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)

Case history (1)

Mr S. is 85 years old and lives alone in a bungalow. His neighbours noticed that he had failed to collect the milk from the front door for 2 days. They called the family doctor, who found Mr S sitting in a chair with grossly swollen feet. In his letter referring the patient to hospital the doctor confirmed that Mr S had been on salbutamol and ipratropium inhalers for 5 years. However, he hadn’t visited the surgery for some time.

On arrival in hospital Mr S was very confused and unable to give a detailed history. His abbreviated mental test (AMT) score (see Table 7.1) was 3 out of 10.

On examination he had a low-grade temperature of 37.6°C, appeared breathless on minimal exertion, with central cyanosis and had signs of congenitive heart failure: high JVP, an enlarged liver and leg swelling up to the groin.

A chest X-ray showed signs of left heart failure and there was right basal shadowing suggestive of right lower lobe pneumonia.

It was not clear how long he had been confused or how mobile he had been before these problems.

His next of kin was a younger brother who lived far away. He was contacted by telephone and confirmed that the patient was not married and had been able to go out to the local shops (a quarter of a mile away) until 3 weeks ago. He also commented that the patient had been mildly confused and needed some help in running his own affairs for several years, but was self-caring and didn’t need help at home.

Treatment.

Mr S was started on antibiotics – amoxicillin 500 mg × 3 daily, bendroflumethiazide 2.5 mg daily and enalapril 2.5 mg × 2 daily for his pneumonia and heart-failure. He was also found to be hypothyroid and was started on levothyroxine 25 µg initially. His general condition gradually improved and his AMT rose to 7 out of 10.

Progress.

With the help of the physiotherapist Mr S was able to get back on his feet using a Zimmer frame. A home visit was successful and he went home with daily home-care support and follow-up in the day hospital, with adjustment of his medication, to maintain his mobility.

Remember

All elderly persons presenting to hospital with non-specific complaints should have full physical examinations and investigations that include FBC, U&Es, LFTs, Ca²⁺, phosphate, TFTs, ECG, MSU, CXR plus any other investigations as indicated by the findings on examination.

Case history (2)

A 79-year-old man was admitted after having had an unexplained fall. He was mildly confused but on direct questioning denied any symptoms.

On examination he had a tachycardia of 100/min, normal heart sounds and a clear chest. An ECG revealed raised ST segment in leads II, III and AVF, i.e. an acute inferior myocardial infarct (STEMI). He had a raised serum troponin.

• Any illness in old age can present with any of the so-called ‘giants’ of geriatric medicine, i.e. confusion, falls/instability and incontinence.

• In addition, some illnesses present atypically. Examples of this include:

• ‘Silent’ myocardial infarction

• Pneumonia without pyrexia or rise in white cell count

• ‘Silent’ peptic ulcer perforation, i.e. peptic ulcers might perforate with little or no pain but the patient becomes non-specifically unwell, anorexic and bed-bound.

Diagnosis.

This patient has had a ‘silent’ myocardial infarction.

Management

Aspirin 300 mg chewed with clopidogrel 300 mg oral gel were given. He was assessed urgently by the cardiac team who felt that despite his age he should be treated urgently with fibrinolytic therapy (p. 286). He responded well, with a fall in the ST segment to normal, without any complications of treatment.

Progress.

He was discharged and given post MI drug treatment (see below) and follow-up by the cardiac rehabilitation nurse.

Remember

Older patients often do well with active treatment of STEMI (fibrinolysis or PCI). There is no evidence to support not giving therapy to elderly patients.

Appropriate assessment scales

The Royal College of Physicians has produced a list of useful assessment scales/tools for the day-to-day management of the elderly. The following scales are recommended:

• Barthel Index: for activities of daily living (ADL) (Table 7.5).

• Mini-Mental State Examination (MMSE): cognitive screening test for dementia and delirium.

• Geriatric Depression Scale: screening instrument test for depression (see Table 7.3).

• Waterlow Score: for risk quantification for pressure ulcers (Table 7.6).

• Philadelphia Geriatric Center Morale Scale: for quality of life (Table 7.7); provides a multi-dimensional approach to assessing the psychological state of older people, i.e. well-being/life satisfaction/quality of life.

Other scales, e.g. Braden, Walsall and Maelor are also available.

