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Acute Elderly Care

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

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Acute Elderly Care

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  1. Acute Elderly Care Ria Daly Clinical Teaching Fellow

  2. Overview • Acute block curriculum • Falls • Acute confusion • Interactive cases

  3. 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

  4. 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

  5. Falls

  6. Why are older people at risk of falls? • Frailty • Reduced physiological reserve and weakness • Multiple medical problems • Polypharmacy • Social adversity

  7. 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

  8. 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

  9. 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?

  10. 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

  11. Think back to an older patient you have taken a history from....

  12. Difficult due to: • Multiple pathology and aetiology • Atypical presentation • Cognitive impairment • Sensory impairment

  13. 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

  14. A collateral history is a must! • Relatives • Paramedics – ambulance sheet • Care home staff • Nurses/Health care assistants • GP (prescription) DOCUMENT IT!

  15. Causes of falls Internal External • Medical • Cardiac • Neurological • Orthostatic hypotension • Drug related • Gait • Balance • vertigo • Environment • Clutter, footwear, pets, lack of grab rails

  16. Syncope Transient, self limiting LOC, rapid onset, spontaneous, complete, prompt recovery Transient impairment of cerebral blood flow Symptom NOT diagnosis ORTHOSTATIC HYPOTENSION NEURALLY MEDIATED CARDIAC

  17. syncope

  18. Examination following a fall (ABCDE) Any injury? Cardiac Pulse Murmurs? Assess fluid status Postural BP Neuro Motor weakness Sensory impairment Coordination Gait Cognition

  19. Investigations after a fall Bloods: • FBC, U&E, Calcium, Glucose, CRP • Vitamin B12, Folate, TSH ECG Urine analysis Only if specifically indicated: • 24 hour ECG • Echocardiogram • Tilt-table testing • CT head • EEG

  20. 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%

  21. Acute Confusion

  22. 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?

  23. How would you assess her? • AMTS • Collateral history

  24. Dementia vs delirium Dementia Delirium • Insidious (months-yrs) • Progressive • No(less) fluctuation • Attention ok • Conscious level ok • Sudden, may be reversible • Greatly impaired attention and consciousness

  25. 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?

  26. What are the differentials?

  27. Delirium - causes • Often multi-factorial • 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 on admission by unfamiliar hospital environment

  28. How would you investigate? Obs and MEWS hypoxia hydration early sepsis • Bedside: • BM • Urine dipstick • Bloods: • FBC, U+Es, LFTs, Glu, Ca, TFTs • Blood cultures • ECG • Imaging • CXR • CT??

  29. CT head in delirium • Often not helpful • New focal neurologic deficit • New seizure • Head trauma • Fall • Low platelet count or coagulopathy

  30. Imaging in delirium

  31. Think about complications of acute confusion • Falls • Pressure sores • Continence • Feeding

  32. 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?

  33. Managing delirium • Environment - lighting • Maintain orientation • Encourage family • Minimise shift changes (familiarity) • Bowels/bladder addressed • Pain addressed • Avoid restraints – causes more chance of injury

  34. 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

  35. 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

  36. Any Questions?

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