Recognising Sepsis in the Older Patient; An interview study with GPs
Problem
Sepsis in older adults is associated with high mortality. There are several barriers in the assessment of sepsis in this age group; the non-specific nature of the symptoms of sepsis, the different signs of severity in older adults and the complexity resulting from co-morbid conditions and polypharmacy. This interview study explores how GPs diagnose serious infections in older patients in primary care.
Approach
Semi-structured interviews were conducted with 28 GPs purposively sampled to show variation in their experience, role, practice location and practice size. A coding framework was developed from the interview topic guide and thematic analysis facilitated by NVivo computer software.
Findings
The description of a patient not being ‘their usual self’ was a red flag symptom for GPs in the diagnosis of severe infection in older adults. Other noted that non-specific symptoms of serious infection were malaise, change in appetite or functional ability. An inability to get to the surgery and the need for a home visit was considered an almost diagnostic feature for a serious infection. GPs perform a systematic assessment of older adults with suspected infections including measurement of the respiration rate, pulse, blood pressure and oxygen saturation in line with recommendations by the UK Sepsis Trust (UKST), but they also described situations where these signs could be masked. An absence of physical signs was concerning, and in particular dissonance between expected findings and a normal examination often lead the GP to reconsider their diagnosis. Some physical signs were described as more reliable than others. Even the same sign could be interpreted in different ways; presence of a fever in an older adult was always concerning, but its absence was only reassuring if the remaining physical examination revealed no other signs of sepsis. Early warning scores such as the NEWS score divided opinion. They were most often used to communicate severity to secondary care teams. Other GPs described concerns about their validity in the primary care and felt these scores oversimplified the assessment of severe infections in older adults. Many felt overwhelmed by different scoring systems available. Although in the UKST guidelines, point of care blood testing was rarely used to assess sepsis, with GPs uncertain of their clinical use.
Consequences
Diagnosing sepsis in older adults is difficult as recognition can be hampered by non-specific symptoms and a lack of the typical clinical signs of sepsis seen in younger patients. Early warning scores and point of care testing, which could aid risk stratification and support clinical judgement, were infrequently used and GPs need convincing of their potential clinical benefit.