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I am really going to get started on the second half of this. We talk a bit more about the pharmacy and frail. Say, um, this is probably not going to take quite as long as the time we've got. So I will have been tired at the end or any questions about anything related to fail Do that you're interested in, actually, not just this. Okay, so one. So the what? Polypharmacy I love this. The elderly on the biggest consumers of drugs, I was thought it was the youth of today, but they always 15% of the population receive 40% of our prescriptions. We need to be really aware that for reasons we talked about your family, genetics from good in an ICS are freely elderly population are much more sensitive to drugs. No weight on ultragreen all function being to the me and reasons for this they're more susceptible to the side. Effects on the adverse events is well on the side effects that you do have more likely to have serious square life. We have to think about things like falls. So if you're on any more than four drugs of any sort, you are more likely to fall independent. It's an independent respect for falls. Do you think, if it about things that anticholinergic burden a cognitive impairment? Um, there's actually a calculator. The anticholinergic burden. Catch a liter, a CRP if you look it up. Um, a lot of drugs that you wouldn't think off carry some anticholinergics burden on anybody who gets in a CV score of three or more is more likely to develop cognitive impairment. Drugs like solifenacin, um, for bladder instability have a score of three or by themselves. So these are things that we really need to think about the free level, really, especially if they're coming in with confusion. Okay. All right, let's get this back up. Um, the other thing about the free loudly is related to have lots of different diseases and therefore being lots of different drugs. And we think about what people are already on before we prescribe something else. And we have to really think that by no only the drugs that might be interacting with, But what are the side effects you might already have? Our what we seeing could actually be a side effect rather than your pathology of itself. Um, people are often started on one drug contract. Side effects of another night. This is what a mind about Barris. I see people coming in with falls on. They've got quite bad postural hypertension, and I need to pharmacological management, so they get started. Um, For the record, us, um mineralocorticoid causes you to retain water. When you were taking water, your ankles might swell. It's really important to tell people that's when you prescribe it. Um, if you expect a side effect, it's comes last lottery. So you go to your GP or your another doctor on my ankles are swollen, and you could give him fruit might. So you end up on two drugs that are completely bounce, you know, completely contracting each other. Um, if you have lots and lots of drugs, are you like you to take them all properly? No, you are not mean. If you have 17 different medications before breakfast, are you likely to manage to take them? Know if you do manage to take them, Are you likely to eat your breakfast? No. Um, I have a free, loudly relative who, um, had quite a large amount of drugs. We managed to get some of them dying. Um, we discovered when she came in with a stroke that she was taking drugs in the morning because she didn't actually fancy taking the evening ones. So things like picks about twice a day on have to be taken twice a day. Um, we need to think about Is there a way of changing those drugs to see if actually can improve the ability to take them Before you prescribe anything? We have to have a little think about risks and benefits. Do we actually have to prescribe it Until is there something else we could do instead? Um, this isn't so much for any, but for general practice, we just need to drink a swell patients change. We need to review their drugs. You know, something that they were prescribed 20 years ago may know actually still be needed or relevant or even the right therapy today. That's something that we can think about doing in secondary care as well. If, um, it hasn't been done for a while. So when we are reviewing drugs, the first thing we need to think about our interactions did I mention that drug interactions and feel elderly really important. We really think about what drugs might be interaction each other more by because inside effects, we do think about the benefit and the risk of each drug individually. For example, anti coagulation and fall's like people. Do you think about this a lot on our attempted to stop anticoagulation actually, after a few falls, but you actually probably have the have between two and 300 for a year, Actually, be a risk off anti coagulation. But when your risk of stroke, um, is the medication still indicated, as I said, if it was described 20 years ago is actually still the right therapy. So 90 days for you, Whenever I first started I the new treatment for stroke was aspirin and dipyridamole on. We know it's less efficacious than clopidogrel, so we just need to think about if somebody's been prescribed that a long time ago should be actually changing it to a more appropriate treatment. Um, what's the nicest choice you know, even if it's a bit more expensive? What's, um, let's let you to have side effects. I'm sorry to tell the pharmacist that there are maybe saying about the more expensive drugs might be a better choice sometimes. Um, is the drug actually causing the symptoms that somebody's presented with? And if so, can we stop the drug, or can we change it to something else? Um, can we replace one drug? What, two tablets with one tablet makes it much easier for people to take and make it more on what much more likely to be concordant with the drugs. What are they like? How did we give thumb camel swallow pills? Or do we need to actually give somebody a liquid to have to be a thick liquid can be