If you ask a family in Howra h how they handle managing their elderly family members’, it is likely you will hear that they have a folder (usually plastic) either with a rubbers band. This contains discharge summaries from 2-3 hospitals, prescription notes from multiple specialists (who have never seen each other) and lab results which have been passed from counter to counter as no-one is sure which ones are relevant anymore.
A patient is often suffering from multiple issues such as diabetes, hypertension and arthritis. Possibly even some renal decline discovered during a routine test last winter. They will have a different doctor for each issue and although they are doing what they were trained for, there is no one looking at how each issue is affecting the others and the medication. This is often what causes issues for older adults with multiple chronic conditions.
This is what we see with multi-morbidity. As a result there is a real shift in thinking around caring for Elderly Patients, focusing on co-ordination between specialists. This is where a Multi-Specialty Hospital Howrah can really help.
What is Multi-Morbidity in the Elderly?
Multi morbidity is when a person suffers from two or more chronic issues. When you have a patient with heart failure and kidney disease you can’t treat one without considering the other. Medications for the heart can put strain on the kidneys. If they also have diabetes this becomes even more complicated as blood sugars, blood pressure and kidney function all interact.
The Longitudinal Ageing Study in India is the most useful source nationally. An analysis of Wave 1 found approximately 25% of adults over 60 had multi-morbidity. The most common were hypertension, musculoskeletal disease and diabetes. Patients with two or more had a significant decrease in quality of life scores. Those who were female, lived in rural areas and came from lower income households tended to suffer more.
Studies from different areas of the country show varying numbers but overall we can see a large percentage of older adults in India suffer from interacting conditions. This is often managed in a way that treats them as separate.
Why Treating Each Issue Separately Can Be an Issue
There is logic to seeing a single specialty. Cardiologists know more about the heart than general physicians, and patients benefit from this. However when multiple specialists are involved there is no one to bridge the gap.
Imagine an elderly patient is prescribed medication to control their blood pressure. After a few weeks they develop swelling in their ankles. This could be a known side effect of this medication. However if they attend a different doctor next time, they may just be given a diuretic. This causes dehydration or electrolyte imbalance. They feel dizzy and fall over. Each decision made was justifiable but combined they became an issue.
A review of evidence surrounding medication safety in older adults in India found polypharmacy, potentially inappropriate medications and medication omission were common. This review also highlighted that transitions in care such as discharge from hospital were particularly risky. This is because this is when families are given the most information but no support.
Interestingly this review also found that when deprescribing was supervised there was no statistically significant increase in mortality or hospitalisation. So carefully removing unnecessary medication isn’t as risky as assumed. However leaving a growing list of medication may be riskier.
Why Falls Should be Considered
Falls in the elderly are often considered an Orthopaedic issue. This is true as they need to fix the fracture. However this is often the end result of:
Research from urban slums in Siliguri, West Bengal found that a little over 2 in 5 elderly adults had fallen in the past 6 months. Comorbidity significantly increased the odds of falling. A study from rural West Bengal found a lower but still significant prevalence. Hypertension, diabetes and cardiovascular disease were common in those who fell. These are not unusual groups of people. These are just everyday elderly adults with everyday chronic issues.
This suggests we can’t rely on one department to help prevent falls. Medication causing dizziness when standing, sedatives slowing reaction times, poor eyesight, weak muscles and uneven flooring at home all play a role. A co-ordinated review will consider this. However a single specialty clinic will not typically consider this. Not due to negligence but due to the nature of the clinic.
Delirium
Delirium is another issue which highlights the issues with fragmented care. A study from a hospital in Kerala found a significant proportion of elderly inpatients developed delirium. Polypharmacy was present in the majority. Delirium is a sudden change in concentration and awareness. Families often describe it as the patient appearing detached or overly agitated.
On a busy ward the patient may be given a sedative. This is understandable. However if the agitation is due to an interaction between medications, electrolyte imbalance or an untreated infection, giving them a sedative will only mask the symptoms. A co-ordinated approach will look at their full medication list, kidney function, hydration and infection.
The Caregiver
Most discussion around multi-morbidity will centre around the patient. However the family member managing this can often carry a heavy burden. A scoping review of elderly caregiving in India, Bangladesh and Pakistan found that lack of access to healthcare, high levels of multi-morbidity and heavy caregiver burden were recurring themes. Financial burden and urban/rural differences were also noted.
