ACUTE ELDERLY CARERia DalyClinical 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 2A 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 DeliriumA) 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?