Heatwave! Acting on the weather forecast to reduce morbidity in frail older people

Duncan Forsyth has been a consultant in geriatric medicine, at Addenbrooke’s Hospital, for 27 years. A believer in global warming, he noticed that staffing levels in hospital were often inadequate to ensure adequate hydration of his patients during any heat-wave and that admissions due to acute kidney injury were especially prevalent in care home residents and frail older people receiving substantial packages of home care. He advocates incorporating the weather forecast in to the risk stratification for hospitalised patients, care home residents and those receiving three or more home care calls per day; in order to promote a review of potentially nephrotoxic medication.

As you look forward to enjoying the (hopefully) warm summer weather, spare a thought for those less fortunate than yourself, who are frail; less able to increase their fluid intake; who are dependent upon others for provision of drinks; and at risk of acute kidney injury due to the potentially nephrotoxic drugs that they are prescribed. A leader article in the BMJ 2009 (Olde Rikkert, et. al) highlighted the dangers of heat waves and dehydration in frail older people and the resultant excess mortality in this population.

Throughout most of my consultant career I have taught my trainees the importance of monitoring long-range weather forecasts in the acute care of frail older people. Prior awareness of the likelihood of prolonged hot weather (>3 days of ≥25^oC) allows for preventative action to be taken in reducing or stopping diuretics, ACE-inhibitors and NSAIDs in frail vulnerable older people in our acute hospital, most of whom barely manage to maintain adequate fluid intake in normal climatic conditions! Staff are particularly asked to consider the possibility of a heat-wave at week-ends and over Bank Holiday weekends, when medical supervision is reduced.

I then extended this teaching to general practitioner colleagues caring for the most vulnerable older people - those in care homes or those living alone and in receipt of home care. The advent of specific GPs or GP practices having responsibility for individual care homes should help facilitate this preventative action, as should engagement of community pharmacists in medication review within care homes. Proactive management can help avoid: constipation leading to delirium; dehydration and acute kidney injury; and reduce risk of falls, hospitalisation and mortality.

Most of those who are at greatest risk from dehydration during a heat-wave are already known to health care professionals and this will be increasingly so as the electronic frailty record is rolled out across the country. Reminders to watch the weather can be disseminated electronically to all prescribers within our hospitals; and a reminder also sent to GP colleagues and community pharmacists with responsibility for medicines management, through the relevant CCG. Or you could simply put an electronic reminder in your personal calendar for May-September. So, preventative action is possible if only we seek to prevent problems rather than waiting for the crisis to happen!