Table 7.5 The Barthel Index

Item	Categories
Bowels	0 = incontinent (or needs to be given an enema)
	1 = occasional accident (once per week)
	2 = continent
Bladder	0 = incontinent/catheterised, unable to manage
	1 = occasional accident (max. once every 24 h)
	2 = continent (for over 7 days)
Grooming	0 = needs help with personal care
	1 = independent face/hair/teeth/shaving (implements provided)
Toilet use	0 = dependent
	1 = needs some help but can do something alone
	2 = independent (on and off, dressing, wiping)
Feeding	0 = unable
	1 = needs help cutting, spreading butter, etc.
	2 = independent (food provided in reach)
Transfer	0 = unable – no sitting balance
	1 = major help (one or two people, physical), can sit
	2 = minor help (verbal or physical)
	3 = independent
Mobility	0 = immobile
	1 = wheelchair independent (includes corners)
	2 = walks with help of one (verbal/physical)
	3 = independent (may use any aid, e.g. stick)
Dressing	0 = dependent
	1 = needs help, does about half unaided
	2 = independent, includes buttons, zips, shoes
Stairs	0 = unable
	1 = needs help, (verbal, physical) carrying aid
	2 = independent
Bathing	0 = dependent
	1 = independent (may use shower)

Table 7.6 Waterlow pressure ulcer risk assessment

The Waterlow assessment is mainly used in acute hospital settings in order to highlight patients at risk of pressure sores who will require special nursing care, including aids, and to prevent the development of pressure sores.

Table 7.7 The Philadelphia Geriatric Center Morale Scale

	High morale response	Low morale response
Do little things bother you more this year?	No	Yes
Do you sometimes worry so much that you can’t sleep?	No	Yes
Are you afraid of a lot of things?	No	Yes
Do you get mad more than you used to?	No	Yes
Do you take things hard?	No	Yes
Do you get upset easily?	No	Yes
Do things keep getting worse as you get older?	No	Yes
Do you have as much pep as you had last year?	No	Yes
Do you feel that as you get older you are less useful?	No	Yes
As you get older, are things … than you thought?	Better	Worse or same
Are you as happy now as you were when you were younger?	No	Yes
How much do you feel lonely?	Not much	A lot
Do you see enough of your friends and relatives?	Yes	No
Do you sometimes feel that life isn’t worth living?	No	Yes
Do you have a lot to be sad about?	No	Yes
Is life hard much of the time?	No	Yes
How satisfied are you with your life today?	Satisfied	Not satisfied

References

Lawton MP. The Philadelphia Geriatric Center Morale Scale: a revision. Journal of Gerontology 1975; 30: 85–89.

Royal College of Physicians. Report of a joint workshop with the Royal College of Physicians and the British Geriatrics Society standardised assessment scales for elderly people. RCP, 1992, London.

The Barthel Index should be used as a record of what a patient does (not as a record of what the patient could do). The main aim is to establish the degree of dependence on any help, physical or verbal. A need for supervision means that the patient is not independent. Performance over the preceding 24–48 h is used when completing the Barthel Index but longer periods of assessment might be more relevant. A patient’s performance should be established using the best available evidence. Ask the patient or carer but also observe what the patient can do. The use of aids to be independent is allowed. Direct testing is not needed. Unconscious patients score ‘0’ throughout.

Stroke

This is the sudden onset of focal neurological symptoms caused by interruption of the vascular supply to the brain (ischaemic stroke) or intracerebral haemorrhage (haemorrhagic stroke).

Case history

A 78-year-old man presents with a reduced conscious level, GCS = 12, weakness of the right arm and leg and inability to speak. His daughter thinks that he has had a stroke. She also says that her father has been well and is still working 2 days a week.

Information

Each year in England about 100 000 (1.6–2 per 1000) people have a first stroke. Stroke is the most common cause of severe disability in adult life. There are 64 000 deaths attributed to first or recurrent strokes, which makes it the third commonest cause of death in the UK.

Questions you need to address

• Is it a stroke?

• What type of stroke?

• What part of the brain is affected?

• What is the prognosis?

• Are there complications to treat or prevent?

Pathology

• 80–90% of strokes are ischaemic, i.e. due to thrombosis or embolism.

• 10–20% are the result of primary cerebral haemorrhage or aneurysm rupture.

Common sources of emboli

• Carotid artery and aortic arch atheroma

• Intracardiac sources, e.g. left atrium in AF, left ventricle mural thrombus, left-sided heart valves

• Vertebral artery atheroma or dissection.

Uncommon causes of thrombotic stroke

• Giant cell arteritis

• Other vasculitides

• Haematological disorders, e.g. polycythaemia vera, hyperviscosity syndrome.

Typical signs of a stroke

The typical signs of a stroke are listed in Table 7.8.

