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Acute medicine and the older patient 

Acute medicine and the older patient
Chapter:
Acute medicine and the older patient
Author(s):

Punit S. Ramrakha

, Kevin P. Moore

, and Amir H. Sam

DOI:
10.1093/med/9780198797425.003.0017
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date: 04 August 2020

The older patient on the acute unit

At present, 65% of acute admissions to hospital are patients aged over 65,1 with an ageing population meaning that these figures are likely to increase. Acute physicians play an important role in the care of older patients, as the majority are admitted via acute medical units. When approaching an older patient, it is key to remember that patients should not be discriminated against due to age alone and should be given equal access to beneficial interventions. There has been a move towards integrated care of older patients on acute medical units, with timely access to specialist geriatric care and education of acute physicians.

This chapter serves to equip acute physicians to treat and prevent crises in an older patient’s health that may contribute to future morbidity and mortality.

It is important to remember that older patients are vulnerable to the same conditions as the younger population, as detailed throughout this book, and that the same treatments apply universally. Older patients are, however, more likely to: present with atypical or non-specific symptoms; decompensate quicker; and suffer Acute medicine and the older patient mortality and morbidity following an acute illness. Older patients are also more likely to have multiple comorbidities and may have an extensive drug history. This needs to be taken into account when assessing and treating the acutely unwell older patient.

References

1. Cornwell J, Levenson R, Sonola L, Poteliakhoff E (2012). Continuity of care for older hospital patients: a call for action. The King’s Fund, London.Find this resource:

Assessing the older patient

A full history and examination are the physician’s primary tool for diagnosis and guiding focused investigation. In older patients, examination skills are the same as for the younger patient, but there are a few considerations to bear in mind:

  • Time: the more frail patients in particular may find the process of examination tiring and some elements difficult. It may take more time to complete a full examination.

  • Pain: may limit the examination due to underlying chronic conditions, e.g osteoarthritis, and consideration should be given to this.

  • Non-compliance: confusion is common, which means examination can be challenging. Often it may be useful to decide what is important to examine now, and what could be perhaps left until the environment is optimized (patients with dementia may be more compliant in the morning, for example).

  • Sensory impairment: recognizing the need for hearing and visual aids early to aid examination.

  • PR examination: constipation is common in elderly patients and can lead to confusion, anorexia, or pain. A PR examination should be considered.

  • Postural hypotension: a lying and standing BP is often forgotten and can give valuable information around the fluid status and can identify the cause for falls.

  • General examination: is the patient unkempt? Are they wearing appropriate clothing/footwear? Are there any concerns around their safety in the community, and are they likely to need support on discharge? Recognizing this early can allow for timely discharge planning.

  • Cognitive screen: an Abbreviated Mental Test should be performed as a screen for cognitive impairment. A score of <7 prompts further investigation of impairment and a formal MMSE, Montreal Cognitive Assessment (MoCA), or Addenbrooke’s Cognitive Examination-III (ACE-III).

  • Collateral history: can often be an extremely valuable tool. Available from multiple sources—family, carers, and GP. It is useful to aim to gain this at the time of assessing.

Admission to hospital can be dangerous for older patients. They are at risk of hospital-acquired infections and hospital-acquired disability. If available, patients should be considered for ambulatory pathways and acute geriatric clinics in order to maintain independence but supply rapid, comprehensive intervention. These provide investigation and management without the risks of admission. Of course, this requires an assessment of their safety at home while unwell.

Assessing frailty

Frailty is the clinical state of Acute medicine and the older patient vulnerability related to age-associated decline in physiological reserve. Frailty is not an inevitable part of ageing and can manifest in a variety of ways.

Be careful in judging frailty based on initial impressions and partial information—the fit older person with an acute illness, once stuck in a bed and hospital gown, looks very similar to the frail older patient in the same outfit.

In the acute setting, it is most likely that frailty will present with a ‘frailty syndrome’—an acute event that has been exacerbated by their underlying vulnerability. These syndromes can often mask a serious acute medical condition (such as MI, stroke, or sepsis). Remember that all of these ‘syndromes’ can occur in the absence of frailty.

The frailty syndromes

  • Falls.

  • Delirium/acute confusion.

  • Reduced mobility.

  • Polypharmacy/Acute medicine and the older patient susceptibility to medication side effects.

  • Incontinence.

  • Exacerbation of chronic conditions.