second, Um, if you can't swallow or we're not like to take our drugs and the essential is there another way of doing it? But transdermal, they have a gender of pain. We need to think about all these things as well. Before we prescribe, we have to think about timing of drugs. Before you describe them. We have to think about Is there any way we can actually help people take them on to take them properly? So, for example, Firaxis on alcohol shouldn't be given together and should be separated in adults a box, and that isn't always done. Things like docile boxes and phone alarms can remind people you are frail and you may have memory problems to take the drugs. But the most important thing about getting people to take the drugs is to make sure they understand why they're on them. So if you tell somebody what the drug is, what it does on why they need to take it, they are much more likely to take it in. Somebody randomly says, Take this pill when we're starting new medications and this is probably more relevant. TD R E M is why we're doing it. It's to cure something to modify the progression of the disease. And if it's not to do that, then it's to control. The symptom are occasional for prevention of further complications as well. And the free level really the most important thing to think about when we're prescribing is start at a low dose. You don't necessarily need to go in with the walking great big dose straightaway and again I get my 90 year old non office. The example start low on increase slowly. They do need to be increased to therapeutic benefit. You low is important But actually the drug doing the job is important as well. Before we're changing things, sometimes you have to think about. Has it had a long enough to be effective? If you see somebody they've started on on antibiotic one day and become the evening the next day or attempted to change the antibiotic because you know they're here, it's not working. But actually, we need to give it long enough to see if it is working. Before we think about changing things on again, consider the overburden of drugs. Is there anything else we could do without getting a prescription pad? I I want to know about Betty. That is actually be a stone. A real patient that I knew in before I come back to that island Barely was amazing. She waas relatively frail, but she still lived alone on it. Waas independent on she had never arthritis got sore knee. So she went to as, uh, she bought some your family because she you that you're a family was good for joint PM. She did it for a few days and she got some indigestion. But that must be normal because I am old. That was her expectation. She was expecting that this tablet, you know what the symptoms she was getting. She didn't so see it with. It's just thought it was something she was going to get because she was really something. She then, unfortunately, have not pretty. I bleed free. Lovely people are more prone to the side effects of drugs in younger people. She collapsed because her home, Easy Asus was impaired because she's feeling on older. Um, unfortunately, she wasn't able to cope with the blood loss on Diovan, a smaller volume of blood loss than her BP dropped. Um, so she collapsed. She was also on to empty hypertensives, which she's been taking so again the interactions of drugs with the impaired homeostasis labor more likely to collapse. She fractured her hip because she had coexistence. He's had osteoporosis. Um, so she's more like to have fractured because she was independent. I didn't have any carriers. She actually lay on the floor for 24 hours until she was find by. Can't remember if it was the water the postman on. They called the police to get to her, but she's been on the floor for 24 hours and that was treated so called social circumstances again in a field or elderly person. She got admitted to the hospital, but remained very mobile. She either hit fixed. Um, but actually, it took a bit of time, because when she was first came in, she was actually pretty sick. She had quite a high cpk. She had significant pressure burns. She had a lot of oxygen. She was in fasting after that. This point, it was a lot of things going on my body. So she didn't get her head fracture fixed within the golden 24 hours, which was the, um And she's still been any, um, so she wasn't bad a bit longer MP and delirious before she could have her hip operation POSTOP. She was already very friel. She'd become delirious GTP in constipation. On medical sickness. She developed a really bad pneumonia. Um, it was her second pneumonia. Um, it was orthostatic because she could still be in bed, and she wasn't able to get out because she had the delirium. She she was given antibiotics again, and she's already had antibiotics for onset from recently. And she got diarrhea. I after Janet calls and she actually died from C. Diff. Um, it's very, you know, isn't an unusual patient. Somebody who is pre about relatively independent has gone and bought a drunk that's really available. It's triggered this whole thing whole sequelae of events so freely elderly people that had versus went to much more like to be severe. In this case, it would result in about his death. So I know we've already covered this a little bit, but I just want to talk a little bit more about what is frailty. The wh. You'll have a different definition, which, you know anybody who's doing research into frailty or this is what we take is our definition recognizable states. Older people cannot cope so well with everyday or kids stressors. This is due to increased vulnerability. Agency to decline in physiological reserve. I'm functional cause multiple consistency mean it's a bit worried, but it is what it is. New. It's wrong. What says in the 10, however, is frailty, and you think you know it's not. Shakespeare described it beautifully, and as you like it, the six H shifts into the lean and slipper pantaloon with spectacles on nose and pouch on side his youthful hose well see of the world to wide for his shrunk