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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


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


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


Points in history taking
Points in history taking

Difficult due to:

  • Multiple pathology and aetiology

  • Atypical presentation

  • Cognitive impairment

  • Sensory impairment


  • 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)



    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:


    • Gait and balance

    • Medical problems

    • Psychological problems

    • Drug related


    • 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’


    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


    FBC, U&E, Calcium, glucose, CRP

    Vitamin B12, folate, TSH


    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’


    • 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)


    • Neurology including speech

    • Alcohol withdrawal – tremors

    • Nutrition status

    • Observations, especially temperature, saturations off oxygen


    Urine analysis

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

    Blood cultures




    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


    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