patient experience surveys.
• Melbourne Health conducted a ‘Board to Bedside Consultation’ in 2012, which surveyed more than 300 staff and consumers about what matters to them when receiving healthcare. It also developed an audiovisual resource, Lola’s Story, which emphasises patient experience and has been used to open executive/board meetings. Melbourne Health also runs tailored sessions on person-centred practice.
• Peninsula Health has embedded person-centred practice principles in employment position descriptions; they are also a formal component of orientation.
• Western District Health Service has developed and implemented a Partnering with Consumers policy, and principles of person-centred care are included in orientation for new staff. Fifty staff have attended education sessions on person-centred care, and older people are represented on the Consumer Advisory Committee.
• Barwon Health has introduced electronic bedside assessments on tablets to increase the time nursing staff spend with their patients and their families when gathering information and developing care plans and facilitate shared decision making.

Measuring person centred practice

Measuring person-centred practice is helpful in assessing services, the outcomes of particular initiatives and whether or not people’s needs are being met¹. It is important in improving the patient experience and reducing the risk of functional decline, creating a culture of constant learning, keeping services accountable, encouraging cultural change and boosting morale.

However, before measuring person-centred practice, we need to know what we are measuring. Do we want to understand what person-centred care means to different people, the type of care patients expect or experience, or the impact?

The tool we choose will depend on whether we are measuring definitions, preferences, experiences or outcomes⁵.

There are three common methods used to measure person-centred practice:

• surveys and interviews with patients and carers
• surveys and interviews with health professionals
• observation of practice.⁵

Other methods include focus groups and reviewing patient notes⁵.

A variety of tools have been used in the field, but there is no one specific resource that can evaluate all aspects of person-centred practice.

Person centred practice and discharge planning

The chronic nature of many of the conditions our older patients experience means that we must encourage them to participate in their care in hospital and involve them and their families and carers, as appropriate, in the process of discharge planning.

Patients and their families and carers play a critical role in keeping themselves well once they are discharged. Consider how aspects of each person's unique biological and psychosocial needs interact with their environment. By understanding their particular values, preferences and social supports we can shape meaningful discharge plans, encourage participation in social activities of interest and equip them with realistic strategies they can implement once discharged to keep well. Each of the clinical topics on this site emphasises the role of partnership in this process.

Older people have a higher risk of functional decline and preventable harm during a hospital stay than younger people. This is due to changing physiology and the presence of multiple, complex and often chronic problems.

Clinicians often focus on an older person’s acute health problems that led to the hospital admission. We may neglect to prioritise issues such as nutrition and hydration, maintaining mobility, providing good pressure care and the psychosocial and emotional needs of the person - all of which can impact negatively on an older person’s outcomes.

The issues of social isolation and loneliness, which are distinct but related concepts, are gaining increasing attention in Australia and overseas as they can have a significant impact on an individual’s health. Identifying those at risk of these issues and developing a person-centred plan to actively engage the older person, encouraging them to participate in their care in hospital and after their discharge, is integral to good care.

Providing the best care for older people rarely requires a single intervention. However, the complexity of integrating multiple assessments, managing best practice interventions for different risks and integrating patient preferences is not a straightforward task.

Screening and assessment on admission and throughout an older person’s hospital stay can help us to quickly identify and respond to actual or potential risks to patient safety and wellbeing.

This topic provides an overview of some components of screening and assessment. It is to be read in conjunction with the accompanying clinical topics and with health service policy and procedures.

Assessment and ageing

Screening is the process of identifying risks that indicate a patient would benefit from further or more detailed assessment.

Assessment is the process of collecting information to identify the exact nature of a patient’s problems and protective factors (medical, physical, social and psychological). The information collected during an assessment should be analysed, interpreted, verified and communicated. It is used to inform the development of a prioritised, individualised person-centred care plan that includes evidence-based responses to treat a problem and prevent harm.

Screening and assessment are more than completing forms. As clinicians, we draw on our clinical reasoning skills, work with our team, and with the older person and their family, to establish their needs, wants and status.

Screening and assessment of our older patients, on admission and throughout their hospital stay, can identify concerns and changes, monitor progress and inform safe, effective and appropriate care.

Screening and assessment of older patients

Screening and assessment for older people is different to screening and assessment of younger people because older people often present to hospital with non-specific symptoms, and those symptoms may indicate different concerns and mask other issues that occur with ageing. For example, the symptoms of a urinary tract infection in a younger person may be frequent urination, pain from bladder spasms, blood in the urine, and fever. In an older person, the first sign of a urinary tract infection may be confusion or a fall as the other symptoms can be masked by changes that occur with ageing.¹

Normal age-related changes

Older age provides a challenge for patients and clinicians to identify ‘normal’ from ‘abnormal’. While everyone is different and therefore ages in a different way and at a different rate, ‘normal’ ageing is generally accompanied by a decline in many homeostatic and metabolic processes.

Normal ageing can cause changes that require interventions to prevent further deterioration and to assist the person maintain their wellness. If illness does occur, the older person often has less reserve and less capacity to recover than younger people.

Changes in physical, cognitive and mental function are ‘normal’ ageing. Things to consider for older people in hospital include:

• Decreased muscle strength and aerobic capacity
• Decreased bone density and joint flexibility
• Vasomotor instability
• Skin thins and loses elasticity
• Changes in nutritional requirements and loss of appetite
• Changes in bladder and bowel function
• Decreased glucose tolerance
• Reduction in sensory perception
• Memory loss and reduced cognitive awareness
• Changes in mental health and wellbeing
• Altered sexual functioning.

Losses, such as bereavement and changes in function, are common experiences for older people and can be risk factors for loneliness and social isolation. These can in turn increase risk of various health problems.² Older patients are also more likely to have multiple comorbidities which may increase their risk of social isolation.³

It is up to us to be curious, determine what matters to our patients, think about the information we collect and consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.

Screening

Screening identifies people or conditions that would benefit from further assessment. The aim is to identify concerns early and avoid further problems in hospital.

Screening usually involves using a prompt to identify various ‘red flags’ or risks associated with the patient. These can include medical, functional and psychosocial risk factors such as:

• being older than 70 and living alone. This includes an increased risk of isolation or loneliness that negatively affects a person's physical and mental health, and increases the risk of mortality⁴
• a diagnosis of dementia or displaying signs of cognitive impairment
• a recent stay in hospital
• polypharmacy, a history of falls, mobility problems and incontinence
• a recent unexplained weight loss
• a functional limitation with personal care, domestic and community participation
• relying on a significant amount of community service support.

Once we have identified any of the above red flags, we can use targeted screening tools as outlined in the individual topics in this section. Trained staff can conduct screening at any time during a person’s time in hospital. Ideally screening is conducted on admission and regularly throughout the episode of care. Early screening is important in establishing a baseline for monitoring an older person’s level of function and identifying changes in health.

Screening can identify increased risk for functional decline and in many cases trigger an immediate response to mitigate risk until further assessment is possible.

Examples of screening tools

Identification of Seniors at Risk Screening Tool (ISAR)⁶ - a six item screening tool for seniors in the emergency department.

Fulmer SPICES: An Overall Assessment Tool for Older Adults - SPICES is an alert system that obtains information to help prevent health deterioration in the older adult patient.

UCLA Loneliness Scale - a set of three questions currently recommended in the International Consortium for Health Outcome Measures (ICHOM) to measure if an older person is feeling lonely

Assessment process

Assessment tools cannot substitute for good clinical skills and judgements. As clinicians we need to be aware that assessment tools can tell us more than just a score.

Assessment involves collecting information that gets to know the patient in detail, evaluates their risks and the nature of problems to be identified.

Assessment should integrate all the relevant issues. It should explore the medical, physiological, social and psychological function of the older person.

The assessment process encourages us to be curious and to consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can ultimately involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.

Assessment supports us to:

• treat the condition that caused the admission (such as shortness of breath)
• detect and quantify additional conditions or psychosocial issues that contribute to or complicate the admission and respond to them as able both during the admission and when planning for discharge. For example
  • depression - consider if the person needs a medical review
  • poor nutrition - consider what can be done to optimise the person’s intake
  • social isolation, or risk of loneliness - consider how you can encourage the person to participate in their care by harnessing their personal and social connections, and consider linking them to supports that are meaningful to them on discharge
• use strategies to prevent conditions that often emerge during hospital stays but can be avoided (such as delirium and falls).

We can gather information as part of the assessment process from multiple sources, and these may vary at the stages of a hospital admission.

The four main sources of information are:

1. Older people themselves - self report.
2. Others who know the older person well - informant report.
3. Observation of the person undertaking various activities - direct observation.
4. Various secondary written or verbal sources - including hospital records, medical reports, investigation results, communication from community care providers.

Unless there are reasons to suspect otherwise the older person is considered the best source of information about their own health¹. Direct observation is the best source of information about physical function; however, we should consider how the environment or setting where observations take place may impact on the older person’s performance.

Assessment tools

Assessment tools can be focussed on exploring one particular condition such as pain, pressure injury or nutrition. They can also be more comprehensive and encompass a broader focus beyond one particular issue. Examples of these types of tools include:

• InterRAI Comprehensive Assessment Tool: Acute
• Systematic Evaluation and Intervention for Seniors At Risk (SEISAR) - a short, standardised, comprehensive tool for the evaluation of active geriatric problems in seniors in the emergency department.

The assessment tool or scale should enable collection of useful patient data that supports interpretation of the holistic health status, identifies patient needs, and informs care planning and interventions to restore health and wellbeing.

Selecting an assessment tool

Consider the following factors when selecting an assessment tool include:

• A standardised tool can reduce variation in practices and interpretation of findings and allow comparison across assessments.
• A validated assessment tool ensures the right data is captured to evaluate the patient and their progress.
• Is a specific tools mandated for specific circumstances or settings? See the individual topics for examples.
• Does the tool cater for cultural or language differences?
• Is the tool appropriate for the physiology of ageing?

The format used will also depend on the discipline, skill and expertise of the clinician, the context and setting of the assessment, the time available and the number of assessors involved. The assessment can be:

• unstructured – if the professional expertise of the assessor is high
• semi-structured – incorporates specific tools and checklists
• structured and standardised – using global assessment instruments.

Comprehensive Geriatric Assessment

There is no gold standard for assessment of older people; however, a Comprehensive Geriatric Assessment is highly recommended to understand the multidimensional complex care needs of frail older people and to determine both short and long term care needs.

A Comprehensive Geriatric Assessment can be undertaken by any member of the interdisciplinary healthcare team who has the required knowledge and skills. Multiple team members with specific skills may need to be involved depending on the patient’s needs.

Ideally, the assessment should be completed within the patient’s first 24 hours in hospital and communicated to all team members, the patient and informal carers.

Conducting assessments

We also need to be aware of the following when conducting assessments of older people:

• At all times, it is vital that we maintain an understanding the older person’s perspective.
• In acute hospital settings, circumstances may mean older people are not able or willing to be actively involved when health professionals assess them.
• Older people may take more time to complete tools than younger people, so allow for rests during formal assessments.
• Ensure that any needs for communication assistances are met. These may include use of interpreters, ensuring the older person is wearing their glasses and/or hearing aids if they are used routinely.
• Do not assume older people know why they are being assessed. Explain why certain questions or tests are being undertaken.
• Establish cognitive status as early as possible in an assessment. Do not assume older people are able to hear, comprehend what is said or are capable of accurate, intelligible responses (for example if they are acutely unwell).
• Note that appearing ‘flat’, minimal eye contact and being non-committal responses may indicate depressive symptoms are present. Depressed older people can give the appearance of being cognitively impaired.
• Consider the need for an interpreter for those with limited English proficiency. The interpreter can also assist with cultural care delivery.
• Consider specific cultural issues and seek assistance necessary from cultural liaison officers or Indigenous health workers.

Applying clinical skills to assessment

Good clinical skills, observation, listening, interpreting and clinical judgement are all vital in decision-making.

When we assess older patients, we use tools and draw on our clinical reasoning skills. The reasoning cycle⁷ sets out the elements of effective clinical decision-making:

• Consider the patient situation
• Collect cues and information – through observation, questions
• Process the information – what does it mean?
• Identify problems and issues – what does the information indicate?
• Establish goals – what actions need to be taken?
• Take actions
• Evaluate outcomes
• Reflect on process and new learning.

Responding to assessment

The result of the screening and assessment process is the development and implementation of a care plan in conjunction with the patient and their family.

The aim of a care plan is to meet the individual patient’s needs and goals. When compiling a care plan, take the time to get to know what matters to your patient and what they would like to achieve. Maximise their opportunities to participate in their care, tailor simple evidence based strategies to their needs and encourage them to play an active role in maintaining their health. Revisit and update the care plan following reviews of progress or changes in the patient’s status.

Interventions identified in a care plan can involve:

• curative care - to improve specific conditions
• comfort care - to improve quality of life when an older person is receiving palliative care
• preventive strategies to minimise risk of functional decline such as pressure care, nutrition and hydration, regular mobilisation, maintaining continence, pain management, orientation and cognitive functioning, and maintaining social connections both during and after a stay in hospital.

Once we have introduced the interventions, we need to regularly assess the older person’s ability to participate in the implementation of the plan and adjust the interventions as required.

By communicating effectively with patients we can find out what matters to them and tailor care to meet their needs and wishes.

Communication is a ‘procedure’ in good clinical care¹ that we can use to improve our patients’ experience and their participation in care. This will help minimise their risks of functional decline in hospital.

Like wound care or surgical procedures, we need to learn and practise good clinical communication skills.¹

Every interaction we have with our patients, their family and carers, and our colleagues requires us to draw on our communication skills. This includes screening, assessing, developing and delivering intervention and discharge plans, and providing safe and effective clinical handover.

This topic gives an overview of communication and recommends actions that we and our organisations can take, in addition to health service policy and procedures, to communicate effectively with our older patients.

Purpose

During their stay in hospital, people often require care from many clinicians; they may move wards and their care plans may change. This can cause stress, particularly in older patients. We can use communication to reassure patients, alleviate their fears and develop a partnership to reach the best possible outcomes^.

We can think of communication as a ‘procedure’² that we use to encourage patients to participate in their care. We know from the feedback received by hospitals, that communication and the quality of our interactions are very important to our patients. Older people remember how we made them feel during their hospital stay and not necessarily what we did. We also know that failures of communication and teamwork can play a role in avoidable adverse events in hospitals.

Elements of communication

Communication is more than information exchange, it includes the subtle ways we interact and how we use and respond to verbal and non-verbal cues^2,3. Often, communication is about being curious, observing your patient and, most importantly, listening and responding to their concerns.

Communication is the interplay of many elements including:

• language and speech
• eye contact
• body language, gestures and postures
• facial expressions
• active listening
• empathy
• touch
• distance from the person
• voice quality, rate, pitch, volume
• communication tools and frameworks
• written aids
• communication aids (for example, interpreters, hearing aids, glasses)
• identifiers such as red trays, the cognitive identifier, falls risk signs to indicate a prevention plan is in place to staff and patients
• health system design
• health system roles, hierarchies and teamwork.

Effective use of these elements encourages older people and their families and carers to participate in their care.

Communicating effectively

Effective clinical communication is about building a relationship, providing and sharing information, and sharing decision-making. Here are some things we can do to communicate effectively with our patients.

Communicating with team members

As clinicians we communicate with other clinicians in person, in the patient record, in handover documentation and in other charts. We also have discussions during ward rounds, in meetings with treating team members, at handovers, and in informal conversations. All of these tasks require skilful clinical communication⁷.

Teamwork impacts on patient wellbeing

A supportive health service team culture has been associated with higher functional wellbeing for patients post discharge².

Communication is a critical element in effective teamwork. A well-functioning team fosters an environment where we can ask questions and be ‘respectfully assertive’ with other team members, no matter the role or position, whenever a patient appears at risk^3,4. Good team member communication processes support clinicians, translating into better individual interactions.⁵

Effective teamwork does not just happen; it requires skill development, practice and a supportive environment. Excellent individual skills do not guarantee effective team performance in delivering care^4,6.

Team meetings

Team meetings can be used effectively to organise and learn⁶. Even brief one to five minute team meetings at handovers (and within shifts if required) to assess and organise are important⁴.

Items to address in team meetings to improve patient care include:

• identifying team members and leaders
• establishing or re-establishing situational awareness
• assigning or re-assigning responsibilities and tasks
• making team decisions
• discussing problems
• reviewing lessons we have learned.^{4, 6}

Teamwork actions

Individual teamwork actions are the most common teamwork activities. Failures in four individual teamwork actions have been most implicated in medical errors⁴. The following are the four clinical teamwork skills that most reduce medical errors:

1. Know what protocol or plan is being used. This should be clear to everyone on your team.
2. Advocate for your patients. Assert your opinion or a correction to team members if you believe a patient is at risk. Leaders have a responsibility to create an environment where this is possible.
3. Understand the care plan and prioritise tasks for your patients accordingly.
4. Cross-monitor the actions of team members for simple errors and act to correct if required. Leaders should create an environment where this is an acceptable practice.

Documentation

Documentation helps us monitor interventions to minimise functional decline in our patients and communicate with the team.

In addition to following local documentation policy and procedures, consider the following actions to provide the information needed by the team⁷.

Record observations and actions accurately; clearly state the facts, what you saw, heard, smelt, felt and did.

• Record enough information so that another clinician can continue care, include what preceded an event or change in care if that information is relevant to continuing care (for example, if a code grey is called for an older person with dementia, the events preceding the code grey are important for other clinicians to know how to deliver safe and effective person-centred care).
• Document information about medications completely. Write medication names in full.
• Document every assessment while the older person is in your care. This establishes a baseline, a record and a timeline of the person’s health.
• Document as soon as possible to ensure important details are recorded and facts are not lost or shaded by subsequent events. Timely documentation also aids in treatment.

Communication and ageing

Some older people have conditions that can impair their capacity to communicate, for example, stroke, COPD, dementia and hearing impairments.

There are also less obvious symptoms and conditions that can affect communication with our patients particularly when they are unwell. These include:

• pain
• frailty
• mobility impairments
• self-care impairments
• under-nutrition
• dehydration
• delirium
• depression
• low mood
• anxiety
• sleep deprivation
• medication effects and side-effects
• polypharmacy
• hearing impairments
• vision impairments
• acquired brain injury.

We can use our communication skills to assess what is affecting the person’s ability to receive or give information and to show that we are interested and care.

‘The people who do come in and treat you as a person, with a family, with a history, with… a life. You respond to so much better. There’s… a link, a communication that takes place.’ (patient)

We can also use communication skills to solve problems by asking the patient about their needs, concerns and their condition.

There is increasing interest in the role health literacy plays in determining outcomes for older patients. Health literacy is a person’s ability to seek, understand and use health information and services¹.

‘...he said you got SOBOE…I had to go look it up to see what…he was talking about.’ (patient)

Only 40 per cent of adults can understand health messages in the form they are usually presented². Questions we can ask to help assess our patients’ health literacy include:

• Can you tell me why you are in hospital?
• Can you tell me about what medications you are taking and why?
• Is this an accurate understanding? If not, what appears to be the cause of the misunderstanding? (for example, insufficient explanation/language/cognition)

If we understand our patients’ health literacy and our own abilities to meet their needs we can better tailor our communication and our care to meet their needs.

Communicating with older people who have diverse needs

Older people with specific communication needs have an increased risk of experiencing functional decline in hospital. Identifying any functional or psychosocial barriers to communicating in hospital and responding to these will enable the older person to participate in their care, both in hospital and on discharge.

Vision and hearing loss

It is common for older patients to have vision and hearing impairments. These can be challenging during an inpatient stay and can limit a person’s confidence to participate in their care and ability to follow instructions, and may contribute to social withdraw.³ To reduce the risk of this happening:

• Encourage the older person to wear their prescribed glasses in hospital.
• Encourage the older person to wear their prescribed hearing aids in hospital. Check the hearing aids are on and the batteries are working if the older person is still having trouble hearing.
• Ensure your patients’ glasses and hearing aids are within their reach if they choose to remove them.
• Consider encouraging the older person to have their vision or hearing assessed if communication is difficult.

Speech impairment

Speech impairments range from mild (where there is only an occasional problem) to severe (when a person may have lost all ability to use and/or understand speech).

• If an older person is unable to use speech as an effective form of communication, work with them and their family and carers to use an alternative method of communication.
• Refer to speech pathology as appropriate.
• Use appropriate communication aids and written aids.
• Ensure the older person is given adequate time to communicate.

Cognitive impairments

Older people with cognitive impairments can communicate their wants and needs.

• Be positive in your approach to communication.⁴
• Greet the older person you are caring for by name, address and speak to them; do not ignore or talk over them.
• Include the older person in their care to the extent they are able and want to be involved.
• Allow time for the older person to express their needs.² Behaviours of concern are often expressions of unmet needs.
• Talk to family and carers; they often have valuable information about caring for an older person with a cognitive impairment.
• If the older person no longer has capacity to consent to medical treatment, identify and record the name and contact details of the Medical treatment decision maker⁵, the substitute decision-maker under the law. Shared decision-making about care will require effective communication with the Medical treatment decision maker.

They’ve got to listen to the family in that situation, and it’s very hard if they don’t, because you do know that person better than what they do, they’ve only met that person only just then.
Relative of a patient

Culturally and linguistically diverse communities

In Victoria, a significant number of older people who use hospital services are from culturally and linguistically diverse communities. Be aware that not having English as your first language can add an extra layer of complexity for an older person and their family, and may increase feelings of loneliness or isolation, both in and out of hospital.

• Ask your patient and their family and carers if they need an interpreter and, if so, organise this through your hospital’s interpreting services. Consider the older person’s and family’s wishes if there is a preference not to use an interpreter.⁶
• When selecting an interpreter, consider confidentiality, kinship and gender issues.⁶
• Focus on the older person’s strengths and wishes⁷. Be positive in your approach to communication.³
• While written aids that have been professionally translated might be helpful, be aware that literacy might be a barrier to use. Over-reliance on written materials should not replace individualised care.⁶
• Be aware that literacy might be a barrier to completing forms.
• Try to learn a few basic words in the language of your linguistically diverse patients.³
• Try to link together patients on the ward that speak the same language; for example, by sharing a room.
• Cue cards can be helpful, but should not be used in place of accredited interpreters. Cue cards can be used by our patients, families and carers to communicate simple needs such as hungry, thirsty, telephone. We can use the cards to communicate simple instructions or ideas.
• Connect older people to culturally specific and/or bilingual community services and clinicians, as appropriate.
• Be prepared to explore the cultural context of some symptoms and diseases. For example, in some cultures there is a stigma around dementia and depression and a patient may use a different term to describe their feelings, for example they may say they are 'heart sick'.
• Always check your understanding of what the older person has said.⁴
• Screening and assessment tools often have cultural biases and many ‘standard’ tools have not been validated in multicultural samples in Australian hospital. Seek specialist advice for appropriate use and interpretation of results.

Aboriginal and Torres Strait Islanders

In Australia, many Aboriginal and Torres Strait Islanders experience morbidities typically associated with advancing age, such as cardiovascular disease and dementia, up to 20 years earlier than non-Aboriginal people. Therefore, from the age of 45, functional decline in hospital is a concern for Aboriginal and Torres Strait Islanders.

Be mindful that Aboriginal and Torres Strait Islanders come from a variety of cultural and personal backgrounds.⁷

• Many Aboriginal and Torres Strait Islanders find institutions such as hospitals particularly daunting or frightening, and being in hospital may trigger feelings of loneliness and isolation from networks. Ask the person to identify strategies that might help them during their stay, and optimise their ability to retain social connections on discharge.
• To enable culturally safe care, identify with your patient and their family or carer if a cultural liaison officer is required and make a referral if needed.
• Communicate with your patient, their family and carers to identify if an interpreter is required and organise this through your hospital’s interpreting services.
• When selecting an interpreter consider confidentiality, kinship and gender issues⁶.
• While written aids that have been professionally translated might be helpful, be aware that literacy might be a barrier to use. Over-reliance on written materials should not replace individualised care.⁷
• Literacy might be a barrier to completing forms.
• Source information and advice from Aboriginal and Torres Strait Islander people and culturally specific organisations.
• Connect people to culturally specific and bilingual community services and clinicians, as appropriate.
• Communicate with your patient, their family and carers to build a picture of all family members and significant others. It is not always obvious who has final authority in relation to an Aboriginal or Torres Strait Islander’s health and wellbeing.⁸
• Be aware that an illness may be seen as affecting the entire family, in terms of origins, symptoms and management.⁸
• Screening and assessment tools often have cultural biases and many ‘standard’ tools have not been validated in multicultural samples in Australian hospitals. Seek specialist advice for appropriate use and interpretation of results.

Communication and discharge planning

The relationship between hospital care and ongoing community care within a complex health system can be difficult to understand and navigate for an older person, family and their carers. Discharge summaries should be clear and complete and promote continuity and quality of care in the community.¹ The older person and their family and carers, as appropriate, should understand the discharge summary and be provided with copies to keep, so they can refer to the summary and provide it to community services as required.

