Geriatric Medicine (Elderly Medicine) · 2019-01-09 · 1 Geriatric Medicine (Elderly Medicine) ... know the exact link and overlap between the two conditions so for the moment we

1 Geriatric Medicine (Elderly Medicine)

Geriatric Medicine (Elderly Medicine)

Key Topics

FRAILTY AND SARCOPENIA (LO1) ................................................................................... 2

IMMOBILITY (LO1) .............................................................................................................. 4

ASSESSMENT OF COGNITION IN OLDER PEOPLE (LO2) ............................................... 6

DELIRIUM (LO2) .................................................................................................................. 9

DEMENTIA, WITH A FOCUS ON DEMENTIA IN HOSPITAL (LO2) .................................. 11

FALLS IN OLDER PEOPLE (LO3) ..................................................................................... 14

FALLS - ASSESSMENT OF BALANCE AND GAIT (LO3) ............................................... 17

STROKE & TIA (LO4) ........................................................................................................ 19

PRESCRIBING FOR OLDER PEOPLE (LO5) .................................................................... 22

PRESSURE ULCERS (LO6) .............................................................................................. 24

CGA, COMPREHENSIVE GERIATRIC ASSESSMENT (LO7) ........................................... 26

REHABILITATION OF OLDER PERSONS (LO8) .............................................................. 28

KEY TOPICS NOT COVERED BY THE LEARNING OBJECTIVE ..................................... 30

OTHER TOPICS - SENSORY IMPAIRMENTS IN OLD AGE ............................................. 31

OTHER TOPICS - THE LAW AND OLDER PEOPLE ......................................................... 33

OTHER TOPICS - ASSESSMENT OF ACTIVITIES OF DAILY LIVING ............................. 36

OTHER TOPICS - ASSESSMENT FOR CARE IN THE COMMUNITY ............................... 38


Frailty and Sarcopenia (LO1)

Dr Daisy Wilson

What is frailty? Frailty is a medical syndrome with multiple causes and contributors that is characterized by

diminished strength, endurance, and reduced physiological function that increases an

individual’s vulnerability for developing increased dependency and/or death. Or put simply

an increased risk of adverse outcomes such as death or institutionalisation.

What is sarcopenia? Sarcopenia is the age related loss of muscle mass. It is different to cachexia which is a

metabolic condition resulting in weight loss as well as loss of muscle mass. Sarcopenia is

present if an individual has low muscle mass and either poor physical performance (timed

walk test/TGUG) or low muscle strength (hand grip strength). If all three criteria are present

the individual has severe sarcopenia and if just low muscle mass is present the individual

has pre-sarcopenia.

How are the two conditions linked? Sarcopenia is more common than frailty and is often thought of as either a pre-cursor

syndrome to frailty or the physical components of frailty. They have many of the same

causes and similar treatments appear to ameliorate their effects. However, we don’t yet

know the exact link and overlap between the two conditions so for the moment we should

consider them as separate conditions.

What causes frailty and sarcopenia? The pathophysiology of frailty and sarcopenia is fairly unexplored but the role of the immune

system, hormones, the endocrine and metabolic systems and lack of physical activity are

thought to be important.

How do you diagnose frailty? Frailty is most commonly diagnosed in clinical practice by instinct; this can be very subjective

and should be avoided. It is accepted that diagnosis of frailty following a comprehensive

geriatric assessment (CGA) is a robust method of diagnosis but without an appropriate prior

assessment the term frailty can be incorrectly applied. There are several methods of

diagnosis which can be utilised by the non-geriatrician who is not competent in CGA.

Electronic frailty index is a score computed by GP operating systems; it takes into

account 36 different criteria representing many different domains such as physical,

social and psychological.

Edmonton Frail Scale is used in many surgical settings to help diagnose frailty. It is a

short questionnaire along with a quick assessment of physical function (TGUG) and

cognition (clock drawing).

How do you diagnose sarcopenia? Sarcopenia is currently rarely diagnosed clinically likely due to the current lack of accepted

treatment. One of the easiest methods of diagnosis is to first measure an individual’s gait

speed. If this is less than 0.8m/s they should go on to have imaging (usually a DEXA) to

diagnose low muscle mass. If the gait speed is greater than 0.8m/s they should first have

their grip strength tested and only if this is low should they have imaging.


Why are frailty and sarcopenia important clinical conditions? These are both common conditions which contribute to a significant proportion of morbidity

and mortality in older adults. The direct cost of both these conditions is difficult to calculate

but it was estimated in the US in 2000 the direct healthcare cost of sarcopenia was $18.5

billion.

What can we do about it? Research has shown that both frailty and sarcopenia are reversible conditions. The evidence

base for management is currently small. These interventions have the best evidence and

geriatricians would be confident to recommend these as part of a management plan

especially as the potential negative effects are minimal.

Exercise intervention – particularly involving strength work

Nutrition – particularly involving protein or amino acid supplementation

Comprehensive geriatric assessment – has been demonstrated to reverse frailty

also associated with improved outcomes in hospital setting (see CGA section)

These interventions below have some or conflicting evidence and are not part of routine

practice.

ACE inhibitors – some evidence that this can improve strength and there is an

ongoing trial looking at ACEi and protein supplementation in sarcopenia

Vit D – conflicting evidence some studies have shown and improvement others

have shown negative effects.

Testosterone and DHEA (steroid precursor of testosterone) – variable results but

concerns with steroid replacement due to side effects (cardiovascular)

Reading: Fit for Frailty guidelines from BGS – http://www.bgs.org.uk/campaigns/fff/fff_full.pdf

European working group on sarcopenia in older people – nice background, definition and

diagnosis – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886201/

http://www.bgs.org.uk/campaigns/fff/fff_full.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886201/

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj42NK57YXUAhUGvRoKHcHOBmMQjRwIBw&url=https://openi.nlm.nih.gov/detailedresult.php?img%3DPMC2886201_afq034fig2%26req%3D4&psig=AFQjCNFFT-BNVRA9iyv2JYufE2z2Og4rxA&ust=1495623381908183


Immobility (LO1)

Dr M Goodman

Immobility is one of the most common presenting conditions in the frail elderly and along

with falls, confusion and incontinence is one of the so called geriatric giants. Unfortunately, it

is all too common to regard immobility or “off legs” as a diagnosis but remember that really it

is only a symptom for which a cause needs to be found. Unfortunately, the list of potential

causes is long and typically an individual patient may have several conditions contributing to

their mobility problems. Assessment should always begin with a careful history as this may

give a clue to underlying diagnosis. Conditions such as stroke or fractured neck of femur are

likely to lead to a sudden loss of mobility. The history is likely to be more progressive in

conditions such as arthritis or Parkinson’s disease.

Main causes of immobility in older adults

1. Following a fall -

Falls and immobility are closely linked. Adults who fall frequently often become

frightened to walk and may restrict their movements and in extreme cases take to

bed. Typically these patients resist standing and experience quite marked fall back

and anxiety when attempting to stand. An important consequence of falls is fractured

neck of femur and it is very important whenever there is a history of a recent fall to

exclude a fractured neck of femur in a patient who is unable to walk. The typical sign

of a painful externally rotated leg is not always present and x-ray maybe necessary to

confirm the diagnosis. Pain on weight bearing (even mild) is also a useful warning

sign.

2. Stroke -

Acute onset of a hemiparesis is usually accompanied by immobility to a greater or

lesser degree. Patients with more diffuse cerebrovascular disease often experience

gait abnormalities which can sometimes mimic Parkinson’s disease. Stroke is by

definition of sudden onset and again a clear history should help to make the

diagnosis. Sometimes the history is of a more insidious onset of arm or leg

weakness. In this case consider space occupying lesions such as primary or

secondary brain tumour or subdural haematoma.

3. Osteoarthritis -

Is extremely common in the ageing population particularly of the large weight bearing

joints of the hip and knee. The history is of pain in the effected joint often of months

or years and subject to periodic exacerbations. Degenerative disease of the lumbar

and cervical spine is also common and leads to pain and restricted mobility. Some

older adults have developed rheumatoid arthritis in middle age which they carry with

them into old age. The sudden onset of an acutely painful inflamed joint is an

important cause of loss of mobility and needs to be thoroughly investigated.

Common causes are septic arthritis, gout or pseudo gout but sometimes a flare up of

osteoarthritis can also cause similar appearances.