Table 7.8 Clinical deficits associated with different vascular territories of the brain

Anatomical location	Common neurological deficits
Left middle cerebral artery	Right-sided weakness involving face and arm>leg with expressive, receptive or mixed dysphasia.
Right middle cerebral artery	Left-sided weakness, face and arm>leg, visual and/or sensory neglect or inattention of left side, denial of disability (anosognosia).
Lateral medulla (posterior inferior cerebellar artery and/or parent vertebral artery)	Ipsilateral Horner’s syndrome, Xth nerve palsy (due to infarction of nucleus ambiguus), facial sensory loss (trigeminal nerve), limb ataxia with contralateral spinothalamic sensory loss. Typically, patients are vertiginous and unable to feed by mouth due (mainly) to failure of laryngeal closure during swallowing and ineffective coughing. Cervical radiculopathies may occur due to involvement of radicular branches of the vertebral artery.
Posterior cerebral artery	Homonymous hemianopia with variable additional deficits due to involvement of parietal and/or temporal lobe.
Internal capsule	Motor, sensory or sensorimotor loss, involving face, arm and leg to a roughly similar extent. There may be profound dysarthria due to involvement of corticobulbar fibres but the patient should not be dysphasic or have other cortical type deficits such as dyslexia or dysgraphia.
Bilateral paramedian thalamus (30% of the population have a single common arterial stem supplying the medial aspect of both thalami)	Coma or disturbed vigilance at presentation, ophthalmoplegia (internal and/or external) ataxia and memory impairment. Some patients require ventilation.
Carotid artery dissection	Ipsilateral Horner’s syndrome due to compression of the sympathetic plexus around the carotid artery; the same process can also affect the lower cranial nerves (Xth and XIIth most obvious clinically) in the carotid sheath, or the VIth nerve in the cavernous sinus. If ipsilateral cerebral infarction follows (due to hypoperfusion or embolisation) the clinical picture can minic a brainstem event; in this way, carotid artery dissection can mimic vertebral artery dissection.

Features of a stroke involving the brainstem

• Hemiplegia/quadriplegia

• Ataxia/vertigo/tinnitus

• Dysphagia

• Dysarthria

• Gaze paresis

• Temperature control disturbance

• Altered respiratory pattern.

Is your diagnosis of a stroke correct?

Most strokes are easily diagnosed clinically but errors do occur. Not all acute neurological impairments are due to stroke and other conditions can be misdiagnosed as stroke.

Unusual symptoms and signs should make you question the diagnosis, e.g.:

• Papilloedema

• Persistent headache

• Fluctuating signs

• Unexplained fever

• History of trauma to head or neck.

Clinical problems associated with a stroke (Table 7.8)

The neurological deficit

Early management of a stroke

• Thrombolytic treatment with IV alteplase (tPA) (p. 286) needs to be given in < h (ideal 90 min) of onset of stroke, haemorrhage having been excluded on scanning.

• Aspirin: 300 mg and clopidrogel 75 mg after CT scanning (to rule out haemorrhage), if fibrinolysis is not being used.

• Hydration and/or feeding: early NG or PEG (percutaneous endoscopic gastroscopy) feeding improves outcome in stroke patients who have unsafe swallowing (see below).

• Treatment of hyperglycaemia with insulin regimen initially.

• Paracetamol for pyrexia: if present.

• Prevention of complications:

• Chest infection: attention to swallow and chest physiotherapy

• DVT. TED stockings have been shown not to be helpful. Prophylactic low molecular weight (LMW) heparin (if haemorrhage has been ruled out) should be used early

• Pressure ulcers

• Contractures.

• Rapid treatment of infection (most commonly chest and urinary tract).

• Hypertension: BP often rises in acute stroke but usually settles. Lowering of BP is only necessary in the early stage for severe hypertension. Persistently raised BP requires treatment for its secondary prevention benefits (see below).

• Support and interventions for the patient and family: stroke is a major life event and both the patient and family need information and support.

Remember

The specific symptoms and signs detected will depend on site of the lesion. 75% of strokes occur in middle cerebral artery territory; 15% are in the vertebrobasilar territory.

How would you investigate and treat this patient?

A CT (MR not available) scan was performed approximately 3 h after the onset of the stroke. This showed a middle cerebral artery thrombus.

The National Stroke Guidelines state that fibrinolytic therapy be commenced; fibrinolytic therapy is indicated in patients with a cerebral infarct due to a thrombus which occurred less than 4.5 hours ago (see p. 476). Therapy, however, should be given as soon as possible to allow the damaged brain to recover. CT scan in first 24 h after an infarct might appear normal; if so, it will need to be repeated if no MRI can be performed. Haemorrhage can usually be seen. An MRI scan shows an infarct early in the diagnosis.

Investigations

• FBCs

• U&Es

• Random blood glucose

• ESR

• ECG

• CXR

• CT or MRI scan of brain

Further management – rehabilitation

• Physiotherapy to maximise functional recovery and prevent contractures.

• Occupational therapy for functional assessment, aids and adaptations.

• Speech and Language Therapist (SALT) for assessment and management of speech and swallowing problems.

• Continuing medical review.