The older person should leave hospital knowing:

• their next contact with the health system (next appointment)
• their key contact within the health system (for example their GP) and how to contact them
• the medications and ongoing management or care they should be undertaking until the next appointment
• the medical, functional and psychosocial issues that were identified during the admission
• what to be aware of on discharge
• who to call if they need help or advice.

Psychosocial interventions can play a significant role in an older person’s recovery after discharge. If loneliness or social isolation has been identified as a risk factor, ensure you have identified meaningful activities for the person and refer them to appropriate and accessible resources and community programs.⁹

Shared decision-making between us as clinicians, the older person, family and carers (as appropriate), is imperative to effective discharge planning. One method that has been trialled in a Victorian health service to assist discharge communication is Care Transfer Video.¹⁰ Care Transfer Video involves videoing ward rounds before discharge so patients can take home the discussions on a USB stick to watch with their families, GPs and other services as appropriate for follow-up. CareTV helps patients to remember details from their admissions and the plans for their ongoing care.

Older people presenting to hospital with cognitive impairment are at greater risk of functional decline. Patients who are at risk of developing these problems during their admission are also vulnerable to functional decline. Identifying, investigating and responding to their needs is important to minimise this risk.

These topics provide information and recommend actions that we and our organisations can take to improve care for older patients.

Cognitive impairment screening

Cognitive screening, on admission to hospital and routinely throughout the stay, is important to rule out possible treatable causes. It provides a baseline to identify a decline in cognition that may be due to delirium; depression or dementia. An improvement in a person’s test scores, once treatment has been administered, can help to confirm a diagnosis of delirium.

The most commonly used cognitive assessment tools in the hospital setting are:

• the Standardised Mini Mental-State Examination (SMMSE)¹
• the Abbreviated Mental Test Score (AMTS)
• The Clock Drawing Test (CDT)

Two tools developed for use with people from culturally and linguistically diverse backgrounds are:

• Mini-Cog
• Rowland Universal Dementia Assessment Scale (RUDAS)

A tool developed specifically for indigenous Australians (remote and urban modified versions) is:

• Kimberley Indigenous Cognitive Assessment (KICA)

Informant-based questionnaires are completed by someone who knows the person being assessed well; they provide complementary information on a person’s cognitive status or can be used in situations where testing a person’s cognition is difficult due to illness, dysphasia or literacy deficit. They include:

• Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)

Complete cognitive screening using one of the tools above before administering the Confusion Assessment Method (CAM) to identify delirium.

Depression, dementia and delirium have some features in common. Depression and delirium, particularly hypoactive delirium, may present with apathy, withdrawal and tearfulness. Delirium occurs suddenly (over a matter of hours or days) and the symptoms tend to fluctuate throughout the day; depression describes a negative change in mood that has persisted for at least two weeks; and the onset of dementia is generally slow and insidious.

Differentiating depression from dementia and delirium requires knowing the characteristic features of each condition (see table below) and establishing the patient’s premorbid cognitive status and mood. This involves obtaining the patient’s history (from the patient or if cognitively impaired from an informant - family or carer or staff) and conducting a depression, cognitive and delirium screen.

Delays in investigating and treating underlying reasons for cognitive impairment, or initiating inappropriate treatment, can have serious consequences for an older person’s health and wellbeing whilst they are in hospital and on discharge.

Delirium must be differentiated from Dementia with Lewy Bodies

It is important to differentiate delirium from Dementia with Lewy Bodies (DLB). These conditions can appear identical, however, haloperidol, which may sometimes be used to manage delirium symptoms, can cause severe movement disturbances (such as spasms or rigidity) and can even be fatal to some patients with DLB. The presence of parkinsonism helps in differentiating DLB from delirium.¹

1. Gore, R.L., E.R. Vardy, and J.T. O'Brien, Delirium and dementia with Lewy bodies: distinct diagnoses or part of the same spectrum? J Newurol Neurosurg Psychiatry, 2014. 23.

“We must recognise and respond to delirium as we would any other medical emergency…[if we don’t] the outcome is as bad for older patients as if they experienced an acute myocardial infarct” (Geriatrician, Clinical Leadership Group on Care of Older People in Hospital)

Delirium is a serious condition where the person experiences a disturbance in attention, perception, awareness and cognition. Delirium may be caused by general medical conditions (for example, infections, hypoxia), certain medications, intoxicating substances or a combination of these.

Delirium develops quickly and symptoms fluctuate throughout the day. It usually lasts for a few days but may persist for weeks or even months in vulnerable older adults^1,2. Delirium may be the only sign of medical illness or a rapidly deteriorating patient.

Delirium can be hyperactive, hypoactive (‘quiet’ delirium) or mixed. Hyperactive delirium is characterised by increased motor activity, restlessness, agitation, aggression, wandering, hyper alertness, hallucinations and delusions, and inappropriate behaviour. Hypoactive delirium is characterised by reduced motor activity, lethargy, withdrawal, drowsiness and staring into space. It is the most common delirium in older people. ‘Mixed’ delirium is where people have features of hyperactive and hypoactive delirium.

Delirium symptoms develop quickly

Delirium develops quickly, over hours or days, and symptoms fluctuate throughout the day and are often worse at night.

Symptoms include:

• difficulty directing, focusing, sustaining or shifting attention
• confusion
• fluctuating or reduced consciousness
• disorientation to time and place (particularly time)
• disturbance of the sleep-wake cycle, for example, agitated or restless at night and drowsy during the day
• impaired recent memory
• speech or language disturbances, for example, rambling speech
• increased or decreased psychomotor activity
• emotional disturbances, for example, fearfulness, irritability, anger, sadness
• hallucinations and delusions
• lethargy and fatigue.

Delirium and ageing

Studies have reported that:

• older patients in surgical, palliative care and intensive care settings experience the highest rates of delirium³
• patients may come to hospital with delirium or may develop delirium while in hospital⁴
• patients are frequently discharged from hospital with persisting symptoms of delirium5
• delirium is preventable in 30–40 per cent of cases⁵.

Older people who experience delirium are at greater risk of functional and cognitive decline, falls, hospital acquired infections, pressure injuries and incontinence. Delirium can cause longer lasting cognitive impairments in patients after surgery and may ‘lead to permanent cognitive decline and dementia in some patients’³. Delirium is also associated with higher mortality and morbidity, increased length of hospital stay and admission to residential care^6,7.

Risk factors for delirium

A range of factors affects an older person’s risk of developing delirium in hospital. Some factors are predisposing, that is they are related to characteristics of the person; some are precipitating, that is they are related to the person’s illness or the hospital environment. Delirium involves an interaction between the patient’s predisposing vulnerabilities, which puts them at greater risk when faced with precipitating factors.

Involve the patient, carers and other professionals

• Involve the older person and their family or carer in discharge planning.
• Obtain recommendations from the treating team and allied health.
• Give the person and their family and carer written information about delirium and who to contact if they have any ongoing concerns.
• If the person is socially isolated, consider what extra supports they will require and how you can address these needs.

Document the episode, patient status and medication

The discharge summary paperwork to be provided to the GP should include:

• the patient’s episode of delirium, including details of persisting symptoms
• the person’s cognitive and functional status on discharge compared with their pre-morbid status
• any changes to their medication, including the reason for the change, possible side effects or drug interactions, how long the medication should be taken, and when it needs to be reviewed and by whom
• antipsychotics should be ceased unless there is good reason for their continuation; an ongoing evaluation and a plan to cease use should be included.

Refer to community health and support services

Describe the person’s need for monitoring and support by health professionals and other services in the community.

• The person’s GP will do the monitoring and follow-up, so provide test results and reports of all key and unresolved issues, including those needing further consideration or ongoing surveillance.
• Identify additional services needed and refer to inpatient or community health and support services.

Preventing and managing delirium

There are many things we can do to help older people and their families and carers understand, prevent and manage delirium. Here are some recommendations.

Depression is more than a low mood; it is a serious illness that impairs a person’s ability to function and causes significant distress for them and their family¹.

Depression presents as a complex combination of:

• behaviours – such as withdrawing from people and activities, neglecting personal appearance and commitments
• thoughts – for example, indecisive, negative comments
• feelings– such as moodiness and irritability
• physical symptoms – for example, unexplained headaches or pain, digestive upsets or nausea, dizziness, constipation.

Depression can be an acute or chronic condition. It can occur for the first time in an older person (referred to as late onset or late-life depression) or can be a recurrence or relapse of a previous episode².

Depression is a serious illness

Characteristics of clinical depression

Clinical depression (major depressive disorder or depressive episode) is characterised by five or more of the following symptoms during the same two-week period. The symptoms must represent a change in functioning and include a depressed mood or loss of interest or pleasure. Symptoms include the following³:

• Depressed mood most of the day, nearly every day (subjectively reported or objectively observed; for example, reports feeling sad or empty; appears tearful).
• Marked decreased interest or pleasure in all, or almost all, activities most of the day, nearly every day (subjectively reported or objectively observed).
• Significant weight loss or gain (more that five per cent of body weight in a month) or increased or decreased appetite (nearly every day).
• Insomnia or hypersomnia (feeling sleepy throughout the day) nearly every day.
• Psychomotor agitation or retardation nearly every day (observable and not merely subjective feelings of restlessness or being slowed down). For example, unintentional and purposeless movements due to mental tension (such as pacing or hand wringing); or slowing of thought, coordination and speech, presenting as sluggishness or confusion in speech.
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt (may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (subjectively reported or objectively observed).
• Recurrent thoughts of death (not just fear of dying) or suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.
• These symptoms cannot be attributed to direct physiological effects of a substance or general medical condition.

Subtypes of major depression include melancholic (a severe form of depression where many of the physical symptoms are present, particularly moving slowly, and where more likely there is a loss of pleasure in most or all things), non-melancholic and psychotic (include hallucinations and delusions)¹.

Severity of depression

Depression can be divided into four categories of severity:

• Mild: characterised by five to six symptoms with mild functional impairment or the capacity to function normally with substantial effort.
• Moderate: lies between mild and severe.
• Severe (without psychotic features): characterised by the presence of most of the symptoms with observable functional impairment.
• Severe with psychotic features: also includes delusions (for example, false beliefs, typically of being a bad person, deserving punishment or that bad things will happen) and hallucinations (such as hearing voices, smelling bad smells or other physical sensations).

Depression and ageing

Being admitted to hospital can be daunting for older people and their families. People can be afraid of the unknown and concerned about loss of independence. Their concerns may be shaped by their past experience of illness, episodes in hospital and the support systems they have in place.

Treatment for depression can be complicated and take longer to take effect in older people; however, prognosis for depression in older age is no worse than for younger patients⁴.

Given two-thirds of older people in hospital have been found to have a mild depression there is much we can do to improve their experience and outcomes.

In hospital I was so depressed, and I was there for about eight days … it was just the whole experience, I felt depressed because nobody much was around… Nobody is taking any notice because they just think you’re old and quiet I think… [In rehab there are] lots of people around to talk to… They were lovely there and so helpful. Depression is something that a lot of people deny. I got to the point [in hospital] where I was ready to go to the doctor and get an antidepressant ... and I have never been depressed in my life… [Depression can be prevented by hospital staff]. …acknowledging, and talking to you.
- Patient, 87 years old

The experience of loneliness, like mild depression, can change over the day. It may arise due to certain trigger events, or it can be long-lasting. It is also associated with a ‘feeling of disconnection from community, and of feeling like a stranger or an outsider’.⁵ It is important to recognise that loneliness, like depression, can have a negative impact on a person’s health, and some people can feel very reluctant to speak openly about it. ⁵

Risk factors

Depression, like dementia, is difficult to diagnose in hospital due to the high probability of delirium. However, there are key risk factors that we should be aware of in order to investigate further and respond appropriately. Identifying risks early and implementing prevention strategies can help prevent depression becoming severe and improve the older person’s chance of recovery.

The following are identified risk factors:

• multiple physical health problems and chronic conditions
• a past or family history of depression
• cognitive decline or dementia (approximately 20 per cent of older people with dementia experience moderate to severe depression)
• chronic pain
• medication side effects (particularly drugs used to treat high blood pressure, some steroids and hormonal treatments, painkillers, tranquillisers and tablets or patches used for quitting smoking)
• bereavement, grief and loss, including loss of relationships, independence, work, lifestyle, self-worth, mobility and flexibility
• social isolation, lack of intimacy, poor social supports
• the experience of loneliness
• significant change in living arrangements, such as moving into a residential care setting⁶
• caring for a family member with chronic illness, particularly dementia
• prolonged stress, chronic or acute
• drug or alcohol abuse
• gender - older women have double the risk of depression compared to men.⁶

Screening and assessment

Screening

As mild depression is common among older people in hospital, it is essential to conduct a screen on admission or as soon as the patient’s acute condition has stabilised. At the same time, it is essential to conduct a cognitive impairment screen, which assists us to rule out other possible causes such as delirium, which can be treated, or dementia. This process is known as differential diagnosis.

When screening older people for depression, involve their families and carers as they can recognise a change in the older person’s normal ways of thinking and reacting and may be able to identify early signs of depression in hospital. It is important to recognise that depression and loneliness are closely related.

Screening tools used with older people for depression or loneliness

Geriatric Depression Scale short form (GDS-15 or GDS 5/15)

This is a tool for screening depression in cognitively intact older people. It is available in English and other languages.

Cornell Scale for Depression in Dementia (CSDD)

This tool is designed for people with dementia. It comprises both an informant and patient interview. Many patient interview items can be filled by observing the patient. About 20 per cent of people with dementia have moderate or severe depression; both conditions need to be addressed if present. Instructions and a demonstration are available online.

UCLA Loneliness Scale

Use this scale if you suspect that your patient is experiencing loneliness. It is a set of 3 questions currently recommended in the International Consortium for Health Outcome Measures (ICHOM).

Assessment

A comprehensive mental health assessment involves a one to one interview, patient history and suicide risk assessment. A diagnosis of depression may require the following^{7, 8, 9}:

• a physical examination and laboratory investigations to identify any underlying condition that could be causing the symptoms, such as delirium, anaemia or thyroid problem
• medical history and medication review and reconciliation to identify any medication side effects that may be causing the symptoms
• clinical and/or mental health interview regarding:
  • the number, severity and duration of symptoms, including the risk of suicide or harm due to neglect, and associated disability
  • any major life changes that may have caused the depression; past and family history of mood disorders, successful and unsuccessful past treatment, and availability of social support.

Assessment may also involve families and carers, particularly if the patient has cognitive impairment.

Once we have identified concerns, we should consider the interventions and discuss with the treating team whether the patient would benefit from a referral to a medical specialist to complete a differential diagnosis.

Many hospitals have access to a clinical psychology or older adult psychiatry service to confirm the diagnosis, and to determine the duration and the impact of the patient’s depressive symptoms on their everyday functioning. The degree of impairment is key to developing the most appropriate management and treatment plan⁸.

Preventing and managing depression

We can implement various strategies to improve an older person's outcomes during their stay in hospital, contribute to their recovery and prevent the risk of functional decline.^{8, 9, 10, 11}

We know it's the simple things that actually significantly improve the care of older people, straightforward things, such as …a team-based approach …involving and listening to patients and their families and carers is so important… whether the meal tray is in reach during meal time, whether there's plenty of fluid available during the day to prevent dehydration, it's getting people out of bed and making sure they are kept ambulant and mobilising during the course of the day. It's making sure that we look out for the problems of depression and anxiety and actively manage those with the patient.
-Geriatrician

Encourage patients to be active

Assist and encourage patients to participate in their care and to keep mentally, socially and physically active.

• Encourage and help patients to eat and drink well and help prevent constipation. Depressed patients have more eating and digestive problems and there is a significant link between under-nutrition and depression¹¹.
• Encourage patients to care for themselves when they can, such as washing, dressing etc.
• Provide stimulation and interaction.
• Encourage or assist patients to get out of bed and move regularly.
• Implement and monitor strategies to reduce the patient's risk of falls and pressure injuries.
• Minimise isolation. Frequent brief visits from staff, volunteers, family and friends can help maintain the patient's morale. If family, friends and carers can't visit, encourage them to telephone the patient.

Communicate with patients

Communicate with patients and provide reassurance, encouragement and comfort.

• Acknowledge the patient and help them maintain their sense of self; consider their physical, emotional, social and spiritual needs.
• Encourage communication by demonstrating warmth, concern, a non-judgemental attitude and patience.
• Give the patient time to respond to questions and requests. Speak calmly and give clear and concise explanations about care and treatment.
• Use gentle but persistent encouragement and reassurance to engage the patient in tasks. Ask the whole healthcare team to adopt a consistent approach.
• Encourage patients to talk about their mood. Respond with respect; gently challenge negative thoughts by providing an alternative perspective; avoid dismissive statements such as “It can't be that bad”.
• Reinforce positive responses; reinforce the patient's strengths and positive attributes; avoid criticism.
• Point out progress in the patient's condition no matter how small (patients may not recognise these).

Consider night-time strategies

Difficulty getting to sleep, restlessness, nightmares, waking early, loneliness, and the lack of distractions can lead patients to ponder over fears or feelings of hopelessness.

• Encourage habits that promote sleep, for example don't have caffeine before bedtime, avoid afternoon napping, make sure the room is dark and noise is minimal.
• A familiar staff member who listens can be comforting. It may be easier for some people to express their thoughts and feelings when the ward is quieter.

Explore treatment options

Talk to the person and the healthcare team about treatment options.

• Encourage strategies to reduce anxiety, such as relaxation techniques.
• Request a medication review to determine whether pharmacological treatment is appropriate. Note that antidepressants may be overprescribed and should be reserved for patients with chronic, recurrent or severe depression.
• Discuss whether a referral to a psychologist for Cognitive Behavioural Therapy (to change negative thought patterns) and Interpersonal Therapy (to improve relationships and cope with grief) may be appropriate. In mild cases of depression therapy may be more effective than medication.
• During admission have volunteers and pastoral care workers spend time with patients, helping them explore their feelings of loneliness, and keeping them company.
• Explain the importance of maintaining social connections. If someone is socially isolated, encourage them to initiate new social activities and contact their local council, neighbourhood house or library to find out about activities in their area.

Involve patients and families

Always involve the patient and their carers and family in the care plan and decision making. Give patients and their family and carers information about depression and how to stay well.

Discuss lifestyle changes

Talk to the older person about incorporating some lifestyle changes to manage their symptoms, such as diet, nutritional supplements, exercise and social activities.

Depression and discharge planning

The discharge plan promotes continued improvement in a person’s mental health through psychological intervention, medication, physical activity, social connection, and regular contact with the patient’s GP.

A discharge plan must address issues such as the risk of self-harm and self-neglect, non-compliance with diet and medication instructions¹, low social supports and limitations in daily activities.²

Discharge planning should involve educating the older person, family and carers and identifying strategies to enhance recovery. Provide patients and families or carers with information about depression and staying well.

In addition to referring to the patient’s GP, consider the following referrals:

• Aged Care Assessment Service for follow up in the community
• planned activity groups and local councils, neighbourhood houses, libraries, churches and men’s sheds to enhance opportunities for social connection based on patient's interests
• community supports such as Home and Community Care (HACC) and Meals on Wheels
• psychologist, psychiatrist, old age psychiatrist or aged psychiatric team.

If the patient is at risk of developing depression post discharge, monitoring (via the GP) is important.

Cognitive screening, on admission to hospital and routinely throughout an older patient's hospital stay, is important to identify risk of functional decline and rule out possible treatable causes. It provides a baseline to identify a decline in cognition that may be due to delirium; depression or dementia. An improvement in a person’s test scores, once treatment has been administered, can help to confirm a diagnosis of delirium.

The most commonly used cognitive assessment tools in the hospital setting are:

• the Standardised Mini Mental-State Examination (SMMSE)¹
• the Abbreviated Mental Test Score (AMTS)
• The Clock Drawing Test (CDT)
• 4AT

Two tools developed for use with people from culturally and linguistically diverse backgrounds are:

• Mini-Cog
• Rowland Universal Dementia Assessment Scale (RUDAS)

A tool developed specifically for indigenous Australians (remote and urban modified versions) is:

• Kimberley Indigenous Cognitive Assessment (KICA)

Informant-based questionnaires are completed by someone who knows the person being assessed well; they provide complementary information on a person’s cognitive status or can be used in situations where testing a person’s cognition is difficult due to illness, dysphasia or literacy deficit. They include:

• Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)

Complete cognitive screening using one of the tools above before administering the Confusion Assessment Method (CAM) to identify delirium.

Dementia is not one specific disease; it is an umbrella term to describe a set of symptoms caused by a number of neurological diseases that affect the brain and a person’s ability to think, remember, understand, make judgments, communicate, socially interact and perform everyday tasks.

The type of symptoms and how they develop vary depending on the form of dementia a person has and the areas of the brain that are damaged.

Dementia usually has a gradual onset and is progressive and irreversible.

Symptoms and signs

Most people are aware that dementia affects a person’s memory; in particular their short-term memory. It can also impact a person’s thinking, behaviour, movement and ability to do everyday tasks.

Symptoms and signs of dementia can include:

• loss of insight, difficulty learning and following instructions
• difficulty with language and comprehension
• problems with calculation, judgment and reasoning
• difficulty with decision making and concentration
• lack of motivation, including apathy and withdrawal
• change in their personality and social behaviour
• problems with orientation to time and place
• difficulty sequencing tasks, such as coordinating getting dressed
• poor hygiene and dental care.

Behavioural and psychological symptoms of dementia (BPSD)

Changes in behaviour, such as wandering, pacing, agitation, depression, aggression, social inappropriateness, repetitive behaviour, sleep disturbances and hallucinations, are common in people with dementia - affecting up to 90 per cent of people with dementia.

Severity

The severity of dementia is commonly referred to as mild, moderate or severe:

• Mild – at the early stage, deficits are noted in a number of areas but the person can function with minimal assistance.
• Moderate – deficits become more obvious and greater levels of assistance are needed to help the person function.
• Severe – the person is almost totally dependent on the care and supervision of others¹.

Types

There are many types of dementia. Alzheimer’s disease is the most common (50–70 per cent of all dementia cases worldwide); vascular dementia accounts for 20–30 per cent of cases, frontotemporal dementia accounts for 5–10 per cent of cases, and Dementia with Lewy bodies (DLB) accounts for 5 per cent of cases. Other types of dementia include younger onset dementia, alcohol-related dementia (Korsakoff’s Syndrome) and dementia in other diseases (such as Parkinson Disease, Huntington’s Disease, AIDS and Down syndrome). Mixed dementia may be more widespread with Alzheimer/vascular dementia accounting for 25 per cent of dementia cases and Alzheimer/DLB accounting for 15 per cent, particularly with increasing age.

Dementia and ageing

Older people with dementia are admitted to hospital each year at twice the rate of older people without dementia. They have longer lengths of stay, are at risk of falls, gait and balance impairments, inattention, hypotension, eating and hydration problems, sleep problems, pneumonia, untreated pain, delirium, urinary tract infections, sepsis, pressure injuries, fractures, functional decline and even death.^{2,3 4} The longer a person stays in hospital, the worse their outcomes.⁵

For people with dementia, the hospital environment, routines and interactions with multiple people can be overwhelming, and can increase their confusion and trigger changes in their behaviour and emotions. It is important that we address these behaviours and do not label patients with dementia as ‘difficult’.

Carers and family members often find hospital environments overwhelming. It is important to include them in your assessment and be alert for signs of for carer stress and carer fatigue. Involve carers and family members when developing a person-centred care plan. If the person does not have family or carers, seek information from other sources, such as their GP and service providers.

All people aged 65 and over should be screened for evidence of cognitive impairment on admission to hospital. Screening identifies the existence and extent of cognitive impairment and provides a baseline to help identify any decline or fluctuation in cognition that may be attributed to treatable causes, such as delirium or depression. This process is known as differential diagnosis.

Identifying dementia - screening and assessment

Use a validated screening tool

There is a range of validated tools suitable for screening older patients for dementia. These include tools designed for hospital settings, for people from culturally and linguistically diverse backgrounds, for Indigenous people and for family members and carers. For descriptions of tools, see Cognition screening tools.

Most people are aware that dementia will affect a person’s memory, in particular their short-term memory. It can also impact a person’s thinking, behaviour, movement and the ability to do everyday tasks. You may include the older patient is experiencing things including:

• difficulty following conversation and instructions and learning new tasks (such as post-surgery precautions)
• problems with orientation to time and place
• difficulty navigating an unfamiliar environment, such as filling in a menu, eating off a meal tray,
• unable to recall your previous conversation or whether they have eaten their meal and are drinking water regularly and taking medications
• difficulty sequencing tasks, such as coordinating getting dressed, getting our of a hospital bed
• problems managing hygiene and dental care.

