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.

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.

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.

Further reading

www.profane.eu.org Prevention of falls network Europe; focuses on the prevention of falls

Delirium (see p. 515)

This is also known as ‘toxic confusional state’. It is the commonest psychosis seen in the general medical setting. It is ‘brain failure’ with impairment of attention and abnormalities of perception and mood.

Case history

A 76-year-old female is admitted to MAU with a 3-day history of confusion associated with hallucinations.

On examination she has signs of consolidation at the left lung base. Her temperature and white cell count, however, were within normal limits.

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.

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)

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.

Risk factors for delirium

• Dementia

• Severe physical illness

• Raised urea/creatinine

• Visual impairment

• More than three prescribed drugs.

Further reading

Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198.

Inovye SK. Delirium in the older persons. NEJM. 2006;354:1157–1185.

Young J, Inovye SK. Delirium in older people. BMJ. 2007;334:824–826.

Help website http:/hospitalelderlifeprogram.org

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.

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.

Further reading

Ballard C, Gauthier S, Corbett A, et al. Alzheimer’s disease. Lancet. 2011;377:1019–1031.

NICE (2006) Dementia: supporting people with dementia and their carers in health and social care.

http://en.wikipedia.org/wiki/Mini%E2%80%93mental_state_examination

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.

• Physical examination and investigations to detect/exclude physical causes of depression, such as hypothyroidism, hypercalcaemia, malignancy. In a patient with a normal physical examination it is recommended that FBC, U&Es, LFTs, vitamin B₁₂, Ca²⁺, TFTs and chest X-ray are performed.

In this patient, these blood tests and the CXR showed no abnormality.

Table 7.3 Geriatric Depression Scale

From Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS). Clinical Gerontologist 1986; 5: 165–173.

Remember

Always ask the patient about suicidal thoughts/intent.

Further reading

Frye MA. Bipolar disorder – a focus on depression. NEJM. 2011;363:51–59.

Non-specific presentation of illness in the elderly

Many illnesses in the elderly population can present in a non-specific manner. Taking a detailed and informative history can be very difficult because underlying memory loss due to dementia can be exacerbated by an acute medical problem (delirium). Information regarding the previous medical, mental, functional and social conditions is needed to make an accurate assessment of the patient’s current state.

History obtained from the patient should be augmented by information from the patient’s doctor, district nurse, carers, relations and neighbours, if necessary, particularly if the patient is confused.

These problems are highlighted in the following case. MEWS (Table 7.4) is a simple physiological scoring system that can be used at the bedside in a medical admission unit. It identifies patients at risk of deterioration and who may require more specialised care.

Table 7.4 Modified Early Warning Score (MEWS)