In Howrah this burden often falls on the daughters in their 50s or spouses in their 70s. They will be the ones repeating their medical history at each counter, chasing up reports, deciding which instruction to follow when there are two conflicting ones and noting any changes. When they become tired the discharge plan isn’t adhered to as closely, small changes are picked up on later and the patient may not reach the correct department until they are in crisis. Supporting caregivers is crucial in elderly care.
What is a Real Co-ordinated Approach?
Many hospitals claim to be multi-speciality. Fewer can explain what actually happens when an elderly patient with 4 issues presents on a Friday evening. Real differences include medication reconciliation, sharing of notes between departments and involvement from those who will continue their care.
Shree Jain Hospital and Research Centre in Shibpur, Howrah has a real co-ordinated approach. It is a super-speciality hospital with 169 beds and has over 20 departments including cardiology, nephrology, neurology, orthopaedics, pulmonology, gastroenterology, general medicine and urology. Their dialysis unit can undertake around 100 sessions a day and can accommodate 35 patients. This means if they have renal failure they can be reviewed by both their cardiac and internal medicine teams in the same building. They are also empanelled with West Bengal Health Scheme and Swasthya Sathi which is very important for families considering the cost of co-ordinated care.
| Care Situation | When Specialists Work Separately | When Care Is Coordinated |
| Discharge medicines | Prescribed by each team independently | Full list reviewed before the patient leaves |
| A fall | Fracture treated; cause not investigated | Medicines, vision, gait, and home risks assessed together |
| Sudden confusion | Treated as a psychiatric symptom | Drugs, electrolytes, and infection checked first |
| Repeat investigations | Often duplicated across clinics | Shared records reduce duplication |
| Family instructions | Collected piece by piece | Single plan with one point of follow-up |
This doesn’t mean every elderly patient will need hospital level care for their issues. Most elderly care should be provided in the community with a trusted family physician. However if there are multiple issues interacting then a co-ordinated environment can help stop a series of justifiable decisions becoming dangerous.
How a Multi-Specialty Hospital Howrah Helps
A common question families will ask is who is looking at the big picture? Whilst a cardiologist will be best for the heart and a nephrologist for the kidneys, someone needs to take ownership of the area in the middle. This is often where issues build up without being noticed. A Multi-Specialty Hospital Howrah will have a role in this due to how they operate.
Frequently Asked Questions
Do all Elderly Patients with 2 issues need to see a geriatrician?
No. Whilst they have great training in patient centred care, complex cases often benefit. However fundamentally it is about co-ordination. Are they looking at the patient as a whole?
What is medication reconciliation?
It is a structured review of all the medications a patient is taking, including OTC and supplements. This will be compared to what they should be taking based on their kidney function, recent hospitalisations and diagnoses. It is important as medication builds up over time. The review found polypharmacy and inappropriate medications were common in older adults in India. Especially around transitions in care.
Can a hospital reduce delirium?
Not entirely but they can reduce the avoidable causes. The study from Kerala found that in the majority of cases delirium was linked to polypharmacy and electrolyte abnormalities. By reviewing medications, hydration and infection before prescribing sedatives delirium, which would have been an isolated psychiatric issue, can be seen as a sign that a wider clinical review is required.
What should families bring to a co-ordinated review?
A medication list. This should be handwritten with doses, who prescribed it and when it was started. Include anything they have bought without a prescription. Recent discharge summaries, test results and a brief note of any changes at home, such as appetite, balance or confusion in the evenings. These can often influence the care plan.
How can families in Howrah access co-ordinated care at Shree Jain Hospital?
They can do this through the hospital website or by attending the outpatient department in Shibpur, Howrah. When they have multiple issues they should ask if they can have a co-ordinated review. The multi-speciality OPD and inpatient services will allow them to be reviewed by multiple departments.
Conclusion
Multi morbidity is often referred to as having multiple diseases. However it is actually multiple risk factors. Medication causing issues with another condition, falls due to changes in medication, confusion before checking the medication list and having a caregiver silently holding the whole thing together. This isn’t an issue with individual issues, this is how they become dangerous.
Whilst a Multi-Specialty Hospital Howrah may not have a high number of specialities, they will have processes in place to ensure they are working together. Shree Jain Hospital and Research Centre have a wide range of departments, dialysis facilities and are empanelled with state health schemes. For families asking what they can offer, remember to ask who will be looking at the whole file? If there is a clear answer then the file won’t grow and the risk will reduce.