Acute Geriatric Problems

Dr D SamaniClinical Teaching FellowMay 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

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

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? Infections (MRSA/CDT diarrhoea) Falls Malnourishment Increased dependency Delay in investigations Delays in discharge

Older people in EDManagement maybe difficult because:

Unable to give a story and often unaccompanied

Multiple and complex problemsMore likely to require transport homeAttendance is often a result of something

more long-term

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

‘Geriatric Giants’

Intellectual failure

Incontinence

Immobility (off legs)

Instability (falls)

Iatrogenic (medications)

Inability to look after oneself (functional decline)

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 takingDifficult 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 examinationA 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)

AMTSAgeDate of BirthTime (to nearest hour)Short term memory (“42 West Street”, recall at

end)Recognition of 2 persons (e.g. doctor, nurse)Current yearName of place they are inStart of WW1Name of present monarchCount back from 20-1

8-10 Normal

7 Probably abnormal – repeat

<6 Abnormal – check other tests e.g.MMSE

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? - precipitantWhy this person? - underlying problems

Causes of fallsCombination of:Internal Gait and balance Medical problems Psychological problems Drug related

External Environment

Clutter, footwear, pets, lack of grab rails

Drugs

Age Related

Medical

Environment

History after a fallEye 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 fallAlong with a full physical examination:

Functional – sit-stand, gait assessmentCardiovascular – Postural BP, pulse rate and

rhythm, murmursMusculoskeletal – footwear, feet, joints for

deformity (new or old) Nervous system – neuropathy, un-diagnosed

pathology e.g. Parkinson's, vision and hearingDon’t forget AMTS

Investigations after a fallBloods:

FBC, U&E, Calcium, glucose, CRPVitamin B12, folate, TSH

ECGUrine analysis

Only if specifically indicated: 24 hour ECG Echocardiogram Tilt-table testing CT head EEG

Management after a fallTreat 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 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 - causesOften 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 Patient and collateral

Baseline intellectual functionPrevious episodes of confusionOnset and courseSensory deficitsSymptoms of underlying causeFull drug and alcohol history

Focused examination Full will be necessary but include:

Conscious level (up or down)AMTS/MMSENeurology including speechAlcohol withdrawal – tremorsNutrition statusObservations, especially temperature,

saturations off oxygen

Investigations Urine analysis

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

Blood cultures

ABG

CXR

ECG

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 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…

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