4. Parkinson’s Disease -

This condition, which mainly affects older adults, typically causes mobility problems

with tremor and bradykinesia. The onset is often rather insidious and consequently is

often missed. Medication can help symptoms but doesn’t slow disease progression.


Drug treatment (e.g. neuroleptics) is a frequent cause of potentially reversible

Parkinsonism in the elderly.

5. Chronic Cardiorespiratory Disease -

Chronic heart failure and COPD are extremely common. Mobility is often restricted by

breathlessness, poor stamina and lethargy.

6. Visual Impairment -

Commonly due to macular degeneration, patients may manage within their own

homes because of familiarity but outside the home or in an alien environment may

become immobile especially in hospital where the surroundings are often very

frightening and threatening.

7. Feet and Footwear -

An extremely common cause of mobility problems. Always look at the patients shoes

which you may find are either inappropriate or in poor condition. Remove the shoes

and socks and look at the feet. Painful calluses, overgrown toenails, bunions,

ischaemic ulcers, arthritis etc. are all cause of pain in the feet, which restricts

mobility.

8. Miscellaneous Condition -

There are a range of other things which can contribute to a patient’s poor mobility.

The depressed patient may become isolated and immobile. Patients with dementia

may have gait abnormalities which affect their mobility and in addition may have

become lost in an unfamiliar environment. Of course some patients with dementia

exhibit the reverse and have a tendency to wander whatever their surroundings. The

older patient in hospital often finds it particularly difficult to mobilise, urinary

catheterisation with a catheter bag trailing on the floor is equivalent to applying a ball

and chain to an older person who already has mobility difficulties. Provision of poorly

fitting clothes, trousers that won’t stay up and inadequate shoes often compounds

the problem.

Management

This is a multidisciplinary activity. The doctors job is to formulate an accurate diagnostic list,

which may be multiple and then to institute treatment with medication (sometimes removal

of) and/or surgery where appropriate. Physiotherapists clearly have a major role in

promoting mobility and will need to be involved immediately. Remember, they rely heavily on

the Clinician for an accurate diagnosis. Occupational Therapists have an important role

particularly in resettling the patient at home and providing aids and equipment to assist

mobility within hospital and around the home. Social Workers have a role in the provision of

home support and when necessary residential or nursing home care.


Assessment of cognition in older people (LO2)

Dr T Jackson

Impaired cognition is a frequent accompaniment to illness in old age. Usually it is transient

and precipitated by acute illness (i.e. delirium). Sometimes a person presents with a

background of longer term impaired cognition or dementia. Often the two can occur together.

The key is first to identify delirium. If it is delirium, then treat and manage as such. If not,

then it is likely to be chronic cognitive impairment. Sometimes teasing out the two is very

difficult, and requires excellent diagnostic skills and a collateral history.

In any case, we know that both delirium and dementia confers a greater risk of adverse

outcome during and after hospital admission (increased mortality and new care home

placement) so it is important to recognise and not see it as something that is not important.

So – what test should I use?

Well, there are many detailed and comprehensive tests of cognition available, but in clinical

practice such tests are often unworkable, particularly in the setting of an ill patient in a busy

ward or A&E department. At various times the NHS has mandated cognitive assessment of

inpatients linked to financial incentives (CQUINs)

Delirium screening should be done using the 4AT test –

4 or above: possible delirium +/- cognitive impairment

1-3: possible cognitive impairment

0: delirium or severe cognitive impairment unlikely (but delirium still possible if information

incomplete)

1 ALERTNESS - This includes patients who may be markedly drowsy (e.g. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating. Normal (fully alert, but not agitated, throughout assessment) 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4

2 AMT4 - Age, date of birth, place (name of the hospital or building), current year.

No mistakes 0

1 mistake 1

2 or more mistakes/untestable 2

3 ATTENTION - Months of the year backwards:

Ask the patient: “Please tell me the months of the year in backwards order, starting at

December.” To assist initial understanding one prompt of “what is the month before

December?” is permitted.


Achieves 7 months or more correctly 0

Starts but scores <7 months / refuses to start 1

Untestable (cannot start because unwell, drowsy, inattentive) 2

4 ACUTE CHANGE OR FLUCTUATING COURSE

Evidence of significant change or fluctuation in: alertness, cognition, other mental function

(e.g. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs

No 0

Yes 4

Cognitive impairment, if not delirium evident, can be screened for using the Abbreviated

Mental Test Score or AMTS – a cut off in hospital patients of <7 (i.e. 6/7 cut off) indicates

possible dementia

1. Time of day (to nearest hour)

2. Year

3. Place

4. Identify two people (i.e. nurse, doctor, relative)

5. Age

6. DOB

7. Address to be remembered (patient must repeat this to ensure registration and again

after 5 minutes – 42 West Street is the one used in the paper

8. Name of monarch

9. Year of start of First World War

10. Count backwards from 20 –1

Score one point for each correct answer

Clearly, these are screening tools, and further investigation of impaired cognition should then

be undertaken. Comprehensive cognitive tests such as Montreal Cognitive Assessment

(MOCA) or Addenbrooke’s Cognitive Assessment 3 (ACEiii) can then be used.

Informant tools such as the Informant Questionnaire of Cognitive Decline in the Elderly

(IQCODE) and Alzheimer’s disease * (AD8) can be very useful, and also help diagnose

dementia in the context of delirium

Issues are often present with respect to IQ, but also language and culture, when using these

tests and this should be taken into account. Also, remember that a test result like this does

not diagnose dementia – the doctor does!

The Mini Mental State Examination (MMSE) is a 30 question cognitive assessment which

was used routinely in clinical practice (normal 27+/30) however it is now copyrighted in a

classic example of ‘stealth patenting’ so should be avoided.

Consideration of depression should be made, and the 15 point Geriatric Depression Scale is

useful here


In departments of geriatric medicine, the Occupational Therapists have developed

considerable expertise in the administration of cognitive tests as well as its interpretation in

the context of a functional assessment of the patient’s capabilities


Delirium (LO2)

Dr T Jackson

Delirium is a common, severe neuropsychiatric syndrome that affects mainly older people in

hospital. Delirium occurs in up to 1 in 5 people in hospital and doubles the risk of mortality

in people who have it. It was thought of as a ‘normal’ response to illness in older people but

this is simply not the case. Delirium also accelerates cognitive decline in people with

dementia as well as being a risk factor for developing new dementia.

So not ‘what you expect’, but a medical emergency

Risks, precipitants and recognition

Delirium occurs as a result of an acute precipitant event – usually infection or surgery – and

occurs more frequently in people who are vulnerable to it. However, anyone can get delirium

if they are ill enough, and there are high rates of delirium in paediatric and adult intensive

care for example.

The most important vulnerability in older people is dementia – with up to two thirds of people

with delirium also having dementia (often mild and previously unnoticed). Other key

vulnerabilities are frailty, multimorbidity, sensory impairment, polypharmacy (especially anti

cholinergic drugs), and poor mobility.

Infection – though not always UTI! – and surgery are the most common precipitating events.

In fact delirium is the most common post-surgical complication seen in older people,

especially after hip fracture surgery and laparotomy. Other important precipitants not to miss

are pain, urinary retention, faecal impaction, drugs (especially opiates and anit-cholinergics)

Delirium is poorly recognised by medical staff, especially junior doctors – the reasons for this

are unknown and frankly a bit strange!

The key thing with recognising delirium is to suspect it - Think Delirium

The most important question to ask is – Is this new? – and will require you to get a good

collateral history from family, carers and healthcare staff.

People with delirium have reduced alertness and awareness – this is the key diagnostic

criteria, and may be described as ‘knocked off’. A drowsy or agitated patient is an unwell

patient and requires urgent assessment.

There will be cognitive change – ‘confusion’ – this may be memory loss, but more usually is

perceptual and orientation change. People think they are somewhere else and can have

very frightening hallucinations and thoughts.

The key cognitive deficit in delirium is attentional deficit. Patients will not follow the train of a

conversation, talk on about things of the point, or not make eye contact with you.


The 4AT test is the best screening and recognition tool at present and should be completed

on all acute admissions of older people to hospital and when you suspect delirium.

Right, I’ve recognised delirium – now what?

Management of delirium is centred on promptly recognising and treating the underlying

precipitant. As is often the case in geriatric medicine causes and usually multifactorial, and

examination and investigations will be opportunistic.

