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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

slide2
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)

slide11
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

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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