Chapter 39. Care of the elderly
The proportion of the population that is over the age of 70 is rising.
Old age may bring a combination of factors rendering the old person especially vulnerable to an acute breakdown in their capacity to cope:
• Social isolation
• Poor housing
• Low income
• Precarious functional capacity
• Dependency on others.
Many old people are fiercely proud and independent and may fail to recognise or acknowledge their increasing vulnerability.
Negative attitudes to old age (ageism) must be avoided by healthcare professionals.
The nature of acute illness in old age
Acute illnesses in old people often fail to present with convenient and characteristic symptoms or physical signs:
• A myocardial infarct may not present with crushing central chest pain but rather with a fall, acute onset of mental confusion or simply breathlessness
• Acute infections may fail to mount the response of an immune reaction (raised white cell count) or a raised body temperature.
Acute illnesses in old people arise in the context of a general background of failing health such as:
• Memory loss and impairment of intellect. The elderly brain is especially susceptible to the toxic effects of any acute illness, so that acute onset of mental confusion may be a presenting symptom
• Failing eyesight or hearing
• Increase in postural sway so that acute illnesses may present as falls
• Impaired central control of bladder function so that acute illnesses may present with urinary incontinence
• Perhaps most importantly, an accumulation of other diseases; for example, a fairly trivial acute illness may arise in a person already compromised by heart failure and further limited by impaired mobility following an operation for a fractured neck of femur.
Acute illnesses in old people often arise in a situation of precarious social circumstances in which the support network for the individual is already stretched.
The paramedic called to an emergency must be aware that an apparently minor illness in an old person can have very different consequences from the same illness in a young person.
Major health problems in old age
Intellectual disorder
In simple terms, intellectual disorder is of two types: due to disease outside the brain (extrinsic) and due to intrinsic brain disease (dementia).
Extrinsic causes
Mental impairment may be caused by:
• Drugs
• Infections
• Hypoxia
• Dehydration
• Electrolyte disorders
• Disturbances of carbohydrate metabolism
• Renal or hepatic failure
• Hypothyroidism and vitamin B 12 and folate deficiency (rare)
• Head injury.
The intellectual dysfunction associated with these extrinsic causes is usually short-lived, unless there is co-existing intrinsic brain disease.
Two cardinal features distinguish this type of mental disorder from dementia:
• Acute onset (and usually rapid resolution)
• Disturbed or fluctuating conscious level.
Intrinsic causes
Dementia is a pathological state characterised by diffuse loss of brain tissue. When brain tumour and other focal conditions have been excluded, the usual causes are Alzheimer’s disease, multifocal vascular disease and a mixture of the two. Dementia also occurs in Parkinson’s disease, Huntington’s chorea and other rarer brain diseases.
Alzheimer’s disease is a slowly progressive disease with a 10-year course on average. Most cases appear in the 8th and 9th decades.
Vascular brain disease, also called multiinfarct dementia, occurs in hypertensive patients who suffer progressive loss of brain tissue, with or without focal neurological signs. Many of these patients die from cardiac disease or stroke.
The history
Patients may give a very misleading history of the illness as they are unable to assess their current state, but may be able to talk convincingly and positively of their past life. Be very wary of patients who make even the slightest lapse from consistency of accuracy in answering questions and seek information from relatives who have watched them over a period of time.
Eventually a crisis occurs, which carers can no longer accept and this fracture of sound support may masquerade as a medical emergency.
Indicators of intellectual disorder in the elderly
• An increased use of the telephone, especially in the middle of the night
• Frequent losses of key, pension books, money, jewellery
• Accusations that others have stolen these
• Burning out kettles
• Leaving the gas on unlit
• Resistance to bathing and changing clothes
• Changes in sleep–wake patterns
• Soiling of clothes and neglect of personal appearance
• Leaving the house and getting lost
• Repeatedly asking the same question
• Misidentifying or failing to identify near relatives
• Speaking of the past as if it were the present and of dead people, e.g. parents, as if they were still alive.
Immobility
Immobility can be defined as an inability to occupy space (the life-space, ranging from anywhere in the world to the confines of an upstairs bedroom).
What are the consequences of immobility?
Loss of choice:
• Being able to go where we want to be and thus be able to do what we want to do
• Being alone or with others
• Having the TV on or off (look around any hospital ward or old people’s home).
Loss of capability:
• Getting to the toilet in time, answering the door or getting upstairs
• Social responsiveness
• Worsening physical dependency.
An old person’s world may thus contract and after becoming housebound, he (or more often she) then becomes restricted to the lower half of the house and eventually perhaps to one room.