Examination should be comprehensive – ensure you make special reference to:

Consciousness (GCS/AVPU/mRASS) Neurological exam - ?focal deficit

Evidence of head injury or meningism Palpable bladder

Hips, especially if recent fall Possible focus of infection

Investigations should be guided by the above

FBC, U+E, CRP, Glucose SaO2 (ABG if <93%) BP, RR, temp

Blood cultures if temp TFTS, Calcium ECG

CXR Bladder scan

Consider:

CT Brain scan – especially if recent head injury, on anticoagulants, and evidence of focal

neurological deficit, and /or persistently reduced consciousness

Lumbar puncture – if indicated after thorough assessment

Non pharmacological treatment essentially represents best care, but try to reduce

noise/stimulus, ask family to come in, and correct sensory deprivation – glasses and hearing

aids. Never physically restrain.

‘Please give them some sedation?’

Pharmacological treatment of delirium may be necessary if all other measures have not

dhelped and the patient is at risk to themselves, others, or has severe distress.

In this case use Haloperidol 0.5mg orally (1mg IM) and titrate up to a maximum of 5 mg to

relieve symptoms (you are not trying to flatten them)

If they have Parkinson’s disease or Lewy Body Dementia avoid haloperidol and use

lorazepam (0.5 mg); and benzodiazepines have a specific role in alcohol withdrawal states

If treatment is required for longer than several days, seek guidance from specialist in

geriatric medicine and /or old age psychiatry. The balance of risk vs benefit is finely

balanced.

Reading – see links on Canvas

NICE guidelines for delirium, AEME mini-gem on delirium


Dementia, with a focus on dementia in hospital (LO2)

Dr P Wallis, updated 2017 Dr T Jackson

Dementia is a global impairment of mental function, including intellect, memory and

personality without impairment of consciousness. It is persistent (at least 6 months) and

progressive. What separates dementia from normal cognitive ageing and Mild Cognitive

Impairment (MCI), is that is interferes with everyday function. Corroborative history from

family or friends is useful to confirm the duration of onset.

Dementia is not a diagnosis, but an umbrella syndrome, the most common causes being

Alzheimer’s disease and cerebrovascular disease. Its prevalence rises with age, but affects

about 6-7 % of all people over 65 years, and up to 20% of those aged over 80 years. There

has been a spotlight on dementia recently through the Prime Minister’s Dementia Challenge.

A key to this is to increase access to diagnostic services through memory clinics to improve

the current diagnostic rate – it is estimated that only 2/3 of people living with dementia have

a formal diagnosis, but this is better than it was 10 years ago.

1 in 4 people in hospital have dementia, and people with dementia in hospital are more

likely to receive poor care, suffer hospital adverse events such as falls and delirium, and are

twice as likely to die while in hospital. Treating medical and surgical conditions in people with

dementia should be seen as core business for all hospital doctors (well, maybe not

paediatricians!).

Causes

Alzheimer's disease (AD) - the commonest cause of dementia (45 - 50%). Insidious onset

over months and years without evidence of focal neurological damage. Survival is usually 8 -

10 years. Impaired short term memory and cognitive function are early features. AD is a

pathological diagnosis based upon the presence of neurofibrillary tangles and plaques

throughout the cerebral cortex. No laboratory test available thus diagnosis based upon

characteristic clinical features and exclusion of other causes.

Multi-infarct (vascular) dementia (MID) – is the second commonest cause of dementia (10 -

20%). Stepwise decline with sudden intellectual deterioration followed by a period of

improvement. History of vascular risk factors such as hypertension, AF, diabetes etc.

Evidence of focal neurological damage, labile emotions, abnormal gait (hemiparesis or 'petit

pas').

Lewy Body dementia (LBD) - up to 20% of cases. Lewy bodies (see Parkinson's disease)

present in cerebral cortex, limbic area and basal ganglia. Associated with Parkinson's

disease in most cases. Characterised by fluctuations in alertness, visual hallucinations,

delusions and falls. Extreme sensitivity to neuroleptic medication, e.g. Haloperidol etc.,

causing drowsiness, rigidity and immobility - sometimes with fatal consequences.


What else could it be?

Alcoholic brain damage (Korsakoff’s syndrome), Chronic head trauma (e.g. dementia

pugilistica in boxers), Creutzfeldt - Jacob disease, neuro-syphilis, Wilson's disease (measure

serum copper and ceruloplasmin) and AIDS related dementia should be considered

The classic ‘dementia screen’ looks for other mimics and checks for hypothyroidism, B12

deficiency and hypercalcaemia

So called ‘pseudo dementia’ can also be due to Normal pressure hydrocephalus (consider in

context of classic triad including new incontinence and gait dyspraxia), Space occupying

lesion (e.g. meningioma) and other psychiatric disease such as depression.

How do we diagnose it?

History is the most important tool to diagnose dementia. Tools such as the Informant

Questionnaire of Cognitive Decline (IQCODE) is a good way of operationalising this.

Neuroimaging is usually completed to exclude mimics such as a space occupying lesion or

hydrocephalus – but most people will tell you they had a scan to diagnose dementia. Newer

functional neuroimaging can help to ‘diagnoses’ dementia, especially in difficult to diagnose

cases or in working age dementia.

You have the diagnosis – what now?

Making the diagnosis of dementia provides the patient and carers with a cause for their

symptoms, and allows for robust advances care planning and the avoidance of ‘crisis’.

Some people (AD with mild/moderate disease) will benefit from Acetylcholinesterase

inhibitors donepezil, galantamine and rivastigmine. Memantine (NMDA antagonist) also has

a role.

MID – No evidence at present for aspirin and/or modification of vascular risk factors such as

hypercholesterolaemia. LBD - avoid neuroleptics, caution with dopaminergic therapy for

associated Parkinsonian symptoms owing to risk of exacerbating psychiatric symptoms.

There is an emerging role for Acetylcholinesterase inhibitors in LBD

Behavioural and Psychiatric Symptoms of Dementia (BPSD) can be very difficult to manage

at times and may require pharmacological treatment (ie atypical antipsychotics such as

respiridone) – but this should be done by specialists and fully recognising the risk that these

drugs increase mortality through vascular disease.

Recognising dementia should also prompt evidence based preventative strategies for falls

and delirium, especially while in hospital.

Reading:

Challenges and opportunities in understanding dementia and delirium in the acute hospital.

Essay in PLOS Med https://doi.org/10.1371/journal.pmed.1002247

NICE Guidance on the Use of Donepezil, Rivastigmine and Galantamine for the Treatment of

Alzheimer's disease. Technology Appraisal Guidance No. 19, 2001; National Institute of

Clinical Excellence, London www.nice.org.uk

https://doi.org/10.1371/journal.pmed.1002247

http://www.nice.org.uk/



Falls in Older People (LO3)

Dr J Rowe, updated 2017 Dr H Moorey Incidence

Risk of falling rises steeply with age. One third of people aged >65 will fall in a year and half

of those do so repeatedly, this rises to over 50% in the over 80’s. About a third of the A&E

attendances in the over 65’s follow trauma, such as a fall or other accident. A fall <2m in an

older person is now the most common mechanism of major trauma in patients attending

A&E. Fear of falling and limitation of activity effects between 30 and 50%. Pressure sores,

hypothermia and dehydration may also result from falling.

Aetiology

Most people with falls have age related disease affecting different parts of their balance

system such as problems with vision, arthritic joints, slowed central processing etc. There

are many environmental risk factors that interact with this e.g. poor fitting shoes,

inappropriate environments, particularly institutional; and sedatives, which sedate balance as

much as consciousness. Inter-current illnesses, such as a chest infection, may be the final

straw that precipitates a fall.

Fall or Syncope?

Many people who have lost consciousness have amnesia for the event. Syncope (sudden,

temporary loss of consciousness) requires a different work up and specialised assessments.

Inability to recount the incident, lack of premonitory dread immediately before the fall, failure

to appreciate the impact or see the ground coming up to meet the subject are historical tips

that point towards syncope as a cause.

How should we assess patients who have fallen?

Most patients with falls will need assessment in several different domains. Dedicated falls

services are being available and include virtually all members of the multidisciplinary team.

However, it is important for any clinician assessing a patient who has fallen to understand

the components of a falls assessment and initiate parts of the assessment if able.

A falls assessment may include:

identification of falls history

assessment of gait, balance and mobility, and muscle weakness

assessment of osteoporosis risk

assessment of the older person's perceived functional ability and fear relating to falling

assessment of visual impairment

assessment of cognitive impairment and neurological examination

assessment of urinary incontinence

assessment of home hazards

cardiovascular examination and medication review

The Risk Factor Intervention

Attending to multiple risk factors has also been shown to be effective. This includes personal

factors such as poor vision, inadequate footwear, reduction of medication etc. balance

training programmes, and environmental risk reduction. However, current evidence suggests

that this type of intervention reduces the risk of falls and the number of falls older people


have, but not the rate of falls, or the number of older people who fall in the community. This

may be due to the complexity of these interventions.

