Acute Geriatric Problems Dr D Samani Clinical Teaching Fellow May 2011

Aims Introduction to care of the elderly patient in the acute setting Falls in the elderly Acute delirium

Older people In 2015, population less than 16 will equal population over 65 In UK in % 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 ED Management maybe difficult because:  Unable to give a story and often unaccompanied  Multiple and complex problems  More likely to require transport home  Attendance is often a result of something more long-term These are also some of the reasons that lead to increase admissions

‘Geriatric Giants’ 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 taking Difficult due to:  Multiple pathology and aetiology  Atypical presentation  Cognitive impairment  Sensory impairment But Use all sources available, e.g. family, carers, neighbours, district nurse, GP, old notes And always make a problem list

Points in examination A full examination will be necessary, but also look at: Function – aids, watch sit to stand, don’t help unless struggling Face – depressed, Parkinsonian Joints – gout, osteoporosis (Self) neglect – clothes, nails, pressure sores Nutrition status – obese, cachectic Conversation – dyspnoea, mood Always check cognition level – Abbreviated Mental Test Score (AMTS)

AMTS Age Date of Birth Time (to nearest hour) Short term memory (“42 West Street”, recall at end) Recognition of 2 persons (e.g. doctor, nurse) Current year Name of place they are in Start of WW1 Name of present monarch Count back from Normal 7Probably abnormal – repeat <6Abnormal – 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? - precipitant Why this person? - underlying problems

Causes of falls Combination 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 fall Eye witness account if possible Symptoms before or during Previous falls or ‘near-misses’ Location Activity level (function) Time of fall Trauma sustained

Examination after a fall Along with a full physical examination:  Functional – sit-stand, gait assessment  Cardiovascular – Postural BP, pulse rate and rhythm, murmurs  Musculoskeletal – footwear, feet, joints for deformity (new or old)  Nervous system – neuropathy, un-diagnosed pathology e.g. Parkinson's, vision and hearing  Don’t forget AMTS

Investigations after a fall Bloods: FBC, U&E, Calcium, glucose, CRP Vitamin B12, folate, TSH ECG Urine analysis Only if specifically indicated:  24 hour ECG  Echocardiogram  Tilt-table testing  CT head  EEG

Management after a fall Treat all underlying and contributing causes Treat any injuries Review all medications Balance training (physiotherapist) Walking aides Environmental assessment (OT) Reduce triggers if possible To prevent consequences of future falls:  Osteoporosis prevention  Teach how to get up after fall (physiotherapist)  Alarms  Supervision Change of accommodation does not necessarily lead to decrease risk of falls

Acute Delirium ‘Acute confusional state’ Features: Acute onset and fluctuating course AND Inattention, PLUS either Disorganised thinking, OR Altered level of consciousness Other features not essential for diagnosis:  Disturbed sleep cycle, emotional disturbance, delusions, poor insight

Delirium - causes Often multi-factorial but consider the following:  Infection  Drugs  Electrolyte imbalances  Alcohol/drug withdrawal  Organ dysfunction/failure  Endocrine  Epilepsy  Pain Pre-existing brain pathology is a risk factor, e.g. previous cerebrovascular disease Accentuated on admission by unfamiliar hospital environment

Focused history Patient and collateral  Baseline intellectual function  Previous episodes of confusion  Onset and course  Sensory deficits  Symptoms of underlying cause  Full drug and alcohol history

Focused examination Full will be necessary but include:  Conscious level (up or down)  AMTS/MMSE  Neurology including speech  Alcohol withdrawal – tremors  Nutrition status  Observations, especially temperature, saturations off oxygen

Investigations 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: Blackhurst, H. (2010) UHCW guideline for the management of falls in the elderly Lismore, R. (2007) UHCW guidelines for acute delirium