shank and his big, manly voice turning again towards childish trouble hikes and whistles. And it's signed. Lasting of all that ends this strange event from history is second childishness and Miracle avian salty. So so that Shakespeare, describing somebody becoming more freely, more vulnerable from like it. Seven ages, man. So you know, spectacles and his nose because his vision has changed. We talked about the change in our tissues, the change in our college in structures that can, you know, get into that his youthful who's well see of the world to white as he has older. He has lost weight. He's become stark, a peanut. He's lost muscle mass on his tries. You're too big on those days. They would have seen them for somebody else. His big, manly voice turning again towards childish travel. He isn't taking as much testosterone as you get older, so testosterone causes vocal cords and man to you become thicker and wider. Puberty. As that decreases, boucle chords again become longer and thinner on our pitch increases and the last thing of all second childishness. Mira believing no teeth. No, I think that describes Realty. Really? Well, I don't Also, I think highlights. This isn't a new problem, so I just feel the actually looked like So what we're going to see is things that unintentional weight loss feeling of just tired us. I am tired. Um, this is probably the main complaint that I get from patients and their families is why are virally tired all the time. Why can't we fix it? But this actually indicator of frailty weakness usually due to a loss of muscle mass or sarcopenia slow walking speed on low levels of physical activity. Those are the things that sort of think you think about. Is this person frail? Well, why do we need to worry about frailty? You know, what is it important? So illness and older people is usually continue with the dietician to get in middle age. But everybody is more likely to have more illnesses existing at the same time. On that is again in the context of all the things we talked about about physiology, about loss of muscle mass and again with Beth Day. We touched on the social situation of the person people living alone maybe more vulnerable. A swell, um, biological model while we get for you is what we've already touched upon myself. Messes Frailty is probably approve. Inflammatory. See it? Those say two kinds. That s E s p B talked about leads to things like Sarcopenia, which again? Loss of muscle mass. You've got your excessive cattle Accordions. Your cortisol. You are losing your under ginger growth hormone, Dan y. Our voices get higher for a man when we get older. Muscle mass loss treated, lost growth hormone. The change in our add a close race you to lean muscle mass actually encourages insulin resistance. The more sort of visceral fat you have, more likely you are to the internal resistance, which again means you're more like this, Teo not develop diabetes. But actually you're more likely to have heart disease, street, vascular disease, all those things as well. The immune function that we talked about not being as well also feeds into this biological model my commuting deficiencies and oxygen stress. I either free radical damage So all those things come together with them and said the background with Cenestin sales were sitting there with all this inflammatory decided kinds going on as well. The other model of failed to people think about it is the multiple pathologies model of frailty. As we get older, all the changes need us more vulnerable to disease. Disease is interact as you their treatments. Um, that actually causes us to dysregulated and you become Friel, um, some diseases which are inflammatory, one of the sort of sit in a metabolic syndrome type diseases, street buster, disease. They could be a cause on effect of underlying disease, and the thought is that no one disease is more associated with family. But it's like it's critical mass on when you hit critical mass. It's like a straw that finally breaks the camel's back. That's this. One more thing, and that just makes you feel which of these is more likely to be the underlying cause of frailty. I think it's probably the two. I think they're actually linked. I think the more we knew about frailty, an aging, I think, the sort of snacks that sales on that inflammatory condition, the Proinflammatory state is probably been taking this that's causing frailty or unhealthy aging, whichever way you want to protect. All right, we've talked about why it's important. But why is it important to us in hospital? Um, why is it important? Any d especially real elderly people sometimes feel to read the text books on They do not come in and say I have central crushing chest pain. Please look at my ST segments. They come in because they're suddenly become confused. They're delirious. And actually, they may have had an MRI lead into the delirium. Um, they may may signs. So, you know, I had a free a person come in with one of the most horrendous looking You're blessed. It was ever seen on his only physical sign was a slight right arm weakness and a little bit of right arm drip on a right leg we considered cause to fall. Um, you know, his signs were no proportionate, Teo. The burden of disease he had They may not present with all the right symptoms on, Actually, sometimes even may not when we're doing blood work and things, you know, something may have uninfected in but have a normal crp to Sometimes as we get older, um, are physiological responses or delayed and early on disease, we may not have the seam um, test results that we would We will do a little bit down the line. It just doesn't happen quite as early. We're more likely to get disease be that infection or B that together married of things we talked about, but we are less likely to recover from it on. We're more likely to recover more slowly. Our response to treatment may be different, and we're more susceptible to side effects in directions of avoided talk to by what is this all lead into this leads to