What Else Can Be Done?

Group and home based exercises programmes can reduce rate of falls and risk of

falling. Programmes usually include a combination of balance, gait and strength

training.

Home safety assessments and modifications can reduce rate and risk of falls. These

are most successful in those at highest risk and when carried out by an occupational

therapist.

One study has shown a reduction in falls rate just from stopping sedative and

hypnotic medication. A prescribing modification programme has also been shown to

reduce the risk of falls.

.

What Does Not Work?

Overall vitamin D supplementation does not reduce the rate of falls. However there

is evidence that supplementation may be beneficial in patients with vitamin D

deficiency and to prevent fractures in those at risk. This remains controversial and is

well worth a Google.

Interventions to treat visual problems have in some trials increased the rate of falls.

However, they can be effective as part of multiple risk factor interventions and

specifically correction of cataracts has been shown to reduce falls.

Cognitive behaviour therapy and education programmes have not been shown to

effectively reduce falls in the community.

What about falls in hospitals and care Homes?

Falls in hospital are common, with over 600 reported every day across England and Wales.

All older patients admitted to hospital should be assessed for their risk of falls. Multifactorial

interventions in hospitals have been shown to reduce the risk of falls and rate of falls.

Falls incidence in nursing homes is about three times higher than in the community. With

more than 40 trials on Falls Reduction Programs in institutions evidence that they are

effective is inconclusive. However it is important to consider that low falls rates in care

homes may indicate inactivity or the use of restraint. Vitamin D supplementation in care

home residents, who are likely to be deficient, is effective at reducing the rate of falls.

Falls clinics

Can only see very few patients and A&E interventions and exercise programs probably deal

with them much more cheaply.

How Should We Assess the Risk of Fragility Fracture and Manage Osteoporosis?

Older people are at increased risk of sustaining a fracture following a fall compared to

younger people. About 7% of falls are complicated by fracture, but in only 1% is this a

fractured neck of femur. We should take the opportunity to assess the risk of fragility

fracture, especially if patients have a history of falls or other risk factors, in patients

presenting with a fall.

FRAX and QFracture are online tools used to assess 10 year risk of fragility fracture. Scores

are based on the presence of risk factors such as age, previous falls or fractures, steroid use


and smoking and alcohol use. If the risk is high, bone mineral density can then be measured

using dual-energy X-ray absorptiometry (DXA). However it should be noted that risk scores

for patient over 80 should be interpreted with caution, as the short term risk of fracture is

likely to be higher.

Osteoporosis is diagnosed in patients with a BMD T-score of −2.5 or lower. Vitamin D and

calcium supplementation and a bisphosphonate, such as alendronic acid, have been shown

to reduce the risk of fragility fracture in patients with osteoporosis and should be prescribed.

However, concerns have emerged regarding the side-effect profile with long term use of

bisphosphonates and it is important to offer a medication review and reassess risk after 3

years of treatment.

Other points to consider

Alarm-raising: Even with no trials, common humanity suggests we should prevent a

protracted lie on the floor. These are associated with a poor prognosis and consequent

mortality (up to 50% at 6 months).

Suggested Reading

National Institute for Health and Social Care. (2013). Falls in older people: assessing risk and

prevention.

https://www.nice.org.uk/guidance/cg161

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M.,

& Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community.

In L. D. Gillespie (Ed.), Cochrane Database of Systematic Reviews. Chichester, UK: John

Wiley & Sons, Ltd.

http://www.cochrane.org/CD007146/MUSKINJ_interventions-for-preventing-falls-in-older-

people-living-in-the-community

Cameron, I. D., Gillespie, L. D., Robertson, M. C., Murray, G. R., Hill, K. D., Cumming, R. G.,

& Kerse, N. (2012). Interventions for preventing falls in older people in care facilities and

hospitals. In I. D. Cameron (Ed.), Cochrane Database of Systematic Reviews. Chichester,

UK: John Wiley & Sons, Ltd.

http://www.cochrane.org/CD005465/MUSKINJ_interventions-for-preventing-falls-in-older-

people-in-care-facilities-and-hospitals

https://www.nice.org.uk/guidance/cg161

http://www.cochrane.org/CD007146/MUSKINJ_interventions-for-preventing-falls-in-older-people-living-in-the-community

http://www.cochrane.org/CD007146/MUSKINJ_interventions-for-preventing-falls-in-older-people-living-in-the-community

http://www.cochrane.org/CD005465/MUSKINJ_interventions-for-preventing-falls-in-older-people-in-care-facilities-and-hospitals

http://www.cochrane.org/CD005465/MUSKINJ_interventions-for-preventing-falls-in-older-people-in-care-facilities-and-hospitals


Falls - Assessment of Balance and Gait (LO3)

Physiotherapy Department – Geriatric Medicine, Birmingham Heartlands Hospital,

updated 2017 Dr T Jackson

‘Decreased mobility’, ‘falls’ and ‘off legs’ are descriptions all too familiar to the elderly

medicine multidisciplinary team. Falls represent 4% of admissions of patients over 65. In this

age group falls account for 40% of injury related deaths and 1% of total deaths (1). In

addition to the investigation of possible medical and environmental causes, a thorough gait

and balance assessment should be standard for these patients.

To examine an individual’s gait one must be aware of the normal components of walking to

identify deviations. Normal gait includes balance, adequate muscle length and strength,

normal joint range of motion, intact central and peripheral nervous systems, ability to transfer

weight from foot to foot/forefoot to hind foot and sensation, in particular proprioception. Gait

is classified into 2 phases: stance (60%) and swing (40%). If essential components are

absent during either phase, it is the physiotherapist’s job to identify the cause and retrain the

affected component (2). This is done by specific, goal-oriented exercise therapy, which has

been shown to significantly improve function, stability and reduce the risk of falling (3).

Thankfully there are some helpful tools which, although are not a substitute for thorough

clinical assessment, can give us a reasonably accurate predictor of function and postural

stability. Two examples of such assessments are:

1. The Timed up and go test (TUAG) (4)

2. The Berg Balance Scale (5)

The Timed Up and Go test (TUG) is commonly used as a method of assessing an older

person’s mobility, but gives you useful information about gait, gait speed, and risk of falls.

You may see it being used in Falls clinics for example. It requires both static and dynamic

balance while a person walks. The TUG measures the time it takes for a person to rise from

a chair, walk a set distance (usually 3 metres), turn around, walk back to the chair, and then

sit down.

Patients who score poorly on this assessment are likely to need additional physical

assistance to mobilise safely and are at higher risks of falls.

The Berg Balance Scale is a more detailed assessment particularly useful for patients who

appear to mobilise independently but have had falls. It can identify which type of tasks are

risky for that individual and has been used as part of risk assessment for fallers. There are

16 basic items which examine transfers, balance during double leg, tandem and single leg

stance, balance during reaching, turning and stepping, and the effect of eyes closed on the

individual’s postural sway. A low score indicates a high likelihood of falling.

Both tests are sensitive enough to detect problems that might not be obvious in simple

observation of walking (6). For instance, a patient who can walk safely with a frame might

not be safe to proceed independently through a doorway. The latter activity requires enough


balance to let go of the frame, reach for and open the door and needs adequate spatial

awareness such that the frame does not catch on the doorway.

For therapists such tests help plan treatments and are useful outcome measures for therapy

interventions. For medical staff, particularly those working in an isolated setting (community

or GP practice), they can be useful tools to aid the decision of safe or vulnerable. Patients at

risk from falls will benefit from the preventative advice of an Outpatient/Day Hospital falls

clinic.

Spend time with physiotherapy colleagues when they do these assessments, usually on

medical wards or falls clinics.

REFERENCES

1. Lord SR, Sherrington C, Menz, HB (2001) ‘Falls in older people – Risk factors and

strategies for prevention’ Cambridge University Press

2. Carr J, Shepherd R. ‘A motor learning model for stroke rehabilitation.’ Physiotherapy

1989;75:372-80

3. Buchner DM, Cress ME, ed Lateur BJ, et al. ‘The effect of strength and endurance

training on gait, balance, fall risk, and health services use in community-living older

adults.’ Journal of Gerontology, Series A Biological Sciences and Medical Sciences

1996;52:M218-24.