Post-stroke care and rehabilitation in stroke units has been shown to reduce mortality and early disability.

Secondary prevention after stroke

• Hypertension: persisting at 28 days after stroke should be treated according to British Hypertension Society Guidelines (p. 317).

• Anti-platelet agents: aspirin (75–150 mg daily) and clopidogrel 75 mg daily should be started. Dipyradamole MR (200 mg) is used if clopidogrel 75 mg daily is contraindicated or not tolerated.

• Anti-coagulation in patients with ischaemic stroke who make a reasonable recovery and have AF, mitral valve disease, prosthetic heart valve or within 3 months of myocardial infarction.

• Carotid endarterectomy if carotid stenosis of 70–90% is present in patients who are not severely disabled by their stroke. Early investigation and surgery should be performed within one week (p. 478).

• Statins for those with cholesterol > 3.5 mmol/L.

• Stop smoking – refer to anti-smoking clinic.

Progress.

This 78-year-old man improved a few hours after the fibrolytic therapy. Two days later he was able to stand with help. With physiotherapy and speech therapy he became fully ambulant in 6 days and his speech was improving. At assessment, 3 months later, he was living an independent life.

Further reading

Hughes T. Stroke on the acute medical take. Clin Med. 2011;10:68–72.

Langhorne P, Bernhardt J, Kwakkel G. Stroke Care 2. Lancet. 2011;377:1693–1702.

Rothwell PM, Algra A, Amarenco P. Stroke Care 1. Lancet. 2011;377:1681–1692.

www.dh.gov.uk/en/healthcare/stroke

www.rcplondon.ac.uk/stroke

Heart disease in the elderly

Case history

A 78-year-old man with long-standing atrial fibrillation was admitted with tiredness and breathlessness. He also complained of indigestion and recent falls.

Examination revealed a radial pulse of 96, apical rate 110 irregular, a raised JVP, swollen ankles and crackles up to both lung mid-zones.

He was taking digoxin 125 µg daily and aspirin 75 mg daily.

What investigations would you do?

• FBC, UE, LFTs, TFT, troponins

• ECG

• CXR.

Investigations revealed AF with no R wave progression on his ECG, suggesting a possible acute myocardial infarct.

His CXR showed pulmonary oedema (Fig 7.2a). The FBC showed an Hb of 98 g/L with an MCV of 70 fL, suggesting an iron deficiency anaemia, possibly related to his aspirin intake.

Figure 7.2 A pair of chest X-rays taken from a patient before (a) and after (b) treatment of acute pulmonary oedema. The CXR taken when the oedema was present demonstrates hilar haziness, Kerley B lines, upper lobe venous engorgement and fluid in the right horizontal interlobar fissure. These abnormalities are resolved on the film taken after successful treatment.

Learning points

• Cardiac failure in the elderly may present with non-specific symptoms such as tiredness and falls.

• Aspirin, even at low dose, can be associated with occult GI blood loss.

• Always check compliance in older people, especially if patient thinks that medication is not effective.

• Benefits have been shown for anti-coagulation of elderly patients in AF up to age 85, but contraindications (e.g. falls or gastrointestinal haemorrhage) are more common in this population. In this case the microcytic anaemia (see p. 79) would need to be investigated before starting warfarin.

• Risks of anti-coagulation in the over 85s are high and no study has shown a benefit in this age group.

• ACE inhibitors should be used in the elderly, starting with a low dose, and renal function closely monitored due to increased risk of renal impairment (p. 236).

Acute MI

The management principles of heart disease in the elderly are the same as those in young people, with a few exceptions:

Age alone is not a contraindication to thrombolysis/percutaneous coronary intervention in acute MI; in fact the greatest benefits are seen in older patients. However, other co-morbidities causing contraindications are more common in older people.

Acute MI may present silently (with no pain) more commonly in the elderly.

Treatment

He was given diuretic therapy with furosemide 40 mg orally daily. This helped his breathlessness and his ankles became less swollen. His CXR improved (Fig. 7.2b). As his presentation was over a few days he was not given fibrinolytic therapy. He was started on an ACE inhibitor with enalapril 2.5 mg.

Endoscopy was performed and he was found to have gastric and duodenal erosions due to his aspirin intake. The aspirin was stopped. Colonoscopy showed no lesion.

Progress.

Three weeks later he was feeling much better. He was given iron therapy. He was started on warfarin anti-coagulation.

Transient ischaemic attack

This is a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction. The arbitrary time of <24 hours is no longer used; the criteria depend on having no demonstrable lesion.

Case history

A 68-year-old man presents to the A&E with weakness of the right arm and leg, expressive dysphasia and a facial palsy. While being examined his symptoms and signs start to improve and have resolved by the time he returns from the X-ray department. A diagnosis of a transient ischaemic attack (TIA) is made.

