Care of the Elderly

These features can help distinguish pathological causes (intrinsic) from those with a major external factor (extrinsic), although in practice most falls are multi-factorial. Falls or ‘collapse’ can be seen as a final common pathway for many diseases common in the elderly.

Falls – examination

Full physical examination, especially:

• Cardiovascular:

• BP including postural changes after 1–3 min

• Evidence of heart failure or rhythm disturbance

• Murmurs.

• Musculoskeletal:

• Arthritis: acute or chronic and evidence of joint instability

• Muscle wasting, especially quadriceps.

• Neurological:

• Focal signs, don’t forget cerebellar/brainstem

• Hearing or visual impairment

• Gait: observation of the patient standing from sitting (with arms folded) and walking (with turns) provides a good assessment of risk for falling.

Orthostatic hypotension

This is defined as a > 20-mmHg drop in systolic BP on standing or during head-up tilt:

• Common in elderly: occurs in up to 30% of healthy older people and it is not clear why some develop symptoms.

• ‘Physiological’ changes in elderly: decreased baroreceptor sensitivity increases risk of postural hypotension.

• ‘Pathological’ changes: e.g. sepsis with vasodilatation; poor LV function; neurological disease affecting reflex pathways.

• Pharmacological causes: beta blockers, vasodilators, anti-parkinsonian drugs, sedatives, neuroleptics, diuretics.

Investigations of falls

• BP and heart rate measurement with patient lying flat, with patient standing upright or at 45° on tilt table after 1, 3 and 5 min.

• FBC for evidence of infection, anaemia.

• U&Es, creatinine for evidence of dehydration, renal impairment (eGFR is calculated).

• Blood glucose for hypo-/hyperglycaemia.

• Thyroid function tests for subclinical hypothyroidism.

• CXR for infection, tumour.

• ECG for ischaemia, arrhythmias, silent MI.

• Heart beat monitoring (beat-to-beat variation) for autonomic neuropathy.

• MSU and Stix testing for infection.

Management of falls

• Review medications and withdraw exacerbating drugs if possible.

• Treat medical factors, e.g. sepsis.

• Assessment and reduction of osteoporosis risk.

• Advice to patients (see below).

• Drug treatment occasionally used in patients with persistent disabling symptoms:

1. Fludrocortisone 100–200 µg at night. Watch for fluid retention and hypokalaemia

2. If still symptomatic, add sympathomimetic agent, e.g. ephedrine 15 mg × 3 daily. This can be increased to 45 mg × 3 (side effects: hypertension, tachycardia, tremor).

Progress.

In this patient with postural hypotension, the atenololwas stopped and a careful watch was kept on his blood pressure (he had his own blood pressure machine) over the following few weeks. He should stay on aspirin and bendroflumethiazide. His BP stabilized at 115/80 and therefore no further medication was required.

Advice for patients with postural hypotension

• Get out of bed in stages.

• Pause between positional changes.

• Wear leg support tights during day; take them off at night.

• Raise head of bed.

• Avoid alcohol.

Delirium in the elderly

An elderly person presenting with acute confusion associated with disorientation, agitation ± hallucinations is a common medical emergency. In a hospital setting, the elderly develop delirium while receiving treatment for other medical or surgical problems, the reported incidence varying from 10 to 60%.

As a condition (syndrome) it is associated with increased morbidity and mortality.

Diagnosis

Use DSM (IV-TR) criteria or the Confusional Assessment Method (CAM), which is based on the DSM criteria (see below).

Delirium – diagnostic criteria (derived from DSM-IV-TR)

• Disturbance of consciousness:

– clarity of awareness of environment

– ability to focus, sustain or shift attention

• Change in cognition:

– memory deficit, disorientation

– language disturbance, perceptual disturbance

• Disturbance develops over a short period (hours or days)

• Fluctuation over course of day

Information

The Diagnostic and Statistical Manual (DSM) is published by the American Psychiatric Association and provides clear descriptions of diagnostic categories. The 4th edition (DSM-IV-TR) was published in 2000. The 5th edition will be available in 2013.