Behavioural and psychological symptoms of dementia (BPSD)

Changes in behaviour, such as wandering, pacing, agitation, depression, aggression, social inappropriateness, repetitive behaviour, sleep disturbances and hallucinations, are common in people with dementia. These behavioural and psychological symptoms of dementia (BPSD) can be stressful to the individual, their family and carers, staff, other patients and visitors. BPSD affect up to 90 per cent of people with dementia.

Determining diagnosis

There is no definitive test for dementia; we use findings from a variety of sources and tests, often conducted over many months, to build a case for diagnosis.

Some investigations may commence during the patient’s hospital stay (to eliminate treatable causes), however, most generally occur post discharge. A referral for post discharge follow-up, either through a geriatrician or referral to a Cognitive, Dementia and Memory Service (CDAMS), is essential because there are benefits to early diagnosis of dementia.

When a patient is suspected of having dementia, we can undertake a range of medical investigations, such as^1,2:

• a medical history; including a review of all medications
• physical examinations and laboratory tests to rule out other conditions such as vitamin deficiency, infection, metabolic disorders and drug side effects. Pathology tests include full blood examination, urea and electrolytes, liver function tests, thyroid function tests, vitamin B12, folate, calcium and random glucose. Additional tests may be required depending on clinical indications
• cognitive testing, which may include referring to a neuropsychologist for further tests. Neurological tests examine different areas of function in greater detail, such as memory, language, reasoning, calculation and ability to concentrate. They help distinguish between different patterns of decline and help identify the individual’s particular type of dementia
• brain imaging: computerised tomography (CT) scans, magnetic resonance imaging (MRI) or positron emission tomography (PET)/single-photon emission computerised tomography (SPECT) help rule out other conditions, such as brain tumours, blood clots, or hydrocephalus, and detect patterns of brain tissue loss that help determine the form of dementia
• collateral information from those who know the older person, such as their family and carers, their GP and regular service providers.

Assessing behavioural and psychological symptoms in hospital

As clinicians, the primary goal of assessing BPSD is to understand how the person’s cognitive impairment impacts their day-to-day function and behaviour. We can then reduce the risk of adverse events in hospital and make suitable plans for discharge.

By closely observing a patient’s symptoms, we can determine which BPSD are present, identify triggers for the behaviour and implement a person-centred response to minimise the risk of functional decline during admission.

We should clearly and fully document the patient’s behaviour and the circumstances that lead to the behaviour.

A cycle of evaluation that includes acceptance, assessment, action and reassessment is recommended³. This involves:

• accepting the person and their history and the involvement and expertise of different health professionals and families and carers
• assessing the physical and psychosocial care needs of the patient
• developing and implementing an action care plan
• reassessing the person and outcomes and refining the care plan.

The ABC (Antecedent-Behaviour-Consequence) approach is another model of understanding and supporting patients and staff when behaviour change³ occurs.

There are strategies we can use to improve care for patients with dementia. These can include working with family and carers, staff and other health professionals, as well as adapting the environment.^1,2,3

Involve family and carers

• By involving family and carers in assessment, care planning and in delivering care we can improve outcomes for people with dementia, provide comfort, and also help family and carers understand and cope.
• Use the TOP 5 initiative to draw on their knowledge and experience of the patient and their care needs. Family and carers understand what is normal for the patient with dementia and this knowledge helps us identify changes that may be indicative of delirium, pain or other treatable conditions.
• Collect information from family and carers. Use forms such as the ‘This is me’, Information about ‘me’ for planning care in hospital. These forms include questions related to the patient’s social care needs and preferences, and behavioural management strategies (including mobility, toileting, medication administration, and what comforts or distresses the patient).
• Inform them about what to expect during an admission and how they can work with hospital staff.
• If possible, provide one contact person within the organisation for any queries.

I really got to know her and her husband. He had a lot of behaviours and caused a lot of problems on the ward. But I sat down with them both and did the Key to Me [a form similar to the ‘The information about me for planning care in hospital’] … I think that was really good. I’ve been nursing for a long, long time, and sometimes you forget …they’re not just a patient… It made me realise that he’s not a naughty patient who caused a ruckus on the ward. He was a very kind man. After that I had a lot more patience with him…he was wonderful remembering his past, he had the most amazing life… it blew me away.… You don’t get the same sense completing the form compared to when you talk to someone and fill it in with them.
- Enrolled nurse

Alert all staff

• Consider a method for informing all staff that a patient has dementia, for example a discreet bed-based sign such as the Cognitive impairment Identifier.
• Ensure that all staff are trained to respond appropriately to the needs of patients with dementia.

Communicate clearly and effectively

• Introduce yourself and explain your role.
• Make sure you have eye contact at all times.
• Remain calm and talk in a matter-of-fact way.
• Keep sentences short and simple.
• Focus on one instruction at a time.
• Give time for a response.
• Repeat yourself – don’t assume you have been understood.
• Do not give too many choices.
• Involve family and carers.

Assist with activities of daily living

• Assist the patient with toileting, eating and drinking; encourage regular movement, prompt with self-care and other activities of daily living where required. These interventions play a key role in minimising the person’s risk of under-nutrition, falls, pressure injuries and delirium.

Change the environment

• Place familiar personal belongings around the patient and, where possible, follow familiar routines.
• Have large faced clocks and calendars and clear signage to the toilet to assist the patient with orientation. If not available on your ward, talk to your team about purchasing them.
• Normalise the surroundings and reduce environmental stimuli as much as possible.
• Keep walkways clear to prevent falls.

Consider referrals

• Access the expertise of comprehensive geriatric medical services or on-site geriatricians or psychogeriatricians, or in emergency departments, dedicated aged care staff.
• Where appropriate, consider alternatives to hospital admission, for example, hospital in the home or return to their residential aged care facility with Residential In-reach services.
• It’s important that the person living with dementia, as well as their family and carers, maintains their social networks. Explain how this can reduce the risk of becoming socially isolated or experiencing loneliness, both of which can have a negative impact on a persons’ health. Local councils, local newspapers, neighbourhood houses and libraries can be a good place to find out what activities exist in each neighbourhood. Alzheimer’s Australia can help with information about local activities and groups. Ask a social worker for ideas.

Managing behavioural and psychological symptoms of dementia

We can use a range of strategies to help manage behavioural and psychological symptoms of dementia (BPSD).

Non-pharmacological strategies are the first line of action and require us to identify and address internal stressors, such as illness or care needs, and external stressors, such as noise and glare.

Family and carers should be included in the development and implementation of the care plan.

The following strategies may assist you develop a person centred intervention plan when these symptoms arise.^1,2,5

Reassure and reduce triggers

• Actively listen to, respond and reassure the patient.
• Be aware that patients with dementia are very sensitive to non-verbal cues and mirror the affective behaviour of those around them; a calm and gentle manner has a positive effect.⁶
• Identify and reduce triggers for BPSD.
• Avoid surrounding the patient with too many staff at one time, minimise multiple assessments and provide the same staff.
• Provide activities to reduce agitation and quiet areas where the patient with dementia can retreat to in order to avoid the over stimulating hospital environment. Be aware that these symptoms can be an expression of an unmet need such as pain or discomfort.⁷
• Use specialist support from services such as The Dementia Behaviour Management Advisory Service which provides a 24-hour telephone support service.

Wandering

Wandering is one of the most troubling behavioural symptoms reported by family and carers. There are different patterns of wandering behaviour and different management issues and levels of risk. Screening tools can help differentiate between different types of wandering and help develop an individualised person-centred intervention⁸. Some strategies to try include:

• keep objects that might encourage wandering out of sight (for example a coat or handbag)
• make sure the patient’s room is convenient for observation, is away from stairs or elevators, and is located so the patient has to pass the nursing station to reach an exit
• make sure all staff are alerted to the possibility of the patient wandering
• provide appropriate opportunities for exercise and activity. The family or carer, allied health assistants or trained volunteers can help (for example, take the patient for a walk within the hospital grounds at appropriate times)
• designate a safe place for the patient to mobilse
• ensure the patient has identification intact at all times. Keep a description of what the patient is wearing on a daily basis and ensure a current photo is available.
• check the patient regularly
• consider using a bed or chair alarm.

Sundowning

Sundowning is restlessness, increasing confusion or changed behaviours in a patient with dementia that can occur late in the afternoon or early evening. Some strategies to try include:

• use early evening routines that are familiar for the patient; ask their family or carer
• find out what activities or strategies calm the patient (for example, warm milk, back rubs, calming music). The This is me, Information about ‘me’ for planning care in hospital, Top 5 or equivalent form completed by or with a family or carer can provide this information.
• allow the patient to mobilise in a safe environment
• encourage an afternoon rest, if fatigue is making sundowning worse
• consider environmental factors, such as lighting and noise
• avoid activities in the late afternoon that may be unsettling (for example, showers, dressings).

Anxiety or agitation

It is important tounderstand the reality the person with dementia is experiencing and validating this may help settle the patient. Some strategies to try include:

• talk about the anxiety-producing thoughts
• reassure the patient
• identify and relieve the cause of the anxiety.

Aggression

Physical or verbal aggression can be triggered by issues such as fatigue, an over-stimulating environment, asking the patient too many questions at one time, asking the patient to perform tasks beyond their abilities, too many strangers in a noisy, crowded atmosphere, failure at simple tasks or confrontation with hospital staff. Some strategies to try include:

• identify and address the triggers and underlying emotion or feelings
• simplify the task and communication
• ask a ‘why?’ question to understand and reduce repetitive questioning
• if an explanation doesn’t help, a distraction or activity may diffuse the situation
• remain calm and use a low tone of voice
• state things in positive terms – constantly saying ‘no’; or using commands increases resistance
• don’t force or restrain the patient.

Hallucinations or false ideas

These can be present in later stages of dementia. The person may hear voices or sounds or see people or objects. This can cause severe reactions such as fear, distress, anxiety and agitation. Strategies include:

• don’t argue and don’t take any accusations personally
• maintain a familiar environment, with consistent staff and routine, as much as possible
• ignore some hallucinations or false ideas if they are harmless and aren’t causing agitation
• avoid triggers
• pharmacological treatment may be part of a coordinated response for some patients who may benefit from treatment with antipsychotics (see below).

Disinhibited behaviour

By understanding why a patient is behaving in this way (for example due to memory loss, disorientation or discomfort), we can help avoid triggers. A patient may have forgotten where they are, how to dress, the importance of being dressed, where the bathroom is and how to use it; they may have confused the identity of a person; they may be feeling too hot or cold or their clothes may be too tight or itchy; or are confused about the time of day and what they should be doing. Some strategies to try include:

• respond with patience and in a gentle, matter-of-act manner
• don’t over-react; remember it is part of the condition
• reassure and comfort the person who may be anxious
• gently remind the patient that the behaviour may be inappropriate
• lead them gently to a private place
• provide clothing that is more comfortable
• distract the patient by providing something else to do.

Pharmacological treatment

Psychotropic drugs can play an important but limited role in managing BPSD; there are modest benefits and significant potential adverse events⁵. They should be avoided where possible and used only if there is a risk of self-harm or harm to others, and only after a thorough examination has eliminated other possible causes (for example pain or illness) and where behavioural and psychological interventions were proven inadequate^1,5.

Pharmacological treatment will not assist with some behaviours, such as wandering or repetitive questioning⁹.

Work closely with doctors to monitor medication effects. Refer to a geriatrician or specialist and pharmacist as part of the care team.

Be aware that:

• medications should be administered orally, in low doses and for a limited time
• usage should be monitored (for effectiveness and side effects) and adjusted accordingly; medication should be ceased if not effective or if side effects are evident
• multiple psychotropic medication are not recommended.

Pharmacological treatment should always be used in conjunction with a consistent, non-pharmacological management plan.

Dementia and discharge planning

We can help patients, their family and carers, and their healthcare professionals provide appropriate care in the person’s home or care facility.

Inform their GP

If we suspect that a patient may be suffering from dementia, we must communicate this to the patient’s GP who will provide ongoing primary care and coordinate diagnosis and management. Provide the GP with results of cognitive and other screening and tests performed during the person’s admission.

Other referrals

Consider referring the person to other relevant services.

Memory clinics are known as cognitive dementia and memory services (CDAMS) in Victoria. These clinics incorporate a range of specialists (such as neurologists, geriatricians, psycho-geriatricians, psychiatrists and neuro-psychologists) involved in diagnosing dementia and provide diagnostic services for all types of dementia. They have more detailed knowledge of memory and behaviour changes associated with dementia and may perform, or arrange, in-depth assessments. In Australia, a specialist must confirm the diagnosis of Alzheimer’s disease for a patient to be eligible for subsidised Alzheimer’s medications.

Aged care assessment services (ACAS) comprise multidisciplinary professionals who conduct comprehensive, medical assessments for older people needing community services or aged care residential services. They help identify the type of care that best meets the needs of older people and their family and carers, put them in contact with relevant services, make recommendations about the level of care required and approve eligibility for certain services and packages.

Dementia Australia provides information and support for people and carers with dementia. Their national dementia helpline is 1800 100 500.

Meaningful activities enhance opportunities for social connection and participation. Encourage the older person and their family or carers to make contact with their local library, council or neighbourhood house, or check their local newspaper, to determine what activities might be available in their area.

Discharge summary

Provide patients, family and carers with a written discharge summary, including dates and contact details for any follow-up required.

Continence issues are rarely the reason for hospital admission. Older people who experience incontinence or constipation, or develop these issues during their stay, are at risk of poorer outcomes than those who do not.

Incontinence and constipation are often signs that an older person is experiencing other health conditions.

Targeted screening, assessment and intervention can have a positive impact on the patient’s ability to participate in all recommended activities in hospital, reduce the person’s risk of experiencing a range of cascading problems such as infection, wounds and delirium, and have a lasting effect on their social and functional quality of life when they are discharged.

Continence and ageing

As a person ages, their bladder and bowel changes, which affects their function.

Bladder changes include¹:

• the elastic tissue of the bladder wall becomes tough and less stretchy and unable to hold as much urine
• weakening of the bladder muscles
• increases in involuntary bladder contractions
• urethral blockage:
  • in women this can be due to weakened muscles causing the bladder or vagina to prolapse
  • in men this can be due to an enlarged prostate gland
• increases in post-voiding residual volume (50–100 mL)
• increases in fluid excretion at night.

Bowel changes include²:

• sphincter weakness (for example, due to childbirth stretch injury)
• loss of anal sensation
• impairment of gastrocolic reflex
• softening of stools.

Incontinence has a big impact on health and quality of life

Incontinence has an enormous impact on an older person’s quality of life. It adds significant burden on family and carers and is a major factor in deciding to go into residential care.

Incontinence also puts people at greater risk of health issues such as falls and pressure injuries.

Incontinence has financial implications due to the cost of continence aids. It can affect a person’s general wellbeing and make them socially isolated due to embarrassment.

Continence problems can develop with other issues

In older patients, incontinence is usually caused by a combination of factors, including age-related changes to the urinary tract.

Continence problems can develop or become more severe if an older person is experiencing:

• Reduced mobility – can lead to falls when attempting to reach the bathroom. This is the single most predictive factor for incontinence, and urge incontinence has been identified as a high falls risk for men and women and as a major contributing factor to hip fractures in older women.³
• Impaired cognition – including delirium, dementia and depression, limit a person’s ability to self-toilet, particularly in an unfamiliar environment. Incontinence may add to the burden of depression.⁴
• Under nutrition (hydration and fibre) – adequate hydration and fibre intake is essential in maintaining bladder and bowel function. Many older people report limiting their fluids to avoid getting up to go the toilet while in hospital. This can contribute to constipation and urge incontinence.
• Medication side effects (particularly diuretics, sedatives, caffeine and alcohol) – medications can cause constipation and drowsiness, which can increase the risk of falls. Diuretics can increase frequency. Caffeine and alcohol are bladder irritants and can also increase urinary frequency.
• Skin integrity problems – exposure to urine and faeces can cause skin breakdown and leave the skin susceptible to damage from friction and pressure, dermatitis, and bacterial and fungal infections.
• Frailty – people who are frail and functionally impaired need accessible, safe toilet facilities and often benefit from assistance or supervision in hospital.

Identifying continence issues

Incontinence is rarely the reason a patient is admitted to hospital; however, it plays an important part in their recovery. Continence issues are often treatable and, in some cases, reversible.

Hospital admission presents an excellent opportunity to investigate continence issues and develop a management plan. This could improve the patient’s experience and recovery, and have lasting positive impact after discharge.

In addition to following health service policy and procedures, the following actions can help identify patients with continence issues and risks.

Screening questions

Continence is a sensitive issue. Even though we might talk about this topic with patients every day, we need to be mindful to:

• actively listen to the patient and avoid making judgements
• respect the patient’s right to choose the most appropriate treatment option.

While there are no validated screening tools available, when a person is admitted it is useful to establish their usual bowel and bladder habits. Ask these screening questions:

• Do you leak urine before you get to the toilet?
• Do you have to wear pads?
• Do you suffer from constipation or diarrhoea?
• Do your bowels or bladder ever cause you embarrassment, pain or concern?
• Are you rushing to the toilet or looking for the toilet all the time?
• Are you going to the toilet every half an hour? (in addition to leaking urine, overflow incontinence can also be identified by frequency)
• Was this an issue before you were ill or has it become worse?

If a patient answers YES to any of these questions, they should be assessed for incontinence.

If the person has a pre-existing cognitive impairment or is experiencing delirum, confirm their answers with their family or carer. If applicable, contact the patient’s residential care facility to obtain their continence plan. This information will help identify the risk of episodes of incontinence during their stay.

Assess contributing factors

As a first step, we should seek to eliminate as many contributing factors to incontinence as possible.

Use DIAPPERS to screen for reversible causes⁵:

• Delirium
• Infection--urinary (symptomatic)
• Atrophic urethritis and vaginitis
• Pharmaceuticals
• Psychological disorders, especially depression
• Excessive urine output (for example, from heart failure or hyperglycemia)
• Restricted mobility
• Stool impaction

Also ask about:

• decreased fluid intake
• urinary retention
• lack of toilet access
• whether the patient is emptying their bladder, especially if they have a neurological condition.

Use the Urinary Distress Inventory to check for symptoms of incontinence on admission.

Once you have identified an issue and treated underlying causes, further assessment may include physical examination, taking a brief targeted history, gathering more information on the person’s usual baseline functional abilities and using standardised tools to gather more evidence.

Take a history

A person may have a mixture of continence types, which can make the underlying cause more difficult to work out. Take a brief and targeted history, gathering the following information.

Preventing and treating incontinence

Continence interventions can reduce or minimise functional decline and promote social continence and good bladder habits and strategies.

In hospital, there are many barriers to maintaining continence and many factors contribute to incontinence. These include:

• medical factors – such as the person’s existing medical conditions, acute illness and medications
• environmental factors – such as poor signage on doors, inadequate lighting, shared bathrooms and an unfamiliar environment
• need for assistance to toilet.

We are all responsible for helping older people to maintain continence in hospital. This requires an individualised approach at the patient level, but needs to also include policy, systems and environmental design.

There are many things we can do to support continence and treat incontinence. Here are some recommendations.

Continence and discharge planning

People experiencing continence issues may have difficulty managing their continence, particularly outside the home, or feel embarrassed by their condition. They may feel reluctant to seek help due to social stigma. This can cause them to restrict their activity, increasing their risk of experiencing social isolation.⁷ We can help patients make a smooth transition from the hospital to their home or care facility by finding out what they understand about their condition, acknowledging their concerns, demonstrating sensitivity and developing a care plan that addresses the person’s ongoing continence management needs:¹³

• Do they need a referral to a continence clinic?
• Should their GP be advised of continence issues identified in hospital?
• Do they need written materials and resources to help manage continence? Refer to Continence Foundation of Australia website.
• Are they eligible for government funding support for the cost of continence aids?
• Do they need referrals for aids and specialist services?
• Would they benefit from a continence nurse follow up phone call or assessment in the community?
• Would they benefit from a referral to a dietitian for advice on maintain healthy bowels?
• Where is the person going after discharge – their own home, supported accommodation (with or without stand-up staff overnight) or residential care?
• If the person is going home, will they be alone or have help? Do they have a carer who can assist them?
• Can they afford the cost of aperients (mild laxatives) and continence appliances?
• Are they eligible for an aids assistance scheme, for example, from the Department of Veterans’ Affairs, Continence Aids Assistance Scheme or the Department of Health and Human Services’ Aids and Equipment Program?

Your organisation can develop a discharge kit that includes resources and contact details specific to your local area.

Older people who present to hospital with a fall, a history of falls or mobility problems are at risk of functional decline. Patients who are at risk of developing these problems during their admission are also vulnerable to functional decline. Identifying, investigating and responding to their needs is an important part of minimising this risk.

These topics provide information and recommend actions that we and our organisations can take to improve care for older patients.

Regardless of why an older person is admitted to hospital, their ability to move and care for themselves will determine the care and services they will need while in hospital and after discharge.

Older people in hospital are at risk of functional decline and de-conditioning as early as two days after admission¹. As clinicians, we should encourage older people to maintain or improve their mobility and self-care skills participating in activities.

This topic gives an overview of the importance of mobility and self-care, tools to identify issues, and strategies to improve an older person’s mobility and self-care. In addition to following health service policy and procedures, consider the following actions and discuss them with colleagues and managers.

Understanding how patients move

Functional mobility is the capacity to move from one position to another, enabling participation in normal daily routines and activities. It includes bed mobility, transfers, walking, wheelchair mobility, accessing toilets, getting in and out of a car, driving and taking public transport. It is important to be aware that mobility restrictions and using gait aids can have a significant impact on a person’s ability to access their home and local area. This can result in difficulty maintaining and initiating social connections within their community.

In hospital, functional mobility refers to your patient’s ability to get in and out of bed, to walk to and from the toilet and around the ward.

Self-care is the personal care carried out by a person. Common self-care activities while in hospital include eating, bathing, personal grooming and using the toilet. An older person may require assistance, supervision or guidance from healthcare workers for these tasks.

In hospital, mobility and self-care are often key measures we use to predict length of stay, discharge destination and need for support services. It is important that we understand our patients’ prior levels of ability and how they move and care for themselves in their usual living environments.

Wherever possible, we should ensure that our patients’ mobility and capacity for self-care is maintained or improved while they are in hospital. This will increase the likelihood that they can return to their previous levels of function, independence and social activities after leaving hospital.

Mobility and self-care support independence

By maintaining mobility and adequate self-care, it is possible for older people to maximise their opportunities for personal independence, social connectedness, security, activity and dignity.

During a hospital stay, a person-centred partnership with the older person is necessary to ensure mobility and self-care are maintained or improved. Mobility and self-care are fundamental to many of the other functional domains addressed on this website. For example, an older person's ability to walk to the toilet may help to maintain continence. Promoting or facilitating mobility and self-care is recommended for minimising the risk of depression, delirium, under-nutrition and can reduce the likelihood of falls and fall-related injuries and loss of confidence due to fear of falling.

Bed rest has considerable impacts on an older person’s ability to be independent. This includes impacts on self-care and walking. Bed rest during hospitalisation can lead to functional decline and deconditioning as early as two days after admission.

Effects of bed rest

Screening for mobility and self-care difficulties is often done in the context of screening for other issues such as falls or frailty. It is important that we identify our patients at risk of:

• de-conditioning – a decline in strength, balance or endurance
• falls
• loss of independence.

Assessment

A Comprehensive Geriatric Assessment (CGA) (initial and ongoing) will assist in identifying factors contributing to functional decline. A CGA includes an assessment of ADLs and Instrumental ADLs as well as other factors such as cognition, continence, vision and hearing, psychological wellbeing and social supports⁴.

Physiotherapists undertake a full assessment of mobility and occupational therapists undertake assessments of ADLs. You can use assessment tools to identify underlying risk factors and prompt a more detailed assessment.

Tools to identify underlying risk factors to prompt a more detailed assessment

Maintaining and improving mobility and self-care

We need to understand our patient’s prior level of mobility, independence in self-care and usual living situation if we are to implement appropriate and effective mobility and self-care interventions. For example, if a patient's mobility restrictions affected their ability to remain socially connected and manage their own affairs, we should develop a plan with them to rectify this.

Consider five areas of mobility and self-care interventions as part of an interdisciplinary strategy: incidental activity, exercise, retraining activities of daily living (ADLs), ensuring appropriate supervision, and environmental modifications.

Interventions should be discussed and implemented in partnership with the older person and their family and carer, as appropriate.

Incidental activity

Incidental activities are those where physical activity occurs as part of regular daily activities, for example, walking to the toilet, transferring and dressing. Performing regular daily activities, including self-care, is the easiest exercise for our patients to undertake in hospital. Self-care can be beneficial to your patient’s mobility.

Encourage your patients to:

• dress (consider the possibility of wearing their normal day clothes and footwear)
• get out of bed and move around the ward, with supervision or assistance and an appropriate gait aid if required
• sit out of bed as soon as it is considered safe to do so, as much as possible as appropriate to their condition
• walk to the toilet, with supervision or assistance if required
• eat meals out of bed, preferably in a communal dining room where available and appropriate
• undertake or participate in showering and other grooming and self-care activities.