What points do you need to ascertain in the history?

• Previous episodes of amaurosis fugax (sudden transient loss of vision in one eye)

• History of palpitations, hypertension, diabetes, high cholesterol or stroke

• Smoking history

• Current and previous medication

• Functional status: mental and physical.

Should you admit this patient?

Updated National Stroke guidelines for the UK recommend that a patient with a TIA should be admitted to hospital if he/she cannot be assessed and investigated in a neurovascular clinic within 7 days of TIA.

Other reasons for admission:

• Doubt over diagnosis, e.g. need to exclude space-occupying lesion.

• Multiple TIAs in short time: these patients should also be fast-tracked to carotid endarterectomy.

• Identification of pathology requiring immediate intervention, e.g. cardiac arrhythmia.

• Background disability with poor social circumstances.

How would you manage a case of TIA?

• Aspirin 75–150 mg per day and clopidogrel 75 mg.

• Anti-coagulation with warfarin in patients with atrial fibrillation.

• Statins for those with hypercholesterolaemia (cholesterol > 3.5 mmol/L).

• Treatment of risk factors, e.g. hypertension.

• Stop smoking.

• Advice not to drive for 1 month following the event.

Further management – carotid endarterectomy (see also p. 478)

Carotid endarterectomy is recommended for patients with TIAs and minor strokes who have 70–90% stenosis of the relevant carotid artery and who are otherwise fit, with no major persisting disability.

Investigation and treatment should be performed within 1 week. MRI angiography is required prior to surgery. Carotid endarterectomy has a 1–2% perioperative stroke risk in the most experienced hands but reduces the incidence of stroke by 75% over the next 2–3 years.

The ABCD² score can help to stratify stroke risk in the first 2 days (see p. 478).

Note: asymptomatic carotid stenosis is associated with a lower stroke risk and benefit from surgery is not proven.

Prognosis after untreated TIA over 4 years

• 25% dead

• 25% stroke

• 10% MI.

Progress.

This man had a carotid endarterectomy performed 6 days after his admission to hospital. He made a good recovery and at review at 6 months he was still taking treatment for stroke prevention and had started on an exercise programme.

Hypothermia

Information

Hypothermia is defined as core body temperature of < 35°C. It is associated with many clinical conditions and in most patients aetiology is multifactorial.

Case history

An 89-year-old female is found lying on the floor by her carer. On arrival at the A&E department she is noted to be confused and have a rectal temperature of 34°C.

Clinical features

These vary with the degree of hypothermia. Whereas those with a core temperature of 33–34°C can be confused and have slow cerebration, those with a temperature of 30°C are more likely to be drowsy and have muscular stiffness.

Some patients with hypothermia have features such as slow relaxing reflexes, which are suggestive of hypothyroidism.

The electrocardiograph can show changes such as sinus bradycardia, slow AF, prolonged PR interval, ‘J’ waves (commonly seen in leads V3-V4) (Fig. 7.3).

Figure 7.3 ECG showing J waves.

Complications of hypothermia include pancreatitis, oliguria, cardiac arrhythmias (particularly during re-warming) and aspiration pneumonia.

Investigations

• Arterial blood gases

• ECG

• CXR

• Thyroid function tests

This patient was found to be grossly hypothyroid with a TSH of 14.3 mU/L and a T4 of 4 pmol/L.

How would you manage this patient?

This patient was managed as follows:

• Nursed with space blanket in a warm room (allow temperature to rise by 0.5°C/h).

• Oxygen: remember that patients with COPD might require 24% oxygen.

• IV fluids (through blood warmer).

• Her severe hypothyroidism was treated with triiodothyronine 5–10 µg slowly IV 12-hourly.

A severely hypothermic patient will require admission to ITU and require positive pressure ventilation, CVP line, and ECG monitoring may be necessary.

Progress.

This woman made a slow but steady recovery and was discharged home on levothyroxine 125 µg daily with a follow-up appointment.

Further reading

Mallet ML. Pathophysiology of accidental hypothermia. Quarterly Journal of Medicine. 2002;95:775–785.

Pressure ulcers

Pressure ulcers are common. Ill elderly people are most at risk of developing pressure ulcers. The reported prevalence rates vary widely – on average 5–10% of this group.

Case history

A 78-year-old woman with a right hemiplegia from a previous stroke was brought to A&E having fallen at home. She had been on the floor for at least 24 h because she was unable to get up.

On examination she was conscious and aware of her surroundings. There were no specific abnormalities on physical examination, apart from evidence of a right hemiparesis. When examining her you notice a dusky area over the right hip overlying the greater trochanter.