increase time and hospital. Increased time in hospital means that you have more bad days. More bad days means that the hospital gets fill up quickly. And what does that happen? It backs up three D. The actual risk of admitting it free lovely person to hospital is much more so than in a younger, more robust person. Um, ability, because what we do is sick people where you put them in the gallons and we put him in bed. Inability leads to rapid deconditioning, which leads to rapid late altering. I comes much more risk for delirium and I don't know about you guys, but we're seeing hugely more months of delirium post covet people that have been isolated for a year, and then there are conceivable again, we suspect being exposed to infection or having your symptoms. And I'm presenting with them. We're seeing a lot more really significant delirium. And I think you're seeing that medias well, more likely to be susceptible to hospital acquired infections. All these people, they're still in the hospital waiting for their social search. Circumstances to be sort of diet are more likely to develop a hospital fired infection. Mother in hospital. From the surgical point of view on the e d point of view, they're much more likely to have altered surgical like comes to more susceptible to delirium. Her wouldn't healing infection. I know later on today as well you're gonna talk about silver trauma. What you think of something really, really important to think about? I'm in a nutshell. We know that actually really lovely people benefit from specialized care. We know that thinking about for allergy people as a whole rather than as a single organ system. I'm thinking about them in terms off psychology, physiology, social circumstances. Um, there's the elliptical reserve in capacity. I'm thinking about things early on is much more likely to improve. I come and that just is already talked about this. I'm going to skip a note very briefly. What are the conditions associated with aging and final date? We're not lead to call them the geriatric Giants anymore. Apartment us, Sort of. You know, um is going a lot of the same way of things that previously would have thought. The geriatric Giants is the big guys. Mobility in constant instability, imperative collects or confusion. Now we should think about frailty sarcopenia, anorexia again. Incontinence, carpal tunnel compare mint. Those are the big five that we're going to see. More and more off on that are gonna be putting people to your a day because they are going to Call's Falls had fractions to freshen the Depression delirium. These are things that you're gonna be seeing more and more off, and it's difficult. It's costly. It takes a little time, Um, here in cause we I said, we are trying to increase our sort of frailty at the front door. We're trying to increase our presence here. We're trying to increase the input three d a year, especially for, like to take more people nine with cold, but they're So if there's anything more that you want to ask about frailty or DHEA you I'm in for it. Thanks so much somewhere that that was Bob. Um, could you maybe just touch on trying to help the guys? I guess it's just trying to help the guys knew which patients to refer to. The, um Which patients to get the medicine. Yeah. There may be sort of chemical pointers that you could get, um, just to give them an idea. So I'm really, I think you're mean. It's I don't think it might be trying to do it for me, but you're right, you know, is just for Well, sorry. I'm sorry. I didn't hear I didn't have that nasty question. I'm sorry. You talk. I think he was asking about who's pretty you. Who's for gentlemen? I think at the moment, the people for DEA you were concentrating on other people that we I think our hopefully going to be able to turn around in one day. So it's anybody with a ruptured frailty score really a five or above. Although I'm happy to talk about anybody he started last real. Um the people. We did have a a t for a while. Um, e t for a while. And the people that that didn't need any medical importantly, drugs were more suitable for them. But night, the i t is gone. That's, um we're happy to see people upstairs as well. You may need, um, more of a social input or more of any I t and foot to, um the people that are going to be a medicine. I'm probably gonna be. People just need treatment for sort of 48. 72 hours are eventually plan for DEA You is that we will try and admit all those people through the A you and get them straight to an elderly short stay units that we're still seeing them when we're getting them up more quickly. But I do think that is going to be a few months down the line, but it will be more like and I am you or a medical admissions unit for the free. Louder. Late for us. You know, you be able to bring us in the day. We'll see. See people bring them up, getting through and get them into a bad. But the moment we haven't got capacity to. That's something we're working on in terms of the medical model is, well, so very funky. Emily, Um, suppose allergic question I'd kind of have for you is from the other end from our perspective. And what do you see is the candid Big Pet Falls or the big things are messed from a d kind of perspective. Are there any big things that you've noticed or trans? No. I mean, there's not too fair. There's no awful lot missed out. Think things like thinking about drugs would be the mean issue, um, thinking about it, whether we need to continue them thinking about drug treatment in delirium. Um, I know the delirium pathway is very, very hot. Haloperidol, um, I'm going to speak about that because whilst haloperidol is useful sometimes, actually it's a bit of a 30 drug with lots of side effects on. There are other options, but you that we might need to consider instead of a bit cleaner, um, things like thinking about constipation in delirium, something really about That's off, miss. People coming in vomiting off legs. It's a UTI, but quite often isn'tt. I think about just really