As staff, we can:

• supervise or assist older people during walking, transfers and ADLs if required
• create a continence and mobility plan that fits with patients sitting out of bed for meals
• adjust bed height to allow for safe, independent transfers
• orient our patients to the ward, showing them where the toilet is
• provide a culture that encourages incidental exercise
• provide aids to assist with optimal transfers and mobility
• avoid using bed rails, which may limit mobility and be a hazard
• improve our understanding of the risks of restricting mobility and provide strategies to prevent de-conditioning.

Exercise

As part of an interdisciplinary intervention, an exercise program may benefit your patient.

Exercise programs can be administered in both individual and group settings and may include strength, balance, functional retraining and aerobic (or endurance) exercises. Group classes also provide an opportunity for social interaction and may help prevent loneliness.

We can refer older patients to physiotherapy for prescription of individual or group exercise.

Retraining ADLs

Our patients’ abilities to live independently may depend on retraining their skills in ADLs. We can:

• provide the minimal amount of assistance required to encourage optimal participation; assistance should be reduced as the person’s condition improves
• encourage and guide our patients to promote independence
• assist with alternative strategies for self-care, as necessary
• refer our patients to occupational therapy, as appropriate
• make sure aids are available to assist with optimal independence
• ensure bed and chair heights are optimal for independence
• recommend patients for self-care programs, such as cooking groups and self-care education sessions, as appropriate
• consider use of everyday clothes and footwear
• clear any clutter
• ensure obstacles to mobility or self-care are moved
• ensure any tools or aids for mobility or self-care are clean and maintained
• ensure bed and chair heights are optimal for independence
• avoid using bed rails, which may limit mobility and be a hazard.

Ensuring appropriate supervision during mobility and self-care tasks

We can:

• supervise patients who are acutely unwell during walking and transfers. It may be appropriate to reduce supervision as medical stabilisation occurs and familiarisation with the environment and equipment is achieved.
• consult physiotherapy if we are in doubt about the supervision needs of our patients. Use strategies such as a traffic light colour coding system, a common way to inform all care staff of an individual's mobility supervision needs.

Environmental modifications

The hospital environment is important in promoting mobility and self-care for older people. We should:

• clear any clutter
• ensure obstacles to mobility or self-care are moved
• ensure any tools or aids for mobility or self-care are clean and maintained
• ensure bed and chair heights are optimal for independence
• avoid using bed rails, which may limit mobility and be a hazard.

Mobility and self-care in discharge planning

Planning for discharge should occur as early as possible. Discharge planning should be person-centred and undertaken with the patient and their family and carers, as appropriate.

• Aim to create person-centred discharge plans that our patients and significant others understand and support
• Understand our patients’ normal daily routines and living arrangements and what supports they will require after discharge.
• Provide referrals to appropriate community services and equipment providers for older people who require assistance with self-care or who may be at risk of falls post discharge
• Consider referrals to community services if premorbid mobility and self-care levels have not been attained by discharge.
• Identify people at risk of becoming isolated on discharge because of immobility or changes in mobility. Encourage them to remain socially connected, for example by contacting their local library, council, Neighbourhood House or Men’s Shed as sources of neighbourhood activities.
• Provide appropriate written resources and ensure our patients and their significant others understand the resources.
• Encourage and facilitate physical activity beyond discharge.

Falls occur everywhere, including in hospital, and can cause injury and functional decline. They are the result of the interaction between personal and environmental factors and are often associated with fear, depression, anxiety and loss of confidence in older people.

Many falls can be prevented; so we all need to be aware of our patients’ falls risks and respond appropriately.

This topic gives an overview of falls in hospital, assessing and responding to falls risk, and preventing and managing falls in hospital. In addition to following health service policy and procedures, consider the following actions and discuss them with colleagues and managers.

Falls in hospital

In Australia, there are more hospital admissions for fall-related injuries than for transport related injuries¹.

Falls are one of the most common adverse events in hospital and can result in serious injury or death; falls are particularly common in older patients¹³. Every person admitted to hospital has risk factors for having a fall while in hospital.

According to the World Health Organization, a fall is defined as "an event which results in a person coming to rest inadvertently on the ground or floor or other lower level"². This includes slips, trips, loss of balance and applies to events that are witnessed as well as unwitnessed.

Falls contribute to increased length of stay, risk of functional decline and may trigger residential aged care admission.

Investigating a patient's risk of falls while in hospital will also help to reduce their risk of falls after they are discharged.

Falls can be described as:

• Accidental: resulting from environmental factors, such as clutter, tubing or spills that cause a patient to slip or trip.
• Anticipated physiological: stemming from known intrinsic factors (such as postural hypotension, dementia and gait or balance deficits) or extrinsic factors (for instance, certain medications or improper ambulatory aids).
• Unanticipated physiological: caused by unexpected or unknown medical episodes (such as sudden myocardial infarction, stroke, syncope, or seizure). These falls can’t always be prevented, which is one reason why organisations can’t expect to achieve a zero fall rate.
• Intentional: when patients intentionally fall to the floor; these are rare in general hospital settings³.

Regardless of falls classification or category, falls result from the interaction between the individual and their physiological risk factors, behaviour and the environment.

Identifying falls risks

Screening can determine whether a person has a low or high risk of falls and assessment of risk can inform the development of prevention strategies.

Currently, the National Standards require that all patients have a documented falls risk screen on admission to hospital and on transfer between settings.

Examples of screening tools currently in use in Victorian hospitals include:

• Falls Risk Assessment Tool: FRAT⁴
• STRATIFY^,5,6

Experts emphasise that drawing on our clinical judgement can be equivalent if not superior to using these types of tools. Given this we should consider the following patients as having a higher risk of falling:

• aged 65 and over
• aged between 50 and 64 who are at higher risk of falling (according to clinical judgement) due to an underlying condition⁷, for example Parkinson’s disease, stroke, early onset dementia
• all inpatients admitted following a fall.

For all these patients, we should undertake falls assessment and provide one to one patient education.

Assessment of falls risk and falls risk factors

Early identification of falls risk factors enables us to tailor care and respond to each patient's individual needs. Whilst the evidence for multifactorial intervention based on risk assessments is weak in the hospital setting, identifying, exploring and addressing these issues will be of benefit to the older person.

Assessment of risk factors should include assessment for individual risk factors such as:

• past history of falls
• cognitive impairment
• delirium
• incontinence, indwelling catheters
• extended period of medical illness
• foot problems and footwear
• visual impairment
• poor balance
• problems with walking and self-care
• health conditions that may increase the risk of falling, such as stroke, Parkinson’s disease, peripheral neuropathy and postural hypotension
• medication, including number and types of medication associated with falls, particularly sedatives, analgesics (opioids and antineuropathic pain medications) and antipsychotics
• musculoskeletal conditions, such as osteoarthritis of the knee and hip
• frailty
• significant weight loss and under nutrition leading to loss of muscle mass and strength
• prolonged bed rest.

Assessment for injury risk

Assessment for the risk of injury (for example, fracture, head injury) also needs to be undertaken and we should consider:

• conditions such as osteoporosis
• long term steroid use
• previous fractures
• conditions such as metastatic bone disease
• use of anticoagulants such as warfarin.

Assessment of the environment

Assessment of the environment is also vital. Scan the ward environment for hazards such as:

• clutter
• poor lighting
• slippery surfaces
• equipment in need of repair
• equipment or gait aids without brakes locked appropriately.

Falls prevention in hospital

Falls are a complex problem with multiple causes and risk factors. Preventing falls in hospital is not easy, but there are many things we can do to help reduce the risk.

Some hospitals may routinely use some or all of the following strategies to prevent falls. Please note that not all strategies have been proven to work for all patients in all settings.

We should choose strategies in consultation with our care teams, considering all clinical and organisational factors.

Identify falls risk

• Use falls risk identifiers, for example coloured signs or traffic light symbols, to communicate level of falls risk.
• Ensure staff understand what the identifiers mean and what strategies they should be implementing.
• Explain what the identifiers mean to the patient and their visitors.

Intentional rounding

Consider undertaking regular rounds (for example hourly or two hourly) to check on patients to ensure fundamental needs are being met. Note that while there is evidence to suggest that rounding is associated with improved patient experience, the impact on falls is less clear.

Low-low beds

Consider using low-low beds for patients at risk of falling or rolling out of bed. Consult with all team members, considering the following aspects:

• Is the patient at risk of rolling out of bed? Would they benefit from a low-low bed with an adjacent floor mat?
• Is the use of the low-low bed a form of restraint? It may be inappropriate to use a low-low bed for patients who are mobile.
• Does the patient have enough strength to stand up but has poor balance or walking and has risk taking behaviour (such as decreased awareness of ability, perceptual difficulties, delirium, dementia)? A low-low bed may be contraindicated in this case.
• Is the use of a mat next to the bed a trip hazard for staff and other patients/carers?
• The availability of one low-low bed for three standard beds may contribute to a decrease in the rate of serious fall-related injuries⁸ whereas providing one low-low bed per 12 beds does not seem to effect rate of falls.⁹
• Where is the low-low bed placed? If it is close to the wall but there is space between the wall and the bed, this can be a hazard.
• What height is appropriate? For example, low when resting, raise bed for transfers and care activities.

Bed or chair alarms

Consider using bed or chair alarms for patients who do not ask or wait for assistance or who require supervision to mobilise.Note that there is high level evidence indicating that the use of bed or chair alarms as a single strategy has no effect on the rate of falls.

Clinical judgement should be used in deciding whether to use a bed or chair alarm, considering factors such as:

• patient characteristics: can and will the patient use their call bell?
• staffing: are there enough staff to respond? Is there a risk of ‘alarm fatigue’: have staff become desensitised to alarms?

Non-slip socks

Many hospitals have introduced non-slip (red) socks to identify individuals at risk of falls and focus attention on prevention strategies. Note there is no published high-level evidence to suggest that non-slip socks prevent falls in the hospital setting.

For patients with bone conditions

Patients with conditions such as osteoporosis, previous fracture and metastatic bone disease are at greatest risk of fracture following a fall. For these patients consider the following:

• hip protectors (worn at all times)
• low-low bed (low when resting, raised for transfers and care activities)
• evaluation of osteoporosis.

For patients with bleeding disorders

Patients with bleeding disorders due to use of anticoagulants or an underlying clinical condition are at increased risk of haemorrhage following a fall. For these patients consider the following:

• evaluate use of anticoagulation medication, including considering risk vs benefit
• use of a low-low bed (low when resting, raised for transfers and care activities)
• use of protective helmets for some patients.

For surgical patients

Surgical patients are at increased risk of falls. For these patients, consider the following:

• pre-op education
• post-op reinforcement about using call bell
• toileting prior to providing centrally acting pain medication.¹⁰

Referral to other health professionals

Consider whether the patient should be referred to other health professionals such as physiotherapists, occupational therapists or pharmacists. On completion of a comprehensive assessment, all health professionals should work with the patient and their family to develop an intervention plan.

Multifactorial interventions

Multifactorial interventions have been shown to work in some, but not all, settings^11,12. This type of intervention refers to strategies to address risk factors identified in a comprehensive falls risk assessment. It can include a combination of interventions such as:

• treatment of delirium and agitation
• improving continence, for example through regular toileting, treating constipation, referral to a continence nurse specialist, urinalysis to check for infection
• footwear: ask family and carers to bring in supportive shoes or slippers
• foot problems: provide foot care and refer to podiatrist
• visual impairment: ensure patient has the right glasses and they can reach these easily
• poor balance: refer to physiotherapist, consider using a gait aid, assist or supervise the patient when walking to the toilet
• stay with patients who require assistance on the toilet or while showering
• medication review: consider medications known to increase falls risk such as sedatives, centrally acting analgesics, psychotropic medications
• treat postural hypotension
• ensure nutritional needs are met and consider referral to a dietitian
• exercise program: strength and balance training may be effective in reducing falls and improving awareness of risk.

Educate the patient, their family and carers

Provide personally tailored falls prevention education to the patient and their family and carers. Talk to them about their knowledge and perceptions of falls risk, their goals for their hospital stay, and things they can do to reduce the risk of falls. Encourage patients to ask for assistance. Remember, simply providing a brochure on falls prevention is not enough: talking to the patient and their family and carers is essential.

On each shift, we can:

• orientate new patients to the ward, including to the toilet, and provide regular reorientation for patients with cognitive impairment
• place the call bell within reach
• reduce clutter around the bedside
• position the gait aid within reach
• provide easy access to objects according to patient’s needs and preferences, for example the TV control, glasses, magazines
• lock wheels on the bed and other equipment
• help the patient put on appropriate footwear and clothing
• ensure adequate lighting
• encourage the patient to walk regularly, even for short distances
• provide assistance or supervision for walking as needed
• keep hallways clear, provide safe seating opportunities.

Responding to falls

If a patient falls in hospital, review their falls risk status as they are at high risk of falling again. Refer to your health service’s policies and procedures for post-fall management guidelines. These may vary between hospitals and settings but will generally include actions such as:

• reassuring the patient
• calling for assistance
• checking for injury
• providing treatment as indicated
• assessing vital signs and neurological observations
• notifying medical officer and nurse in charge
• notifying next of kin
• ensuring falls risk assessment and interventions are updated and implemented
• providing education to patient and family.

Some health services use post-fall huddles to decrease the likelihood of patients experiencing recurrent falls by determining the cause of the fall and guiding intervention.

Generally a huddle is an immediate bedside evaluation of a fall, which includes staff present, the patient and their family and carers and the interdisciplinary team. The purpose of the huddle is to analyse the factors leading to the fall and plan for prevention of falls. The huddle information should be documented.

Falls and discharge planning

You can help patients make a smooth transition from the hospital to their home or residential aged care facility through comprehensive and clear discharge planning and communication.

When a patient is being discharged:

• Reinforce the strategies you have outlined to the patient and their family to prevent falls.
• Emphasise the importance of maintaining a combination of interventions.
• If the person has experienced a fall, explain that maintaining levels of physical activity, perhaps in group settings, may not only minimise their risk of further falls but may also be helpful to increase opportunities for socialising and decrease loneliness.
• A fear of falling may limit a person’s confidence to maintain or initiate new activities or social connections. Explore with them ways they might address their fears.
• Provide documentation about falls risk and falls risk factors in discharge information for the person’s GP and other services.
• Ask the GP to reinforce the strategies and to monitor their effectiveness post hospitalisation.
• Consider referral to other services for ongoing management of fall risk. Victoria's Health Independence Program provides ambulatory care support for people following hospitalisation. Falls and mobility clinics are provided through HIP. Group strength and balance classes are available through most community centres, and are also useful to promote socialisation. The Victorian Falls and Balance Directory provides information on services and locations .

Frailty is a multidimensional geriatric syndrome characterised by a decline of physical and cognitive reserves that leads to increased vulnerability.

Frailty increases with age and is associated with falls, longer stays in hospital, difficulty recovering from illness and surgery, and mortality.

It is important to recognise frailty in older people in hospital so that we can develop and implement individualised care plans, reduce the risk of onset or deterioration and provide people with the opportunity to retain their independence and social connections on discharge.

Frailty and ageing

Frailty affects a person’s ability to recover from a clinical episode, their resilience, and function across multiple body systems. Frailty increases as we age.

Older people who are frail often experience poor health, falls and disability as well as longer stays in hospital and increased mortality.¹

Older people who are frail can have difficulty coping with minor illnesses and events, such as infections and constipation, and they can be more susceptible to side effects from certain medications. They are more likely to have difficulty recovering from surgery and periods of acute hospitalisation or rehabilitation.

We should identify and respond to a frail older person’s vulnerabilities during their admission to reduce their risk of functional decline so that people don't just survive hospital, but make a full recovery.

Signs of frailty can be obvious or subtle

While some signs of frailty and risk of frailty are obvious, others are not. Common presentations of frailty² include:

• non-specific signs - extreme fatigue, unexplained weight loss, frequent infections
• falls - frequent falls, fear of falling, restricted activity
• delirium - acute changes to their cognition
• fluctuating disability - day-to-day variation in ability to look after oneself, for example a loss of interest in food, difficulty getting dressed, experiencing good and bad days.

We can help patients make a smooth transition from the hospital to their home or residential aged care facility through comprehensive and clear discharge planning and communication.

Educate patients, family and carers

• Remind patients and their family and carers about strategies to optimise function and wellbeing at home.
• Emphasise the importance of maintaining a combination of interventions, which includes optimising opportunities for social connections.

Refer to health professionals and support services

• Include documentation about frailty and contributing factors in the discharge summary to the GP and other services.
• Inform the patient’s GP about ongoing treatment goals for the patient.
• Refer the patient to community or hospital based specialists to support functional independence in the longer term.
• Discuss services and opportunities for social participation based around the patient’s interests. This could include planned activity groups, or activities sourced through local councils, local newspapers, libraries, Neighbourhood Houses or Men’s Sheds that can keep the patient socially connected.

Practise person-centred care

• Encourage patients to ask questions or raise concerns about their recovery.
• Tailor plans to the individual patient, as discharge planning is not a one size fits all approach.

Responding to frailty

Frailty is a complex problem that usually requires multiple interventions. These interventions should target physical performance, nutritional status, mental health and cognition. There is emerging evidence that a person’s health assets - that is, the strength of their social supports, stability of their housing, their economic independence, level of education - could mitigate the effects of frailty.³

There has been little research into the effects of interventions on frailty in hospital; however, best practice suggests that healthcare professionals should consider the following actions.

When screening and assessing for frailty, we should consider a person’s physical performance, nutritional status, cognition and mental health and be proactive in providing preventative and tailored care when the person is in hospital. It is also useful to understand the person's health assets and how these might act as protective factors. Health assets can include supportive family, community supports, social connections and economic independence.

In addition to following health service policy and procedures, the following actions can help us identify patients with or at risk of frailty.

Screening tools

There are very few validated tools that specifically screen for frailty. Recognising the importance of this emerging issue, the Failsafe Initiative is testing a new screening tool in UK acute hospital settings. The results of this study are yet to be published.

Some ways to determine the risk of frailty include:

• measuring walking speed: people aged 75 and over who have a walking speed of less than 0.8 m/s are at high risk of frailty¹
• evaluating the presence of risk factors, including poor mobility, reduced strength, poor nutrition, delirium, falls, impaired cognition and low mood.

Assessment tools

Overview of frailty assessment scales

Adapted from Goldstein et al 2012⁷

Fried’s Frailty Phenotype

This is the most common scale used to screen and assess for frailty. It measures deficits in the five domains:

• Weight loss (self-reported unintentional weight loss or decreased appetite)
• Exhaustion (self-reported energy levels)
• Physical activity (frequency of moderate intensity activity)
• Muscle strength (measured grip strength with dynamometer)
• Walking speed (self-reported slow speed or measured slow gait)².

Frailty Index

The Frailty Index is calculated by counting the number of deficits out of a total list of potential deficits for that person³. For example, if an individual has 10 deficits from a total of 40, the index is 0.25. Scores of 0.2 and over are considered as approaching frailty. The Frailty Index is the best predictor of poor outcomes in older people in hospital⁴. It includes deficits such as osteoporosis, chronic illness, depression, anaemia and cognitive impairment. The more deficits a person has, the more likely they are to be frail.

Clinical Frailty Scale

The Clinical Frailty Scale⁵ classifies levels of frailty as follows:

• Very Fit– robust, active, energetic, well motivated and fit; these people commonly exercise regularly and are in the most fit group for their age
• Well - without active disease, but less fit than people in category 1
• Well, with treated comorbid disease – disease symptoms are well controlled compared with those in category 4
• Apparently vulnerable – although not frankly dependent, these people commonly complain of being “slowed up” or have disease symptoms
• Mildly frail – with limited dependence on others for instrumental activities of daily living, which includes meal preparation, ordinary housework, managing finances, using the phone, shopping, transportation
• Moderately frail – help is needed with both instrumental and non-instrumental activities of daily living which includes, mobility in bed, transferring on and chairs, toilets and into and out of bed, walking, dressing, eating, toilet use, personal hygiene, bathing
• Severely frail – completely dependent on others for the activities of daily living, or terminally ill

People in categories 4, 5 and 6 may not be as easily identified as being at risk of frailty.

This version of the Clinical Frailty Scale was extended in 2008 to include two more levels, a total of nine, and includes a comment about scoring frailty in people with dementia. This extended version is available for use in research and educational purposes only.

Edmonton Frail Scale

People with no training in geriatric assessment can use the Edmonton Frail Scale. It measures level of frailty through questions and activities related to cognition, general health, functional independence, social support, medication use, nutrition, mood, continence and functional performance.

Older people presenting to hospital with nutrition and swallowing problems are at risk of functional decline. Patients who are at risk of developing these problems during their admission are also vulnerable to functional decline. Identifying, investigating and responding to their needs is an important part of minimising this risk.

These topics provide information and recommend actions that we and our organisations can take to improve care for older patients.

For older people, adequate food and drink can help them recover from illness and surgery, remain independent, reduce their length of stay in hospital and help avoid readmission to hospital.

Malnutrition is common in older people. To identify people over 65 at risk of malnutrition, they should be screened within 24 hours of admission and at regular intervals throughout their hospital stay.

This topic gives an overview of nutrition and hydration and recommends actions that we and our organisations can take, in addition to health service policy and procedures, to provide quality nutrition and hydration care to our older patients.

Impacts on health

Nutrition is the intake of food and fluid to meet a person’s dietary and biological needs. Good nutrition is fundamental to physical and mental wellbeing.

Under-nutrition occurs when a person is not consuming enough calories or nutrients to meet their energy requirements. It can cause weight loss, health problems, muscle and skeletal loss and lead to serious conditions such as frailty and sarcopenia¹. Under-nutrition is more common in older people and can be exacerbated by illness and hospitalisation.

Some causes of under-nutrition include:

• choosing to eat less
• medical conditions that affect the absorption of nutrients by the body
• poverty, social isolation and functional decline that affect a person’s ability to buy food²
• depression³ and other conditions that affect cognition.

Malnutrition or malnourishment occurs when food and nutrient intake is not appropriate to maintain body function. It can lead to iron deficiency anaemia and sarcopenia.

Common causes of malnutrition are:

• medical conditions that reduce appetite or impede the person’s ability to care for themselves
• changes that impact on the swallowing process
• weight loss and low body weight is common in patients with dementia; in particular those with advancing Alzheimer’s disease.⁴

Over-nutrition occurs when a person eats more food than their body needs. This can lead to obesity, diabetes and cardiovascular disease.

Hydration is essential to life

Hydration is having enough fluids each day for health and function; 6–8 glasses per day are recommended.

Dehydration can lead to delirium, constipation, urinary tract infections, swallowing problems, falls, inability to regulate medications and life-threatening conditions, especially in people with co-morbidities⁵.

Nutrition and hydration and ageing

As we age, many physiological factors can affect our ability to maintain optimal nutrition and hydration, such as:

• changes to taste and smell can decrease appetite and interest in food
• hormonal changes can affect weight and mood
• musculoskeletal changes can impact on a person’s mobility and ability to feed themself
• underlying disorders can reduce our food and fluid intake and affect the absorption of important nutrients and vitamins

Changes to a person’s routine can affect nutrition and oral intake. For example, losing a spouse, moving house or entering residential care can mean usual eating and drinking habits are disrupted and this can lead to poor nutrition and hydration.

For older people in hospital, poor nutrition and hydration care can result in a loss of functional independence, delayed recovery from surgery, falls, infection, slow wound healing, delirium, frailty and increased mortality⁶.

Hospital provides an ideal opportunity to identify existing or potential nutrition problems and focus on preventative measures to help patients achieve good nutrition in hospital and when they leave.

Identifying nutrition and hydration issues

When nutrition and hydration issues are identified early, we can tailor care and treatment to respond to each patient’s biological and medical needs, abilities, and their lifestyle and cultural preferences.

In addition to following health service specific policy and procedures, the following actions can help identify patients who have or are at risk of problems.

There are many things we can do to improve a patient’s food and fluid intake and help prevent functional decline. Here are some recommendations.

Nutrition and hydration and discharge planning

Nutrition and hydration are always important and treatment is often ongoing. We can help patients make a smooth transition from the hospital to their home or care facility.

Educate patients and carers

• Provide nutrition and hydration advice and print out information that people can take with them.
• Remind patients and their family and carers that regular and healthy eating and drinking is important if they are to stay healthy and independent.
• Stress the importance of eating a variety of foods. Tell patients to select fresh, healthy options across all food groups and include protein with each meal.
• If the patient needs to take supplements, make sure they know when and how much to take, where they can buy them and if they can afford them.
• Tell the family and carers how to position the patient to help them digest food and techniques for encouraging people to eat and drink.
• Make sure the patient understands how their medicines may impact on nutrition and vice versa.