Other patients at special risk

• Undergoing surgery particularly orthopaedic surgery

• With neurological disease

• With spinal cord injury including cord compression

• Having palliative care.

Why do pressure ulcers occur?

Pressure greater than the mean capillary pressure (25–32 mmHg) will occlude blood vessels and lead to anoxia of the skin. Hard surfaces can generate pressures greater than 100 mmHg, therefore the damage to the skin results from the pressure applied and the length of time exposed to the pressure. In addition to pressure, shearing force is another significant factor.

Pressure ulcers can be graded into superficial (grades 1 and 2) and deep (grades 3 and 4).

How would you manage pressure ulcers?

Prevention is definitely better than cure and all at-risk patients require immediate assessment.

Remember

• Pressure ulcers can develop in 1–2 h

• Beware of leaving patients on hard A&E trolleys or X-ray tables for too long.

• Relief of pressure with appropriate support mattress and/or cushion for chair:

• Low-risk patients: a soft overlay to the mattress may be adequate

• High-risk patients: an alternating pressure support system, e.g. special pressure-relieving mattresses.

• Appropriate dressings for wounds. Note: dry dressings should not be used on moist wounds. Examples of dressings include:

• Hydrocolloid for superficial granulating wounds

• Alginates for exuding or bleeding wounds.

• Treatment of infection (cellulitis or associated septicaemia) when present, with appropriate systemic antibiotics.

• General management of the patient:

• Pain relief

• Treatment of medical conditions, including anaemia

• Review of drug treatment: NSAIDs and steroids delay wound healing

• Review of nutrition: including use of supplements, including vitamin C and zinc

• Management of incontinence.

• Severe pressure ulcers often require surgical debridement and skin grafting by plastic surgeons, when non-infected.

Most hospitals have tissue viability specialist nurses to advise on prevention and treatment of pressure ulcers. For quantification of risk, these nurses can use the Waterlow score or Norton Scale (see p. 165).

Progress.

This patient was admitted to MAU and the tissue viability nurse was contacted to assess her pressure areas. However, despite immediate treatment she developed a pressure ulcer over her right hip.

Further reading

National Institute for Clinical Excellence (NICE). Pressure ulcer risk assessment and prevention. London: NICE; 2001.

Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers; a systematic review. JAMA. 2006;296:974–984.

Urinary tract infection and incontinence

Case history

An 80-year-old woman with mild dementia presented with 24 h of increasing confusion and drowsiness. She had a 3-day history of urinary incontinence and diarrhoea. She was taking co-dydramol for arthritis.

Examination revealed a woman with confusion, with no knowledge of her surroundings or time of day. Her GCS score was 12. Examination of her abdomen was normal but rectal examination showed constipation with faecal impaction and overflow diarrhoea. A urine sample was offensive, and positive to Stix testing for nitrites, leucocytes, blood and protein.

Particular points to note in the history

• Urinary tract infection in the elderly can present with non-specific symptoms such as confusion, drowsiness or falls.

• Recurrent UTIs should be investigated (> 3 in a woman, > 1 in a man) with renal tract ultrasound, including assessment of post-micturition bladder volume.

• New urge incontinence may be precipitated by infection leading to an unstable bladder.

• Infection can be precipitated by obstruction: most commonly caused by constipation or prostatic hypertrophy.

• Drug history for precipitating causes: drugs causing constipation, diuretics, sedatives.

Examination of this patient included:

• Full physical examination for coexisting causes of confusion, e.g. chest infection.

• Rectal examination – to assess for constipation/overflow (prostatic enlargement in men).

• Neurological examination to exclude neurological causes of urinary retention and constipation.

How would you treat this patient?

• Treat infection with oral antibiotics.

• Trimethoprim 200 mg × 2 for 3–5 days is a good first line treatment. Only use parenteral antibiotics if the patient is very ill or vomiting.

• Treat constipation: enemas and laxatives (see p. 36). Stop co-dydramol. Repeat residual volumes after constipation is treated as this patient’s constipation was likely to be due to the codeine in co-dydramol. The latter was replaced by paracetamol.

Progress.

This patient’s confusion and drowsiness improved with successful treatment of her UTI. Her faecal impaction was relieved by the enemas but she is still inclined to constipation and this is treated symptomatically with Magrols.

Further reading

2011 Elements of provisional discharge plan. Clinical Medicine. 2011:80.

Arteritis

Case history

An 82-year-old widower was admitted with left-sided temporal headache of 3 days’ duration. He is known to have Type 2 diabetes (on insulin), visual impairment due to macular degeneration, hypertension and an old left hemiparesis. He lives alone in a house and has one son who lives far away.

Medical assessment

On examination he had signs of an old left hemiparesis and a peripheral neuropathy (probably due to longstanding diabetes) and visual impairment. His BP was 150/80 on losartan therapy. In addition, it was noted that the left temporal artery was pulsatile but tender.

