Consultant geriatrician at Cork University Hospital (CUH) Dr Kirstyn James focuses on the “unique needs” of older people in her work at the geriatric emergency multidisciplinary service at the hospital.
“Older people are among the most frequent users of the emergency department [ED], but often the system isn’t set up to meet their needs.
“So in our unit, which is made up of myself, a registrar, a physiotherapist, an occupational therapist and a clinical nurse specialist with support from doctors and nurses, we start every day with a joint huddle with the ED team. The ED staff highlight any older people that have come to the ED and would benefit from our input.”
The patients are assessed so that they can be offered the most appropriate care pathway as soon as possible, says Dr James.
“Often, these patients have multiple medical conditions. And due to Covid-19, they’ve been spending a lot of time at home and may not have had the opportunity to do the normal daily activities that help keep them fit and healthy.
“They can also be quite anxious about having to come to the hospital. We usually try to speak to their families over the phone, particularly now that families cannot generally come with them to the ED because of Covid-19.”
At 12.30pm, another meeting takes place where a plan is devised with the team, the patient and their family.
Coming to the emergency department without family can be stressful for the older patient.
“We try to make them feel as comfortable as possible by regularly checking in on them, offering them a snack or a drink, and giving them the opportunity to speak on the phone with a family member.”
Dr James and her colleagues see between six and ten older patients a day.
“Towards the end of the day, around 4pm, we link in with the ED team again and try to summarise every case we’ve seen.”
Dr James says she and her team are happy to see patients with mental health issues as well as physical problems.
“Sometimes, patients can also have a mental health diagnosis like depression. While we will see them, if they have a very complex mental health issue, then it’s more appropriate for them to see a psychiatrist.”
Have mental health issues increased among older people in the pandemic?
“We have definitely seen a lot of social isolation and patients who have been very disconnected. That’s because a lot of social activities they did before — like going to the pub, going to Mass or meeting friends for coffee — have been taken away from them. I think that has taken a great toll on the mental health of older adults who have a history of mental illness.”
Mental health issues are also presenting in older people who don’t have a history of mental health problems.
“It is a huge challenge for older people since the pandemic started. When we’re treating an older person it’s not just about the medications we prescribe, it’s really about everything to do with health and wellbeing.
“Socialising and having hobbies are so important for our physical and mental health. We have seen the toll [that missing those things] has taken on older people.
“Some of these older people have limited life expectancy. They want to get the most out of their lives. What matters most to them are their families. But when older people come to the ED, at least they’re met with a friendly face.
“We don’t just address the main medical problem. We look at the patient as a whole person.
“Older people are such an important part of our society and the experience of dealing with the challenges arising from Covid-19 really highlights how vulnerable they are.”
Nursing home patients are also seen. They generally come to the hospital if referred to the ED. However, for those who can’t present at the hospital and because it can be geographically challenging “to get to every nursing home in Cork, we provide telephone support. Parts of Cork are a two-hour drive to CUH.”
Telemedicine, comprising telephone and video consultations, is very much a feature of medical care in the pandemic.
“We offer telemedicine to any of our patients that are suitable for outpatient follow-up. Or maybe the patient just doesn’t want to come to the hospital because of concerns about Covid-19 transmission. Or they may not be able to walk and might have limited access to transport. Some of our patients actually prefer telemedicine than coming into the hospital.”
Dr James says that older people may find accessing technology challenging.
“In my experience, most older people are very open to the concept of having a telemedicine ‘visit.’ They may need someone to help set up their technology and we can help with that if they’re interested. All they need is a smartphone or a tablet device that has a camera.
“If they’ve never used the camera function on the device, we can talk them through it on the phone.
“Also, family members may be more familiar with technology and in a better position to help them set things up. Being connected, even if only virtually, has never before been so possible.”