Refer to health professionals and support services

• Inform the patient’s GP about treatment goals and any referral that have been made to other health professionals.
• Tell the patient and their family and carers how they can access a community or hospital based dietitian.
• Inform existing services about strategies to help the patient optimise their nutrition.
• Discuss services such as Meals on Wheels, transport and shopping services.
• Discuss social supports to keep the patient socially connected, such as lunch clubs or Casserole Club.

Practice person-centred care

• Encourage patients to ask questions or raise concerns about their recovery.
• Tailor plans to the individual patient, as discharge planning is not a 'one size fits all' approach.

Swallowing difficulties, medically known as dysphagia, are most apparent to an older person, their family and hospital staff when the person is eating, drinking or taking medication. Swallowing difficulties can have an acute onset during illness and may be short term in nature or they can be a symptom of severe illness and become more severe due to neurological diseases such as Parkinson’s disease or dementia.

Mild swallowing difficulties are common in older people, particularly in those over the age of 80. There are many strategies we can implement to optimise food and fluid intake to avoid the difficulties becoming more severe and avoid a series of cascading risks.

This topic provides an overview of swallowing difficulties. It recommends actions that we and our organisations can take, in addition to health service policy and procedures, to provide quality care to older patients with swallowing difficulties.

Swallowing process and its impact on health

Swallowing difficulties (dysphagia) range from mild to severe, can be short or long term in duration, and acute or progressive in nature. Although it is not considered a normal part of ageing, dysphagia can occur due to the physiological ageing process, especially in people over 80. However, it is often a symptom of an underlying disease or condition.

Swallowing is a complex process that relies on many nerves and muscles of the mouth, throat and oesophagus¹. Swallowing difficulties can cause problems with drinking, eating, chewing, controlling saliva, taking medications and protecting the airway². An older adult with swallowing difficulties is at increased risk of pain³, dehydration and malnutrition.

Swallowing problems can mean that food and fluids entering the airway (laryngeal penetration) or the lungs (aspiration) can cause chest infections (aspiration pneumonia), choking or even death.

The swallowing process

The normal adult swallowing process occurs in four stages:

• Oral Preparatory Phase – also known as the pre-oral stage, involves the cognitive response to food and fluid and the ability of the person to think about eating. This is the initial phase, which starts with the mouth closing and chewing the food.
• Oral Transit Phase – is where the tongue works to move the food back towards the throat. Food and liquid is chewed and mixed with saliva, which is then pushed into the pharynx by the tongue.
• Pharyngeal Phase – is where the soft palate elevates and creates pressure within so food doesn’t go back into the nose. The food or fluid reaches the pharynx and triggers the swallow reflex. This acts to protect the airway so that food or fluid pass into the oesophagus and not into the lungs.
• Oesophageal Phase – is the final stage and involves the passage of the food and fluids down the food pipe (the oesophagus) into the stomach⁴.

Dysphagia

Dysphagia occurs when one or more of the four phases of swallowing is disrupted.

There are two main types of dysphagia:

Oropharyngeal dysphagia – trouble with moving food around the mouth and forming a bolus, as well as ‘initiating a swallow’. Patients are often medically unwell, and the most common causes are neurological disorders, such as stroke, Parkinson’s disease and dementia⁵.

Oesophageal dysphagia – the sensation of having food stuck in the throat or chest when swallowing and patients may complain of chest pain. Causes include gastro-oesophageal reflux disease (GORD), cancer, Zenker’s diverticulum, infection, inflammation, motility disorders and certain types of medications⁶. Oesophageal tract changes, which may contribute to swallowing difficulties, are common in people over 80 years.

Causes of dysphagia are varied and patients may present to hospital in the acute or chronic stage with varying symptoms. Patients who are severely ill or have a disability or who have suffered from stroke, brain injury, Parkinson’s disease or dementia, are especially at risk of developing dysphagia⁶.

Impacts of dysphagia

The more unwell an older patient is and the more their overall function is affected, the more vulnerable they are to developing swallowing problems. Critically ill older patients with dysphagia are at higher risk of developing life-threatening conditions, including aspiration and aspiration pneumonia, obstruction, pneumonitis and abscess^7,8.

Aspiration

Aspiration occurs when material is ingested and ends up in the lungs. This may be food particles, fluids, oropharyngeal secretions containing infectious agents⁹ or bacteria, which can cause an inflammatory condition⁸. Patients with dysphagia are at increased risk of developing aspiration, as are patients who are critically ill.

Silent aspiration and silent strokes

Silent aspiration is aspiration without any key clinical symptoms and signs, making it difficult to identify without imaging and assessment¹⁰. However it is common, occurring in more than 50 per cent of patients who aspirate⁵.

Similarly, ‘silent strokes’ are those occurring without symptoms and they are also a common cause of swallowing difficulties.

Aspiration pneumonia and pneumonitis

Dysphagia is also a risk factor for aspiration pneumonia – pneumonia caused by inhaling secretions or food that have been colonised by bacteria. Aspiration pneumonitis is caused by aspirating gastric contents. It is the most common cause of death in patients with dysphagia.

Malnutrition and dehydration

Older adults in hospital who have swallowing difficulties of any type are prone to weight loss and developing malnutrition and dehydration, which can severely impact their ability to recover from illness or surgery and remain independent and can increase the risk of other problems including delirium and falls.

Swallowing and ageing

Dysphagia is not considered a normal part of ageing; however, it can occur due to the physiological ageing process, especially in people over 80. Older people may have difficulty swallowing (mild) or may not be able to swallow at all (severe).

The ability to swallow can be affected by:

• loss of muscle mass and strength
• faitigue or exhaustion
• loss of dentition
• a decrease in mouth and tongue movements
• changes in eating habits and taste buds (often due to loss of senses of taste and smell)
• extended time in eating and drinking
• difficulty managing oral secretions¹¹
• food taking longer to travel down the oesophagus to the stomach.

For older people in hospital, swallowing difficulties can prolong recovery time and contribute to functional decline, frailty and loss of independence. Severe dysphagia is often indicative a person is in the end stage of their disease.

Hospital provides an ideal opportunity to identify signs of swallowing difficulties and help older patients achieve and maintain optimal nutrition and hydration during their stay. This assists us to prevent cascading problems such as delirium, incontinence, falls and pressure injuries.

Identifying people at risk of swallowing problems

Screening older people for swallowing difficulties is vital to avoid choking, dehydration, malnutrition and extended hospital stays due to complications with other illnesses. When swallowing difficulties are identified early, we can tailor care and treatment to respond to each person’s biological and medical needs, their abilities and their lifestyle and cultural preferences.

Screening patients who present with a stroke

Prompt screening is particularly important after stroke as no food, drink or oral medications should be given to the patient until it is clear there are no swallowing problems.⁷

Screen all patients who present with a stroke within 24 hours of hospital admission.

Speech pathologists recommend using the ASSIST (Acute Screening for Swallow in Stroke) screening tool (and training staff in its use), which is the most widely used, thorough, evidence-based dysphagia screen. It is one component of The Victorian Dysphagia Screening Model and consists of five short questions.

Screening patients with certain medical conditions

Many medical conditions can impact on the normal swallowing process. Finding out whether a person has experienced any difficulty is crucial, particularly with the following conditions:

• Parkinson’s disease and other neurological problems
• head strike due to a fall
• depression
• dementia (mild, moderate or severe)
• delirium
• previous surgery to the mouth, throat, nose, spine or brain
• cancer of the mouth, throat, head or neck
• GORD
• multiple comorbidities
• frailty which is associated with a high risk of dysphagia and malnutrition⁸.

Oral health should be screened at the same time as swallowing. Poor oral health and dental issues can seriously impact on swallowing and enjoyment of foods and liquids

Signs of swallowing difficulties

Look for signs of:

• difficulty swallowing or lack of swallowing⁷
• coughing before swallowing⁷, during meal times, or after eating
• heartburn⁷
• drooling^12,13
• taking a long time to eat and drink, wasting food
• altered level of alertness or reduced response
• speech or voice changes as they may indicate silent aspiration. Look for slurred speech, a weak, hoarse, crackly, gurgling or wet-sounding voice. If in doubt, ask family members if they have noticed any recent vocal changes
• a history of recurrent chest infections¹⁴ or suspected aspiration
• tongue, facial or lip weakness or altered appearance
• pocketing food or tablets in the cheeks
• the patient describing food as sticking to the roof of their mouth or throat, or the sensation of a ‘lump’ or discomfort in the throat or chest, or frequent throat clearing during meal times (can indicate GORD)
• unexplained weight loss⁷
• reluctance to swallow food, water or medication.

“I had difficulty swallowing tablets when I was in hospital. I had to take my teeth out and I didn’t want the staff to see me, but they have to see you swallow. They have to make sure that you take the medication. I don’t know if anything can be done about that. It was just my vanity but… It’s an issue”. Consumer

Gather information from the patient, their family and carers

If we observe any of the signs or symptoms of swallowing difficulties or the patient complains of any of these problems, we should gather further information from the patient and their family and carers, explore the history of these issues, raise the concern with the treating team and work together to mitigate any immediate risks.

As a first step, ask the patient, their family and carer:

• about the severity and duration of their swallowing problem
• if they have been self-managing this issue, and if so, ask them what strategies have been helping them
• to describe the location of the difficulty in swallowing
• about the types of foods or liquids which make swallowing difficult
• whether the swallowing issue is progressive or intermittent⁷
• if they are experiencing reflux, as it is often associated with dysphagia.

Swallowing and discharge planning

The ability to swallow and eat and drink easily is important for our health and wellbeing. As clinicians, we can help patients make a smooth transition from the hospital to their home or care facility.

A change in a patient’s swallowing ability can be daunting for an older person and their family to manage once they leave the hospital. To improve outcomes in this area:

• check that the patient understands their treatment goals and provide them with handouts and information to aid in their comprehension
• inform the patient's family and carers about the swallowing issues and ongoing interventions required so they can work closely with the patient to keep them well
• emphasise the importance of maintaining safe swallowing and good nutrition while at home or an alternative care facility
• provide verbal and written information about safe swallowing practices if these have been recommended, as well as oral hygiene and food preparation
• stress the importance of keeping well hydrated to sustain recovery and assist with managing dysphagia; dehydration can lead to a dry mouth and throat which will affect swallowing ability
• ensure the patient and their family and carer are aware of how to take prescribed medication
• provide the patient with information on where to purchase nutritional supplements if needed and check that they have the funds to do so
• consider referring the person to a community dietitian and speech pathologist to provide ongoing support
• refer the patient to social support services if necessary
  • There is a risk of older patients with dysphagia becoming socially isolated, as they may be reluctant to eat in front of others¹⁵
  • Find out if the patient was experiencing social isolation prior to their admission, and help them with strategies and referrals to access support
• recommend that the patient has regular dental checks as dental hygiene is an important factor in managing dysphagia.

As we get older, physiological changes can affect our metabolism, making it more likely that we will experience adverse reactions and side effects from medications. With age, we are more likely to have multiple medical conditions and be taking multiple medications, which puts us at higher risk of falls, delirium, hospital admissions, declining nutritional status, decreased physical and social functioning and death.

The ability to manage complex medication routines is influenced by a person’s level of social support and connectedness, with lower levels of support being associated with higher medication use.¹ If we understand a patient’s circumstances we can help them to manage their medications successfully.

Up to 30 per cent of hospital admissions for patients over the age of 65 are medication related and half of these are potentially preventable.²

This topic gives an overview of issues around medication use in older people. It recommends actions that we and our organisations can take to ensure older patients have an effective medication regime that they can manage.

In addition to following your health service specific policy and procedures, consider the recommended actions and discuss them with colleagues and managers.

Medication and ageing

“Medicines…have the potential to provide great gains as well as significant harms to older people” ¹

Physiological changes can cause adverse reactions

Medicines can be problematic for older people because as we age physiological changes can affect the way our body absorbs, distributes, metabolises and eliminates drugs. These physiological changes include increased body fat, decreased body water, decreased muscle mass, and changes in renal and liver function and in the Central Nervous System. These changes can cause adverse drug reactions (ADRs) in older people.

Frail older people are more likely to have pronounced changes in response to medicines. Generally, medications in frail older people aim to control symptoms and help maintain function.

For older people there can also be a higher risk of unintended consequences of medical treatment (iatrogenesis) related to medication.

Polypharmacy increases risk of adverse events and errors

As people age they are more likely to be taking several medications, including prescribed medications, over the counter or complementary medicines.

Taking multiple medications – known as ‘polypharmacy’ – increases the risk of medications being implicated in hospital admissions, particularly when an older person presents with falls, confusion or incontinence³. Polypharmacy can cause problems due to prescribing errors, problems with taking the medicines, and interactions of medicines.

When people take multiple medications, they are at greater risk of:

• falls and associated harms, such as fractures
• dehydration
• functional decline
• cognitive impairment
• delirium
• declining nutritional status
• adverse drug reactions
• hospitalisation
• mortality⁴.

Also, the more medications a person takes, the greater the risk of medication errors. These errors may be due to difficulty in getting an accurate medication history and review, in prescribing and in following complex medication regimes.

An average of five to seven medication changes are made during the hospitalisation of an older person⁵, which also increases the risk of prescribing errors and adverse drug events.

Hospital admissions can be related to medications

It is estimated that up to 30 per cent of all hospital admissions of people aged 65 years and over are medication-related, and approximately half of these could be prevented⁶.

Medication-related admissions in older people can be caused by:

• ADRs
• failure to receive or take a prescribed medication
• errors with taking medications.

Identifying medication risks and issues

Identifying people at risk

A patient is considered at risk of medication issues if they:

• are aged over 65 years
• take five or more medicines
• have conditions that are commonly associated with preventable medication-related hospital admissions – such as asthma/COPD, depression, cerebrovascular event, hip fractures, renal failure, acute confusion, bipolar disorder and hyperkalaemia¹.
• are identified as at risk of falls or have decreased mobility – some medications can alter balance and coordination
• have a cognitive or sensory impairment – the patient may not be able to follow medication instructions
• are identified as at risk of under-nutrition – nutrition and hydration play a major role in the absorption of medications
• are identified as at risk of incontinence – some medications may cause continence problems
• are identified as at risk of delirium – some medications can cause delirium
• are identified as at risk of depression – apathy may impact on the patient’s ability to take medications accurately
• manage their own medications and live alone or are socially isolated. They may be taking medications inaccurately, or they may have difficulty in accessing medication or seeking support regarding their medication. Conversely, social connectedness helps with medication adherence.²
• have been recently discharged from hospital - this is a high risk time for medication errors due to the number of medication changes that are typically made during a hospital stay
• have poor literacy or are from a non-English speaking background - this may impact on their understanding of how and when to take medications and what they are for.

Assessment can inform medication management

If a person is identified as being at risk of or as experiencing medication issues, we need to refer them to the pharmacist and treating doctor for a comprehensive assessment. This will inform our intervention plan. In addition, start by completing a Best Possible Medication History.

Best Possible Medication History (BPMH)

This is a complete medication history that should be taken for each patient identified as being at an increased risk of issues with medication management.

Obtain information for the BPMH by interviewing the patient and a family member or carer.

Collect the following information for the BPMH:

• current dosing schedules
• duration of treatment
• current indications
• allergies and ADRs (including a description of the reaction)
• current levels of adherence (the extent to which a patient follows the agreed instructions or recommendations for taking a medication as given by the health care provider).

Confirm the information through other sources, such as the patient’s medicine containers and medication list, their family (particularly if the person is quite unwell, has a cognitive impairment or receives assistance from someone to take their medications), GP, community pharmacy and other health services.

Medication reconciliation

To avoid errors in transcription, check that all of the medications the patients should be taking are what they are actually taking.

Repeat this process on admission, discharge and transfer of care between healthcare settings, for example, from the Emergency Department to the General Medical Ward.

To reconcile medications prescribed:

• verify against medicines ordered on the medication chart
• compare to admission, transfer and discharge orders
• resolve any discrepancies with the prescriber.

Reviewing the medications list

When complete, the medications list should be reviewed to focus on medications that are associated with the development of geriatric syndromes.

Targeting medications with the highest risk of causing injury could prevent more adverse drug events and emergency department visits.^1,2,3 These medications include Warfarin, Insulin, Digoxin, narcotics, opiates and sedatives. If an older person is taking any of these medications, discuss them with the treating doctor and refer to the ward pharmacist for further assessment. Along with the team’s clinical judgment, use the prescribing appropriateness criteria and the STOPP/START tool to minimise inappropriate prescribing during the review process.

Optimising medication use

Medication safety is improved and errors decrease significantly when strategies are put in place to increase the accuracy of medication history taking and medication reconciliation⁸.

There are several things we can do to support an effective and easy to manage medication regime for older people while they are in hospital.

Document medication information

Keep detailed records of medication to monitor for changes to the older person's baseline Best Possible Medication History (BPMH).

The records should include:

• BPMH
• medication reconciliation
• key information about each medicine (drug name, dose, form, frequency, duration)
• patient compliance/adherence issues
• support for managing medications, for example carer and family help the patient manage medicines; the patient collects medicines in a medicopak/webster pack from community pharmacy
• risk factors
• medicines recently ceased
• allergies and adverse drug reactions
• plans to continue, cease or change medicines during the patient’s episode of care, which can be used to inform the discharge summary and prescriptions at time of discharge.

Medication information tools

The following tools for documenting and sharing medication information can be used to reduce prescribing, dispensing and administration errors.

• Medication Management Plan (MMP) – use this standardised form to ensure complete and accurate documentation of medication information on admission and throughout the episode of care⁹.
• National Inpatient Medication Chart (NIMC) - is an evidence-based, best practice suite of nationally standard medication charts. The NIMC enables information to be communicated consistently between health professionals¹⁰. Use of the NIMC is a mandatory requirement for health service organisations seeking accreditation against NSQHS Standard 4.

Deprescribing

Deprescribing is reducing the dosage or discontinuing a medication with the aim of reducing the risks associated with polypharmacy and improving quality of life¹¹.

Talk to the patient, the doctor and pharmacist about the possible benefits of deprescribing and consider it after a thorough medication review when¹²:

• there is a risk of polypharmacy
• the patient is experiencing adverse drug reactions
• the treatment has been ineffective
• the patient has experienced a fall
• the patient's treatment goals have changed.

Approach deprescribing with caution, as there are both risks and benefits. Focus on improving quality of life, reducing risks and alleviating symptoms. Ensure that this is a shared decision with the patient¹⁰.

When considering deprescribing, the nursing, medical and pharmacy teams will:

• weigh up the benefits with the potential adverse consequences
• target patients with highest Adverse Drug Event risk
• target non-beneficial medications
• target drugs known to do harm or are inappropriate
• set a discontinuation regime and ongoing evaluation (ideally with the same clinician)
• set shared goals with the patients and provide education, as it can be daunting for patients and families to discontinue medications they have been taking for many years.

Balance the risks and benefits of medications

Medication use in older people involves balancing disease management with avoiding adverse events.

Discuss the risks and benefits of each treatment with the patient.

Consider how treatments may affect the patient’s care goals, such as maintaining physical function and independence.

Consider how medications may impact on the person’s quality of life.

Medication and discharge planning

As discharge can be an overwhelming time for patients and families, there is high risk for medication errors and misunderstandings. We can help patients make a smooth transition from the hospital to their home or care facility by providing comprehensive and clear information.

Prepare a discharge summary

Discharge summaries should include:

• a comprehensive discharge medication list
• detailed medication information (generic medication name, dosage form, dose, directions, route of administration, regular and PRN medication)
• indication and duration for new medication
• explanation of any changes that may have been made to their usual medications (differences to pre-admission medications)
• details of ongoing medication management plan and medication management needs (issues with taking the medications, recommendations for home medication reviews).

Educate patients and carers

• Provide the patient, and family and carers with an accurate list of medications
• Educate the patient and family and carers prior to discharge, including
  • proper storage and use of medications – demonstrate where possible
  • what to do if a dose is missed
  • potential side effects
  • when to call the GP or pharmacist about any concerns
  • refill information.
• Provide a written copy of all information that is given verbally.
• Consider what strategies will assist the patient to take their medication properly.
• Ensure the patient is able to follow medication instructions.
• Sometimes, pharmacists in hospitals can arrange a medication trial. This is a good way to see if the patient can take their medications independently before they are discharged home.
• Some Victorian hospitals have a pharmacy outreach service that can visit patients at home after discharge to review their medication management, provide education and facilitate continuity of care. These services do not require a GP referral. Link the patient to this service if needed. This is especially important if the patient lives alone and is socially isolated.

Make medication use simple

• Medication regimens should be as simple as possible – ideally with once or twice daily dosages.
• Medication instructions and dosages should be clearly written.
• Consider if the patient would benefit from the use of dose administration aids (DAAs), such as monitored dosage boxes. Remember that DAAs are not suitable for all patients, for example, patients with cognition impairments, vision impairments or limited dexterity. Assess the need and suitability first¹³.

Simplify medication supply

• Ensure the patient has enough medications to last to their next GP visit.
• Encourage the patient and their family and carer to:
  • always carry an up-to-date list of medications
  • use only one pharmacy and visit only one GP.
• Synchronise medication quantities so the patient can make repeat orders at the same time.

Inform the GP

• Ensure discharge information is accurate and reaches the GP in a timely manner.
• Provide the following information to the GP:
  • medication changes and the reasons why
  • need for follow up or review
  • need for a GP-initiated Home Medicines Review (HMR). Commonwealth Government-funded HMRs must be initiated by the patient’s GP and carried out by an accredited pharmacist.

Inform the pharmacy

Ensure discharge medication information is provided to the patient’s community pharmacy, especially if a pharmacy-packed DAA will be used after discharge.

Inform the care services

If the patient is being discharged to a residential aged care facility or a community nursing service, ensure that a medication chart will be available to facilitate continuity of medication administration (usually this requires provision of an interim medication chart from the hospital).

Practice person-centred care

Medicine safety is best achieved in partnership with older people and the risk of error is greatly reduced with patient involvement. Older people place great importance on maintaining independence in self-management of medicines and have a strong sense of responsibility for this¹⁴.

To improve the quality of life of older people and prevent functional decline, pain should be identified, assessed and managed.

All healthcare professionals should be alert to the possibility of pain in older people. We should be prepared to treat the cause of pain and the pain itself.

Pain and ageing

Almost 46 per cent of hospital patients aged 80 years or older report experiencing pain and almost 13 per cent of those are not satisfied with the pain control provided¹.

Older people can be under-treated for pain because of misconceptions about ageing and pain.

Some older people are less likely to report pain as they think it is a natural part of ageing, they don’t want to be a nuisance to staff, or they worry that pain signals disease progression which could mean more medications with undesirable side effects, diagnostic tests and loss of independence².

Common causes of pain in older people

Common causes of pain in older people include:

• arthritis (osteoarthritis and rheumatoid arthritis)
• fibromyalgia (a condition characterised by widespread pain and other symptoms)
• cancer
• circulatory problems
• bowel disease
• urinary tract infections
• pressure injuries
• old injuries
• infections.

Impacts of pain on older people

Pain can have a negative impact on an older person’s quality of life, contributing to:

• impaired mobility or immobility and associated muscle wastage
• depression and anxiety
• social isolation
• financial distress
• sleep disturbances
• reduced participation in everyday activities
• confusion and delirium
• fatigue
• delayed healing and recovery
• pulmonary complications
• increased mortality.

Persistent pain in older people can also have a negative impact on their:

• gait
• physical condition and muscle strength
• risk of falls
• cognitive function and mood
• nutrition
• ability to participate in rehabilitation activities.

Identifying pain

Screening questions

Ask the patient if they are experiencing any pain using questions like the following.

• Do you have pain/are you aching or hurting anywhere right now?
• Where do you have pain/are you aching or hurting?
• How long have you been in pain/aching/hurting?
• Does pain/aching ever keep you from sleeping at night?
• Does your pain/aching ever keep you from participating in activities/doing things you enjoy?
• Do you have pain/are you aching or hurting every day?

If the older person has no pain on admission, record ‘0’ as the pain score and advise them to let staff know if pain develops.

If the older person does report pain during the initial screening interview, then further assessment of pain intensity, location, quality and symptoms is needed to guide diagnosis and treatment.

Assessing for pain

There are two main methods for identifying pain in older people: self-report and observational.

Self-report

Self-report is the most reliable source of information on pain. Use it with all older people, including those with a cognitive or communication impairment.^3,4 Self-report of pain may be obtained by:

• asking an older person questions about their pain – consider using terms such as ‘hurting’, ‘aching’ and ‘soreness’ and document these terms if the older person uses them³
• using a pain intensity scale
• using a multidimensional self-report tool.

All self-reports should be taken seriously, including those from older people with a cognitive impairment.⁶ Self-reported pain from people with a severe cognitive impairment or non-communicative patients should be cross-validated with an observational pain assessment and, where appropriate, discussed with the patient’s family or carer. However, take care when using family or carer reports of pain in an older person, as pain intensity may be over- or under-estimated.⁴

Self-report pain assessment tools

Multidimensional tools are used for an initial comprehensive pain assessment. They evaluate the sensory component of pain (what the person is feeling), the emotional response to pain (impact on the person’s function and relationships, and the meaning of the pain) and quality of life (activities, mood, sleep). The following tools may be used.