Confusional assessment method (CAM) criteria

Need points 1 and 2:

1. Acute onset + fluctuating course: this history is usually obtained from the family/carer or from the nurse caring for a patient already in hospital.

2. Inattention: is the patient easily distractible or does he/she have difficulty keeping track of what is being said?

… and either 3 or 4:

3. Disorganised thinking: is the patient incoherent? Is the conversation irrelevant?

4. Altered level of consciousness: the patient might be hyperactive, hypoactive/lethargic or semi-conscious.

Remember

• One in four patients with delirium are hypoactive

• Although history/observations can confirm the presence of CAM features, it is also useful to assess the patient’s cognitive functioning using serial mental test scores, e.g. Abbreviated Mental Test (AMT) (Table 7.1). Other tests using questions on: orientation (e.g. time, place, date), registration (naming objects), attention and calculation (simple arithmetic), recall (previously mentioned objects) and language (understanding commands) can be used.

Table 7.1 Abbreviated Mental Test (AMT)

Total score ten (one point for each item)

Age

Time (to nearest hour)

Address for recall

Year

Where do you live (town or road)?

Recognition of two persons

Date of birth (day and month)

Year of the start of the First World War

Name of present leader of the country

Count backwards 20 to 1

What should you do when delirium is suspected/diagnosed?

• Identify the cause by taking a medical history, physical examination and appropriate investigations.

• Manage the delirium.

Medical history

Illness in old age can present in a non-specific or atypical way. It is therefore necessary to go through a systematic enquiry to detect symptoms of physical illness, particularly those relating to chest infection and urinary tract infection. The family/carer or doctor should also be questioned about recent changes to drug therapy.

Physical examination

Full physical examination including neurological examination is essential as any physical illness in older people can lead to delirium.

Investigations

• FBC

• U&Es

• Liver function tests

• Calcium

• Phosphate

• Thyroid function tests

• CXR

• ECG and MSU

• Other investigations as indicated by clinical findings

Causes

For causes, remember the mnemonic delirium and think of common conditions:

D drugs: side effects, toxicity of drugs, e.g. hypotensives, sedatives

E electrolyte/endocrine disturbance, e.g. hyponatraemia, hypernatraemia, hypothyroidism

L lack of drugs: withdrawal of drugs

I infections, e.g. pneumonia, cellulitis

R reduced sensory input, e.g. visual impairment

I intracranial: TIAs, epilepsy

U urinary retention/faecal impaction

M myocardial: ischaemia/infarct, arrhythmias, CHF.

Remember

The presentation of illness in the elderly can be altered, e.g. not all patients with pneumonia will have a raised temperature or raised white cell count.

Risk factors for delirium

• Dementia

• Severe physical illness

• Raised urea/creatinine

• Visual impairment

• More than three prescribed drugs.

How would you manage a patient with delirium?

• Treat cause(s) of delirium. Review present drug therapy.

• Environmental measures and general support: fluids/nutrition; bladder/bowel care + environment (nurse in quiet, dimly lit room if possible), providing reassurance and reorientation.

• Pharmacological management: only appropriate if general supportive measures are not adequate to reduce patient’s distress and if there is danger to patient. Drugs of choice:

1. Lorazepam up to 2 mg IV or IM up to 4-hourly

2. Haloperidol 0.5 mg IV or IM, repeating if necessary after 30 min

3. Olanzapine 5 mg is also used.

Progress.

In this patient the cause of her delirium was pneumonia. She did not mount a raised white count or have a temperature. Her delirium resolved on treatment with antibiotics.

Dementia

Definition.

Dementia is defined by the Royal College of Physicians as global impairment of higher cortical functions, including memory:

• The capacity to solve problems of day-to-day living.

• The performance of learned perceptuomotor skills.

• The correct use of social skills.

• The control of emotional reactions in the absence of gross clouding of consciousness.

