ACUTE ELDERLY CARE
Ria Daly
Clinical Teaching Fellow
OVERVIEW

Acute block curriculum

Falls

Acute confusion

Interactive cases
AIMS – ACUTE BLOCK CURRICULUM
Falls
 Diagnose the cause of falls in the elderly by history,
examination, appropriate use of investigations
Acute Confusion
 Differentiate acute from chronic confusion
 Common causes
 Initiate management of commoner causes
OBJECTIVES



Be able to assess an older adult following a fall.
Formulate differential diagnosis
Be able to investigate an older adult following a fall
Be able to assess an older adult with confusion.
 Know how to investigate and initially manage acute
confusion

FALLS
WHY ARE OLDER PEOPLE AT RISK OF
FALLS?

Frailty

Reduced physiological reserve and weakness
Multiple medical problems
 Polypharmacy
 Social adversity

CASE 1
Dear Doctor,
Re: Mr A. Notherfall
Thank you for seeing this 82 yr old gentleman who collapsed at
home. Has fallen before.
PMH: HTN
Yours sincerely
HISTORY - HPC
What questions would you ask and why?
 Frequency/time course
 What were they doing before they fell?



From sitting to standing, turning of head
Preceding symptoms
SOB,CP, palpitations
 Light headed
 Room spinning
 Unsteady on feet


LOC?
Do they actually remember falling, hitting the floor etc
 How long were they unconscious for?
 Any suggestion of fit?
 Was it witnessed?


How long were they on the floor for?

could they get themselves up?
If mechanical – any precipitants?
 Any injury?

HISTORY - OTHER

PMH:






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Previous falls
Confusion
Stroke
PD
Dementia
Balance problems
Hypertension
DH:


>4 drugs = independent risk factor
SH
Alcohol
 Environment
 ADLs - Dressing, eating, ambulating, toileting, hygiene

Think back to an older
patient you have taken a
history from....
Difficult due to:
Multiple pathology and aetiology
 Atypical presentation
 Cognitive impairment
 Sensory impairment

ABBREVIATED MENTAL TEST SCORE
<8/10 = Cognitive impairment
Needs further assessment!
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
Dates of WW2
Name of present monarch
Count back from 20-1
A COLLATERAL HISTORY IS A MUST!

Relatives

Paramedics – ambulance sheet

Care home staff

Nurses/Health care assistants

GP (prescription)
DOCUMENT IT!
CAUSES OF FALLS
Internal

Medical






Cardiac
Neurological
Orthostatic hypotension
Drug related
Gait
Balance

vertigo
External

Environment

Clutter, footwear, pets,
lack of grab rails
SYNCOPE
Transient, self limiting LOC, rapid onset,
spontaneous, complete, prompt recovery
Transient impairment of cerebral blood flow
Symptom NOT diagnosis
CARDIAC
ORTHOSTATIC
HYPOTENSION
NEURALLY
MEDIATED
SYNCOPE
Type
Causes
Cardiac
Structural, cardiopulmonary,
arrhythmia
Orthostatic
Hypotension
Drugs
Autonomic failure – PD, DM
Volume depletion
Neurally
Mediated
Vasovagal
(Situational syncope)
Carotid sinus syncope
Examination/
Investigation
EXAMINATION FOLLOWING A FALL

(ABCDE)

Any injury?

Cardiac



Pulse
Murmurs?
Assess fluid status

Postural BP

Neuro


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Motor weakness
Sensory impairment
Coordination
Gait
Cognition
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
INVESTIGATIONS
 12

lead ECG + postural BP (together)
Provides diagnosis in 2/3rd 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%

ACUTE CONFUSION
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
How would you assess her?
HOW WOULD YOU ASSESS HER?
AMTS
 Collateral history

Confusion Assessment Method for Delirium
A) Sudden onset/Fluctuating
Course
Hrs-days?
Change from patient’s baseline?
Come and go?
B) Inattention
Unable to focus
Doesn’t keep track of what is asked
Difficulty following demands
C) Disorganised thinking
Rambling/irrelevant conversation
Illogical flow ideas
Switching from subject to subject
D) Altered level of
consciousness
Hyperactive/agitated
Quite/withdrawn
Drowsy
Reversal normal sleep-wake cycle
common
DEMENTIA VS DELIRIUM
Dementia
Insidious (months-yrs)
 Progressive
 No(less) fluctuation

Attention ok
 Conscious level ok

Delirium

Sudden, may be
reversible

Greatly impaired
attention and
consciousness
WHAT ELSE WOULD YOU WANT TO FROM THE
HISTORY?
Symptoms of underlying cause
 Drug history
 Alcohol use

ON EXAMINATION?
Signs of infection
 Fever, crackles, abdo pain, PR??
 Alcohol withdrawal

WHAT ARE THE DIFFERENTIALS?
DELIRIUM - CAUSES

Often multi-factorial



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Fluid and electrolyte disturbances
Infections (UTI, resp, soft tissue)
Drug or alcohol toxicity
Withdrawal from alcohol
Metabolic disorders


Hypoglycemia, hypercalcemia, ureamia, liver failure,
thyrotoxicosis
Postoperative states, especially in the elderly
 Accentuated
environment
on admission by unfamiliar hospital
HOW WOULD YOU INVESTIGATE?


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Bedside:
BM
Urine dipstick

Bloods:
FBC, U+Es, LFTs, Glu, Ca, TFTs
Blood cultures

ECG

Imaging
CXR
CT??

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
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Obs and MEWS
hypoxia
hydration
early sepsis
CT HEAD IN DELIRIUM

Often not helpful
New focal neurologic deficit
 New seizure
 Head trauma
 Fall
 Low platelet count or coagulopathy

IMAGING IN DELIRIUM
THINK ABOUT COMPLICATIONS OF ACUTE
CONFUSION
Falls
 Pressure sores
 Continence
 Feeding

CASE 3
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?
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)



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1st line haloperidol (0.5 – 1mcg)
Risperidone also
Lorazepam 2nd line
See guidelines on intranet
TAKE HOME MESSAGES
Importance of a good history & collateral

Determine the acute event that has precipitated the
admission (often on a background of ‘problems’)

Thorough examination and tailor investigations

Think about medium-long term
ANY QUESTIONS?