in this population and may manifest as one of the geriatric syndromes described earlier.
In addition, cognitive impairment and sensory impairment may make it difficult for these patients to communicate with healthcare staff, which means they are less able to be involved in their own care than younger people, thus increasing their vulnerability to errors.
Decision‐making in the care of older people
Safe, high‐quality care for older people requires staff to make complex decisions about medical and non‐medical matters, with the involvement of the whole multidisciplinary team and with the aim of meeting patients’ best interests. This applies across the entire healthcare system, including decisions relating to the prevention and management of long‐term conditions in primary care, when and whether to refer or admit patients to secondary care, inpatient care, and the complex planning required to maximize patient safety on discharge from the hospital. The challenge is to make these decisions in the safest possible way by anticipating and pre‐empting potential errors or harm and always acting in the patient’s best interests.
Very old people, particularly those who are frail and complex, have in the past often been excluded from the large clinical and pharmaceutical trials46 that have formed the basis of our pharmaceutical approach to treating many common conditions. To a certain extent, this is understandable: the different physiological characteristics, coexisting medical conditions, and therapies associated with old age can lead to a variety of responses to drug therapy, both beneficial and adverse; these responses can be difficult to predict, detect, and adjust for accurately in terms of measured outcomes. As a consequence, optimal therapeutic decision‐making for the individual – for instance, in terms of drug dosing or combinations – may be difficult to achieve because of the lack of an appropriate evidence base. Hence a degree of clinical judgement based on the risks and benefits of treatment in the context of elderly, frail physiology needs to be used to make such decisions. In recent years, it has become more apparent that older people are the target group for many treatments, and trials have increasingly been designed with these patients in mind.47
Commonly used therapeutic guidelines can also be difficult to generalize to older people; particularly when used by those who are not au fait with geriatric medicine (such as relatively inexperienced prescribers or prescribers in settings that are more used to dealing with younger or fitter people), this can result in inappropriate treatments being given to frail older people, with adverse consequences that may include over‐ or under‐treatment, for example with opiate analgesia. Even in conditions where a strong consensus and clear guidelines for management exist, there is evidence that treatment remains inadequate. This is particularly true of conditions such as delirium, where appropriate management requires a concerted team effort and a multifaceted approach. There is evidence that such guidelines are not always followed: this demonstrates that if they are to be implemented universally and successfully, concomitant educational and organizational changes are necessary.48
As the needs of each person within this population are so heterogeneous, care must be taken to tailor decision‐making to the individual. Training to develop these difficult decision‐making skills is also often lacking, and this ability is usually expected to develop with experience. Cognitive biases and failed heuristics23 are more likely to occur when the information presented to the decision‐maker is complex and of varying quality, as is often the case in the care of these patients. Another problem is that whereas younger people might expect and be able to take part in the clinical decision‐making process, older people often prefer not to be involved to the same extent49 or are not able to do so. When making complex decisions such as care planning near the end of life, multiple factors need to be taken into consideration, such as the health status of the patient and their values and individual goals, so that the best interests of the individual are met. All of these factors make decision‐making difficult with the frail elderly, and any failure in this process can lead to undesirable consequences.
Multidisciplinary teams and communication
The complex needs of elderly patients often require equally complex treatments or interventions, usually involving the combined efforts of a highly skilled multidisciplinary team. Of course, this is in general a highly beneficial way of working because decisions and clinical management are enhanced by the expertise contributed by a variety of professionals; however, working as a team can be associated with its own problems.
If optimal patient outcomes are to occur, the multidisciplinary team needs to communicate effectively. Some of the barriers to effective communication in healthcare teams described in the literature include conflict or ambiguity about individual roles within the team, perceived hierarchical difficulties, and interpersonal conflict.50 There is some evidence that this is compounded by different professions differing in their ratings of collaboration, perceived barriers to teamwork, and beliefs of what the best outcomes for patients might be.51 In addition, there can be difficulty in ensuring that team members do not work in silos and have a common understanding of goals of care. Ineffective multidisciplinary teamwork can adversely affect communication with patients and carers, in turn causing decisions to be made without adequately involving patients.
Of course, the wider team caring for an older person usually extends across health and social care sectors; here, coordination and continuity of care can be a problem. In particular, poor communication at times of transition of care can cause problems. It has been shown that inadequate communication at discharge from the hospital, particularly in relation to medication management and monitoring arrangements, can lead to preventable readmissions in older people.52 It is also crucial that decisions made with patients about preferred levels of future intervention are adequately communicated at the time of discharge; otherwise, patients may be subjected to unwanted or unnecessary intervention after discharge.
Attitudes and ageism
Unfortunately, despite standard one of the UK’s National Service Framework for Older People in 2001 being ‘rooting out age discrimination’, there is still evidence that negative attitudes toward older people, including ageism, can result in poor quality of care and problems with patient safety.53 Ageism is the act of discrimination against people on the grounds of age alone. Commonly cited consequences are that older people may be denied treatment or investigations that may benefit them or may be subject to mislabelling or misdiagnosis.54 For example, several studies show that older people with ischaemic heart disease are less thoroughly investigated and receive less interventional treatment than younger patients, even when it is clinically indicated.55 This is despite growing evidence that older people are likely to experience substantial benefit in terms of quality and length of life from appropriate cardiac interventions. Such differences may occur not as a result of overt ageism but rather due to uncertainty about the best and safest clinical practice in this age group, particularly among those who are not specialists in caring for older patients. Of course, one of the unique skills of geriatricians is striking the correct balance for the individual patient between therapeutic nihilism (the avoidance of treatment entirely) and therapeutic heroism (where all interventions and treatments are given, even when there is unlikely to be any therapeutic benefit).
The care of older people in general is regarded by some within the healthcare profession as a specialty with very little reward (in terms of clinical outcomes or prestige) for sometimes very heavy physical work. This can lead to staff feeling undervalued and lacking in motivation to implement change. There can also be a negative attitude toward patients, leading to reduced dignity, loss of patient empowerment, and a sense of infantilization. One of the observable manifestations of this is elderspeak, where patients, particularly those with cognitive or sensory impairment, are talked down to as if they are children; this lack of meaningful interaction can contribute to depression and cognitive and functional decline.
Systems and processes of care for frail older people
Frailty and comorbidity bring many challenges for healthcare systems, the greatest of which is ensuring