Investigations revealed a significantly elevated ESR (> 100 mm in 1 h).

A clinical diagnosis of temporal arteritis (see p. 212) was made. His response to steroids was very good, although he remained tired and slightly more frail than previously

How would you organise his discharge?

The patient needs a multidisciplinary assessment before his discharge to ensure his safety. His son should also be contacted, with the patient’s permission.

General points for discharge planning

Discharge planning of an elderly person should start as early as possible after admission. Once the person’s medical problems have been accurately diagnosed and treated, his/her potential for returning home should be assessed by a multidisciplinary team (MDT) of professionals, taking into account the elderly person’s views.

Remember

A competent adult has a right to decide whether he or she wishes to go home, even if this decision is against the advice offered by member(s) of the multidisciplinary team (MDT).

The assessment by MDT includes:

• Assessment by a physiotherapist to assess his/her mobility, transfers and ability to climb stairs.

• Assessment by an occupational therapist to assess independence and safety in activities of daily living, kitchen assessment and/or a home visit.

• Social work assessment that will take into account the assessments of other professionals to quantify his/her needs for care on discharge.

• Assessment by a speech and language therapist, dietitian or a psychologist in some cases.

• Referral to a district nurse, e.g. for treatment of leg ulcers, monitoring of diabetic control, monitoring of medication.

• Discussion with GP about on-going medical care.

Following discharge it might be possible to continue further rehabilitation or monitoring of medical or nursing care in a day-hospital setting.

Progress.

This patient was keen to go home, even though he was still frail. He required full support at home with community nurses managing his insulin therapy. His headaches disappeared on his steroid therapy which was reduced, making his diabetes easier to manage. He continues to improve.

Acute hot joint

Case history

An 80-year-old man presents with a hot, painful, swollen knee joint. He takes a thiazide diuretic for hypertension and has recently had a chest infection treated by his GP.

Particular points you should elicit in the history

• Trauma or injury: entry for infection

• Drug history: particularly diuretic

• Known arthritis or previous episodes, e.g. of gout

• History of intercurrent illness.

On examination you should look for:

• Temperature, pulse: systemic signs of infection/inflammation

• Joint colour, temperature and tenderness

• Evidence of trauma

• Other joint disease, including evidence of RA or osteoarthritis (OA).

Joint fluid should be sent for culture, cell count and examination under polarised light. Urate crystals are distinguished by being negatively birefringent. Calcium pyrophosphate consists of weakly positively birefringent rhomboidal crystals.

Investigations

• X-ray joint

• Tap joint under sterile conditions: fluid for culture, crystal detection and cell count

• Blood cultures

• FBC for WCC and ESR

• Serum uric acid

• Rheumatoid factor, CCP and autoantibody screen if appropriate

• Colchicine (rarely used only because it causes diarrhoea): 1 mg initially, 0.5 mg every 2 h until attack subsides or 0.5 mg × 2 daily for 5 days if symptoms are not severe.

• Intra-articular corticosteroids: injection with methylprednisolone 40 mg with 1 mL of 1% lidocaine.

Allopurinol should not be used acutely. Prophylactically, it is started at least 4 weeks after the acute attack has settled to prevent further attacks of gout.

Progress.

This man’s knee became less painful and the swelling settled after 1 week’s NSAID therapy. His thiazide diuretic was stopped and replaced with losartan. He has had no further attacks of gout.

Further reading

Neogi T. Gout. NEJM. 2011;364:443–452.

Parkinson’s disease

Case history

An 80-year-old man with a history of hypertension presents with a fall. He has had numerous falls recently and on questioning said he had slowed down generally.

You notice immediately a tremor in his left arm, lack of facial expression and a monotonous voice. The diagnosis is Parkinson’s disease (PD).

Clinical diagnosis of PD

PD is a clinical diagnosis; there are no diagnostic tests. Diagnosis requires two cardinal features, including:

• Akinesia/bradykinesia of the upper body

• Asymmetrical onset with resting tremor

• Clear response to levadopa.

What is the differential diagnosis of PD?

Remember

You must question a diagnosis of PD if there is:

• Poor response to L-dopa

• Early instability

• Pyramidal or cerebellar signs

• Early autonomic failure, e.g. postural hypotension, incontinence

• Dementia early in course of disease

• Voluntary downward gaze palsy.

How would you manage this patient?

• This patient was started on L-dopa as first-line treatment (e.g. Co-beneldopa 62.5 mg × 2 daily) as it is useful in the elderly. Dose requires titration depending on improvement and side effects of medication, e.g. postural hypotension, nausea, hallucinations.