4. Smith R. ‘Validation and reliability of the elderly mobility scale.’ Physiotherapy 1994;

80 (11). 744-747

5. Berg K et al. ‘Measuring balance in the elderly; preliminary development of an

instrument.’ Physother Can. 1989;41 (6): 304-311

6. RCP (1992) ‘Standardised Assessment Scales for elderly people’, Royal College of

Physicians and British Geriatric Society, London.

7. Rodgers H, Curless R, James O.F.W. (1983) – ‘Standardised functional assessment

scales for elderly patients’ Age and Ageing 1993;22;161-163

8. Woolley SM, Czaja SJ, Frury CG. ‘An assessment of falls in elderly men and

women.’ Journal of Gerontology 1997; 52A(2):M80-7

9. Cho C-Y, Kamen G. ‘Detecting balance deficits in frequent fallers using clinical and

quantitative evaluation tools.’ Journal of the American Geriatrics Society

1998;46;426-30

10. Lord SR, Clark RD. ‘Simple physiological and clinical tests for the accurate prediction

of falling in older people.’ Gerontology 1996;42:199-203


Stroke & TIA (LO4)

Dr C Welch

Stroke

Presentation

A stroke is defined by the World Health Organisation as ‘a sudden onset of a focal or

generalised neurological deficit which lasts for 24 hours or leads to death for which the only

apparent cause is vascular’. Neurological deficits commonly produced include hemiplegia,

sensory loss, ataxia, visual field defect, transient monocular visual loss, dysphagia,

dysarthria, dysphasia (expressive and receptive) and difficulty performing tasks (apraxia).

The constellation of symptoms will depend upon the part of the brain involved.

Aetiology

There are two types of stroke – haemorrhagic and ischaemic. In the UK, about 10% are

haemorrhagic. Patients should have a CT head within one hour of arrival in hospital to

identify if there is intracerebral haemorrhage. The incidence of stroke increases with age but

it can affect people at any age.

Acute management

Ischaemic stroke

The key to acute management is to salvage the

“ischaemic penumbra” surrounding infarcted brain

tissue. The penumbra can remain viable for several

hours, but the earlier treatment is instituted the

better. Thrombolysis can be given up until 4.5

hours after symptom onset – this service is now

provided 24 hours/ day within the UK by a senior

clinician trained in giving thrombolysis.

In addition, thrombectomy is now recommended as

a treatment for patients with severe disabling

stroke and proximal intracranial large vessel

occlusion (initially identified on CT angiogram).

This treatment should be given in addition to thrombolysis (unless there are

contraindications) and within 5 hours of symptom onset.

Patients, in whom it is not possible to perform thrombolysis or thrombectomy, should be

given 300mg aspirin OD (oral/ rectal) for 2 weeks. Aspirin therapy is normally started 24

hours after thrombolysis, unless there are contraindications (e.g. secondary haemorrhage).

Figure 1 - The ischaemic penumbra, image via The Internet Stroke Center


Haemorrhagic stroke

There is currently no specific treatment for haemorrhagic stroke, but patients who are on

anticoagulants should be given immediate medication to reverse the effect. Blood pressure

control is also important. Individual hospitals will have their own local protocol; however, it is

recommended that patients who present within 6 hours with a systolic blood pressure (sBP)

above 150 mmHg should receive urgent treatment to maintain the sBP below 140 mmHg.

Rehabilitation

There is clear evidence that all patients benefit from early transfer to a stroke unit. This

means that they will receive early specialist input from nurses familiar with stroke medicine,

speech therapy, physiotherapy and occupational therapy, as appropriate.

Patients with stroke are at increased risk of venous thromboembolism – do not prescribe

enoxaparin to any stroke patients regardless of type. Intermittent pneumatic compression

stockings are being used in many hospitals and the key is commencing early rehabilitation.

Secondary prevention

Following identification of a stroke, it is important to identify possible risk factors that can be

addressed to prevent further strokes in the future. All patients with ischaemic stroke should

continue treatment with clopidogrel 75mg, unless they require anticoagulants. As a

minimum, most patients should have:

12 lead ECG to assess for AF (most will also need prolonged monitoring e.g. 24 hour

or longer) – Patients with AF will require anticoagulant therapy long-term

Cholesterol (target < 4.0)

HbA1c

Carotid dopplers to assess for carotid artery stenosis

Blood pressure management

Smoking cessation advice

Other investigations may be required depending on the clinical picture (e.g. younger patients

with no risk factors, history consistent with neck dissection)

Transient Ischaemic Attack (TIA)

Presentation

A TIA presents with symptoms similar to a stroke but with complete resolution within 24

hours. In reality, most TIAs are much shorter than this.

Investigations

If a patient presents after symptoms have fully resolved, there is normally no indication for

urgent brain imaging. Further investigations will be arranged in TIA clinic as necessary.

Management

Previously, TIAs were triaged by use of the ABCD2 score. However, the updated RCP stroke

guidelines advise that all patients with suspected TIA should be reviewed urgently within 24

hours, unless they present more than 7 days after the onset of symptoms (in which case

they should be seen as soon as possible within 7 days).


Suspected TIAs should be given 300mg aspirin and referred to their local TIA clinic. If a

diagnosis of TIA is confirmed, they will be given 75mg clopidogrel and screened for possible

predisposing factors as above in secondary prevention for stroke.

Further reading RCP National Clinical Guideline for Stroke – Fifth Edition 2016; Available via URL: https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx Thrombolysis video at AEME

https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx

https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx


Prescribing for Older People (LO5)

Dr Helen Chamberlain, updates 2017 Dr T Jackson

Older people in the UK account for the majority of prescriptions dispensed in the NHS.

Although many older people benefit from their medication, the potential for harm is high and

prescribers need to be aware of the particular needs of older patients.

Physiological changes

The ageing body experiences physiological changes with age including reduced renal

clearance, a reduction in lean body mass and increased body fat. These can affect drug

distribution and clearance. Reduced renal clearance is the most important change, affecting

water-soluble drugs with a narrow therapeutic window such as digoxin. Doses may need to

be reduced as a result.

Multiple pathology and polypharmacy

Around 20% of people aged over 70 take five or more drugs a day. Polypharmacy is

associated with many adverse events such as adverse drug reactions, hospital admission

and increased mortality rate. However, these events may be attributable to frailty rather than

prescribing per se and there may be solid indications for the drugs used.

Inappropriate prescribing

Certain drugs pose particular problems when used in older people. Examples include

benzodiazepines, which are associated with an increased risk of falls, and non-steroidal anti-

inflammatory drugs, which have a high risk of renal impairment and gastrointestinal

haemorrhage. All drugs prescribed should have a clear indication, and care should be taken

to avoid adding another drug to treat the adverse effect of another. An example might be use

of prochlorperazine to treat ‘dizziness’ caused by anti-hypertensives.

Improving prescribing

All medication should be reviewed regularly and those drugs no longer indicated

discontinued. This is also an opportunity to add drugs that may be beneficial such as

warfarin for AF, or calcium & vitamin D supplementation for osteoporosis.

The most important prescriber for older people is the GP. Medication errors are common

when people are discharged from hospital, and there is evidence that a smaller number of

prescribers are associated with a lower rate of errors. Where patients have particularly

complex regimes, the drug review may be better carried out by a geriatrician who can

assess the multiple co-morbidities.

Non-pharmacological therapies should also be used, such as TENS and physiotherapy to

treat musculoskeletal pain.

Drug administration

Most older people at home manage their own medication, but many cannot due to problems

such as visual impairment or poor manual dexterity. Labels and containers can be modified

to take account of this. For people with cognitive impairment, carers (formal and informal)

may administer oral medication, as may district nurses for injections such as insulin.


Drug regimes should have as few dosages per day as possible. It is also possible to use

fixed-dose combination tablets (for example co-tenidone) to reduce the total number of

tablets taken. Many medications can be given as liquids, which can be helpful to people with

swallowing difficulties.

What tools can I use?

