Transcript Acute geriatric problems

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 2060 24% of the population are
estimated to be over 65
Illness in older people
Present atypically and non-specifically
 Greater morbidity and mortality
 Rapid progression
 Health, social and financial implications
 Co-pathology common
 Lack of reserve to cope
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Why is hospital a dangerous place
for frail older people?
Infections (MRSA/CDT diarrhoea)
 Falls
 Malnourishment
 Increased dependency
 Delay in investigations
 Delays in discharge
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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 20-1
8-10 Normal
7
Probably
abnormal
– repeat
<6
Abnormal
– check
other tests
e.g.MMSE
Falls - scope of problem
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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
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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:
– 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
 Functional
Investigations after a fall
Bloods:
FBC, U&E, Calcium, glucose, CRP
Vitamin B12, folate, TSH
ECG
Urine analysis
Only if specifically indicated:
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24 hour ECG
Echocardiogram
Tilt-table testing
CT head
EEG
Management after a fall
Treat all underlying and contributing causes
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Treat any injuries
Review all medications
Balance training (physiotherapist)
Walking aides
Environmental assessment (OT)
Reduce triggers if possible
To prevent consequences of future falls:
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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
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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 reexamine
 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
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Then, only at lowest effective dose and
short-term use
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Commonly used are haloperidol and lorazepam
Old age psychiatry opinion maybe needed
Take home messages…
References
Bowker L.K., et al (2006) Oxford Handbook of
Geriatric Medicine. Oxford University Press
Nicholl C, Wilson K.J. and Webster S (2007)
Lecture Notes Elderly Care Medicine. Blackwell
Publishing
University Hospitals Coventry and Warwickshire Clinical Guidelines
available at: http://webapps/elibrary/index.aspx
Blackhurst, H. (2010) UHCW guideline for the management of falls in
the elderly
Lismore, R. (2007) UHCW guidelines for acute delirium