Barriers to maintaining mobility in old age
Physical barriers (often more than one):
• Joint problems, especially osteoarthritis of knees and hips
• Neurological deficit: impaired balance, stroke, Parkinson’s disease
• Previous falls
• Sensory deprivation: deafness, impaired vision
• Cardiovascular and respiratory diseases.
Mental barriers:
• Reduced expectations of an active life
• Loss of adaptability and creativity
• Introversion with reduced social contact
• Anxiety and fear of going out (or of allowing others to).
Social barriers:
• Retirement brings with it dangers of reduced social contact and a drop in income
• Living alone: an epidemic problem in ageing women
• Nowhere to go – insufficient outside interests or activities.
Incontinence
Anyone can become incontinent if not able or not allowed to have access to proper toilet facilities. The elderly are more vulnerable because of poor mobility and frequency and urgency of micturition. Any acute illness is likely to be associated with deterioration in continence but usually, this is transient. Any change of environment such as admission to hospital may also lead to a temporary period of incontinence.
Extrinsic causes
Common causes for incontinence in old people include:
• Faecal impaction – easily diagnosed by rectal examination and quickly cured by enemas
• Chronic brain failure – partly due to a diminished response to sensation of bladder filling
• Following the removal of indwelling catheters
• Urinary tract infection.
The problem may be exacerbated by:
• Diuretics
• Hypnotics and sedatives (especially at night)
• Anticholinergic drugs such as antidepressants
• Antiparkinsonian drugs and verapamil can cause urinary retention with overflow.
Intrinsic causes
Intrinsic causes include disorders of the bladder, sphincter or their nerve supply. Incontinence may be caused directly because of over- or underactivity of the bladder itself or the sphincter.
Instability
Balance
Under normal circumstances, the body undergoes oscillations around a fixed point known as the ‘sway path’. As these balance mechanisms deteriorate with increasing age, sway increases.
Ocular mechanisms
Under normal circumstances, visual cues are constantly used to correct minor deviation from the fixed point. In old people, visual acuity is frequently reduced, as is the threshold for light stimulation.
Vestibular mechanisms
The vestibular apparatus is mainly involved with rotatory movements of the head and neck, whereas the otolith organ is involved with acceleration and deceleration. With advancing age, these mechanisms are relatively inefficient.
Proprioceptive mechanisms
Sensory information from proprioceptors in the spine and major weight-bearing joints may be impaired with ageing and arthritis. Failure of these mechanisms leads to an increased likelihood of falls.
Falls
About 20% of elderly men and 40% of elderly women will give a history of a recent fall and the liability to fall rises with age; the probability going up from 30% chance of falling at 65 years to 50% at 85 years. Fall is one of the most common causes of emergency admission to an acute geriatric ward, often after a prolonged period lying on the floor unable to get up.
Where and when do falls occur?
Most falls occur indoors or very close to the house, in the daytime. Falls on stairs are more likely to occur when the person is descending.
What are the clinical features?
Falls may be divided into two broad categories: extrinsic and intrinsic.
• Extrinsic falls are those in which an external factor is responsible, e.g. tripping or accident. This type of fall occurs in a younger, fitter person and the vast majority are unreported and cause no serious injury
• Intrinsic falls are those in which the dominant cause is failure of balance for the reasons described above and in which one or more precipitating causes may play a part. In this case, the patient is older and more frail.
Precipitating causes for falls
Change of posture
Getting out of a chair – an unstable situation requiring strength and coordination in antigravity muscles – is a typical precipitating cause.
Extended movement
In falls due to extended movement – the person reaches out or up, which puts the centre of gravity outside the ground base but owing to a slowing of postural reflex movements, is unable to compensate by moving the feet quickly enough to prevent a fall.
Illnesses
Any acute illness such as cardiac disease or arrhythmias may lead to a fall, as may poor vision.
Drugs
Diuretics, hypnotics and drugs for hypertension are particularly implicated in falls in the elderly and reducing multiple drug therapy is the most powerful preventive measure that can be taken.
Consequences of falling
• Fractures (7–10% of falls), usually wrist, hip, pelvis, upper humerus and ribs. The most serious, proximal hip fracture, has a mortality up to 40% and serious morbidity including loss of mobility in survivors
• Other injuries: soft tissue injuries (5–10% of falls), including bruising, subdural haematoma and dislocations, can occur. Inability to rise from the floor after a fall can result in pressure sores, incontinence and hypothermia and even death
• Psychological effects: fear of falling often results in delay in re-establishing mobility and a re-setting of postural mechanisms which cause a temporary tendency to fall backwards after standing up
• Institutionalisation: recurrent falls are a particularly powerful reason why patients may lose the confidence to live independently.
