Geriatric Emergencies Dr Jack Bond Teaching Fellow June 2012

Objectives How to assess the older adult Know how to investigate and initially manage falls Know how to investigate and initially manage acute delirium

Why is it happening now? Co-pathology Less physiological reserve Drugs Acute stress event Internal External Severity

Obtain a collateral history Who?

Collateral history Mobility, cognition, continence, living situation How do they eat? Can they wash/dress themselves PMH and DH are crucial

Case 1 83 male, found on floor at home by son. You see in A+E, obs are sats 92%, RR 25, Temp 34, BP 100/78, HR 98, GCS 13. PMH: angina, parkinsons disease, diabetes, hypertension, DH: bendrofluazide, Imdur, aspirin, metformin, Sinemet 1. What further history would you like to take? 2. What clinical examination is necessary? 3. What is your differential diagnosis? 4. What investigations would you request?

Balance Combination of:- Neuro MOTOR SENSORY COGNITION Cardio CARDIOVASCULAR External

Causes of falls Internal Medical Cardiac Neurally mediated Motor, sensory, vagal, autonomic Orthostatic hypotension Drug related Gait/balance External Environment Clutter, footwear, pets, lack of grab rails

Cardiac vs neurogenic symptoms Cardiac –exercise induced –Chest pain, SOB –Palpitations –Symptoms when lying down –Immediate recovery Neurogenic –Pain, fear, warm environment –Light headed, dizziness, blurred vision, abdo pain –Symptoms on prolonged standing, or change in posture –Post event nausea –Pallor, sweating – vagal –blue – seizure –Amnesia, confusion

Examination in syncope Cardiac –Pulse –Heart sounds Postural BP and HR Neuro –Motor weakness –Sensory impairment –coordination

Investigation of syncope T/F 1.Most patients with syncope require echocardiogram T/F lead ECG and postural BP measurement provides a diagnosis for syncope in 2/3 rd of all falls T/F 3. Postural hypotension is defined as 20/10 drop in systolic/diastolic BP T/F 4.24 hour ECG provides a diagnosis in remaining 1/3 rd of all falls T/F 5. Limb jerking suggests a diagnosis of epilepsy T/F

Investigations 12 lead ECG + postural BP (together) –Provides diagnosis in 2/3 rd cases Echocardiogram –If murmur and clinically suspect relevant 24 hour ECG –Very low yield (<1%) –Specifically best in people with daily symptoms, even then <30%

Drugs in falls >4 meds = more falls Specific drug classes include –Antihypertensives (ACEi, diuretic, ca2 etc) –Sedatives (benzos) –antidepressants

Case 2 A 78 year old woman is found by her neighbours confused and wandering in the street at night wearing her night clothes. In the emergency room she appears unkempt and dishevelled. She is alert, but disoriented in time and place and cannot recall her home address. She engages well with questions, but tends to shift the conversation to stories about her husband and children. She is admitted to hospital and wanders around the ward appearing lost and, when asked, says that she is looking for a bus stop to go home What is the underlying diagnosis and why?

Dementia vs delirium Dementia –Slow, gradual, progressive –Attention ok –Conscious level ok Delirium –Sudden, may be reversible –Greatly impaired attention and consciousness

Acute delirium – DSM 4 Reduced attention Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Change in cognition that is not better accounted for by a pre-existing dementia. Short time period usually hours to days and tends to fluctuate. Identifiable cause evidence history, examination, or laboratory findings medical condition, substance intoxication, or medication side effect.

Case 3 A 85 year old gentleman is admitted from a nursing home with confusion. The staff tell you that he normally walks with a stick but in the last few days he has been very aggressive, shouting and threatening people. He has generally been fine apart from some arthritis for which his GP saw him a few days ago. A urine dip in A+E shows 1+ protein, trace blood. He takes furosemide 40mg OD. What is most likely to have changed his behaviour? A. UTI B. TIA C. Alcohol withdrawal D. hyponatremia E. co-codamol 8/500mg TDS

UTI diagnosis No reliable test Dipsticks – most helpful when nitrites/leucocytes +ve –false negative absence of nitrite occur with atypical organisms common in elderly patients Bacteruria on MSU –Can be asymptomatic – interpret in context

Delirium - causes Often multi-factorial but consider the following: Infection Drugs Electrolyte imbalances Alcohol/drug withdrawal Organ dysfunction/failure Endocrine Epilepsy Pain Accentuated on admission by unfamiliar hospital environment

Investigating delirium Urine analysis FBC – WCC U+Es –Low Na+ Bone profile –High Calcium TFTs B12/Folate Obs and MEWS hypoxia hydration nutrition early sepsis

Imaging in delirium

CT head in delirium new focal neurologic deficit new seizure low platelet count or coagulopathy head trauma fall

Case 4 78 woman is admitted with delirium due to pneumonia. She is pulling at her IV cannula and taking her oxygen mask off. How would you manage the patient? True/False 1.Haloperidol 0.5mcg IM 2.Lorazepam 2mg IM 3.Risperidone 250mcg PO 4.Physical restraint to minimise risk of dislodging cannula 5.Maintain orientation with clocks, lighting 6.Discourage family visitors as it may distress them further

Managing delirium Environment - lighting Maintain orientation Encourage family Minimise shift changes (familiarity) Bowels/bladder addressed Pain addressed Avoid restraints – causes more chance of injury

Sedation in delirium Sedation –When above has failed –Comes with risks Resp depression Increased falls (hangover) –1 st line haloperidol (0.5 – 1mcg) –Risperidone also –Lorazepam 2 nd line –See guidelines on intranet

Take home messages Establish the background Determine the acute event that has precipitated the admission Collateral history Acopia Off legs are not diagnoses They are the visible symptom