• Short-form McGill questionnaire
• Brief pain inventory – short form
• Brief pain inventory – long form
• Pain disability index.

Unidimensional pain assessment tools are used for ongoing evaluation of pain intensity and response to treatment. They evaluate only the sensory component of pain. Examples include:

• Numeric Rating Scale (NRS)
• Verbal Descriptor Scale (VDS)
• Pain thermometer
• Visual Analogue Scale (VAS)
• A pictorial pain scale (FACES pain scale).

Some patients prefer to use numbers to describe their pain, while others prefer words. If you are not successful in using one type of self-report tool with an older person, try a different tool.

Observational

In older people who have severe cognitive impairments or communication difficulties, their behaviour may be the only external indicator of pain.⁴

Pain behaviours are individual, so identifying pain requires clinical judgement and familiarity with the older person. Involving family and carers can help with identifying and confirming observational pain.⁴

The following observation scales are recommended for older people with severe cognitive or communication difficulties.⁷

• Pain assessment checklist for seniors with limited ability to communicate (PACSLAC)
• Pain Assessment in Advanced Dementia (PAINAD)
• Abbey Pain Scale

Pain should be assessed at rest and during activity, such as movement or transfer.

Managing and treating pain

The treatment and management of pain should be based on the findings of a pain assessment.

Treatment approaches vary according to the type of pain, but all involve a combination of pharmacological and non-pharmacological approaches.

Coordinated, multidisciplinary treatment strategies are sometimes required, particularly if pain persists and does not respond to conventional treatment.

The National Pain Strategy (2010)¹¹ , which is currently under review, recommends a multidisciplinary pain management plan that includes a combination of medical approaches, physiotherapy, environmental and psychological interventions based on Cognitive Behavioural Therapy (CBT).

Identify the pain

Classify the pain to inform treatment planning.Most chronic pain may be classified as:

• nociceptive - pain that arises from actual or threathened damage to non-neronal tissue and is due to the activation of nociceptors. This could include post-operative and inflammatory arthropathy (such as arthritis or gout) and may be described as dull, aching or throbbing.
• neuropathic - to describe pain caused by a lesion or disease of the somatosensory nervous pain, it is often described as burning and may be associated with tingling, pins and needles, numbness or itching.

Some types of pain can be both nociceptive and neuropathic (cancer pain)

• Treat pain without a pain score when the older person is not able to focus or use a pain rating scale or is visibly in pain¹².
• Always consider the possibility of pain in all contacts with older people.
• Ask older patients about pain routinely and be aware of behaviours that might indicate underlying pain.
• Regularly record assessment results to facilitate ongoing care.

Manage the pain

Follow your hospital policies and procedures and pathways for pain management.

Consider pharmacological and non-pharmacological approaches:

A pharmacological approach requires an understanding of the mode of action, common side effects and common drug interactions. Medication dose, administration, monitoring and adjustment must be carefully considered, taking into account age-related changes in drug sensitivity, efficacy, metabolism and side effects. Analgesic treatments should be tailored to individual needs.

• Consider pre-emptive analgesia prior to any medical procedure (IV cannulation, dressing change), or rehabilitation procedure (physiotherapy exercises) likely to cause significant pain.
• Consider patient-controlled analgesia post-operatively.
• Chronic pain is best managed with around-the-clock analgesia. Medications should be given, even if the person doesn’t have pain at the time the medication is due.
• Monitor regularly for any side effects following pain treatment (such as nausea, vomiting, sedation, constipation or dizziness)
• Address opiophobia:
  • Many older people with pain respond well to opioid therapy, particularly if nociceptive pain. Opioids should not be denied because of fears of addiction.
  • It is reasonable for a person with severe pain to seek and/or be offered analgesia.
  • Addiction, also known as psychological dependency, is manifested by opioid-seeking behaviours for reasons other than pain relief. Psychological dependency should be differentiated from physical dependency.
  • Physical dependency occurs after a person has been on certain medications for some time, including opioid analgesics, and is manifested as withdrawal symptoms if the drug is suddenly stopped. Chronic opioid therapy should therefore not be abruptly stopped.
  • Opiophobia by health care staff may contribute to persistent unrelieved pain.
• Simple analgesia, such as regular paracetamol, is well tolerated and can provide a background level of analgesia. If the person's pain is not well controlled the addition of opioids provided regularly and/or as required can be an effective strategy to manage a person's pain.
• Some medications that are not typically used for pain may also be helpful for its management. Examples of these include tricyclic or SNRI antidepressants and gabapentinoids. These may improve the quality of opioid analgesia and limit the development of opioid tolerance.

Non-pharmacological approaches include psychological approaches (cognitive behavioural therapy, relaxation, education), physical therapies (physiotherapy, occupational therapy, superficial heat and cold, TENS, gentle exercise, hydrotherapy), and complementary and alternative therapies (acupuncture, massage, other supplements).

• Encourage the older person to move regularly around the ward if they are capable and it is appropriate.

Refer the patient for an inpatient management assessment or to an outpatient multidisciplinary pain clinic on discharge if their pain persists after pharmacological and non-pharmacological therapies.

Re-assess pain regularly

• Interventions introduced to manage pain should be regularly re-assessed.
• Re-assess pain levels every one to two hours until the pain episode is under control (for example, post-procedural pain).
• Increase the frequency of pain assessments if:
  • pain is poorly controlled, that is, if the patient is experiencing moderate pain, scores 5/10 on a measurement scale or the pain stimulus or intervention alters. Consider the potential for undiagnosed serious pathology, including ischaemia.
  • an analgesic infusion is in progress, which indicates a higher intensity of pain and appropriate safety monitoring occurs.
• Reassess pain after analgesic treatment to determine if:
  • the treatment was effective
  • further treatment is necessary
  • any side effects have occurred as a consequence of the treatment (for example, nausea, vomiting, constipation and sedation).
• Wear badges and use stickers on care plans as visual reminders to regularly assess and report pain.

Assess and document the pain assessment outcome and pain management treatment provided^12,13.

Pain and discharge planning

We can help patients make a smooth transition from hospital to their home or residential aged care facility by planning their discharge and providing information about what to do when they leave hospital.

Develop a discharge plan

Pain should be assessed as part of hospital discharge.

Allow enough time to develop a pain management discharge plan with the older person and their family or carer.

Ensure the person’s GP and other healthcare professionals are informed of the care plan and ask them to be involved in developing the plan.

The plan should include:

• the person’s functional goals following discharge
• a list of prescribed medication, including the dose, frequency and expected duration medication is to be taken. If an opioid has been started during the admission, outline the prescribing plan and include the potential weaning strategy as the pain resolves
• prevention and management strategies for potential medication side effects
• restrictions and precautions associated with prescribed medication, such as limitations on driving and work
• potential drug interactions between pre-hospital prescribed medication, over-the-counter medication and medications prescribed on discharge
• details of the person who should be contacted (by the patient or their family or carer) if pain relief on discharge is inadequate
• details of follow-up appointments or referrals for outpatient or community-based rehabilitation.

Share the plan

Give the older person and their family and carers a copy of the pain management discharge plan.

With the older person’s consent, and where appropriate, give a copy of the pain management discharge plan to their:

• GP
• residential aged care facility
• rehabilitation service
• community services.

Educate patients and carers

Older people and their family and carers should be educated about implementing the pain management discharge plan and the importance of maintaining adequate pain control on discharge.

Discuss ongoing pain control with the older person and their carers prior to discharge.

Medication information

Provide information about medication doses, how often the medications need to be taken and for how long, and how to deal with any side effects. Discuss the plan regarding a medication review and weaning strategy if improvement is expected. Encourage older people to request pain relief at the onset of pain.

Self-managing pain

Provide information on self-management interventions to reduce pain, including:

• energy conservation
• pacing activity
• work simplification techniques
• relaxation strategies and anxiety reduction.

Social engagement

Pain can increase the risk of social isolation. Help the older person to find ways of becoming or remaining as engaged as possible and include these strategies as part of their discharge plan.

Informing others

Remind older people to tell healthcare professionals about any pain they feel, where it is, the intensity and characteristics of the pain, activities that make pain better or worse, and how pain impacts on their daily routine (appetite, sleep, mood, mobility).

Managing chronic pain

Sometimes chronic pain cannot be relieved; however, the negative impact can be reduced. Give older people advice on how to deal with chronic pain. Share the following strategies.

• Find out as much as possible about the condition so you understand what is happening and don’t worry unnecessarily about the pain.
• Keep active and exercise gently, even though this may cause some discomfort. Discuss what options would be best with your doctor.
• Take steps to prevent or reduce depression and loneliness by any means that work for you, including talking to friends or health professionals.
• Think positively; identify and challenge negative thoughts you have in response to pain.
• Don’t let pain interfere with your life more than necessary – if you miss activities you used to do before the pain, try reintroducing them gradually and remember to pace yourself. Take pain medication before an activity that you know will aggravate your pain. You may need to cut back on activities if pain flares up, but you will be able to increase slowly again as you did before. Remember: pacing, planning and pre-emptive pain medication.
• Recognise that pain increases your risk of becoming socially isolated. Make an effort to stay engaged and involved with others and your community.
• Focus on finding enjoyable and fulfilling activities that don’t aggravate your pain.
• Seek advice on different types of coping strategies.
• Seek a referral to a pain clinic or chronic pain specialist or team if pain is ongoing.

As modern healthcare has been successful in keeping more people alive, with illness, for longer, the nature of hospitalisation is shifting from cure to care, including managing the end of life. There are more older people in our population; people are living longer; and more people are living with chronic disease, dementia and increasing frailty.

Many people experience disease that results in increased disability often with recurrent hospital admissions and progressive decline over time. Our role is to highlight increasing chronic disease, to shift our focus from prolonging life to maximising quality of life and providing appropriate care to patients and their families.

Palliative care is an approach that improves the quality of life of patients and their families with life-threatening illnesses through the prevention of suffering including physical, psychological and spiritual suffering.

A palliative approach to care is relevant and will benefit any older person who has an illness or condition that is likely to affect how long they will live or if they are becoming frail.

Palliative care is 'an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.'^1.

Palliative care is not just for when the person is dying or at the end of their life; it is for any time during a terminal illness. 'Palliative care:

• provides relief from pain and other distressing symptoms
• affirms life and regards dying as a normal process
• intends neither to hasten or postpone death
• integrates the psychological and spiritual aspects of patient care
• offers a support system to help patients live as actively as possible until death
• offers a support system to help the family cope during the patient’s illness and in their own bereavement
• uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated
• will enhance quality of life, and may also positively influence the course of illness
• is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.'¹

Palliative care and ageing

People and their families with the following conditions may benefit from palliative care.

• Progressive dementia
• People dying as a result of the ageing process
• Advanced heart disease
• Advanced respiratory disease
• End-stage renal failure
• End-stage liver disease
• Secondary cancers
• Degenerative neurological conditions

Specialist palliative care is care provided by those who have undergone specific training and/or accreditation in palliative care/medicine working in the context of an expert interdisciplinary team of palliative care health professionals and the designated service system funded to deliver palliative care.² These services support people with life limiting illness in a number of ways, including:

• direct care for people requiring specialist palliative care interventions for management of complex symptoms/care needs
• consultation and advice to other services and health care teams providing end of life care
• education and training on palliative care and end of life issues
• undertaking and disseminating research about caring for the dying and their families/carers.

Not everyone with a life limiting illness will require access to specialist palliative care. In many instances, the most valuable role specialist palliative care can play is to support other healthcare teams and professionals to provide end of life care to their patients.

All patients with a life limiting illness and their families and carers will require support and care from health professionals who understand and are skilled in the palliative approach to care.

A palliative approach to care incorporates an holistic approach that considers and meets all aspects of the person’s and their families, physical, emotional, spiritual and psychosocial needs.

A palliative approach to care emphasises comfort and quality of life and involves a team approach to care.

A palliative approach to care also considers some of the challenges for older people as they near the end of life:

• loss of independence
• having to rely more on others for assistance
• losing control of their life
• not being able to think as clearly as they used to
• changes in physical appearance and functional abilities
• depression/anxiety
• increased social isolation and/or feelings of loneliness
• not feeling valued
• feeling a sense of being a burden to others
• not being treated with respect or understanding.

Responding to the need for palliative care

Communication

When we have identified that a patient needs palliative care, we should introduce the approach to the patient, and to their family and carers, in a clear and sensitive way.

When introducing and providing palliative care, good communication is critical.

Communication occurs in many forms with the person, family member and between team members and other care providers. It can be verbal, non-verbal and written.

The key principles of communication are:

• Individualise communication
• Listen
• Check and clarify
• Maintain dignity.

Communication needs to be individualised by considering:

• The person’s culture
• Their emotional state
• The diagnosis
• Current conditions
• Disabilities and impairments such as vision, speech and cognitive impairment.

It also needs to involve family members as appropriate.

Greet the person by name, use eye contact and position yourself at their eye level.

Consider non-verbal language such as movements, posture, gestures, facial expression and eye contact.

Ask open questions.

Avoid providing lengthy explanations early in your interaction and take time to hear issues from the person’s perspective.

Use facilitative statements such as “tell me about that”.

And maintain a person’s dignity at all times by:

• Greeting the person and calling them by name
• Treating the person as an adult
• Giving them privacy
• Finding out about their earlier life
• Maintaining their comfort.

Develop a care plan

Good communication can facilitate the development of a comprehensive care plan that is both medically sound and has the patient’s wishes and values at the forefront³. If discussions around the preferences for end of life care are prolonged or avoided, patients and their family may have limited opportunity to appropriately prepare for death.

Do not assume

Be curious and do not assume that the patient does not want to discuss their prognosis or end of life care just because they have not raised the issue themselves or because of their cultural or spiritual background. It is also important not to force the patient to have discussions about their prognosis or end of life care.

Check advance care planning

Check if the person has an advance care plan. Advance care plans identifies and documents and individual’s future wishes and preferences based on the values that are important in their life and ensures that end-of-life goals have been established. It also helps establish a plan based on discussions between the person, the family and their care providers and assists them to understand a person’s end-of-life choices.

Palliative care - grief and loss

Our role extends to caring for the person and their family after death. This care can include the following:

• Making the call to the person’s family that they died. This can be daunting, so speak to experienced clinicians about the strategies they find helpful in this situation.
• Preparing the person’s body and cleaning the hospital room to prepare for viewing as soon as possible after death.
• Being aware that personal care after death is best carried out within two to four hours of the person dying; this preserves their appearance, condition and dignity.
• Providing support to the family and friends and giving them the opportunity to participate in the process of preparing the body if they wish to do so.
• Honouring the spiritual and cultural wishes of the older person and their family and friends, for example, having a family member wash and care for the body or ensuring only someone of the same gender washes and cares for the body.
• Preparing the person’s body for transfer to the mortuary, funeral director or other location based on the older person’s and their family’s wishes.
• Using the person’s preferred name and give families some warning of what to expect if they have not been present. This can be as simple as normalising the fact that once a person has died their body can become stiff and a bit cold to touch, but it can be comforting to touch their hair.
• Ensuring privacy, respect and dignity of the deceased person is maintained.
• Honouring people’s wishes for organ and tissue donation.
• Ensuring the safe return of the deceased person’s personal possessions to the relevant family member or friend.
• Providing family and friends with written information about the processes following death, such as what will happen with their body, how to collect the death certificate, the role of the funeral director and bereavement support services. Provide them with the opportunity to ask any questions. Some hospitals have bereavement procedures and provide a follow up phone call to families. Follow your health service procedures.

We should also be mindful that other patients and their families will be aware the person has died and this may raise some emotions for them. It’s best to acknowledge and respond to these concerns.

Grief and loss

Grief is a common and especially significant concern for carers and family members. Reassure family and caregivers that these responses are common and that grieving is the normal response to the death of a loved one. Grief is profound as it affects so many domains of our lives. Early actions can be taken to minimise distress associated with grief.

It can manifest as sadness, anger, fear distress, despair, anxiety, guilt, worrying thoughts, sleep disturbance, social withdrawal and/or decreased ability to maintain an organised lifestyle.

Grief can also trigger feelings of loneliness and social isolation for family and carers. These feelings may be pre-existing but exacerbated by the loss, or caused by the grief if a person withdraws from their usual activities. It is important to ask how they are feeling, acknowledge their feelings and help them to seek appropriate support and engage with others. It is also important to:

• allow a person to talk about their concerns
• offer practical support
• allow for individual responses
• accept strong responses or stoicism
• take time, don’t rush
• encourage family and friends to take time to say goodbye

Managing physical symptoms

People who need palliative care may experience some of the following symptoms, depending on their illness. These symptoms can impact on their quality of life and be distressing for their family and carers.

We need to be familiar with these symptoms and work with our team to determine what can be addressed:

• Pain
• Delirium
• Nutrition and hydration
• Breathlessness
• Oral health problems.

Palliative care patients may experience more than one symptom at a time.

Pain

Pain is something that is felt and is subjective. It is what the person says it is and not what others think it should be. It is also individual with physical, psychological and spiritual dimensions. And pain is under-treated for many reasons. Under reporting of pain for people with dementia is a particular problem as it can be difficult to assess.

Use simple words to ask about pain such as hurting, aching burning, stabbing. And allow time for the person to reply.

Observe and assess:

• Changes in behaviour
• Facial expressions and grimaces
• Vocalisations
• Crying
• Breathing patterns
• Body language.

Ask about pain regularly, especially when changes have been made to the patient’s regime. Document the responses and consider conducting a comprehensive pain assessment.

We can try to relieve the patient’s pain, for example, by:

• A change of position
• A gentle massage or using hot packs (be careful using these if the older person has a problem with feeling heat or cannot easily move the pack if it causes discomfort)
• Distraction techniques, such as talking, music
• Medication.

Referral to a specialist palliative care service for assistance with pain management should also be considered.

Delirium

Delirium is quite common in palliative care patients, with the incidence reported as high as 85 per cent of patients. Delirium can be caused by a one or a number of factors, including:

• Medications
• Infections, such as a urinary tract infection or chest infection
• Acute metabolic disturbances
• Dehydration
• Poor symptom control, for example, constipation or urinary retention
• Drug withdrawal.

Palliative care patients who have delirium can:

• Appear confused
• Have difficulty focusing or paying attention
• Experience sleep disturbances, for instance awake overnight and asleep during the day time
• Be very physically restless
• Be quiet and withdrawn
• Have no concept of time or place
• See, hear or feel things that are not there¹.

Report and manage delirium by:

• Identifying and treating underlying causes such as infection, dehydration and/or pain
• Reviewing medication to see if it is contributing to the problem
• Speaking calmly to the person and make them aware of where they are, who they are with and orient them to time and place
• Implement strategies to minimise the risk of injury
• Provide routine and a familiar environment to help with the person’s orientation and awareness.

Nutrition and hydration

Many factors can contribute to decreased nutrition and hydration at end of life. Contributing factors can include:

• Difficulty swallowing
• Poor oral health
• Confusion/not recognising food
• Need for increased assistance to eat
• Decreased desire to eat and drink.

Investigate and determine reasons for a change in eating and drinking behaviour. Review and respond to the person’s wishes regarding nutrition and hydration. At the end of life, management will depend on the person’s wishes.

There are often psychosocial implications around loss of appetite and nutritional changes for a person and their family. Often the most distressing symptoms for family members to see if weight loss and increasing frailty. There may also be cultural, symbolic or religious meanings to food, drink and eating that need to be considered.

Artificial nutrition and hydration may not be beneficial in last stages of life and does not prolong life. In some instances it increases the person’s discomfort and the body does not require it in the last few days of life. It is important, however, to have the discussion with families around artificial nutrition and hydration so that they understand the implications for end of life care.

Breathlessness (dyspnoea)

Breathlessness is the unpleasant sensation of difficulty in breathing. It impacts on quality of life, activities of daily living, mobility, anxiety, fear and social isolation.

Observe changes in breathing behaviour including the rate and depth of breathing.

Observe signs of fear or distress that makes breathing worse.

Observe changes in functional ability due to breathlessness.

Observe changes to skin colour.

Assess timing of breathlessness including how often it occurs, when it occurs, how long it lasts and how long between episodes.

To assist with the management of breathlessness:

• Minimise anxiety and distress
• Position the person in a more upright position
• Speak calmly and reassuringly
• Pace physical activity
• Pharmacological agents may be prescribed depending on cause.

Problems with breathing can be distressing for the older person and their family. Keep them informed about what can be managed and what is normal towards the end of life.

Oral health problems

Quality of life is affected by mouth pain, ulceration, dry mouth and swallowing difficulties.

Notice indicators of potential oral health problems such as broken teeth, broken or missing dentures, a swollen face, the condition of the tongue and bad breath.

Regular oral hygiene needs to be provided and encourage the person to drink water after meals and after taking medication.

Dry mouth is often caused by the disease or the medication regime. We can conduct an oral examination to determine what could be causing the dry mouth and implement the following regimes to improve dry mouth:

• Regular mouthwashes with water or water with sodium bicarbonate
• Frequent sips of water to maintain hydration if possible
• Using a soft toothbrush and gentle brushing twice daily
• Offering foods that aid in increasing saliva, such as pineapple chunks, frozen lemon slices and chewing gum
• Using saliva substitutes such as sprays and gels
• Using lip balm or lanolin based balms to prevent cracking of lips
• Referring to a pharmacist consultant for a medication review.

Swallowing difficulties are common at the end of life and dysphagia, a severe swallowing difficulty, is a sign that a person’s disease is at end stage. If a person is having swallowing problems, we can refer them to a speech pathologist for a swallowing assessment and guidance for appropriate interventions.

We can assist an older person with swallowing difficulties to eat by ensuring that they:

• Have meals in a quiet place with no distractions
• Take small mouthfuls and eats slowly
• Avoid talking while eating
• Swallow each mouthful before taking another
• Positioning them sitting upright with the head forward (not leaning back) when meals or drinks are taken and for at least 30 minutes afterwards.

Managing personal, emotional, cultural and spiritual needs

People receiving palliative care can experience heightened emotions and may value the opportunity to express their identity and culture and to practise their spiritual and religious rituals.

We need to enhance our ability to respond to people’s individual wishes so that we can provide quality and respectful care.

Emotional needs

In addition to physical symptoms, people who are at a palliative stage often experience emotional symptoms, such as anxiety, loneliness, depression and anger, which are all associated with grief.

Anxiety can include feelings of apprehension, fear and dread, which can lead to nausea, dizziness, shortness of breath and diarrhoea.

Loneliness is a ‘subjective, unwelcome feeling of lack or loss of companionship or emotional attachment with other people’² . It is often experienced in conjunction with social isolation, if the person has little social contact or others have withdrawn from them. Some people may feel alone even when in the company of others.

Depression may result in a loss of pleasure or interest in things around them. Depressed people may feel hopeless or helpless and become isolated from those around them.

Anger can affect the way people talk, act and accept their treatment and it is a common reaction to a life-threatening illness.

The following are some communication strategies we can use to help older people and their families in palliative care who are experiencing emotional symptoms:

• Listen to their concerns, regardless of how we perceive the situation.
• Acknowledge their emotion: “I can see you are very upset/angry”.
• Invite them to tell their story: “Can you tell me what’s bothering you?” and listen out for goals we may be able to address.
• Reframe emotions or situations from ‘negative or difficult’ to an opportunity or catalyst to further explore a situation.
• Align our body language with the intention to listen, nod, make eye contact, don’t cross our arms, etc.
• Avoid interruption
• Use skills such as empathy, reflection and validation to negotiate a realistic goal – sometimes it can be as simple as saying we will ask the doctor to give them a call.
  • Empathy: “ It sounds like what you are going through is really upsetting and difficult”
  • Reflection: “So I hear you saying you are very concerned that…?”
  • Validation: “It’s understandable that you feel angry about …
  • Negotiate: “It’s afterhours now, but what I can do is…?"

These strategies may not solve the issue every time and we may need to call on support from experienced and senior clinicians, but often just listening to the person’s concerns, displaying empathy and validation can diffuse a situation and provide the person with some sense of control in a situation that can be very disempowering.

Cultural and spiritual needs

Cultural safety is providing an environment that is respectful of an individual’s culture and beliefs. Spiritual care may become more important to people when they are in a palliative state, and their spiritual needs may include finalising things they have set out to do and ‘making peace’ with others or they may be religious or spiritual beliefs.

It is important to be aware of any religious or spiritual beliefs or rituals a person may have during their palliative care and after death.

Aboriginal or Torres Strait Islander

Aboriginal and Torres Strait Islander (Aboriginal) people can have different and unique languages, customs, beliefs, healing practices and cultural practices depending on what community they are from. For many Aboriginal people, the topic of death and dying is a very sensitive area. However, you cannot generalise across all Aboriginal communities in relation to spiritual values and beliefs.