What is the prognosis?
About one-quarter will die within a year of their index fall. If they have lain for more than 1 hour, half will be dead in 6 months.
Visual impairment
Visual handicap remains grossly underreported both to doctors and registering authorities. Failing vision dramatically increases the burden of other handicaps.
Eye diseases
The four major diseases of the eye in old age are:
• Cataract (clouding of the lens of the eye)
• Macular degeneration (deterioration in central vision)
• Glaucoma (increase in pressure of fluid within the eye)
• Diabetic retinopathy (visual failure due to small vessel disease of the retina).
Changes in the ageing eye
Cornea
The cornea becomes more opaque with slight scattering of light and reduction in light transmission, especially at the ultraviolet end of the spectrum. Specific diseases rather than age itself are responsible for any visual handicap.
Lens
The largest contribution to the visual consequences of the ageing process is made by changes in the lens: it becomes thicker, stiffer, denser and more yellow (filtering out blue and violet). The main consequence is presbyopia or reduced ability to accommodate.
Ciliary apparatus
Thickening of the ciliary apparatus may lead to closed angle glaucoma.
Retina
The blood vessels of the retina become narrower. Macular deterioration reduces spatial discrimination, black and white contrast and colour perception.
Hearing impairment
Deafness is a common problem in the elderly which increases in prevalence with age, 30–40% of people over 75 years having some degree of hearing loss.
Pathology
Acquired causes are either conductive or sensorineural deafness and are superimposed upon an age-related sensorineural hearing loss termed presbyacusis. Presbyacusis is characterised by a predominantly high-tone hearing loss caused by degeneration and atrophy of the sensory cells and neuronal connections within the cochlea.
Symptoms
Difficulty understanding speech is the most distressing and common consequence of hearing impairment. Frequency discrimination, sound localisation and reaction time are also impaired. In some patients, distressing tinnitus (whistling or ringing) and abnormal loudness perception may add to their problems.
Hearing aids
Hearing trumpets are still available and, although they may appear outdated, are still effective. Postaural and body-worn aids are readily available; these aids have a volume control and settings marked ‘O’ for off, ‘M’ for on (microphone) and ‘T’ for use with telephones fitted with an induction coupler (telecoil) loop, which cuts out background noise. Some public buildings and phones are also fitted with coupler loop systems. Bone conductor aids are available to patients with severe middle ear disease causing profound conductive deafness.
Social consequences of deafness
• Difficulty in hearing speech during group conversation (early stages)
• Loss of independence
• Social isolation
• Irritation and unhappiness
• Clinical depression
• Suspicion
• Paranoid ideas.
Depression
Depression is both a subjective mood state and an objective psychiatric illness. The psychiatric illness of depression is characterised by low mood, unaffected by external circumstances, feelings of unworthiness and helplessness. Suicidal ideas may be present. Depression in the elderly is characterised by:
• Appetite disturbance
• Weight loss
• Sleep disturbance (early wakening)
• Poor concentration
• Decrease in normal interests
• Delusions and hallucinations
• Hypochondriasis.
Masked depression
Hypochondria or anxiety symptoms predominate and there is no complaint of depression, although symptoms are present and can be revealed by questioning.
Pseudodementia
Pseudodementia is the term given to a syndrome that presents with poor self-care and poor cognitive ability. This change in function is brought about by a retarded depression. All the features mentioned above may be present; lack of interest will result in poor self-care and cognitive function. These patients will often answer ‘don’t know’ to questions rather than confabulate. The history of onset of the illness is weeks or months rather than years, as in a true dementia. There may be a family or previous history of affective disorder.
Adverse drug reactions
The paramedic called to see an old person should (with permission) search for all medications (both prescribed and ‘over the counter’) and bring them with the patient to hospital. They may be crucial in assisting diagnosis, especially when the patient is unable to give an accurate history.
Communicating with old people
Medical problems and the effects of social isolation may cause problems in communicating with old people. Simple measures such as ensuring that a hearing aid is switched on and that dentures are worn, may help. In people with impaired hearing, ensure good lighting and that the patient can see your face clearly to assist with lip-reading.
