Acute geriatric problems
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Acute Geriatric Problems. Dr D Samani Clinical Teaching Fellow May 2011. Aims. Introduction to care of the elderly patient in the acute setting Falls in the elderly Acute delirium. Older people. In 2015, population less than 16 will equal population over 65

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Acute geriatric problems

Acute Geriatric Problems

Dr D Samani

Clinical Teaching Fellow

May 2011


Acute geriatric problems

Aims

Introduction to care of the elderly patient in the acute setting

  • Falls in the elderly

  • Acute delirium


Older people

Older people

In 2015, population less than 16 will equal population over 65

In UK in 2060 24% of the population are estimated to be over 65


Illness in older people

Illness in older people

  • Present atypically and non-specifically

  • Greater morbidity and mortality

  • Rapid progression

  • Health, social and financial implications

  • Co-pathology common

  • Lack of reserve to cope


Why is hospital a dangerous place for frail older people

Why is hospital a dangerous place for frail older people?

  • Infections (MRSA/CDT diarrhoea)

  • Falls

  • Malnourishment

  • Increased dependency

  • Delay in investigations

  • Delays in discharge


Older people in ed

Older people in ED

Management maybe difficult because:

  • Unable to give a story and often unaccompanied

  • Multiple and complex problems

  • More likely to require transport home

  • Attendance is often a result of something more long-term

    These are also some of the reasons that lead to increase admissions


Geriatric giants

‘Geriatric Giants’

Intellectual failure

Incontinence

Immobility (off legs)

Instability (falls)

Iatrogenic (medications)

Inability to look after oneself (functional decline)


A word on medication

A word on medication

The oldest 15% of the population receive 40% of all drug prescriptions

Older people are more sensitive to drugs and their side-effects

Reasons?


Points in history taking

Points in history taking

Difficult due to:

  • Multiple pathology and aetiology

  • Atypical presentation

  • Cognitive impairment

  • Sensory impairment

    But

  • Use all sources available, e.g. family, carers, neighbours, district nurse, GP, old notes

  • And always make a problem list


  • Points in examination

    Points in examination

    A full examination will be necessary, but also look at:

    • Function – aids, watch sit to stand, don’t help unless struggling

    • Face – depressed, Parkinsonian

    • Joints – gout, osteoporosis

    • (Self) neglect – clothes, nails, pressure sores

    • Nutrition status – obese, cachectic

    • Conversation – dyspnoea, mood

      Always check cognition level – Abbreviated Mental Test Score (AMTS)


    Acute geriatric problems

    AMTS

    Age

    Date of Birth

    Time (to nearest hour)

    Short term memory (“42 West Street”, recall at end)

    Recognition of 2 persons (e.g. doctor, nurse)

    Current year

    Name of place they are in

    Start of WW1

    Name of present monarch

    Count back from 20-1


    Falls scope of problem

    Falls - scope of problem

    • 1/3 of over 65s and ½ of over 80s fall

    • 50% of these are multiple, 2/3 who fall will fall again in next 6 months

    • Female > Male

      Why today? - precipitant

      Why this person? - underlying problems


    Causes of falls

    Causes of falls

    Combination of:

    Internal

    • Gait and balance

    • Medical problems

    • Psychological problems

    • Drug related

      External

    • Environment

      • Clutter, footwear, pets, lack of grab rails


    History after a fall

    History after a fall

    Eye witness account if possible

    Symptoms before or during

    Previous falls or ‘near-misses’

    Location

    Activity level (function)

    Time of fall

    Trauma sustained


    Examination after a fall

    Examination after a fall

    Along with a full physical examination:

    • Functional – sit-stand, gait assessment

    • Cardiovascular – Postural BP, pulse rate and rhythm, murmurs

    • Musculoskeletal – footwear, feet, joints for deformity (new or old)

    • Nervous system – neuropathy, un-diagnosed pathology e.g. Parkinson's, vision and hearing

    • Don’t forget AMTS


    Investigations after a fall

    Investigations after a fall

    Bloods:

    FBC, U&E, Calcium, glucose, CRP

    Vitamin B12, folate, TSH

    ECG

    Urine analysis

    Only if specifically indicated:

    • 24 hour ECG

    • Echocardiogram

    • Tilt-table testing

    • CT head

    • EEG


    Management after a fall

    Management after a fall

    Treat all underlying and contributing causes

    • Treat any injuries

    • Review all medications

    • Balance training (physiotherapist)

    • Walking aides

    • Environmental assessment (OT)

    • Reduce triggers if possible

      To prevent consequences of future falls:

      • Osteoporosis prevention

      • Teach how to get up after fall (physiotherapist)

      • Alarms

      • Supervision

        Change of accommodation does not necessarily lead to decrease risk of falls


    Acute delirium

    Acute Delirium

    ‘Acute confusional state’

    Features:

    • Acute onset and fluctuating course AND

    • Inattention, PLUS either

    • Disorganised thinking, OR

    • Altered level of consciousness

      Other features not essential for diagnosis:

      • Disturbed sleep cycle, emotional disturbance, delusions, poor insight


    Delirium causes

    Delirium - causes

    Often multi-factorial but consider the following:

    • Infection

    • Drugs

    • Electrolyte imbalances

    • Alcohol/drug withdrawal

    • Organ dysfunction/failure

    • Endocrine

    • Epilepsy

    • Pain

      Pre-existing brain pathology is a risk factor, e.g. previous cerebrovascular disease

      Accentuated on admission by unfamiliar hospital environment


    Focused history

    Focused history

    Patient and collateral

    • Baseline intellectual function

    • Previous episodes of confusion

    • Onset and course

    • Sensory deficits

    • Symptoms of underlying cause

    • Full drug and alcohol history


    Focused examination

    Focused examination

    Full will be necessary but include:

    • Conscious level (up or down)

    • AMTS/MMSE

    • Neurology including speech

    • Alcohol withdrawal – tremors

    • Nutrition status

    • Observations, especially temperature, saturations off oxygen


    Investigations

    Investigations

    Urine analysis

    FBC, CRP, U&E, LFTs, calcium, glucose, TFTs

    Blood cultures

    ABG

    CXR

    ECG


    Treatment priorities

    Treatment priorities

    • Don’t blindly treat with antibiotics unless septic

    • Review all medications

    • Ensure fluid and nutrition is adequate

      If cause not apparent, use general supportive measures, and continually re-asses and re-examine

      • At this stage, consider neuro-imaging +/- LP


    Drug treatment

    Drug treatment

    ONLY IF: behavioural means not successful and

    • Patient is danger to self/others

    • Interfering with medical treatment e.g. pulling out IV lines

      Then, only at lowest effective dose and short-term use

    • Commonly used are haloperidol and lorazepam

      Old age psychiatry opinion maybe needed


    Take home messages

    Take home messages…


    References

    References

    Bowker L.K., et al (2006) Oxford Handbook of Geriatric Medicine. Oxford University Press

    Nicholl C, Wilson K.J. and Webster S (2007) Lecture Notes Elderly Care Medicine. Blackwell Publishing

    University Hospitals Coventry and Warwickshire Clinical Guidelines available at: http://webapps/elibrary/index.aspx

    Blackhurst, H. (2010) UHCW guideline for the management of falls in the elderly

    Lismore, R. (2007) UHCW guidelines for acute delirium


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