simple things, like constipation, nutrition on. If somebody has a urine dip, that's part of it. So I'm gonna start. Might might my urine dip front? If somebody hasn't got any symptoms, you shouldn't really dip the urine. Um, urine dips in the elderly over 65 between 50 and 70% will be positive. With no infection there. About 20% of people over the age of 75 will have an asymptomatic bacteriuria. I will have bacteria in the urine that that's not causing infection or in from inflammation, inflammatory processes in the body. And they shouldn't be treated as UTI. Um, so I would try and stop dip in urine unless somebody actually has urinary frequency on your incontinence. Smelly urine isn't a a sign of infection, either. Smelling urine is usually urine that has, um, been sat there in a bladder or pad rather than actually being infection. So that's probably and that's not just eating the that's Teepees that doctors on the board as well. It's no a sort of easy only if she but that would be the main thing. But you guys don't miss much. Thank you. Um, Ali? Yeah. We got I I specifically asked Somebody talk on you. The eyes know people because, uh, I think I think we're playing phone. They're finding in the because it gives us some 20 padding their guns on what you say. But, you know, UTI is somebody who has symptoms, a fever on flammatory response. You know, it's not somebody who's confused, and this isn't I mean, you know, people we have coming in who had five different antibiotics for UTI, but they're still confused. But that's because there's another source for a little area. A Z pasta patient is probably, in my experience, the biggest one that is overlooked. Yeah, yeah, And I think I think that's one thing we're looking to get. This day is just kind of highlighting the folks that on those those kind of giant see you're talking about. So, you know, frailty and continents calling the impairments sarcopenia except lots of other things that may be looking at not just putting you on the UTI when they're not symptomatic. Okay, Any other Well, here there's a question just from Emily, um, asking about and they sent them off a uti causing delirium. Is that thing probably know, Um, it's probably another another issue. I mean, delirium could even just be triggered. I mean, delirium, if you know somebody else is talking about delirium later. But I mean, if somebody is very feel, it's very cognitively feel a swell delirium could be triggered, even just by a change in environmental circumstances. So, I mean, I once had somebody tell me that their father had a Colt dementia and stand on. He actually, they had taken there for your elderly father, and this resulted critical to speak and and they put him in in the world, partial pressure, oxygen on unfamiliar environment. And he went totally off his head, delirious on. But it didn't settle so that that family were absolutely ministry. He had caught delirium on the play into spin, but actually, it was just the change of environment. Probably slightly lower partial pressure of oxygen. And then a new, very unfamiliar environment caused a delirium on the back line of a probable underlying dementia. But that they hadn't noticed because he lived in the same house, sold his life. He had a really good routine on that have kept him sort of functional. And then he took a mindset. So sometimes just little tiny things like that. You know, we've locked. All are free. Lovely people up for the last 15 months. Um, then you are starting to let the money on it. Any wonder people are becoming confused or seeing people again? Environments change, routines change. So any of those things configure a slip, you know, a delirium that may not settle. I'm you know, asymptomatic uti aren't huge thing in my experience. Okay? Yeah, I think the other thing just probably it's worth saying is you know, these patients are increasingly complex, Certainly. Yeah. If we try and over some oversimplify, right, then that's just gonna end up with with us months and things. And I guess that's really helpful to see that tying in with just talk on the current sciatic assessment on her that feeds. And so I guess you know, we know we're not gonna do it in the compressed come brands of geriatric assessment any the IV, But there's elements that we can't pick coats on weaken. Try and pick out the ones who are really in need of a full feeling. The assessment of which ones we could maybe makes a small interventions needy and try and get them home safely. I mean, the people that we will probably India you make. The biggest difference to you are those people you are short of the moderately Friel, very free or complex elderly. They're sort of rock words. It's nines. You're more thinking about them is symptomatic management rather than actually you're not going to fix a lot of that's your more thinking about what is our overall, um, is a quality of life symptom control. But the people we can make more of a difference with people that are still at home still mobile, becoming confused, that sort of thing, that you're sort of seeing night. You're seeing a lot more of that present in preschool, but a people are not going back like a hibernation again. But, you know, GP Frax is overwhelmed, you know, they're there 20% up there, something about on their consults. From this time 18 months ago on more and more people, I've got worse over a lot going on or ending up any D acutely various or confused or falls on. Those are the people that are still living at home that we can probably make more of a difference, too. So I think you I don't think any other questions coming up and just a few folks. And thanks again for your talk. So, um, there's no other questions broken up. I think we'll leave it there anyway. Thanks for forgiveness. Your time and sharing talks with us. I apologize. If I was rambling. I said I got thrown by talking to a blank screen. I hear him teaching. How much you all a person. So hopefully we'll be able to do this in person one day. Thank you. Thanks.