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Acute Elderly Care. Ria Daly Clinical Teaching Fellow. Overview. Acute block curriculum Falls Acute confusion Interactive cases. Aims – acute block curriculum. Falls Diagnose the cause of falls in the elderly by history, examination, appropriate use of investigations Acute Confusion

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acute elderly care

Acute Elderly Care

Ria Daly

Clinical Teaching Fellow

overview
Overview
  • Acute block curriculum
  • Falls
  • Acute confusion
  • Interactive cases
aims acute block curriculum
Aims – acute block curriculum

Falls

  • Diagnose the cause of falls in the elderly by history, examination, appropriate use of investigations

Acute Confusion

  • Differentiate acute from chronic confusion
  • Common causes
  • Initiate management of commoner causes
objectives
Objectives
  • Be able to assess an older adult following a fall.
  • Formulate differential diagnosis
  • Be able to investigate an older adult following a fall
  • Be able to assess an older adult with confusion.
  • Know how to investigate and initially manage acute confusion
why are older people at risk of falls
Why are older people at risk of falls?
  • Frailty
    • Reduced physiological reserve and weakness
  • Multiple medical problems
  • Polypharmacy
  • Social adversity
case 1
Case 1

Dear Doctor,

Re: Mr A. Notherfall

Thank you for seeing this 82 yr old gentleman who collapsed at home. Has fallen before.

PMH: HTN

Yours sincerely

history hpc
History - HPC
  • What questions would you ask and why?
  • Frequency/time course
  • What were they doing before they fell?
    • From sitting to standing, turning of head
  • Preceding symptoms
    • SOB,CP, palpitations
    • Light headed
    • Room spinning
    • Unsteady on feet
slide9
LOC?
    • Do they actually remember falling, hitting the floor etc
    • How long were they unconscious for?
    • Any suggestion of fit?
    • Was it witnessed?
  • How long were they on the floor for?
    • could they get themselves up?
  • If mechanical – any precipitants?
  • Any injury?
history other
History - Other
  • PMH:
    • Previous falls
    • Confusion
    • Stroke
    • PD
    • Dementia
    • Balance problems
    • Hypertension
  • DH:
    • >4 drugs = independent risk factor
  • SH
    • Alcohol
    • Environment
    • ADLs - Dressing, eating, ambulating, toileting, hygiene
slide11
Think back to an older

patient you have taken a

history from....

slide12
Difficult due to:
  • Multiple pathology and aetiology
  • Atypical presentation
  • Cognitive impairment
  • Sensory impairment
abbreviated mental test score
Abbreviated Mental Test Score

<8/10 = Cognitive impairment

Needs further assessment!

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

Dates of WW2

Name of present monarch

Count back from 20-1

a collateral history is a must
A collateral history is a must!
  • Relatives
    • Paramedics – ambulance sheet
  • Care home staff
  • Nurses/Health care assistants
  • GP (prescription)

DOCUMENT IT!

causes of falls
Causes of falls

Internal

External

  • Medical
    • Cardiac
    • Neurological
    • Orthostatic hypotension
  • Drug related
  • Gait
  • Balance
    • vertigo
  • Environment
    • Clutter, footwear, pets, lack of grab rails
syncope
Syncope

Transient, self limiting LOC, rapid onset, spontaneous, complete, prompt recovery

Transient impairment of cerebral blood flow

Symptom NOT diagnosis

ORTHOSTATIC

HYPOTENSION

NEURALLY MEDIATED

CARDIAC

examination following a fall
Examination following a fall

(ABCDE)

Any injury?

Cardiac

Pulse

Murmurs?

Assess fluid status

Postural BP

Neuro

Motor weakness

Sensory impairment

Coordination

Gait

Cognition

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
investigations
Investigations

12 lead ECG + postural BP (together)

Provides diagnosis in 2/3rd cases

Echocardiogram

If murmur and clinically suspect relevant

24 hour ECG

Very low yield (<1%)

Specifically best in people with daily symptoms, even then <30%

case 2
Case 2

A 78 year old woman is found by her neighbours confused and wandering in the street at night wearing her night clothes. In the emergency room she appears unkempt and dishevelled.

She is alert, but disoriented in time and place and cannot recall her home address. She engages well with questions, but tends to shift the conversation to stories about her husband and children.

She is admitted to hospital and wanders around the ward appearing lost and, when asked, says that she is looking for a bus stop to go home

How would you assess her?

how would you assess her
How would you assess her?
  • AMTS
  • Collateral history
dementia vs delirium
Dementia vs delirium

Dementia

Delirium

  • Insidious (months-yrs)
  • Progressive
  • No(less) fluctuation
  • Attention ok
  • Conscious level ok
  • Sudden, may be reversible
  • Greatly impaired attention and consciousness
what else would you want to from the history
What else would you want to from the history?
  • Symptoms of underlying cause
  • Drug history
  • Alcohol use
  • Signs of infection
  • Fever, crackles, abdo pain, PR??
  • Alcohol withdrawal

On examination?

delirium causes
Delirium - causes
  • Often multi-factorial
    • Fluid and electrolyte disturbances
    • Infections (UTI, resp, soft tissue)
    • Drug or alcohol toxicity
    • Withdrawal from alcohol
    • Metabolic disorders
      • Hypoglycemia, hypercalcemia, ureamia, liver failure, thyrotoxicosis
    • Postoperative states, especially in the elderly
  • Accentuated on admission by unfamiliar hospital environment
how would you investigate
How would you investigate?

Obs and MEWS

hypoxia

hydration

early sepsis

  • Bedside:
  • BM
  • Urine dipstick
  • Bloods:
  • FBC, U+Es, LFTs, Glu, Ca, TFTs
  • Blood cultures
  • ECG
  • Imaging
  • CXR
  • CT??
ct head in delirium
CT head in delirium
  • Often not helpful
  • New focal neurologic deficit
  • New seizure
  • Head trauma
  • Fall
  • Low platelet count or coagulopathy
think about complications of acute confusion
Think about complications of acute confusion
  • Falls
  • Pressure sores
  • Continence
  • Feeding
case 3
Case 3

78 woman is admitted with delirium due to pneumonia. She is pulling at her IV cannula and taking her oxygen mask off.

How would you manage the patient?

managing delirium
Managing delirium
  • Environment - lighting
  • Maintain orientation
  • Encourage family
  • Minimise shift changes (familiarity)
  • Bowels/bladder addressed
  • Pain addressed
  • Avoid restraints – causes more chance of injury
sedation in delirium
Sedation in delirium
  • Sedation
    • When above has failed
    • Comes with risks
      • Resp depression
      • Increased falls (hangover)
    • 1st line haloperidol (0.5 – 1mcg)
    • Risperidone also
    • Lorazepam 2nd line
    • See guidelines on intranet
take home messages
Take home messages
  • Importance of a good history & collateral
  • Determine the acute event that has precipitated the admission (often on a background of ‘problems’)
  • Thorough examination and tailor investigations
  • Think about medium-long term