The screening tool of older people's prescriptions (STOPP) and screening tool to alert to

right treatment (START) criteria are very useful tools that allow you to identify both

inappropriate prescriptions, but also identify drugs often denied older people where there is

evidence they work. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/

Further resources

Prescribing for Older People. Milton, J., Hill-Smith, I., Jackson S. BMJ 2008; 336:606-9

AEME Mini-gem video: The geriatrician’s scalpel

https://www.youtube.com/watch?v=jXcRHxl9qWw

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/

https://www.youtube.com/watch?v=jXcRHxl9qWw


Pressure Ulcers (LO6)

Dr T Jackson

Pressure ulcers are thankfully on the decline. Talk to some of your older colleagues on the

geriatric medicine placement and they will tell you of commonly seeing grade 4 pressure

sores you could put your fist into. Pressure sores are preventable; however they still occur,

and are a key indicator of quality of care. Pressure ulcers will often present to hospital in the

context of immobility and lack of availability of appropriate preventative care. They should

always prompt an investigation into the cause and usually initiate incident reporting and

safeguarding concerns.

Pressure Ulcers may seem like a small concern in the wider context of an unwell older adult

but they are debilitating, painful, extend length of stay in hospital and can prove fatal owing

to septicaemia. Sometimes surgery is needed to assist with healing. It is estimated that

pressure sores affect 6-7% of the adult hospitalised population.

How can I tell who is at risk?

When a patient is admitted to a ward a pressure ulcer risk tool is used called the Waterlow

Risk Assessment. This covers the most important risk factors for pressure ulcers and the

following areas are assessed.

Malnutrition (common among older people, but can be seen as cachexia driven by

chronic disease such as cancer and respiratory disease)

Neurological deficit (e.g. diabetes, stroke, paraplegia etc.)

Continence (very important, and will usually not be offered by the patient so you have

to ask about it)

Skin appearance (e.g. atrophic due to steroids)

Smoking, peripheral vascular disease and anaemia

Medication (e.g. steroids, cytotoxics, anti-inflammatory drugs)

Weight

Mobility

A total score is achieved by adding all the sections together and the score that fits into the

range that identifies low, medium and high risk.

Using this information nurses can complete appropriate care plans (e.g. regular turning,

control of incontinence, improved hydration & nutrition, good hygiene etc.) and organise

preventative measures such as pressure relieving aids, e.g. special mattresses for beds and

cushions for chairs. Ongoing assessment of the risk should be carried out by weekly re-

assessment. These scores are documented in the care plans, usually held at the foot of the

patient’s bed.

Grading of pressure sores:

Grade 1 Skin discolouration with non-blanching erythema

Grade 2 Partial thickness skin loss with ulceration that does not involve the

subcutaneous tissue


Grade 3 Full thickness skin loss with damage and necrosis of subcutaneous tissue

Grade 4 Full thickness skin loss with necrosis extending down to underlying bone,

tendon or muscle

What can we do when a patient has a pressure sore?

Management is usually led by specialist nurses as part of a Tissue Viability Team. Pressure

relieving equipment and specialised dressings are the first line treatment. However, other

therapies such as negative pressure dressings (VAC dressings), maggot therapy and plastic

surgery may be needed.

Further Reading

ABC of Wound Healing: Pressure Ulcers JE Gray, S Enoch, KG Harding. BMJ 2006; 332;

472-75

Wound Assessment J E Gray, S Enoch, KG Harding .BMJ 2006: 332 285-88


CGA, Comprehensive Geriatric Assessment (LO7)

Dr L McCluskey

What is it?

Comprehensive Geriatric Assessment (CGA) is the gold standard of care for the

management of frail older adults. It involves a ‘multidimensional interdisciplinary diagnostic

process focused on determining a frail older person’s medical, psychological and functional

capability in order to develop a coordinated and integrated plan for treatment and long term

follow-up’. CGA happens in both acute and non-acute settings and is associated with

improved outcomes.

But what really is it?

CGA relies on a core team usually consisting of a clinician, nurse, and social worker and,

when appropriate, input from physical and occupational therapists, nutritionists, pharmacists,

psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians. It is a holistic

assessment of an individual made up of several, overlapping, domains. These are;

Physical symptoms including current and past illnesses, diseases, diagnoses and pain.

Mental health symptoms, including memory and mood and an assessment of cognition.

Functionality in activities of daily living (ADLs), both for personal care e.g. showering,

washing, dressing and mobility, and for life functions e.g. cooking, shopping and outings.

Social and financial support, including where someone lives, facilities, access to transport

and caring support e.g. informally from family and friends and formally via social services.

Goals of care and advance care planning which may include spirituality, resourcefulness and

an individuals’ “resilience” and anxieties for example fear of dementia or dying.

How long will it take?

A full CGA will take at least 1 hour plus additional time for care planning, documentation and

ongoing review. Not every older adult needs a full multidisciplinary CGA with geriatrician

involvement; it is primarily for those with increased frailty. However, the majority of older

adults will benefit from a holistic medical approach based its principles.

How will I remember all that?

The FRAIL mnemonic can be used as a basic framework to remember the above principles.

Falls/functional decline

Reactions (polypharmacy)

Altered mental status

Illnesses

Living situation

What are the components?

Falls: Almost 30% of ED admissions are due to falls among older adults. Factors that

contribute to falls and associated complications can be divided into the following categories:

personal (age, chronic diseases, gait disturbance); environmental (poor lighting, slippery

floor, unstable furniture); and medications (antihypertensives, hypoglycaemics, sedatives).


Functionality: Bissett et al (2013) indicated that more than 50% of older adults who receive

care in the emergency department are unable to execute basic ADLs. This state of

dependence impacts on both physical and psychological health.

Reactions (Polypharmacy): 44% of men and 57% of women older than 65yrs take ≥ 5

medications per week. Inappropriate and excessive prescribing in older people leads to a

decline in the ability to perform ADLs, a high prevalence of adverse drug effects, drug-drug

interactions and other geriatric syndromes such as delirium.

Altered mental state: Delirium affects up to 40% of older patients who present to the

emergency department and more in some surgical populations. Dementia affects 1 in 20

people over the age of 65 and 1 in 5 over the age of 80. Dementia is a risk factor for

delirium, additionally delirium increases an individuals’ risk of developing dementia.

Illnesses: Multi-morbidity is common and greatly increases the complexity of managing

disease in older patients. About one in four adults have at least two chronic conditions and

more than 50% of older adults have three or more chronic conditions.

Living situation: Institutionalised older adults have much worse clinical outcomes following

discharge from the emergency department than their independent counterparts. Collapse of

a social network or excessive social strain can have a big impact on an individuals’ function.

The CGA Framework and Model

CGA is not only about identifying these problems but addressing them. It is both

diagnostic and therapeutic. Remember it involves a holistic, multidimensional,

interdisciplinary assessment of an individual by a number of specialists within the

discipline of older people’s health.

Reading

Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients

Implementation Patient

Discussion

Team

Discussion

Revising

Plan

Data

Collection


Rehabilitation of older persons (LO8)

Dr D Swain

The principles of rehabilitation involve the restoration of the individual to his or her optimal

physical, mental and social capability. In a hospital setting this usually follows on from a

period of illness such a stroke, hip fracture or MI. In the elderly there is usually significant co-

morbidity as well (e.g. arthritis, poor vision, diabetes etc.)

Ideally, rehabilitation should commence as soon as possible following admission to hospital,

with the setting of short and longer-term goals. A full medical history and examination is

crucial, both to define the reason for admission to hospital and the underlying acute and

chronic medical problems causing the functional decline. In addition, information must be

collected in the following areas: 1) cognition 2) pre-morbid function (mobility, transfers and

activities of daily living) 3) accommodation 4) social and family support (Home-Care, MOW,

DN and Carers). During this process it is important to explore the expectations of the patient

and the rehabilitation team, as well as those of the family and carers. Often these

expectations are very different.

A problem list is created, so that all of the medical, functional and social problems can be

identified. Correction of apparently minor issues (such as ill-fitting shoes and bunions) can

have a major impact on functional improvement. It is not unusual for elderly hospitalised

patients to have multiple chronic medical, social and sometimes psychiatric problems.

Problems that can sometimes be overlooked and will impair rehabilitation include poor

nutrition, dehydration, faecal impaction, pressure sores, depression, early dementia and side

effects from drugs. The rehabilitation team need to be alert to the development of new

medical problems that can arise during rehabilitation, e.g. infections, heart failure, renal

failure, strokes, falls and fractures, thus the patient needs regular medical review.

Special problems relating to the rehabilitation of older people include:

Multiple pathology

Polypharmacy

Mental vulnerability (confusion, depression or anxiety)

Low expectations for recovery

Complex social problems

Rehabilitation is multidisciplinary in nature. Teamwork, reinforced by regular meetings to

plan treatment, review progress and set goals, is crucial.