• Synthetic dopamine agonists (Ropinirole, Pramipexole) are less effective but might be useful in early disease. Hallucinations and somnolence are common side effects but they are tolerated by approximately 46% of very elderly patients. They may need to be used with domperidone to avoid gastrointestinal side effects. Other dopamine agonists have ergot side effects and are poorly tolerated by the elderly.

• Monoamine oxidase inhibitor (MAOI-B): selegiline – avoid in patients with postural hypotension or hallucinations.

• Catechol-O-methyl transferase inhibitor (COMT) inhibitors (e.g. tolcapone, entacapone) are used as adjuncts to L-dopa.

• Apomorphine SC infusion is used in specialist centres.

• The frequency of his falls improved with PD therapy but nevertheless, exercise and balance training was started. He was referred to an MDT to assess need for walking aids and changes in the home environment.

Progress.

The patient was commenced on Co-beneldopa 62.5 mg × 2 daily and was able to return home with community support.

Further reading

Lees AJ, Hardy J, Revesz T. Parkinson’s disease. Lancet. 2009;373:2055–2066.

Drug treatment in older people/drug treatment as a cause of illness and admission to hospital

Individuals over the age of 65 make up approximately 18% of the population but represent 25–30% of drug expenditure. Approximately 87% of the elderly take one prescribed medication and one-third of this group take three or more drugs.

Age-associated increases in the incidence of adverse reactions have been well described for certain groups of drugs, e.g. benzodiazepines.

The most frequently used classes are cardiovascular drugs, analgesics, gastrointestinal preparations and sedatives (Table 7.9).

Table 7.9 Drugs that are more likely to produce adverse effects in the elderly

Drug	Adverse effects
Benzodiazepines	Sedation, drowsiness, confusion, ataxia
Non-steroidal anti-inflammatory drugs	Gastric erosions, fluid retention, renal impairment and drug interaction, e.g. diuretics
Opiates	Sedation, confusion, constipation
Antimuscarinic	Urinary retention, glaucoma
Antiarrhythmics	Confusion, urinary retention, thyroid problems
Antipsychotics	Confusion, sedation, tardive dyskinesia, malignant hyperthermia
Diuretics	Dehydration, hyponatraemia, hypo- or hyperkalaemia, postural hypotension, renal impairment, gout
Antibiotics	Renal failure, diarrhoea, auditory complications

Drugs as a cause of illness and delayed discharge

Case history (1)

A 75-year-old woman was admitted to MAU with a severe cough and purulent sputum. She was known to have COPD and this was thought to be an infective exacerbation.

On examination she was tachypnoeic but not cyanosed. Examination of her chest showed diffuse wheeze with some basal crackles. Her oxygen saturation was 92%.

She was started on amoxicillin 500 mg × 3 a day, and erythromycin 500 mg × 4 a day, in addition to nebulised salbutamol and ipratropium, with a good response.

A few days later she developed watery diarrhoea, which was bad enough to require IV fluids. Her stool analysis was positive for Clostridium difficile toxin (see p. 9). She was prescribed a 10-day course of metronidazole 400 mg × 3 a day. Apart from transient nausea, she made a good recovery from her diarrhoea and was able to go home after 6 days.

Case history (2)

A 71-year-old woman was admitted with malaise, fatigue, weight loss and generally feeling unwell.

On examination she looked anxious, underweight and tremulous with a tachycardia.

In the past she had suffered from atrial fibrillation and was taking amiodarone 200 mg once daily.

Investigations revealed thyrotoxicosis (thought to be due to amiodarone) with undetectable TSH < 0.05 mU/L and very high free T3 10 pmol/L and T4 35 pmol/L.

The amiodarone was stopped and her cardiologist contacted about alternative therapy for her AF (p. 275). She was started on anti-thyroid therapy (carbimazole 10 mg × 3 daily) and steroids (prednisolone 40 mg once daily). Her response was slow and she remained an inpatient for 2 weeks before her condition was brought under control. She was seen in the Endocrine Clinic for dose adjustment of her carbimazole.

Case history (3)

A 79-year-old woman with a background of Type 2 diabetes and ischaemic heart disease was admitted to MAU with uncontrolled diabetes and progressive shortness of breath. She was taking gliclazide 160 mg × 2 a day and co-amilofruse (5 mg amiloride, 40 mg furosemide) one tablet in the morning. A few weeks prior to admission she complained of back pain and her doctor prescribed diclofenac 50 mg × 3 a day (an NSAID).

On examination she was in acute left ventricular failure with a tachycardia, raised venous pressure, gallop rhythm and basal crackles. She was treated acutely with oxygen, IV furosemide 50 mg and buccal glyceryl trinitrate 2 mg repeated every 20 minutes. There was no evidence of an acute ischaemic episode or chest infection.