These presentations are umbrella terms encompassing a myriad of aetiologies. Frequently used unhelpful terms, such as ‘acopia’ and ‘off legs’, detract from the possibility of a serious underlying condition and should be avoided when describing a presenting complaint.

Frailty screening

Active screening can be performed in those in whom frailty is suspected, with many tests available. Frailty is best tested for in the outpatient setting, once a patient is at their ‘baseline’ function.

Examples include:

  • Timed up and go test:2 the time taken to stand up out of a chair, walk 3m and back again, with >10s suggesting frailty.

  • Gait speed:3 <0.8m/s measured over 4–6m.

  • Frailty scores: need to be calculated and interpreted by those trained in their use.

  • Polypharmacy: taking >5 medications can be an indicator of frailty. Inappropriate prescribing should be looked for and medications screened for justification, net benefit, and effectiveness. (It should be noted that some conditions call for an appropriately heavier ‘pill burden’.)

References

2. Podsiadlo D, Richardson S. The timed ‘Up & Go’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–8.Find this resource:

3. Abellan van Kan G, Rolland Y, Houles M, Gillette-Guyonnet S, Soto M, Vellas B. The assessment of frailty in older adults. Clin Geriatr Med 2010;26:275–86.Find this resource:

The comprehensive geriatric assessment

Frail older patients admitted should be cnsidered for a comprehensive geriatric assessment (CGA) (see Table 17.1). This is usually performed alongside a multidisciplinary team, including physiotherapists, occupational therapists, speech and language therapists, and elderly care physicians. This ensures a holistic approach to care. Seemingly small changes in a patient’s care can have a large impact on their quality of life and maintenance of their independence. This, in turn, reduces admissions, morbidity, and institutionalization.

Table 17.1 Common components of a CGA*

Medical

Comorbid conditions and disease severity

Medication review

Nutritional status

Problem list

Mental health

Cognition

Mood

Functional capacity

Basic activities of daily living

Gait and balance

Activity status

Social circumstances

Support available (family/friends/formal carers)

Social network

Eligibility for care resources

Environment

Home facilities and safety

Potential use of ambulatory pathways/non-acute beds/telehealth

Transport facilities

* Reproduced with permission from TJ Welsh et al. ‘Comprehensive geriatric assessment – a guide for the non-specialist.’ Int J Clin Pract (2014); 68(3): 290–3. Copyright © 2014 The Authors. International Journal of Clinical Practice published by John Wiley & Sons Ltd.

Falls and collapse

A good history, including collateral history from those around the patient, is key to understanding the cause for a fall. Falls are not a normal part of ageing and often point to an underlying pathology or pathologies. Recurrent falls can cause a lack of confidence, Acute medicine and the older patient risk of injury, loss of independence, and often institutionalization. A comprehensive geriatric assessment can tease out the multifactorial issues.

Initial assessment of a patient who has fallen

Full history (including collateral history—try to gain this yourself, if possible):

  • Circumstance of the fall, e.g. standing (orthostatic hypotension), eating (postprandial syncope), on the toilet (micturition syncope), on turning the head (carotid sinus syndrome), environment (heat, low furniture, loose carpets), witnesses (was there seizure activity? When? Did they lose consciousness?). Note that first-person and collateral descriptions of consciousness are notoriously difficult to interpret.

  • Injuries from the fall, e.g. head injuries, musculoskeletal injuries. Axial injuries or absence of defence injuries may suggest loss of consciousness.

  • Symptoms experienced around the fall, e.g. pre-syncope (arrhythmias, vasovagal syncope), change in level of consciousness (syncope, seizures), shortness of breath (PE, MI, arrhythmia), palpitations (arrhythmia), fever and signs of infection (sepsis), speech disturbance/limb weakness (stroke, intracranial pathology).

  • Previous history of falls and frequency over last year.

  • Comorbidities, e.g. IHD, arrhythmias, stroke, Parkinson’s disease, cognitive impairment, visual and auditory impairment, mood disturbances.

  • Medication review, e.g. antihypertensives, hypoglycaemic agents, sedatives and hypnotics, antiarrhythmics; is there any possibility of OD?

  • Functional assessment, e.g. use of walking aids, ability to perform activities of daily living. Visual aids and footwear.

  • Nutritional assessment, e.g. unintentional weight loss (malignancy). What do they eat? Who does the cooking? Dehydration?

Examination

The history may guide your examination to focus on a particular system, but bear in mind that most falls are multifactorial, and physicians often concentrate on the ‘interesting’ causes more than the likely ones. A brief examination of the following systems will highlight any comorbid issues.