It is important that you find out from the older Aboriginal person their cultural and spiritual values and preferences in relation to:

• Place of death
• Who should be there
• What care is needed when they have died, such as disposal of the body and associated rituals.

For some Aboriginal people, these cultural and spiritual needs may be more important than meeting physical needs, such as pain relief.

It is also important to consider the Aboriginal person’s family and community. An Aboriginal Health Worker or Liaison Officer may help Aboriginal people and their family and carers feel more comfortable and at ease with their care.

Some factors that we need to consider when an Aboriginal person is receiving palliative care in hospital include:

• Involving the family in providing direct care in the hospital environment
• The size of the rooms due to the large number of visitors
• Accommodation for the family
• Access to external spaces
• Type of food provided, with Aboriginal person requesting traditional or ‘bush tucker’
• Environment of the hospital being considered too sterile and alienating; Aboriginal art and artefacts may help make it more welcoming
• Accommodating special ceremonies.³

There may be certain cultural practices that need to be followed after the death of an Aboriginal person.

Culturally and Linguistically Diverse (CALD)

To provide culturally appropriate palliative care to older people, we need to understand the meaning of death and dying from the person’s cultural perspective. As we can’t know all cultural beliefs and practices in relation to palliative care, death and dying, we should ask the older person and their family what is important to them.

If the older person is unable to communicate clearly in English, use a translator and provide written information about services or treatment in the person’s preferred language.

Be aware that not all people from the same country speak the same language, for example, people from China may speak Cantonese or Mandarin. First determine the person’s spoken and written language.

A person’s customs and values may be based on the country they are from or their religion. People from one country may have different religions.

Customs or values that people may have that are important in relation to palliative care may include:

• Importance of the family
• Discussing private issues with health professionals or non-family members
• The amount of information they want about their diagnosis and prognosis
• Whether it is appropriate to communicate with the family about diagnosis and prognosis
• Importance of food or refreshments
• Feelings about hospitals
• Attitudes to pain management
• Certain medical practices that they want withheld
• End-of-life rituals, for example, last rites, visits from friends and family, patient giving away belongings
• Post-death rituals, for example, what needs to happen to the body in preparation for burial
• Post-death procedures, for example, autopsy or organ donation.

Lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual (LGBTIQA+) people

When a person is nearing the end of their life, it is important that the people they choose are included and recognised in their healthcare.

When grieving, it is important that a bereaved same sex partner is provided with the same support as a bereaved heterosexual partner is given.

All people should be provided with the opportunity to express and live as their chosen gender identity during palliative care.

Supporting family and friends

Watching a loved one go through palliative care can be a difficult time, and it is important to support family and friends both during the palliative care stage as well as afterwards. We can help family, carers and friends cope by informing and educating them about:

• What they can do as a carer to help the older person
• The diagnosis and prognosis of the illness
• The cause of the illness
• Symptoms and how to manage them
• Treatment options and side effects
• What to do at the end of life.
• What to expect after their loved one has died
• The experience of grief, isolation and loneliness
• Where to seek support.

As we age, our skin can experience changes that make it more vulnerable to damage.

Older people, especially those who are frail, are at significant risk of developing pressure injuries and skin tears.

Hospital acquired pressure injuries and skin tears are considered an adverse event. Most pressure injuries and skin tears can be prevented by following simple steps such as maintaining good nutrition and hydration, regular but careful mobilisation, good skin hygiene and a good moisturising regime.

This topic defines pressure injuries and skin tears and their impacts; describes methods of screening and assessment for risk; and recommends interventions to prevent and manage pressure injuries and skin tears. In addition to following health service policy and procedures, consider the following actions and discuss them with colleagues and managers.

Definitions

A pressure injury is ‘a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors’.¹ Pressure injuries can also be called pressure ulcers or bed sores.

As pressure injuries usually occur over bony prominences, such as the sacrum or base of the spine, heels and hips, they are often not visible.

The severity of pressure injuries can be classified using a staging system. Management and treatment of pressure injuries depends on the stage.

A skin tear is ‘a wound caused by shear, friction and/or blunt force resulting in separation of skin layers’.²

Skin tear severity can be classified according to the Skin Tear Audit classification system. Management and treatment of skin tears depends on its classification.

Impacts

Hospital acquired pressure injuries and skin tears are considered an adverse event and can have a profound physical, social and psychological impact on the lives of older people.

This is going to affect her mobility, and emotionally this is going to make her shattered.
- Family member, Western Health

Older people who experience pressure injuries and skin tears while in hospital are at increased risk of:

• morbidity and mortality
• pain
• reduced mobility and loss of independence; which increases the risk of developing pressure injuries
• longer hospital stay
• reduced quality of life
• anxiety and worry
• reduced social contact and increased social isolation.
• loneliness.

Skin and ageing

Older people are at risk of skin damage, as changes that can occur to skin as it ages can affect its integrity, making it more vulnerable to damage, and to the development of a pressure injury or skin tears³. In addition, older people in hospital are likely to spend more than 23 hours per day either in bed or sitting⁴.

As skin ages it:

• becomes thinner and less elastic
• loses moisture and can become dry and more vulnerable to splitting and cracking
• develops folds and wrinkles
• loses its cushioning layer of subcutaneous fat
• has decreased sensory perception and is less likely to be able to detect temperature changes or pain
• has decreased temperature control and therefore an older person is less able to regulate their body temperature
• is more easily injured (prone to tearing and bruising)
• is slower to heal^5,6,7.

Pressure injuries and skin tears and discharge planning

We can help patients make a smooth transition from the hospital to their home or residential aged care facility through comprehensive and clear discharge planning and communication.

If a patient is ready to go home with a continued need for wound dressings, talk to the patient and their family and carers about the type of dressing regime that will work for them.

Involve appropriate support services, such as home nursing, and communicate the person-centred care plan to ongoing care providers.

Having a wound increases the risk of a person becoming socially isolated and experiencing loneliness. Find out what social support the person has, and include their engagement with formal or informal supports as part of their discharge plan.

Provide a discharge summary, including the wound management plan, to the patient’s GP. Ensure the patient and their family and carer also receive a copy of the discharge summary and wound management plan.

Make referrals to allied health specialists or other services as appropriate:

• wound specialist or clinic if wound advice is required
• dietitian if malnutrition or dehydration is suspected
• podiatrist if foot care or footwear advice is needed
• physiotherapist if balance or mobility advice is needed
• speech pathologist if there are swallowing problems
• occupational therapist if patient requires specialised equipment at home.

Consider if the person needs personal care, help with other tasks of daily living or appropriate wound dressing, and refer to appropriate services.

Local services such as the council, neighbourhood house or library can link the person to local social activities.

Pressure injuries and skin tears can be classified using a staging system. This staging system provides a consistent method of assessing, documenting and communicating the extent of the injury.

Effective management and treatment of pressure injuries and skin tears depends on their stage or classification.

Classifying pressure injuries

For pressure injuries, examine the:

• location, size and depth of pressure injury
• appearance of wound bed
• condition of wound edges and surrounding skin
• odour, amount and types of exudate
• level of pain and discomfort¹.

Pressure injuries can be classified using a staging system:

• Stage 1 – non-blanchable erythema
• Stage 2 – partial thickness skin loss
• Stage 3 – full thickness skin loss
• Stage 4 – full thickness tissue loss
• Unstageable – depth unknown
• Suspected deep tissue injury – depth unknown².

Use a validated pressure injury healing assessment scale to evaluate the healing progress of the pressure injury:

• Pressure Ulcer Scale for Healing (PUSH)
• Bates-Jensen Wound Assessment Tool (BWAT)
• Sessing Scale³.

Classifying skin tears

For skin tears, examine the:

• location and duration of skin tear
• size and depth
• wound bed characteristics and percentage of viable and non-viable tissue
• type and amount of exudate
• presence of bleeding or haematoma
• degree of flap necrosis
• integrity of surrounding skin
• signs and symptoms of infection
• associated pain⁴.

Skin tears can be classified according to the Skin Tear Audit Research (STAR) classification system:

• Category 1a – a skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened
• Category 1b – a skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened
• Category 2a – a skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened
• Category 2b – a skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened
• Category 3 – a skin tear where the skin flap is completely absent

If a patient has a pressure injury or skin tear, consider whether you should refer the patient to a wound specialist.

Responding to pressure injuries and skin tears

Pressure injuries and skin tears are considered an adverse event, and if they occur we need to manage them. This means being aware of the factors that can promote and prevent healing and taking steps to manage and address injuries and tears. There are several things we can do to promote injury and wound healing and prevention in hospital.

Develop a management plan

A combination of physical, social and environmental factors can have a major impact on a person’s ability to heal from a wound. When developing a management plan for someone with a pressure injury or skin tear, we need to consider and ask the following:

How long have they had the skin problem for? Is this the first episode or have there been episodes of recurrence?

What caused the skin problem? For example:

• Was a skin tear due to being knocked on an environmental hazard at home?
• Was a pressure injury due to their mattress prior to coming to hospital?
• Do they have a diabetes-related foot ulcer because they have suboptimal glycaemic levels for long periods?

Are the dressings and skin care products acceptable to the patient?

• Will the availability of the dressings and skin care products while in hospital and after discharge affect the patient’s ability to manage the care plan?
• Will the cost of the dressings and skin care products affect the patient’s ability to manage the care plan?

Who will care for the skin problem, particularly after discharge?

• Does the patient or family and carer understand what they need to do and what others will do?
• Will the patient or family and carer be able to remember what they need to do and what others will do?
• Does the patient have adequate social support and contact to provide emotional support and help with skin care if needed?
• Have they been provided with precise written instructions, including measurements if appropriate?
• Will they be able to change the dressings and apply the skin care products themselves?
• How often will the dressing need to be changed?
• How often will the skin care products need to be changed?

What is the goal for the skin problem?

• Can it heal, or is that not possible? If it is not possible, what will that mean for the patient?
• Does discharge from the skin problem need to be contained and odours managed to improve the person’s comfort level?

Dress wounds

When choosing an appropriate wound dressing, we should consider:

• cause (aetiology) of the wound
• type of wound
• characteristics of the wound
  • location
  • extent of tissue damage
  • size
  • phase of healing
  • pain
  • odour
  • infection
• cost and availability of dressing
• comfort to the patient, especially overnight
• patient preference
• pain management.¹

Manage pain

When someone tells you that their foot is hurting, take a bit of notice.
- Patient who experienced a hospital acquired pressure injury

Pain can indicate that the patient has a skin problem.

Assess for the presence of pain in people who have a pressure injury or skin tear:

• Use a validated pain assessment tool².
• Develop an individualised pain management plan in partnership with the patient, family and carer and interdisciplinary healthcare team.

Ask the following questions to help develop a pain management plan and monitor wound healing:

• What makes the pain better or worse?
• What kind or pain are you experiencing?
• Would you describe it as sore, aching, deep, cramping, burning, shooting or sensitive?
• Where is the pain?
• Does it radiate? If so, where to?
• Would you describe your pain as none, mild, moderate, severe or excruciating?
• How would you rate the pain on a scale of 0 to 10, with 0 being no pain and 10 being worst pain possible?
• What is the pain intensity at its worst, best and now?
• Is the pain better or worse at any particular time of the day or night?
• When does the pain start and stop?
• Is it intermittent or constant? Or does it only occur when you are moving?

Manage nutrition

Optimise good nutrition and hydration, to reduce risk and optimsie healing, for under-nourished people who do not have sufficient nutrients available to maintain and repair tissues³.

Nutritional interventions, such as vitamin or protein supplements, could be implemented to assist healing of pressure injuries and skin tears if the individual’s diet is deficient. Consider referral to a dietitian.

Support wellbeing

Although the most important concern in relation to the management of skin tears and pressure injuries is healing the actual wound, it is also important to consider the overall wellbeing of the person and how this may impact on the management and healing process.

A wound can have a big impact on a person’s life, and if not treated or managed properly can affect their wellbeing, including their physical, mental, social, spiritual and cultural wellbeing.

Having a wound is often associated with increased anxiety and depression and poor quality of life. Anxiety and depression are also associated with delayed wound healing.

Having a wound can contribute to social isolation and loneliness. Encourage the person to engage with others and return to previous activities wherever possible, and to seek support.

Document interventions and outcomes

Health professionals are required by law to have written evidence of all communication, assessments and outcomes or interventions. This documentation aims to facilitate communication between healthcare staff, patients and family and carers both within and across healthcare settings.

The following information, including date and time completed, should be documented in the patient’s clinical record or notes:

• risk status
• skin assessment
• interventions to prevent skin damage
• interventions to manage pressure injuries or skin tears
• evaluation of the interventions.

Involve and inform the patient, their family and carers

Evidence shows that when patients are involved in their care, their outcomes improve.

We can include the patient in all treatment and management options following pressure injuries, skin tears or any other wounds.

We can educate patients, their family and carers about maintaining healthy skin and reducing the risk of pressure injuries and skin tears by:

• providing relevant, easy to understand information
• offering information in languages other than English if necessary
• checking the person’s understanding of the information you have provided
• asking the patient and their family and carers to assist with the prevention strategies
• displaying pressure injury and skin tear prevention posters in ward areas commonly used by patients, their family and carers⁴.

Patient information should include, but not be limited to:

• risk factors for developing pressure injuries and skin tears, and what can be done to reduce those risks
• how to inspect skin and recognise skin changes and be aware of body sites that are at greatest risk of damage
• how to care for skin, including correct hygiene and moisturising procedures
• use of support surfaces and protective devices
• methods for pressure redistribution including movement and positioning
• treatment schedule and what they need to do
• who and when to ask for further advice or assistance⁵.

There are many things a patient can do to maintain their own skin integrity both in hospital and at home. These include:

• using only unscented, soap free, pH balanced body wash
• performing a daily skin inspection to pick up any problems
• discussing skin problems with their GP or other health professional
• using the right moisturiser type twice a day to protect dry skin
• using skin tear protection strategies, such as taking care when moving (either by self or with the help of a carer), using padding on furniture edges, and removing unnecessary furniture or equipment to reduce clutter
• moving regularly by following a pressure relieving regime to avoid pressure on an area for a long time
• using pressure relieving equipment
• maintaining appropriate and adequate nutrition and hydration
• maintaining good balance and mobility
• avoiding falls.

Risk screening and risk assessment of skin integrity generally refer to the same process, which is used to identify patients who are at risk of developing skin problems or who have skin problems. The results of screening or assessment are used to inform the implementation of prevention and management strategies.¹

As clinicians, we need to be alert to risk factors, use a recommended risk screening tool and complete a head to toe physical examination of the patient’s skin.

Identifying skin problems

Risk factors

The following are risk factors for older people developing skin problems. We must be aware that these risk factors may be unrelated to the primary reason for the person being admitted to hospital.

• Ageing
  • The changes that can occur to skin as it ages can affect its integrity, making it more vulnerable to damage and at a higher risk of developing pressure injuries and skin tears.
  • Changes to the skin include its mechanical properties, geometry, physiology and repair, and transport and thermal properties.
• Previous pressure injuries or skin tears
• Poor nutrition
  • Poor nutrition can result in the patient missing important nutrients and vitamins required to maintain healthy skin and assist with wound healing.
  • People who are malnourished can be both underweight or overweight, which can increase the risk of skin damage, especially pressure injuries.
• Dehydration
  • Dehydration can cause a person’s skin to be less elastic, more fragile and more likely to break down.
• Swallowing or dental problems
  • Swallowing or dental problems can result in poor nutrition.
• Balance or mobility problems
  • Balance or mobility problems may cause patients to fall or knock themselves against furniture, which can cause skin tears.
  • All patients who are restricted to bed or chair rest are considered to be at risk of developing a pressure injury.²
• Skin moisture
  • Faecal and urinary incontinence can result in excess moisture on the skin, which can cause skin problems.
  • Urine on the floor can be a hazard and can cause a slip, resulting in skin damage.
  • Elevated body temperature and perspiration can increase the risk of pressure injury development.
• Cognitively impaired
  • Patients who are cognitively impaired may be unable to:
    • regularly reposition themselves
    • knock themselves on furniture and cause skin tears
    • care for their skin
    • verbally communicate that they are experiencing pain related to a pressure injury or tear.
• Certain medications
  • These medications can cause cutaneous or inflammatory interactions and reactions:
    • antibacterials
    • antihypertensives
    • analgesics
    • tricyclic antidepressants
    • antihistamines
    • antineoplastic drugs
    • antipsychotic drugs
    • diuretics
    • oral diabetes agents
    • nonsteroidal anti-inflammatory drugs
    • steroids.
• Dexterity problems
  • Having difficulties washing or drying any part of their skin (for example, contractures, folds beneath abdominal aprons or hard to reach areas between toes).
• Certain medical conditions
  • Hypotension (low blood pressure)
  • Sensory perception disorders
  • Blood circulation (for example, diabetes)
  • Quality of circulating blood (for example, anaemia)
• Radiation therapy.

Explain the risk factors and the risk of developing a pressure injury or skin tear to the patient and their family and carer so they can play a role in preventing problems.

Screening and assessment tools

Best practice guidelines recommend conducting a structured risk screening or assessment process for all older people as soon as possible after admission (within 8 hours) and as often as required by the individual’s condition or if there is a significant change in their condition².

If the older person has existing pressure injuries or skin tears upon admission to hospital, it is important to classify them and treat and manage them appropriately.

Use an organisational-wide agreed pressure injury risk screening and assessment tool for all people aged 65 and over³.

The most commonly used and recommended pressure injury risk assessment tools for adults are:

• Braden Scale for Predicting Pressure Sore Risk (Braden Scale)⁴
• Norton Scale⁵
• Waterlow Scale⁶.

For skin tears use:

• Skin Tear Risk Toolkit

Once you have identified that an older person is at risk of developing a pressure injury or skin tear complete a nutritional screen and assessment⁷.

Physical examination

A comprehensive head to toe examination of the older person’s skin will help us identify existing damage to the skin, pressure injuries or skin tears and evaluate any changes to the skin². The skin examination should be done as soon as possible after admission (within 8 hours) and as often as required by the individual’s condition or if there is a significant change in their condition^{2, 3}.

During the skin examination, we should make sure that:

• the room is quiet, private and has a stable temperature
• there is adequate lighting to see the skin colour properly
• fingernails are trimmed and jewellery minimised (so we don’t hurt the patient)
• we inspect all areas of the skin, especially those not usually exposed, such as the buttocks, armpits, back of thighs and feet, and pay attention to bony prominences such as the sacrum, heels and ankles, elbows, shoulders and ears
• we note other areas on the body subject to pressure from equipment such as nasogastric tubes, oxygen masks and bed rails
• we include the patient and inform them about what we are doing. Often the patient can give us useful information about what they are feeling.

“It is quite difficult if you are in bed, how can you look at your bottom for instance, and that is where you most likely to get pressure areas. It’s not easy to do that. You just sort of feel that it is not right. It feels tender.” (older patient)

Ask the patient, their family or carer about:

• past medical history, such as diabetes, peripheral vascular disease or continence problems that may affect skin quality or healing
• current medications that treat skin problems or that may have an affect on the skin condition, such as steroids
• previous skin problems
• recent changes to the skin
• any areas of pain or discomfort
• skin care routine – including the products they use, such as soap and creams
• psychological wellbeing – is the patient under any particular stresses at present?

This will help us determine the cause of any skin problems and assist in treating and managing them.

Look and assess:

• signs of dry skin, oedema, variations in skin colour, bruising, inflammation, scratch marks, jaundice, swelling, breaks, ulcers, lesions or rashes
• pressure areas for signs of potential breakdown
• general skin quality of the whole body.

Touch, feel and assess:

• texture – is it smooth or course?
• moisture – is it dry?
• turgor (swelling) – is the skin layer firm and resistant to being pinched? Does it ‘tent’ or stay in condition when being pinched? Tenting can be an indicator or dehydration or malnutrition
• temperature – is the skin hot or cold and are there variations around the body? A hot area could indicate inflammation; a cold area could indicate decreased arterial blood supply and vascular changes
• reddened areas – differentiate whether the skin is blanchable or not. Non-blanchable erythema means there is structural damage to the skin and indicates a stage 1 pressure injury. To assess, apply light pressure with your finger over the erythema for three seconds. If the area remains the same colour as before the pressure was applied, this is non-blanchable.

Smell and assess:

• if the patient is able to wash
• the condition of flexures (skin folds)
• if the patient has incontinence^8,9.

Document the results

Document the results of all risk screening or assessment, including the skin assessment, in the patient’s clinical records or notes². Use these results to develop a prevention or management plan.

Preventing skin problems

Most pressure injuries and skin tears can be prevented by following simple steps such as maintaining good nutrition and hydration, regular but careful mobilisation, good skin hygiene and a good moisturising regime.

Older people in hospital are at risk of experiencing functional decline.

This supporting information provides additional material and examples that reinforce the principles and strategies provided throughout Older people in hospital.

It includes:

• a set of stories showcasing how individual health services have made improvements during the Improving Care For Older People initiative
• an outline of initiatives taken by health services as part of the Improving Care For Older People Program
• a set of fact sheets for clinicians outlining strategies to provide best care for older people in hospital
• information on clinical handover, including a case study outlining best practice principles
• resources to engage consumers in taking active steps to remain as well as possible when in hospital
• information on guardianship and least restrictive practice.

A guardian is a person legally appointed by the Victorian Civil and Administrative Tribunal (VCAT) to make specific lifestyle decisions for another person who, due to disability (including dementia), lacks decision-making capacity for a decision that needs to be made. In cases where there is no-one known to the person who is able and willing to take on this role, the Public Advocate may be appointed as the guardian of last resort. Before this occurs, VCAT must be satisfied that the needs of the person could not be met by other means less restrictive of the person’s freedom of decision and action.

This section was developed in collaboration between a range of expert clinicians from Victorian health services, and representatives from the Victorian Department of Health (DH VIC), the Office of the Public Advocate (OPA), VCAT and researchers from the National Ageing Research Institute (NARI). It explores the concept of least restrictive practice in the context of discharge planning for older people in hospital who have complex needs. It also outlines the importance of having supportive decision making in place for people who require support to make decisions, as well as the types of supportive and substitute decision makers in Victoria.

Discharge planning requires comprehensive assessment of each patient’s unique values, preferences, strengths and risks. This is particularly important when the treating team expects an older person’s care requirements will be quite substantial after discharge. In some cases the team may consider it is not possible or in the patient’s best interest to discharge them to the accommodation they were in prior to admission. This can be very distressing for the older person and their family, and they may disagree, especially in cases where (the team believes) a person’s cognitive impairment is impacting on their ability to understand the consequences of their decision. These situations can also be very challenging for staff involved in the person’s care, and it is essential that each staff member plays a key role in identifying, trialling and documenting least restrictive alternatives to the appointment of a guardian (if feasible).

This resource is intended as general guidance only. Give due consideration to whether or not the advice should be followed in each individual situation. It is not a substitute for individual health services seeking their own independent legal advice. In addition to following policy and procedures specific to your health service, it is important to familiarise yourself with the information outlined on the websites of OPA and VCAT, consider the recommended actions and discuss them with colleagues and managers.

Application processes and the roles of the organisations involved

Before seeking appointment of a guardian of last resort for an older person in hospital, you should explore all least restrictive options. This is in the best interests of the patient, and it is a legal requirement. The Victorian Civil and Administrative Tribunal (VCAT) will need to be satisfied that the treating team has worked with the older person and their family and carers to rule out least restrictive alternatives.

If you are satisfied that seeking guardianship is the most appropriate option, familiarise yourself with the roles of each organisation and the terminology used, to ensure you approach the formal application process in the best possible way. This page provides information about who is involved in the process when applying on behalf of an older person in hospital. You should also follow your health service’s policies and procedures, and consult the Office of the Public Advocate (OPA) website, the VCAT website and the OPA advice service for guidance on the process.

The following table outlines a list of common terms and their meanings.

Who is involved in the application process

Proposed represented person

This term is used by VCAT to describe the older person for whom you are making the application.

Making an application has the potential to remove an older person’s rights to exercise decisions about their life and can be extremely stressful for them, their family and carers. We all play a role in providing support and empathy throughout this process.

Applicant

In many Victorian hospitals, social workers coordinate and complete the application forms for guardianship. However, they can be completed by any clinician who knows the proposed represented person. Whoever completes the application becomes known by VCAT as the applicant. The applicant must explain the process to the older person and their family or carers and keep them informed throughout the process.

The applicant can complete and lodge the application form online, or download it from the VCAT website. It can be lodged by email, in person or by post. Some hospitals in Victoria have an internal system for lodging applications. The applicant is expected to attend the hearing, or delegate the task to a colleague who can adequately speak to the person’s situation.

As the applicant, if you believe that the matter should be heard urgently, seek advice from the OPA advice service. If the risk is unmanageable you may have to apply for a temporary order; speak to the advice service about this.

By law, the applicant must provide a copy of the application to the older person and any other interested parties. Interested parties can include the person’s family and carers.