1. Introduce yourself. Patients do not know who you are and it is a simple courtesy to tell them
2. Shake hands. This friendly action provides information on the patient’s vision (does the patient see and attend to the hand? Does he miss it when he reaches out his own hand?) and on the strength of grip, the temperature and moisture of the palm and the general feeling of eagerness or apathy
3. Sit down close to the patient. It is off-putting to be asked questions by someone who is towering over you. Get down to the patient’s level both physically and psychologically. Speak clearly, have your face in a good light and never put your hand over your mouth
4. Don’t waste questions. Have a clear purpose in mind with every one you ask
5. How well does the patient hear you? Watch the movement of the head, the facial expression and the response to questions, rather than directly asking if the patient hears you.
6. How credible is the patient as a witness? Begin by asking name, address, date of birth and current age. Check these against your own information. Discrepancies are very significant
7. How good is the patient’s memory? Avoid or postpone ‘formal’ tests of cognitive function. You will obtain just as much information, without risking upsetting the patient, by asking about family: the name of spouse (including wife’s maiden name where appropriate), the names of sons, daughters, sons-in-law, daughters-in-law and grandchildren
8. How well is the patient oriented? Establish first orientation by saying, ‘You know who I am, of course, don’t you?’ and following with, ‘Well, who am I?’ and ‘What is my job?’ If you are still in doubt about orientation, continue with, ‘You know what place this is, don’t you?’ Orientation for time is best tested by asking about the month or the time of year, rather than the day of the week. Knowledge of the time of day is also a good guide; but do not ask more questions than you need.
The home environment: clues to aid diagnosis and management
The major illnesses of old age often leave environmental clues to give assistance to the hospital or primary care team. This investigative role of the paramedic is especially crucial when the patient is a recluse, perhaps not well known to neighbours or to the primary care team, or is reluctant to go to hospital and may deny that problems exist.
Consider who initiated the emergency call; was it:
• The patient? (probably wants help – consider fear and loneliness as well as genuine illness)
• A neighbour? (consider antisocial behaviour or genuine concern about failure of the patient to cope)
• Relatives or carers? (consider severe dependency and carer stress. Has the general practitioner been involved? If not, why not?)
Clues in assessing a patient:
• The garden and outside of the house – is it well maintained? If so, by whom? If not, is this because of low income, lack of interest or lack of ability?
• Access to the house – if this is difficult, is the patient a voluntary recluse or socially isolated or is it because of neglect of maintenance, fear of assault or burglary? Check with neighbours
• The patient who is slow or unable to answer the door may be deaf, immobile or ill. Alternatively, the doorbell may not work
• The letterbox test – lift the flap and sniff! If the smell is unpleasant, consider severe neglect, urine or faecal incontinence of cats or dogs as well as humans
• The general state of repair, maintenance and cleanliness inside will give clues to the person’s general level of household competence. Is the house well heated? If there is central heating, is it used? If the house is clean and tidy, who does it? At the other extreme, the visitor’s feet may stick to the carpet and there may be extreme neglect and squalor. A not uncommon condition is what geriatricians call the ‘senile squalor’ (or Diogenes) syndrome. An elderly person (or occasionally a young person) lives in utter squalor, often surrounded by piles of junk or magazines to the extent that movement within the house is almost impossible. Surprisingly the person is not demented or ill and may often have a middle-class background and have lived alone for many years. Usually they function reasonably well. People with long-standing psychiatric problems or alcoholism may also live in such squalor
• The life-space (see section on immobility) – how much of the house does the person occupy? Are there walking aids or grab rails? Does the person go upstairs? Where are the toilet and bathroom? Are they used? Is there a commode? Does the person sleep in a chair? Can they get up and walk safely? Problems in these areas point to difficulties with mobility, recent or previous falls
• The kitchen – is there food around? Is there a refrigerator? If so, is there fresh food in it? Has the person been eating? Who prepares the food? Is the person capable of using the kitchen?
Abuse of older people
Abuse may be physical, sexual, psychological or financial; it may be due to neglect by relatives, carers or (it could be argued) by the welfare state which leaves many old people on very low incomes or insufficiently supported in their own homes.
Injuries such as finger-mark bruising (especially on the upper arms), cigarette burns (which may not be self-inflicted), bruising around the head and neck and on non-extensor surfaces may be due to assaults and should be carefully documented. Usually they are blamed on falls and in direct confrontation, the old person will often deny abuse, which is often from a stressed carer on whom the old person depends. Physical abuse most often occurs within a caring relationship in which the carer, often inadequately supported, is dealing day and night with a person who is mentally or physically very dependent. Management of the situation demands care and treatment not only for the abused person but also for the carer.
For further information, see Ch. 39 in Emergency Care: A Textbook for Paramedics.