Cardiovascular

Lying/standing BP, tachy- or bradyarrhythmias, murmurs (particularly that of aortic stenosis), carotid bruits, ruptured AAA.

Neurological

Gait assessment, peripheral neuropathies, stroke, intracranial bleeds, cerebellar pathologies, visual and auditory impairment, Parkinson’s disease, encephalopathy.

Muskuloskeletal

Osteoarthritis or rheumatological conditions causing deformities, muscle wasting, and weight loss, joint stiffness. Pressure sores. Assessing functional ability is important.

Investigations

  • Blood tests, e.g. FBC (anaemia), U&Es (renal disease, dehydration), LFTs, glucose (hypo-/hyperglycaemia), vitamin B12 (peripheral neuropathy, nutritional), folate, ferritin, Ca2+ (malignancy, arrhythmia, weakness), vitamin D, TFTs (arrhythmia, myxoedema, anaemia), can all be useful.

  • ECG (AV block, arrhythmia, MI, prolonged QTc).

  • The following should be guided by history/examination:

    • Echo (if signs of valvular heart disease or CCF).

    • 24h ECG monitor—not routine, only if suspicion of paroxysmal arrhythmia.

    • Tilt table testing.

    • Investigations for infection/sepsis—CXR, urine dip, blood cultures, lactate, CRP.

    • CT head if focal neurological signs (malignancy, stroke, SAH, subdural haematoma, normal pressure hydrocephalus) or head injury on anticoagulants.

    • CXR if any signs of hypoxia (underlying chronic lung disease, PE, pneumothorax).

    • Toxicology (paracetamol and salicylate levels, ECG, urine toxicology) if OD suspected.

Management

Treat any underlying cause found, and consider referral to specialist falls services.

Medication review

Polypharmacy increases the risk of side effects such as reduced awareness/reactions, postural hypotension, hypoglycaemia, and ECG abnormalities.

Multidisciplinary team approach

Elderly care physician, physiotherapist, occupational therapist, dietician, psychiatrist (dementia, depression), speech and language therapists, social services.

Refer to a specialist, as indicated by above (cardiology, neurology, oncology, audiology, ophthalmology). Consider ongoing rehabilitation with the multidisciplinary team.

Fragility fractures

A fall from standing height or less resulting in a fracture is defined as a fragility fracture. Hip fractures account for three-quarters of fragility fractures in the elderly, and there is a delay in diagnosis in up to 10% (undisplaced fractures, patient unable to give a history). The mortality and morbidity with a hip fracture is high (up to 13% at 30 days), and these patients should be admitted under an orthopaedic team and operated on within 48h. It is important to always consider a hip fracture in a frail patient, particularly following a fall. These patients should ideally be reviewed by an orthogeriatric specialist prior to theatre.

Non-hip fragility fractures are often encountered on medical units, e.g. vertebral crush fractures, pubic ramus fractures, and wrist fractures. Often there is an underlying osteoporotic process, and surgical techniques can be ineffective. Specialist orthopaedic opinion is key, and in the absence of a surgical option, the following should be considered:

  • Analgesia: effective pain relief can avoid complications associated with immobility. Regular paracetamol and low-dose opiates can be effective. Consider topical analgesic patches and non-pharmacological approaches [heat patches, transcutaneous electrical nerve stimulation (TENS)]. Prolonged NSAID use is to be avoided.

  • Non-surgical options: immobilization with plaster/orthopaedic aids helps with analgesia and effective healing.

  • Secondary prevention: Ca2+ and vitamin D replacement should be offered to those who are deficient.

  • Bisphosphonates should be prescribed for patients:

    • 75 years or over without the need for a dual-energy X-ray absorptiometry (DXA) scan.

    • 65–74 years if osteoporosis is confirmed by DXA (T-score –2.5).

    • <65 years if: T-score –3.0 standard deviation (SD) or below, or T-score –2.5 SD plus one or more additional age-independent risk factors.

  • Alternatives to oral bisphosphonates are available.

  • Consider referral to specialist osteoporosis services.

  • Underlying causes: assessment of falls risk, as described under Acute medicine and the older patient Falls and collapse, pp. [link][link]. Smoking cessation and safe alcohol consumption advice. Review medications—long-term steroids, in particular.

