Elderly Care Presentation
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The document discusses the assessment and management of frail elderly patients presenting acutely, highlighting their non-specific symptoms, multi-morbidity, and the importance of recognizing cognitive and mobility impairments. It emphasizes the need for a thorough evaluation, including medical history, cognition, and swallowing ability, while advocating for careful medication management and immediate supportive measures. It also outlines the challenges faced in communication and the importance of timely interventions to ensure the well-being of older patients.
Elderly Care Presentation
- 1. Acute presentations in older people - Assessing frail elderly patients Burhan Umer Chaudhry LAS GPVTS – Elderly Care
- 2. Aims and objectives • Knowledge a. Non-specific presentation of disease to acute services b. Assessment; identifying frail older patients: i. Cognitive impairment (delirium and dementia) ii. Loss of mobility / falls iii. Loss of swallow c. Multi-morbidity • Skills a. Interpret results of basic assessment i. Cognition, mobility, swallow • Attitudes a. Positive / realistic attitude to value of acute care for frail older people
- 3. What is special about presentation of disease in older people? • Non-specific presentation • Multi morbidity • Iatrogenesis (an iatrogenic illness is an illness that is caused by a medical treatment)
- 4. Non-specific presentation of disease • Intellectual impairment (delirium and dementia) • Immobility (‘off feet’) • Instability (falls) • Incontinence • Loss of swallow
- 5. Case presentation 85yrs female – ‘traditional’ assessment • Vague historian • Social admission – not coping at home • PMH • MI, # femur • Drugs –unclear • Lives alone
- 6. Case presentation, 85yrs female • Cognitively slow – responds simple motor commands – 2/4 on AMT4 • History (relative) – 1 week deterioration mobility, assistance to transfer / walk, confusion – Fall out of bed – Urinary incontinence • PMH – MI, # femur, depression – Deaf, hearing aids – Short-sighted, glasses • Drugs – 10 on prescription • FH/SH – Lives alone, home help daily
- 7. Observations / Basic investigations • Temp 38.5 C • BP 112/70 lying, 90/68 standing • Crackles right lung base • Skin intact • Failed water swallow test • Na 118 mmol/L • Urea 15.2 mmol/L • WBC 24.9 • CRP 250 • Blood cultures
- 8. Prescription drugs pre-admission • Amlodipine • Aspirin • Bendroflumethiazide • Ca / vitamin D • Fluoxetine • Furosemide • Ibuprofen • Lactulose • Ramipril • Simvastatin Would you? a)Continue all b)Stop bendroflumethiazide c)Stop ibuprofen d)Stop all except aspirin e)Stop all
- 9. Why stop all these drugs? • She can’t swallow! • Postural hypotension – Bfz, amlod, ram, furos, fluox • Hyponatraemia – Bfz, furos, fluox • Dehydration / renal impairment – Furos, ramipril, ibuprofen • Incontinence – Furos • Irrelevant treatment – Lactulose
- 10. Problem solving in complex case Problems • Non-specific presentation – Delirium – Immobile / fall – Unable to swallow – Incontinence • Physiological – Renal impairment – Fever – Postural hypotension – Hyponatraemia • Major acute pathology – Pneumonia • Co-morbidity – IHD, osteoporosis – Sensory (hearing / vision) impairment – 10 prescription drugs Acute care •Stop all oral medicines •IV co-amoxiclav / clarithromycin •IV fluids •IV/Rectal paracetamol •Prophylactic LMW heparin – (reduced dose) •Hearing aid, glasses
- 11. Rapid access to investigations • Blood tests – U&Es, BS, Ca, LFTs, CRP, FBC – Troponin • Microbiology – Blood, urine, sputum culture • Imaging – CxR – CT brain scan • 12-lead ECG
- 12. Presentation of acute myocardial infarction in older people • Acute confusion • Collapse / fall • New immobility • Breathlessness • Chest pain
- 13. Does this older person understand me? I asked you a question buddy!
- 14. Testing comprehension • Single stage motor commands – Show me your tongue • 2 or 3-stage motor commands – Take this paper in your left hand, fold it in half, and hand it back to me (put it on the floor/table) Causes of impairment •Reduced conscious level •Deafness •Depression •Dysphasia •Resistive / non-cooperative •Severe delirium / dementia •Motor deficit (weakness, pain)
- 15. Is this older person confused?
- 16. Confusion assessment method (CAM) criteria for delirium 1.Acute change in mental status 2.Inattention (fluctuation) 3.Disorganised thinking 4.Altered level of consciousness Delirium requires 1 + 2 + (3 or 4)
- 17. 4-point Abbreviated Mental Test (AMT4) • 1.what year are we in? • 2.what do we call this place you are in? • 3.how old are you? • 4.what is your date of birth?
- 18. Reasons older people score badly on formal cognitive testing • Cognitive impairment – Delirium – Dementia • Deafness • Dysphasia • Depression • Reduced conscious level • Resistiveness
- 20. Is this older person ‘off their feet’?
- 21. Assessing mobility • History (patient / relative / carer) – current and usual status – Bed / chair transfers, walking – Independent / personal assistance (example 1 or 2 people) – Aids (Zimmer, stick etc) • Examination – Transfers (bed / chair, gait) – Usual walking aid
- 22. Is this older person a faller?
- 23. Multifactorial falls risk assessment for older people • Fall, recurrent falls in the past year, or abnormalities of gait / balance • Multi-factorial falls risk assessment performed by healthcare professionals with appropriate skills and experience.
- 24. Can this older person swallow?
- 25. Systemic precipitants -loss of swallow • Delirium / reduced conscious level – Dehydration / metabolic disturbance – Sepsis – Drugs • Nausea / anorexia • GI obstruction – Faecal impaction – Malignant – Ileus
- 26. Swallowing assessment in the frail or dependent older person ‘Bedside’ assessment – Look in the mouth – Water swallow test • Teaspoons of water • 50mls (half-cup) • Inappropriate if patient not responding accurately to simple motor commands eg. drowsy High risk of aspiration / inability to maintain fluid balance by oral intake •Poor lip seal •Delay in initiating swallow •Poor laryngeal elevation •Coughing / spluttering / change in voice quality
- 27. Summary Assessment of the older patient Things to do • Test comprehension / cognition – Simple motor commands, AMT4 – Surrogate history if a problem • Identify immobility / fallers • Water swallow test • Medical investigation • Hearing aid / glasses • Provide fluids • Start active medical Rx asap • Stop harmful Rx asap Things to avoid •Trying to take detailed history from patient with communication impairment •Nil by mouth when swallow safe •Triage to inappropriate inpatient environment •Discharge frail older patient without offering outpatient comprehensive geriatric assessment