The physiotherapist is concerned predominantly with posture and mobility. Zimmer frames,

or a stick and the physical help of 1-2 people may be needed initially.

Nurses ensure nutrition and hydration is maintained, provide skin, bladder and bowel care,

administer medicines and encourage mobility (as defined by the physiotherapist).

The speech and language therapist (SLT) in addition to their traditional role also assess the

safety of swallowing (often impaired in sick patients) and advises on optimum consistency of

food, and whether thickening of fluids is required to prevent aspiration pneumonia.


The dietician, in liaison with SLT as necessary, optimises nutritional intake assessment,

patient choice and route of nutrition (oral, naso-gastric or PEG).

The occupational therapist assesses activities of daily living (ADL) i.e. washing, dressing,

feeding, toileting, transferring and mobility. A Home Visit assesses the patient’s capabilities

in their own environment. Subsequently adaptation e.g. stair-rails or raised toilet adaptations

may be required. Pendant alarms may be needed to raise help in an emergency.

The doctor’s role is to ensure, as far as is possible, the medical stability of the patient and to

ensure that the team is provided with accurate diagnostic and prognostic information.

Patients who become independent or have minimal residual disability and/or live with an

able carer may be discharged directly home. Patients, who remain dependent after a period

of rehabilitation, the Social Worker undertakes a multidisciplinary assessment: discharge

home might require the support of Home-Care, MOW and DN (with Discharge Liaison Nurse

providing communication between hospital and DN).

Opportunities for continued rehabilitation outside of hospital include community therapy

services, Day Hospital and more recently Intermediate Care facilities (sometimes in a

nursing or residential setting, but with significant therapy input).

If discharge home is not safe / possible, Rest Home or Nursing Home placement may be

needed, according to physical dependency. Most patients return home.

Reading:

Rehabilitation of the Older Adult - Keith Andrews, Edward Arnold Publishers


Key topics not covered by the learning objective

There are a number of topics that are very relevant to geriatric medicine but are covered in

other specialties. You will see these problems frequently during your placement so it is worth

reviewing some of these. Specific topics follow this list

Urinary Incontinence

Constipation, faecal incontinence and functional bowel disease

Parkinson’s Disease and Parkinsonism

Visual impairment, especially macular degeneration and cataracts

Musculoskeletal disease, especially osteoarthritis

Ortho-geriatric management of hip fractures

Peripheral vascular disease and venous and arterial leg ulcers

Depression, anxiety disorders, and psychosis

In your anaesthetic block you may see geriatricians involved in peri-operative

management of older people

Specific medical problems in care homes, which you should see during your CBM

This is obviously not exhaustive, and you will see the whole of medicine and surgery if you look hard enough.


Other topics - Sensory Impairments in Old Age

Dr Nigel Page

Hearing loss

Prevalence

Universal decline with increasing age. About 2/3 of those over 75 years have impairment

which can make communication difficult.

Pathology

Conductive loss usually due to ear canals blocked with wax. Sensorineural loss due to

degenerative changes in the inner ear.

Audiometry

Testing individual frequencies shows increased loss at higher rather than lower frequencies,

hence consonant loss more marked than vowel loss making speech difficult to understand.

Consequences

Frustration, anxiety, depression and suspicion often leading to social isolation. Appearance

of apparent cognitive decline due to misunderstanding of conversation. General population

seem more willing to help blind people rather than those who are deaf.

Therapy

Remove wax from ear canal if blocked

Ask others to speak clearly and directly to the deaf person (optimum distance about 1

metre)

Hearing aids (several varieties – behind ear most common)

Telephone/television modifications (Tele-coil induction loop system)

Subtitles

Sign language

Flashing lights for doorbells, vibrating alarm clocks etc.

The rules for communicating with the deaf are 'don’t mumble, don’t shout, be seen’

Visual loss

Prevalence

5% of people over 85 years old registered blind (condition is under reported); many more

partially sighted. Mainly a problem associated with old age. 'Whoever has driven with a

frosty windscreen has experienced the anxiety of visual handicap'.

Pathology

Main causes are cataract, macular degeneration, glaucoma, diabetes and vascular disease.


Visual assessment

Acuity using Snellen chart. Functional ability – i.e. day to day tasks such as making drinks,

avoiding obstacles etc. Routine optician assessment each year or two and specialist

ophthalmological review if needed.

Therapy

Correction – good lighting, spectacles, cataract surgery, retina laser therapy

Adaptation – Braille, talking books/clocks, white sticks, guide dogs etc.

Further reading

Rehabilitation of the Older Adult. Keith Andrews - Edward Arnold Publishing

The Challenge of Geriatric Medicine. Bernard Isaacs


Other topics - The Law and Older People

Dr E Dunstan updated for 2017 by Dr Daisy Wilson

Generally speaking, in law, older people are not regarded as different from any other adults,

apart from areas such as old age pensions, other benefits and tax.

Capacity

The prevalence of cognitive impairment frequently raises issues of capacity in the handling

of affairs, consent to treatment and planning of future care.

Capacity:

is specific to a given decision (e.g. an individual may be able to decide what to eat

but not where they should live)

is assumed to be present unless it is proved otherwise

an unwise decisions does not necessarily mean a person lacks capacity

an individual’s capacity may fluctuate. Every effort should be made to facilitate an

individual to make their own decisions (e.g. assess capacity at several time points)

To have capacity a person must

1. Understand the relevant facts,

2. Retain the relevant information,

3. Consider the information to reach a decision, and

4. Communicate that decision

Under the Mental Capacity Act 2005:

all acts to incapable persons must be in their best interests, (which are wider than

medical interests – and should take into account the person’s past and present

views)

neglect is a crime

the least restrictive option should be chosen

people can execute a Lasting Power of Attorney

Power of Attorney

There are 2 types of Lasting Power of Attorney

Health and welfare

Financial and property

The same person can hold both roles and more than one person can be appointed to each

role. The appointment of LPA should be conducted whilst an individual has the capacity to

do so. A LPA makes decisions on behalf of the individual if they no longer have the capacity

to do so or no longer want to make those decisions. The LPA should act in the best interests

of an individual and take into account previous wishes and opinions expressed.


Independent Mental Capacity Advocate (IMCA)

An IMCA is appointed for all people who (1) lack capacity for specific decisions and (2) also

lack appropriate family or friends.

An IMCA must be appointed if the above conditions are met and a decision is required

regarding:

Any serious medical treatments

A move to a hospital that would be for more than 28 days

A move to a care home that would be for more than 8 weeks

A deprivation of liberty

An IMCA’s role is to discover a person’s current or previously held views on the specific

decision and act as their advocate, always acting in their best interests.

Deprivation of Liberty Safeguards (DOLS)

DOLS is a subsidiary of the Mental Capacity Act of 2005. Its aim is to ensure that any care

which restricts a person’s liberty is both appropriate and in their best interests. It only applies

to people within a hospital or care home setting. A deprivation of liberty only occurs when a

person lacks capacity to consent for the procedure which will then deprive them of their

liberty. The safeguards ensure that anyone being deprived of their liberty has appropriate

representation (e.g. family or IMCA), that the deprivation of liberty can be challenged through

the Court of Protection and is regularly reassessed. A common example of a deprivation of

liberty is putting mittens on a person with an NG tube in situ to prevent them from pulling it

out.

End of life decisions

The law is the same as at any age, but questions are inevitably more frequent. Treatment

(which includes artificial nutrition and hydration) may be withdrawn or withheld if:

Medically futile or not indicated

Refused by a competent patient

Not in an incompetent patient’s best interests after reference to the MCA

DNACPR

There is significant misunderstanding surrounding DNACPR orders (both amongst clinical

practitioners, and patients and their relatives) and huge variations in practice.

DNACPR should be considered in all patients who may be at risk of cardio or respiratory

arrest (the majority of unwell older inpatients). DNACPR does not mean ‘not for active

treatment’ or ‘not for ITU’. In best practice all these should be considered together and

documented in the notes.

If DNACPR is considered to be in all probability unsuccessful (or futile) this should be

discussed with the patient or if they lack capacity their relative or power of attorney. If the

patient or relative disagree with this decision a 2nd opinion should be offered.

If DNACPR may be successful the risks and benefits of CPR should be discussed with the

patient or if they lack capacity their relatives or power of attorney. The patient (or relatives in

lack of capacity) should be involved in the decision about DNACPR.

It is no longer acceptable to not discuss DNACPR with patients or relatives because of a

wish to not cause distress or the relatives are unavailable. (See Tracey case.)