  • Rehabilitation: early mobilization reduces risks of immobility (VTE, pressure ulcers). Ongoing support from physiotherapists and occupational therapists. May need inpatient rehabilitation at a specialist facility, otherwise consider early supported discharge home with active rehabilitation.

Acute confusion syndrome

Delirium is defined as an acute decline in cognitive function. It is a common presentation affecting 20–50% of patients over 65 in hospital. Distinguishing delirium from a dementia process in the acute setting can be challenging (see Table 17.2). The picture is often complicated by a background history of cognitive impairment. Is this presentation an acute delirium or a progression of dementia, or is there an element of both? Development of delirium in the older patient is a complex interaction between vulnerability of the brain to insult and the degree of the insult. Collaborative history with the next of kin is important to assess the patient’s baseline function and cognition and the timescale of their cognitive decline.

Table 17.2 Delirium versus dementia

Delirium

Dementia

Acute or subacute

Chronic or subacute

Tends to fluctuate throughout the day

Little fluctuation. ‘Sundowning’ may be evident—cognitive decline seen in the evening

Conscious level usually affected (Acute medicine and the older patient in hypoactive delirium)

No effect on conscious level

Attention poor and variable

Normal in early stages, progressively worse in later stages

Agitation common (hyperactive delirium)

Agitation not a feature of early dementia, progressively worse in later stages

Hallucinations and delusions not unusual

Not seen in early disease. May be present later. (Lewy body dementia is an exception to this where hallucinations are an early feature. In contrast to delirium, these hallucinations tend to not bother the patient.)

Memory usually severely affected (short and long term)

Short-term memory declines as the disease progresses. Long-term memory usually intact until late stages

Common causes of delirium

  • Drugs:

    • Polypharmacy, sedatives and hypnotics (including withdrawal), dopaminergic and anticholinergic medications.

    • Alcohol withdrawal should be considered.

  • Physiological stressors:

    • Sepsis and infection, dehydration, hypoxia, hypoglycaemia, alcohol withdrawal, constipation, urinary retention.

  • Psychological stressors:

    • Pain, change of environment.

Investigations

History (including collateral history)

  • Assessment of cognitive history: timescale of decline, temporal fluctuation of confusion, previous diagnosis of dementia.

  • Assessment for risk factors: drug history and recent drug changes, alcohol use, features of infection (lower urinary tract symptoms, cough, vomiting, fever).

  • Co-morbidities: e.g. DM, Parkinson’s disease, depression, psychiatric diagnoses, chronic lung disease, epilepsy.

Examination

A full general examination should be performed, with particular focus on signs of infection, dehydration, focal neurological signs (including meningism), abdominal pain, and constipation.

A measurement of cognitive function, such as the Abbreviated Mental Test (AMTS)4 should be performed at this stage to provide a baseline for clinicians assessing the patient’s cognition at a later date.

Further tools, such as the confusion assessment method (CAM)5 or 4AT, can help distinguish between delirium and dementia, and can be used after a formal assessment of attention and cognition has been performed. These tests should be used by those trained in their use but can identify key features of delirium and dementia.

Focused investigation

  • FBC (raised WCC), U&Es (dehydration, AKI), glucose (hypo-/hyperglycaemia), Ca2+ (hypercalcaemia and dehydration), CRP (inflammation), TFTs (myxoedema), LFTs (hepatic encephalopathy), drug levels (e.g. valproate, phenytoin), vitamin B12.

  • ABG (if hypoxia/hypercapnia suspected).

  • CXR (hypoxia, concerns about malignancy—symptomatic hyponatraemia in small cell lung carcinoma).

  • ECG (electrolyte disturbances).

  • CT head if neurological signs present (stroke, encephalitis, subdural haematoma, SOL).

  • LP if encephalitis or meningitis suspected (but do not delay antibiotics).

  • EEG (non-convulsive status epilepticus).6

Management strategies

  • Treat any acute medical issues identified.

  • Medication review: address polypharmacy; reduce or stop any psychoactive medication (or note any missing medications, e.g. ‘PRN’ sleeping tablet actually taken every night).

  • Improve sensory impairment: address visual and auditory deficiencies to improve orientation.

  • Ensure the patient’s safety: avoid bed rails, restraints, ‘boxing gloves’, and sedation (which will add to the confusion and increase the falls risk).7 Use de-escalation techniques, and provide one-to-one nursing care if the patient is at risk of falling or hurting themselves. Discuss with nursing and therapy staff about strategies to maintain calmness—this may include walking with the patient around the ward (if safe to mobilize), rather than trying to continually try to sit them down.

