ACUTE ELDERLY CARE Ria Daly Clinical Teaching Fellow
Jan 01, 2016
ACUTE ELDERLY CARERia 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
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
CASE 1
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: 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 olderpatient you have taken a history from....
Difficult due to:Multiple pathology and aetiologyAtypical presentationCognitive impairmentSensory impairment
ABBREVIATED MENTAL TEST SCORE
AgeDate 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 inDates of WW2Name of present monarchCount back from 20-1
<8/10 = Cognitive impairmentNeeds further assessment!
A COLLATERAL HISTORY IS A MUST!
Relatives
Paramedics – ambulance sheet
Care home staff
Nurses/Health care assistants
GP (prescription)
DOCUMENT IT!
CAUSES OF FALLS
Medical Cardiac Neurological Orthostatic hypotension
Drug related Gait Balance
vertigo
Environment Clutter, footwear, pets,
lack of grab rails
Internal External
SYNCOPETransient, self limiting LOC, rapid onset, spontaneous, complete, prompt recovery
Transient impairment of cerebral blood flow
Symptom NOT diagnosis
CARDIAC ORTHOSTATICHYPOTENSION
NEURALLY MEDIATED
SYNCOPE
Type Causes Examination/Investigation
Cardiac Structural, cardiopulmonary, arrhythmia
Orthostatic Hypotension
DrugsAutonomic failure – PD, DMVolume depletion
Neurally Mediated
Vasovagal(Situational syncope)Carotid sinus syncope
EXAMINATION FOLLOWING A FALL (ABCDE)
Any injury?
Cardiac Pulse Murmurs? Assess fluid status
Postural BP
Neuro Motor weakness Sensory impairment Coordination Gait Cognition
INVESTIGATIONS AFTER A FALL
Bloods: 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
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 historyConfusion Assessment Method for Delirium
A) Sudden onset/Fluctuating Course
Hrs-days?Change from patient’s baseline?Come and go?
B) Inattention Unable to focusDoesn’t keep track of what is askedDifficulty following demands
C) Disorganised thinking Rambling/irrelevant conversationIllogical flow ideasSwitching from subject to subject
D) Altered level of consciousness
Hyperactive/agitatedQuite/withdrawnDrowsyReversal normal sleep-wake cycle common
DEMENTIA VS DELIRIUM
Insidious (months-yrs) Progressive No(less) fluctuation
Attention ok Conscious level ok
Sudden, may be reversible
Greatly impaired attention and consciousness
Dementia Delirium
WHAT ELSE WOULD YOU WANT TO FROM THE HISTORY?
Symptoms of underlying cause Drug history Alcohol use
Signs of infection Fever, crackles, abdo pain, PR?? Alcohol withdrawal
ON EXAMINATION?
WHAT ARE THE DIFFERENTIALS?
DELIRIUM - CAUSES
Often multi-factorialFluid and electrolyte disturbancesInfections (UTI, resp, soft tissue)Drug or alcohol toxicityWithdrawal from alcoholMetabolic disorders
Hypoglycemia, hypercalcemia, ureamia, liver failure, thyrotoxicosis
Postoperative states, especially in the elderly Accentuated on admission by unfamiliar hospital
environment
HOW WOULD YOU INVESTIGATE?
Bedside: BM Urine dipstick
Bloods: FBC, U+Es, LFTs, Glu, Ca, TFTs Blood cultures
ECG
Imaging CXR CT??
Obs and MEWShypoxiahydrationearly 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)
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?