A decision to not offer a futile treatment such as CPR however is a medical decision. Many

misunderstandings arise when people think they are being asked to make a decision,

especially in cases with a patient who lacks capacity to refuse treatment when relatives are

consulted.

Advanced Directives

Doctors must observe the wishes expressed in a valid advance directive (or 'living will'). The

advanced directive must clearly relate to the condition or procedure in question, be legal and

medically practical. The patient must be competent at the time of the directive and the

directive must not be made under duress. Advance declarations may also be positive,

requiring treatment, rather than just refusals

Elder Abuse

Physical, psychological, sexual or financial abuse of an older person is as much a crime as it

would be at any age. The difficulties are much more in recognition and obtaining evidence

(or even getting the victim to complain). Suspected instances of elder abuse should be

reported to the Social Services department.

Reading:

Resuscitation Council (UK) guidelines on DNACPR at https://www.resus.org.uk/dnacpr/

(Essential reading for anyone who will be considering these decisions, discussing this with

patients and relatives or participating in the crash team.)

Cautionary tales about DNACPR – BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i26

Age UK factsheets on Power of Attorney and Advanced Directives

http://www.ageuk.org.uk/money-matters/legal-issues/powers-of-attorney/

http://www.ageuk.org.uk/money-matters/legal-issues/living-wills/about/

Alzheimer Society factsheet on DOLS and Mental Capacity Act

https://www.alzheimers.org.uk/info/20032/legal_and_financial/129/deprivation_of_liberty_saf

eguards_dols

https://www.alzheimers.org.uk/info/20032/legal_and_financial/127/mental_capacity_act

https://www.resus.org.uk/dnacpr/

https://doi.org/10.1136/bmj.i26

http://www.ageuk.org.uk/money-matters/legal-issues/powers-of-attorney/

http://www.ageuk.org.uk/money-matters/legal-issues/living-wills/about/

https://www.alzheimers.org.uk/info/20032/legal_and_financial/129/deprivation_of_liberty_safeguards_dols

https://www.alzheimers.org.uk/info/20032/legal_and_financial/129/deprivation_of_liberty_safeguards_dols

https://www.alzheimers.org.uk/info/20032/legal_and_financial/127/mental_capacity_act


Other topics - Assessment of Activities of Daily Living

Ms. S McArthur

Barthel Self-Care Index

In practice it will often be necessary for the occupational therapist to use more than one

outcome measure in order to get a full picture of the patient’s/client's ability to function

effectively in their home or other place of residence. There is now a wide range of outcome

measures and assessments available to occupational therapists and these are designed to

measure changes in the client’s physical, psychological and social aspects of well-being or

quality of life.

The Barthel index is one such outcome measure of functional independence in activities of

daily living. It was developed in 1965. It is a narrow checklist that was designed for use in

institutional settings with elderly patients suffering from neurological and musculoskeletal

disorders. It was designed to measure function before and after treatment and is often used

to indicate rehabilitation or nursing needs. There have been a number of versions

developed, primarily Mahoney and Barthel's 10 item 1965 version, Granger’s 15 item 1976

version and Shah’s 1989 version.

The Barthel Index assesses and measures an individual’s ability to carry out activities of

daily living. It is based on a 3 point scale. If a patient scores below 40 he/she has a poor

prognosis for discharge home. The daily activities assessed include:

Feeding

Grooming

Toileting

Bathing

Incontinence

Walking/wheelchair locomotion

Stair mobility

The energetic debate over the Barthel index in the British Journal of Occupational Therapy

during 1992-1993 (Murdock 1992 a, b, Shah and Cooper 1993, Eakin 1993) indicates the

assessment’s pitfalls. The debate questions the reliability and validity of the tool. It was

designed for use with a limited range of conditions therefore one must question its relevance

in clinical practice. Due to all of these issues and concerns this tool for assessing activities of

daily living (ADL) is rarely used alone within the occupational therapy profession as an

outcome measure. It is now used more as a generic assessment to indicate rehabilitation or

nursing needs. Many therapists will also document and communicate the actual functional

capabilities of a given patient or client (e.g. dressing, cooking, bathing etc.), relating these

assessments to the specific needs of the individual in their home or preferred environment.


References

Mahoney FI, Barthel DW (1965). Functional evaluation: The Barthel Index

Maryland State Medical Journal, 14, 61-5.(outlines full 1965 version)

Murdock (1992a). A critical evaluation of the Barthel index. Part 1

British Journal of Occupational Therapy 55 (3), 109-111

Murdock (1992b). A critical evaluation of the Barthel index. Part 2


Shah S and Cooper B (1993). Commentary on “a critical evaluation of the Barthel index”


Eakin P (1993). The Barthel index: confidence limits. British Journal of Occupational Therapy

56 (5), 184-185


Other topics - Assessment for care in the community

Ms G Richards

The Discharge Process – transfer of care

Discharge planning for older people should commence on admission, or as soon as possible

after the acute medical phase of illness subsides. Multidisciplinary assessment will take into

account the pre-morbid state of patient and the circumstances of admission. The views and

needs of the patient as well as their relatives and carers should be taken into consideration.

It is also important to involve those professional carers, nurses and therapists who might

previously have been involved prior to the patient's admission to hospital. Discharge

planning for older persons in hospital or Intermediate Care units is usually co-ordinated at a

weekly multidisciplinary team meeting involving some or all of the following professionals:

Dietician

Nurse

Occupational therapist

Physiotherapist

Physician in elderly medicine and/or Senior House Officer

Social worker/Discharge liaison nurse

Speech and language therapist

Pharmacist

Advice from other professionals is often sought as necessary, including Home Care

managers, General Practitioners, Old Age Psychiatrists, District Nurses, Housing Agencies

and of course relatives and informal carers. The emphasis is on achieving a timely yet safe

discharge, with an effective transfer of care and sometimes rehabilitation to the primary care

team.

Services provided by the Local Authority

Access to Local Authority funded services, such as Home Care, Day Care, Respite Care,

Residential and Nursing Home placements are co-ordinated via Social Workers based either

in the hospital or community. Legislation requires that social workers undertake a full

multidisciplinary “needs led” assessment. This assessment is audited and must demonstrate

user/ carer involvement (DOH. 1997 Better Services for Vulnerable People). These services

will attract a cost. All services provided to clients by the local authority are subject to ‘means

testing’, i.e. an assessment of the client's financial status and thus ability to pay. The Local

Authority has fixed assessment criteria for the provision of all services.

Services provided by Health Authority and/or Primary Care Trusts

Access to Local Authority funded services, such as Home Care, Day Care, Respite Care,

Residential and Nursing Home placements are co-ordinated via Social Workers based either

in the hospital or community. Legislation requires that social workers undertake a full

multidisciplinary “needs led” assessment. This assessment is audited and must demonstrate

user/carer involvement (DOH.1997 Better Services for Vulnerable People). These services

will attract a cost. All services provided to clients by the local authority are subject to ‘means


testing’, i.e. an assessment of the client's financial status and thus ability to pay. The Local

Authority has fixed assessment criteria for the provision of all services.

Intermediate Care Services

These are a range of services near to or in the patient's home whose aim is to provide an

alternative to hospital admission or promote early discharge with an emphasis on timely,

therapeutic intervention. There is a strong emphasis on rehabilitation and avoiding

admission to long term residential or nursing home care. Some units are nurse led and

others therapy led. Some services are mobile and assess and treat patients in a range of

settings including A&E, their own home, etc. Medical support is usually available from

general practitioners with specialist support from consultants in elderly medicine. Services

are still evolving following the stimulus provided by the National Service Framework for Older

People.

Examples of Services from the Local

Authority (liable to charge)

Examples of services provided by

Health Authority (free of charge)

Home care - focusing on personal Community nursing care requirements

Residential / nursing home care

(permanent or respite)

Specialist nursing home care (respite &

permanent)

Meal provision Palliative care

Day Centre activities Rehabilitation services

Occupational Therapy – equipment &

adaptations

Specialist transport

Specialist equipment

Specialist Housing (warden controlled,

extra sheltered care etc.)

Financial support - Independent living fund:

Direct payments

Carer's grant

Telephones (Chronically Sick and Disabled

Persons Act)

Alarms

Transport

(This list is not exhaustive)

Reading

Alternatives to Hospital Care. Ed. GP Mulley. Age and Ageing, 2001;30 (supplement 3) ISSN

0002-0729