  • Provide a low-stimulation environment, if possible: a quiet, private room with good lighting, a window, and a clock for improved orientation. Ensure regular interaction. Provide a daily routine, and encourage family/friends to visit.

  • Consider alcohol or nicotine withdrawal. Dependence can be ascertained during a collateral history.

References

4. Inouye SK, van Dyke CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941–8.Find this resource:

5. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233–8.Find this resource:

6. Naeije G, Pepersack T. Delirium in elderly people. Lancet 2014;383:2044–5.Find this resource:

7. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet 2014;383:911–22.Find this resource:

Palliative care and advance care planning

Ideally, the discussion between a physician and a patient about their wishes at the end of life should not occur in extremis, but sometimes this is unavoidable. Often older patients with frailty are admitted to hospital acutely unwell and at risk of cardiopulmonary arrest. In this instance, decisions about escalation to invasive treatments and CPR need to be made. Age alone should not be used as a reason for withholding treatment. Approaching the discussion can seem daunting, particularly with patients who feel well at the time.

Determining those patients that might not survive, despite best medical efforts, is extremely difficult. Many physicians recognize that frail elderly patients can make a remarkable recovery from a seemingly hopeless condition. However, it is not unreasonable to consider that, if full, appropriate, and active treatment fails, then even a ‘successful’ resuscitation is unlikely to leave a frail patient in a better state to benefit from it than before. It is important to be open and honest with the patient (if they have capacity) and next of kin throughout. The following tips can apply to all discussions about resuscitation.

Tips to help the discussion around escalation in the patient with poor prognosis

  • Make a diagnosis and present medically appropriate treatment options to the patient/next of kin, highlighting any invasive or uncomfortable treatments so they can consider them.

  • Discuss with a senior or colleague if you are unsure of whether further invasive treatment would provide benefit, based on the patient’s individual circumstances.

  • Be open and honest about the prognosis and likelihood of recovery to the best of your knowledge. The online prognostic calculator, available at Acute medicine and the older patient http://www.eprognosis.org, can help.

  • Explain the reasoning behind a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) order if placing one, and explain that it does not necessarily mean no treatment will be given.

  • Avoid asking the patient if they want CPR when you have decided it would be futile. The decision rests with the multidisciplinary team, not with the patient/next of kin, although it is not appropriate to make such a decision without informing the patient/next of kin or understanding their wishes.

  • Offer a second opinion if one is asked for.

Discharging the elderly patient near the end of life

Recognizing when a patient is nearing the end of their life can be very useful for opening the dialogue around future care planning. It offers the patient a chance to think about what they would want and the chance to make advance decisions or appoint a Lasting Power of Attorney to another. Discussion with the patient and/or family before discharge around future wishes can be very helpful for advance care planning. You can provide a realistic picture of the likely progression of a patient’s illness and suggest positive treatment goals aimed at improving the quality of life in the last months to year. Polypharmacy can be reviewed at this point, and tablets with no benefit over a year can be stopped, e.g. statins.

Further reading

Abellan van Kan G, Rolland Y, Houles M, Gillette-Guyonnet S, Soto M, Vellas B. The assessment of frailty in older adults. Clin Geriatr Med 2010;26:275–86.Find this resource:

British Geriatrics Society (2010). Comprehensive assessment of the frail older patient. Good practice guide. British Geriatrics Society, London.Find this resource:

British Geriatrics Society (2017). Fit for frailty Part 1. Consensus best practice guidance for the care of older people living in community and outpatient settings. Acute medicine and the older patient https://www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf

British Medical Association, Resuscitation Council (UK), Royal College of Nursing (2016). Decisions relating to cardiopulmonary resuscitation, 3rd edn, 1st revision. Acute medicine and the older patient https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr

Health Protection Agency, British Infection Association (2011). Diagnosis of UTI: quick reference guide for primary care. Health Protection Agency, London.Find this resource:

Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233–8.Find this resource:

Inouye SK, van Dyke CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941–8.Find this resource:

Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet 2014;383:911–22.Find this resource:

Mody L, Juthani-Mehta M. Urinary tract infections in older women: a clinical review. JAMA 2014;311:844–54.Find this resource:

Naeije G, Pepersack T. Delirium in elderly people. Lancet 2014;383:2044–5.Find this resource:

Royal College of Physicians (2006). The prevention, diagnosis and management of delirium in older people. Royal College of Physicians, London.Find this resource: