acute geriatric problems dr d samani clinical teaching fellow may 2011
TRANSCRIPT
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Acute Geriatric Problems
Dr D SamaniClinical Teaching FellowMay 2011
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Aims
Introduction to care of the elderly patient in the acute setting
Falls in the elderly Acute delirium
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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
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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 EDManagement maybe difficult because:
Unable to give a story and often unaccompanied
Multiple and complex problemsMore likely to require transport homeAttendance is often a result of something
more long-term
These are also some of the reasons that lead to increase admissions
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‘Geriatric Giants’
Intellectual failure
Incontinence
Immobility (off legs)
Instability (falls)
Iatrogenic (medications)
Inability to look after oneself (functional decline)
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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?
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Points in history takingDifficult due to:
Multiple pathology and aetiology Atypical presentation Cognitive impairment Sensory impairment
But Use all sources available, e.g. family, carers,
neighbours, district nurse, GP, old notes And always make a problem list
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Points in examinationA full examination will be necessary, but also look at: Function – aids, watch sit to stand, don’t help unless
struggling Face – depressed, Parkinsonian Joints – gout, osteoporosis (Self) neglect – clothes, nails, pressure sores Nutrition status – obese, cachectic Conversation – dyspnoea, mood
Always check cognition level – Abbreviated Mental Test Score (AMTS)
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AMTSAgeDate of BirthTime (to nearest hour)Short term memory (“42 West Street”, recall at
end)Recognition of 2 persons (e.g. doctor, nurse)Current yearName of place they are inStart of WW1Name of present monarchCount back from 20-1
8-10 Normal
7 Probably abnormal – repeat
<6 Abnormal – check other tests e.g.MMSE
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Falls - scope of problem
1/3 of over 65s and ½ of over 80s fall 50% of these are multiple, 2/3 who fall will fall
again in next 6 months Female > Male
Why today? - precipitantWhy this person? - underlying problems
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Causes of fallsCombination of:Internal Gait and balance Medical problems Psychological problems Drug related
External Environment
Clutter, footwear, pets, lack of grab rails
Drugs
Age Related
Medical
Environment
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History after a fallEye witness account if possible
Symptoms before or during
Previous falls or ‘near-misses’
Location
Activity level (function)
Time of fall
Trauma sustained
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Examination after a fallAlong with a full physical examination:
Functional – sit-stand, gait assessmentCardiovascular – Postural BP, pulse rate and
rhythm, murmursMusculoskeletal – footwear, feet, joints for
deformity (new or old) Nervous system – neuropathy, un-diagnosed
pathology e.g. Parkinson's, vision and hearingDon’t forget AMTS
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Investigations after a fallBloods:
FBC, U&E, Calcium, glucose, CRPVitamin B12, folate, TSH
ECGUrine analysis
Only if specifically indicated: 24 hour ECG Echocardiogram Tilt-table testing CT head EEG
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Management after a fallTreat all underlying and contributing causes Treat any injuries Review all medications Balance training (physiotherapist) Walking aides Environmental assessment (OT) Reduce triggers if possible
To prevent consequences of future falls: Osteoporosis prevention Teach how to get up after fall (physiotherapist) Alarms Supervision
Change of accommodation does not necessarily lead to decrease risk of falls
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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
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Delirium - causesOften multi-factorial but consider the following:
Infection Drugs Electrolyte imbalances Alcohol/drug withdrawal Organ dysfunction/failure Endocrine Epilepsy Pain
Pre-existing brain pathology is a risk factor, e.g. previous cerebrovascular disease
Accentuated on admission by unfamiliar hospital environment
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Focused history Patient and collateral
Baseline intellectual functionPrevious episodes of confusionOnset and courseSensory deficitsSymptoms of underlying causeFull drug and alcohol history
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Focused examination Full will be necessary but include:
Conscious level (up or down)AMTS/MMSENeurology including speechAlcohol withdrawal – tremorsNutrition statusObservations, especially temperature,
saturations off oxygen
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Investigations Urine analysis
FBC, CRP, U&E, LFTs, calcium, glucose, TFTs
Blood cultures
ABG
CXR
ECG
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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
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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
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Take home messages…
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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