The applicant must also supply VCAT with a medical report and any other supporting documents (such as a social work report or a neuropsychological report) prior to the hearing date. The medical report must indicate what disability the proposed represented person has, how this was diagnosed, if the person is incapable of making reasonable judgement and how this has been assessed. The application may also be supported by additional clinical reports from physiotherapists, occupational therapists, and speech therapists as required. These reports should provide a context for the application and outline all least restrictive options that have been proposed and trialled. Be mindful that any individual party to the proceedings may apply to VCAT for a copy of these reports. In some circumstances, especially where a professional is feeling threatened by a person, a report may be provided under the name of the hospital rather than an individual.

Registry VCAT Guardianship List

The VCAT Guardianship List receives applications for guardianship or administration, hears the matter and makes orders appointing a guardian or administrator for a person with a disability (who is 18 years of age or over) when there is a need and it is in that person's best interests to do so.

VCAT is like a court but less formal. The Tribunal members listen to the legal cases, facilitate the proceeding and decide whether an order for guardianship is required.

Applications must be heard within 30 days of VCAT receiving the application; the applicant can assist to streamline this process by ensuring all relevant contact details are included on the application form. VCAT will inform all interested parties that are listed on the application of the date and venue of the hearing.

VCAT member

A VCAT member will manage all aspects of the hearing and make a decision which could include appointing a guardian or requesting OPA investigate the matter before an appointment of a guardian can be determined.

VCAT hearing

Who attends the hearing

The applicant or their delegate must attend the hearing and bring copies of relevant evidence. The person about whom the application has been made should be encouraged to attend, particularly if the hearing is on-site at a hospital. Other interested parties listed on the application will be formally invited by VCAT and they may choose to bring support people. Other people who may attend include service providers known to the older person, such as case managers and solicitors. VCAT will organise an appropriately trained interpreter to be present if the applicant has indicated that an interpreter is required on the application form. Hearings are open to the public; however the VCAT member may ask observers to leave if the matter is sensitive. VCAT can also order that hearings be closed to the public, and the applicant can request that VCAT consider this option. It is illegal to publicise any information of a proceeding unless VCAT orders otherwise.

Where hearings are held

Some hospitals in Victoria hold regular guardianship and administration hearings on site. In special circumstances hearings can be held at the older person’s bedside. Hearings can also take place at VCAT in Melbourne and at various local courts throughout Victoria. The applicant can nominate the preferred venue for the hearing, and should take into account the urgency of the matter and whether there might be a need for security to be on-call throughout the hearing. Hearings may also be held with some or all parties attending by phone or video-conference.

What to expect at the hearing

The formality of the hearing can vary depending on the venue and the VCAT member. The VCAT member will generally ask all present to introduce themselves and they will explain the purpose of the hearing.

Sometimes the VCAT member may decide to adjourn the hearing if a particular person is not in attendance. They may also decide to refer the matter to OPA to investigate the issues and report back to them before the matter can be determined. The VCAT member may also adjourn a hearing part heard to enable OPA to gather new information or research issues which have arisen in the course of the hearing. Before deciding to appoint a guardian, the VCAT member must be satisfied that the proposed represented person:

• has a disability that is affecting their ability to make an informed decision
• that a decision needs to be made
• that all least restrictive options have been explored.

Office of the Public Advocate

Advocate guardian

• encourage the represented person to participate as much as possible in the life of the community
• encourage and assist the represented person to become capable of caring for herself or himself and of making reasonable judgements about matters relating to her or his person
• protect the represented person from neglect, abuse or exploitation.

A guardian must also exercise their powers in a way which is least restrictive of the person’s freedom of decision and action.

The OPA website provides detailed information on the role and responsibilities of guardians.

Guardians are not case managers, and when appointed they will rely on the treating team to source and implement least restrictive opportunities. It may take some time for the guardian to come to a decision for the older person in hospital, and as clinicians it is our role to support the older person and their family and carers throughout this process.

It is also essential that we document continued attempts to trial least restrictive alternatives and work with our team to ensure the person’s ability to participate in everyday physical and cognitive tasks is encouraged and assisted.

Making an application and supplying supporting information for the appointment of a guardian of last resort

The decision to lodge an application to VCAT for the appointment of a guardian of last resort should only be made if you and the treating team are satisfied that an older person has a disability that is impacting on their ability to make an informed decision, and when:

• a decision needs to be made
• there is a conflict about the nature of this decision
• you have trialled all least restrictive alternatives.

The application process

In many Victorian hospitals social workers are the 'applicant' and coordinate the application process. This includes:

• completing the application form and an accompanying report
• seeking advice from the OPA Advice Service
• discussing the decision to proceed with the application with the older person and their family and carers
• requesting reports from the treating doctor and other relevant clinicians.

The application

Application forms can be completed and lodged on the VCAT website and downloaded as an alternative if required.

As the applicant, it is essential that you provide the correct contact details for yourself and any interested parties, to ensure that the hearing is listed within the specified 30-day period and that the appointed guardian contacts the relevant parties as soon as possible.

Medical report

Use the medical report form provided on the VCAT website to describe:

• the reason for admission, medical history and current functioning, including
  • previous admissions to hospital
  • nature of the decision-making disability
  • how this is affecting the decision that needs to be made
• the trajectory of the admission, treatment provided, the person's ability to participate in their care routing and the level of support they require
• your recommendation.

Examples of the information required in the medical report is provided in Mrs Brown's case study.

Social work report

Each person’s situation will be unique. As the application form has minimal space to provide the VCAT member with the relevant context, you may need to provide a separate report to support the application.

There is no universal template to guide this process; however, it would be helpful for the VCAT member if you provided as much relevant background information as possible, including the following:

• What is the reason for admission? Outline the person's medical history and current functioning, including
  • previous admissions to hospital
  • nature of the decision making disability.
• What is the trajectory of the admission, treatment provided, the person's ability to participate in their care routine and the level of support they require?
• What is the reason for lodging the application?
  • What decision needs to be made?
  • If the issue is long standing, describe the history and what attempts have been made to address the issue.
• Describe the person's usual living arrangements.
  • Do they own their own home?
  • Are there any relevant cultural, language preferences and values?
  • Do they live by themselves or with others?
  • Who is in their family/support network and what is their opinion of the reason for the application?
  • Outline if the person has been receiving services.
  • Determine if the person has an advance care plan or an advance statement.
• If there is conflict between parties, describe what attempts have been made to negotiate and mediate these issues. What are the risks?
  • Is there a risk of harm?
  • What level of supervision does the team believe the older person requires?
  • Can these risks be minimised with formal services or informal supports?
  • What least restrictive attempts have been made to mitigate the risks?
• What has been done to optimise the person's functioning while they are in hospital?
  • Include physical therapy/retraining, education to the older person and their family/carers, psychological and emotional support that acknowledges and assists the older person and their family and carers with the process of adjustment.
  • Has an occupational therapy home visit occurred? Have assistive devices been considered and trialled?
• Have you spoken to the OPA Advice Service? If so, document their advice.
• What does the treating team recommend?
  • What will the appointment of a guardian achieve?
  • Specify what decisions the team believe need to be made. This can include accommodation, access to services, access to the proposed represented person and medical, dental and other healthcare treatments.
  • Why are you recommending that OPA be appointed as guardian of last resort?

An example of a social work report is provided in Mrs Brown's case study.

Applying to the Victorian Civil and Administrative Tribunal (VCAT) for the appointment of the Public Advocate as the guardian of last resort on behalf of an older person in hospital is a serious decision. All public authorities, including public hospitals, need to be aware that the appointment of a guardian (or an administrator) is effectively a limitation of a person’s human rights.

The central purpose of the Guardianship and Administration Act 2019 is to protect and promote the human rights and dignity of people with a disability, and to support them to make, participate in and implement decisions that affect their lives. The Act also requires that any order made is the least restrictive of the person’s rights that is possible in the circumstances.

Thoroughly exploring the person's values, preferences and motivations, and identifying the unique strengths and risks of the person and their situation is therefore essential. This will help the older person, their family and carers, and the treating team to identify and work towards trialling least restrictive alternatives.

A ‘least restrictive model of care’ aims to enhance an older person’s autonomy and respects their rights, individual worth, dignity and privacy. Any limitations on the person must be the minimum necessary and must allow them to participate as much as possible in all decisions that affect them. Weighing up decisions regarding responsibilities and duty of care within this model can be challenging for professionals and families. Keeping the rights of the older person at the centre can help everyone involved in the process of care planning.

Person-centred practice

Maximise and encourage participation

Being in hospital can be an alienating and at times frightening experience for an older person, and their family and carers. They are removed from their familiar environment, routines and usual supports. People are at their most vulnerable, and it can be helpful to empathise with their situation so that you may build rapport and develop a care plan in partnership.

It is essential that you engage the older person and their family and carers, and ensure they have multiple opportunities to express their wishes and be involved in developing their care plan for discharge.

Establish the person’s goals and develop steps and timelines to achieve them. Revisit the goals with the person, their family and carers, and the treating team and readjust as necessary during the person’s admission. As a team ensure that you:

• Consider the cultural and linguistic background of the older person and their family and use formal interpreters as appropriate.
• Explain options in plain language and be mindful of using health and legal jargon.
• Organise a family meeting and consider which health professionals need to be present at the meeting.
• Locate a private meeting room in which to hold the meeting, to reduce distractions and promote the comfort of the older person and their family.
• Assist the older person and the family to prepare for the meeting.
• Explain the purpose and who will be present; invite them to bring an advocate/support person and explain the process.
• Provide the older person with ample opportunity to be engaged in the discussion - remembering that discussions about care needs can be confronting, especially in front of multiple people.
• Do not assume that the older person or their family understand health and legal language or the complexity of the process.
• Check that the older person and their family and carers have understood what you have told them.
• Clarify the patient's condition, what you expect the impact of the diagnosis on their function to be and what this might mean in terms of care needs once they leave the hospital.

Find out how the older person has usually made lifestyle decisions

Check if the older person has made formal arrangements and appointed a substitute decision maker or support person. Ask to sight and request copies of any relevant paperwork to help clarify the nature of these arrangements.

Find out as much as you can about the older person’s values and wishes. Seek consent to speak with people close to them, including other health and aged care professionals who may have been involved with the older person.

Many people rely on the informal support of a family member, a friend or carer to help make important decisions. In these cases, it remains imperative that you encourage the older person to consider their options and give them opportunities to express their wishes. If the older person would like you to involve a person to support them to make a decision, ensure you remain alert to the possibility of ‘undue influence’. Also check where possible that the informal support person agrees to the arrangement and whether it is appropriate for them to seek formal appointment as a supportive guardian and/or administrator.

Demonstrate empathy and aim to preserve the older person’s significant relationships

Applications for guardianship are often made in the context of conflict between the older person, their family and the treating team. This conflict is frequently about whether an older person requires residential care as opposed to returning to their usual home environment. It is important to note that disagreement can also occur within the treating team about preferred discharge options.¹ To avoid an application and work towards developing least restrictive options:

• Find out what matters to the older person. Actively listen to their concerns and empathise with their situation. The impending loss of independence in lifestyle choices can be very overwhelming and trigger anxiety and anticipatory grief and loss for them and their family.
• Be mindful of preserving the relationship between the older person and the family member, especially if there is disagreement between the older person’s family member or carer and the treating team.
• Be mindful of carer and family stress. An episode in hospital can be very difficult for a spouse, son, daughter or sibling. It can spark a significant shift in family dynamics and be accompanied by grief and loss.
• Give people time to adjust to the team’s recommendation and provide them with the information on the options in a transparent way.
• Acknowledge and mediate family conflictwhere possible.¹ Consider engaging formal conflict resolution strategies to explore least restrictive options. The Dispute Settlement Centre of Victoria (DSCV) is a free dispute resolution service that can provide a professionally mediated family meeting to help resolve conflict and reach an agreed decision. This may not be an appropriate avenue to pursue if you suspect the older person is experiencing elder abuse.

Work as a team to minimise functional decline

Be clear about the older person’s medical, functional, social and emotional needs and aim to minimise the risk of the older person experiencing functional decline in hospital.

Treat the person’s presenting issues and complete a comprehensive geriatric assessment to develop a care plan that can be continuously monitored and adjusted.

All staff play a key role in carefully considering least restrictive alternatives to making an application to VCAT for guardianship and ensuring that, where possible, these have been trialled and that the reasons for your intervention or lack of intervention have been documented in the patient record.

Work with the clinical experts in your health service to maximise the person’s access to regular:

• hydration and nutrition - as this plays a large role in maintaining and maximising function
• medication review - to simplify administration and frequency
• mobility and sitting out of bed - to optimise independence
• toileting - incontinence can be a major trigger for entry into residential care and there are many ways to avoid and treat issues
• pain management - unmanaged pain can limit a person's participation in their self-care
• monitoring for depression - most people with mild depression will respond to simple interventions such as listening, explaining and reassuring
• monitoring for acute changes to cognition - delirium can impair decision making ability and, in many cases, can be prevented and managed.

Focus on the older person’s strengths and work with your team to develop a care plan that maximises the person’s ability to exercise their values and preferences.

A thorough psychosocial assessment should be completed by a social worker in order to determine the nature of the presenting issues and to consider any interventions that have been implemented in the past to mitigate risks. A social worker can assist the team to understand the role of guardians and the process of making an application to VCAT for a guardian, and what happens when the Public Advocate is appointed as the guardian of last resort.

Trial least restrictive alternatives

Be mindful of the concept of ‘dignity of risk’ when developing a care plan in partnership with the older person and their family and carers. Enable the older person to exercise their human right to make decisions that may entail an element of risk. You may not agree with the decisions the older person is making - and traditionally health services may have wished to avoid risks at all cost. ‘Dignity of risk’ prompts you to consider how you can support someone to do what they want to do safely by exploring:

• What decision(s) need to be made?
• What are the specific risks?
• Can these risks be minimised?
• Can the decision be made in a more informal way than making an application for a guardian?

Carrying out our duty of care to a patient is not compromised by incorporating ‘dignity of risk’ when exploring least restrictive options; in fact, it should be considered part of our duty of care.

Considering least restrictive options

• Exploring what the older person's values are. This will help you to determine what sort of risks the older person would accept if he or she had capacity to make their own decisions.
• Involving community services that have been providing services to the older person. There may be additional or alternative services available to address the older person's needs after discharge.
• Arrange an occupational therapist to assess the older person’s function and to complete a home visit.
• Explore the availability of other programs that can provide additional support on discharge, for example the Aged Care Assessment Service (ACAS), the Transition Care Program (TCP) and Health Independence Program (HIP).
• Training willing family and carers to help to the older person with tasks of daily living and trial a period where staff are ‘hands off’.
• Considering a trial discharge with a support package in place. This could be for a day, overnight or for a weekend.

Work with your team, and speak to senior managers and your ACAS to work through issues as they arise. Use the Office of the Public Advocate’s Advice Service to troubleshoot options and document their recommendations.

Complex decision making in hospital and the importance of least restrictive practice

Clinicians are frequently required to make recommendations about the complex care needs of patients in preparing for their discharge. Sometimes this results in an application about Guardianship to the Victorian Civil and Administrative Tribunal (VCAT) for the appointment of the Public Advocate, as a guardian of last resort, for an older person in hospital.

People aged 65 and over with established cognitive impairment are the subject of a significant proportion of these applications. They are often made in the context of a disagreement between the treating team and the older person about the type of accommodation or services that are required to meet the older person’s care needs on discharge.²

The guardianship process can be long with the potential to have a significant impact on an older person’s levels of stress, autonomy and sense of control over their life. It may extend the older person’s hospital admission while they wait for a hearing, for a guardian to be appointed, and for a decision to be made and effected. An extended admission can play a significant role in increasing the risk of the older person experiencing functional decline in hospital, which in turn can further limit their ability to realise their lifestyle choices.³

Before deciding to pursue an application, a model of least restrictive practice should be employed. The Guardianship and Administration Act 2019 embeds the principles of least restrictive practice into supportive and substitute decision making. The Act requires that any order made is the least restrictive of the person’s rights that is possible in the circumstances.

Least restrictive practices include working with the older person and their families or carers to avoid an unnecessary application, maximise their participation and improve care during this process. In this process it can be useful to weigh up the risks and benefits of the older person leaving hospital versus the risks and benefits facing the older person if they are to remain in hospital for a lengthy period of time. By employing a least restrictive model of practice you can work with your team to minimise the extent of any limitations on the person and encourage them to participate in all decisions that affect them.

Supported and substitute decision making in Victoria and the law

Understanding the role of support people

In Victoria, if a person can make their own decisions but may need some support to do so, they can appoint someone they trust to assist them to make, communicate and act on their decisions. These decisions may be about financial, lifestyle or medical issues.

There is different legislation regulating the powers of support people in Victoria. The Office of the Public Advocate (OPA) website includes information, fact sheets and forms. An Advice Service is also available if you need clarification.

In Victoria, there are a number of legally recognised support roles, made under different Acts:

• Supportive attorney - Powers of Attorney Act 2014 (Vic)
• Support person - Medical Treatment Planning and Decisions Act 2016 (Vic)
• Plan nominee - National Disability Insurance Scheme Act 2013 (Vic)
• Nominated person - Mental Health Act 2014
• Supportive administrator (financial and legal decisions) or supportive guardian (medical treatment and lifestyle decisions) - Guardianship and Administration Act 2019 (Vic)

As a clinician it is essential to establish if an older person you are working with has existing arrangements in place to help them make decisions. These arrangements may be formal or informal.

Ask the older person if they have appointed someone to help them to make decisions. Check if any arrangements were made under previous Acts as many will remain valid.

Understanding the role of the substitute decision maker

All adults are presumed to have the capacity to make decisions for themselves unless demonstrated otherwise. However, despite available supports, some people may not have capacity to make a specific decision. Whether a person has decision making capacity is decision specific, and a person may have the capacity to make some decisions and not others. Under the Guardianship and Administration Act 2019, a person has decision making capacity if they are able to:

• understand the information relevant to the decision and its effect
• retain the information to the extent necessary to make the decision
• use or weigh the information as part of the process of making the decision, and
• communicate the decision and the person’s views and needs as to the decision in some way, including by speech, gestures or other means.

If a person does not have decision making capacity in relation to a specific decision, the appropriate substitute decision maker must be identified.

If a person does not have decision making capacity in relation to a specific decision, the appropriate substitute decision maker must be identified.

If the decision is about medical treatment, this will be the person’s medical treatment decision maker. There is a hierarchy for determining the person’s medical treatment decision maker, and the first available and willing person from the list below will be the medical treatment decision maker:

• an appointed medical treatment decision maker
• a guardian appointed by VCAT
• the first of the following with a close and continuing relationship with the person:
  • the spouse or domestic partner
  • the primary carer of the person
  • the oldest adult child of the person
  • the oldest parent of the person
  • the oldest adult sibling of the person.

When making decisions about medical treatment, it is also important to find out if the person has made an advance care directive when they had decision making capacity to do so. An advance care directive is legally binding and may include instructional directives about medical treatment or refusal of care, and/or values directives about general preferences for care. An appointed medical treatment decision maker is also bound by an advance care directive. If necessary, VCAT can review an advance care directive to decide its validity or clarify its meaning.

If the decision is about another financial or lifestyle matter, the person’s enduring power of attorney will be their substitute decision maker.

Be aware that the legal context and decision-making powers of various roles can be misunderstood and confusing. Many people assume that if they are the ‘next of kin’ they automatically have the authority to make decisions on behalf of the older person. If someone indicates that they are legally able to make decisions on behalf of an older person in hospital, best practice involves clarifying what arrangements are in place, by requesting permission to sight, interpret, copy, and document and store any relevant documentation on the patient’s record. Familiarising yourself with some of the commonly appointed roles and responsibilities can help alleviate this confusion and help you to work with the older person and their family or carers.

VCAT appointment of a substitute decision maker

Any individual can make an application to the Guardianship List at the Victorian Civil Administrative Tribunal (VCAT) to determine whether or not a person is in need of a substitute decision maker where an enduring power of attorney and/or medical treatment decision maker has not been appointed, or where there are concerns as to whether the substitute decision maker is operating in the best interests of the person who appointed them. Under the Guardianship and Administration Act 2019, VCAT has the power to appoint a guardian and/or an administrator. VCAT also has the power to instead appoint a supportive guardian and/or a supportive administrator to assist a person to make their own decisions.

VCAT must always try to make an order that is least restrictive of the person’s freedom of decision and action.

A guardian may be appointed for a person who has a disability that is impairing their judgement where there is a need for a specific decision or multiple decisions to be made about lifestyle and healthcare matters. VCAT must be assured the guardian will act in the represented person's best interests. If there is no willing or suitable person to be appointed as a guardian, the Public Advocate can be appointed to this role as a limited or plenary guardian of last resort.

• A guardian can make decisions about health care, accommodation, employment, and access to people, including restricting or prohibiting particular people from having contact with the represented person.
• VCAT may make an order appointing a limited guardian (the order will specify the type of personal and lifestyle decisions that the appointed guardian can make) for the person, or on rare occasions a plenary guardian (this order enables the guardian to make all necessary personal and lifestyle decisions and may include medical decisions).
• The duration of an appointment is specified in the order. All orders must be reassessed within three years, and usually after one year. The date of the reassessment is usually written on the order. Sometimes there are ‘self-revoking orders’ which means that the order will expire on the specified date, unless someone seeks a hearing.

VCAT can also appoint an administrator to make financial decisions when a person cannot make reasonable judgements about managing their estate, and there are concerns about the decisions they are making, or about decisions that others are making for them.

For further information please refer to the Office of the Public Advocate website.

Informal arrangements

Often family and friends can informally assist someone with a decision-making disability to make decisions. As a clinician, you will be aware of cases where these types of arrangements work quite well, and this may mitigate the need to apply for a formal appointment through VCAT.

It is important to obtain consent from a person with decision-making capacity or their substitute decision maker and ensure that there is clarity around who is actually making the decision.

In cases where you believe the wishes of an older person with a decision-making disability are not being respected, or they are experiencing or are at risk of harm or neglect, explore your concerns with them and your team, and contact the OPA Advice Service.

Exploring decision making capacity in the context of lifestyle decisions

All individuals over the age of 18 are considered to have the capacity to make decisions until demonstrated otherwise. A decision to formally assess a person's capacity should always be specific to the decision(s) at hand and start from a presumption of capacity. A person's decision-making capacity is determined by their ability to:

• understand the information relevant to the decision and its effect
• retain the information to the extent necessary to make the decision
• use or weigh that information as part of the process of making the decision, and
• communicate the decision and the person’s views and needs as to the decision in some way, including by speech, gestures or other means.

Capacity is:

• domain specific (domains can include personal and lifestyle, finances, healthcare)
• decision specific (even within domains, for example, the person might be able to consent to a blood test but not to an amputation)
• time specific (note that capacity may fluctuate, for example, the older person might be better at certain times of the day).

Evidence of incapacity can include the person:

• not knowing or understanding the issues
• being unable to provide possible approaches to solving the issues
• not appreciating reasonably foreseeable circumstances
• making decisions based on delusional constructs
• having significant cognitive impairment.

If you suspect that the individual has a disability that is impairing their ability to make an informed decision, consider whether an assessment of decision-making capacity is required. If you can avoid an application to the Victorian Civil and Administrative Tribunal (VCAT) you may not need to complete a capacity assessment.

If the older person and their family agree with the treating team’s recommendation, you may be able to avoid a formal capacity assessment and an application to VCAT for guardianship.

If the person or their family disagrees with the treating team’s recommendation, and you have explored least restrictive alternatives, a formal capacity assessment should be completed to determine the extent to which their disability is affecting their ability to make the specific decision.

Assessing capacity is complex and multidimensional, and can be affected by a range of factors. Clinicians who are experienced in assessing cognition and capacity, such as neuropsychologists and geriatricians, should be used undertake a formal capacity assessment. The Office of the Public Advocate (OPA) can provide advice to health practitioners conducting assessments of decision-making capacity in relation to proceedings under the Guardianship and Administration Act 2019.

Older people are at risk of experiencing functional decline as early as their second day in hospital. There are simple strategies that they and their families can implement to prevent this occurring.

The Get well soon audio visual material and the supporting information sheets, which can be accessed through more information, explains some things they can do to remain well while they are in hospital.

In The patient experience videos older people and their families share their personal stories about the impact of being in hospital. They encourage clinicians to listen to them and to work in partnership with them to achieve the best possible outcomes.

Older people presenting to hospital are at high risk of experiencing functional decline. During the Improving Care for Older People Initiative, Victorian health services made many changes to address these risks. They used the evidence in Best care for older people everywhere: The toolkit, which has now been updated and rebranded as Older people in hospital.

This set of ten stories showcases some of the diverse ways that they have done this. The stories focus on making improvements to communication, assessment, nutrition, person centred practice, cognition, dementia, pressure care, involving consumers and providing education to clinicians on best practice.