Case history

An 89-year-old man with a 6-month history of deteriorating short-term memory and increasing confusion is referred to A&E because of self-neglect. He has become even more confused over the previous 24 h. He was diagnosed as having dementia and referred to the Care of the Elderly team.

Remember

You should distinguish delirium from dementia, but remember that delirium can and does occur commonly in patients with dementia, as in this case.

• Dementia is often irreversible and progressive, and has a number of causes.

• Assessment: this is performed using the 10-point Abbreviated Mental Test (AMT; Table 7.1), or Clock-drawing test (Fig. 7.1).

• Although screening tests are useful in demonstrating the presence of deficits in cognition, they cannot be used for making the diagnosis of dementia or identifying the underlying cause. This requires imaging (CT or MRI scan) and, in some patients, assessment by a clinical psychologist and/or a psychiatrist. A history of progressive decline in memory or cognition over 6 months is significant.

Figure 7.1 Clock drawing test. (a) Normal. (b) Abnormal – inappropriate spread.

Investigations

Initial investigations for dementia:

• FBC and film

• U&Es

• Random blood glucose

• LFTs

• Thyroid function tests (TFTs)

• Vitamin B₁₂ and folate

• Syphilis serology

• CXR

• ECG

• CT/MRI scan of brain or PET scan

Management

• Alzheimer’s disease (AD): although there is no cure for Alzheimer’s disease, research on acetylcholine esterase inhibitors has shown that in selected patients with mild to moderate AD the decline can be slowed down. The National Institute for Clinical Excellence (NICE) has produced a guidance on use of donepezil, rivastigmine, memantine and galantamine in patients with mild to moderate AD by specialists. Other agents/drugs that have some benefit to patients with AD include vitamin E and Ginkgo biloba extract.

• Multi-infarct dementia: treat the risk factors, such as hypertension. Aspirin also has a role in preventing further strokes. Ginkgo biloba (120–240 mg daily) can also help.

• As dementia progresses, the management focus changes to care provision for patients plus support for carers.

• Lewy body dementia: avoid anti-psychotics as they can increase confusion. Some of these patients respond to acetylcholine esterase inhibitors.

Remember

Acetylcholine esterase inhibitors for Alzheimer’s disease are initiated only by a specialist (psychiatrist, neurologist or a geriatrician):

• Donepezil 5–10 mg daily

• Rivastigmine 3–12 mg daily

• Galantamine 8–24 mg daily

• Mematine 5–20 mg daily.

Progress and management.

In this patient, his previous history of hypertension and two small strokes suggested a multi-infarct dementia (avascular dementia). The diagnosis was confirmed by an MRI. The Care of the Elderly team arranged for full support in the community and he was continued on his treatment for hypertension. He is being assessed regularly to see if pharmacological treatment for his dementia is required.

Remember

In all types of dementia it might be necessary to use pharmacological agents to control agitation and other behavioural disturbances, but it must be remembered that patients with Lewy body dementia are very susceptible to the side effects of anti-psychotic drugs.

Depression

Depression is common in old age (see also p. 528). Community studies have revealed a prevalence of 11.3% for depressive symptoms and 3% for depression in the UK. Studies of elderly hospital inpatients have shown that up to 33% have depression. It is common in the elderly with chronic physical illnesses such as stroke, and it can also be the presentation of an occult physical illness such as hypothyroidism, hypercalcaemia or carcinoma of the lung. Physical illness is the biggest risk factor for depression in old age.

Remember

Whereas the clinical features of depression in old age can be the same as in younger patients, somatic complaints, delusions and decline in cognition (‘pseudodementia’) are more frequently noted in the elderly.

Case history

A senior nurse noted that an 83-year-old man with a CVA is not eating poorly and is losing weight. On direct questioning the patient admits to feeling depressed, and feels he has no future.

Examination showed no abnormality apart from slight residual neurological signs from his CVA.

Assessment

• Geriatric depression scale (Table 7.3) as a screening test. The Geriatric Depression Scale (shorter version) is a reliable and valid screening instrument of depression in the elderly. A score greater than 5 indicates probable depression.