Elderly care: overview
Elderly care medicine (also known as geriatrics, care of the elderly (COTE), or ageing health) is increasingly important and relevant. Both as a student and throughout your career you will be dealing with older patients. It is one of the few specialties that incorporate every field in adult medicine. It also involves a much more holistic approach to the patient and their needs. With our ageing population, it is increasingly the specialty with the greatest demand on services.
• The fastest growing age group are people aged 65 and over.
• The proportion of people aged 65 and over will total >20% of the population by 2024.
• By 2046, one in four people will be >65 years (Office for National Statistics, 2016).
• 70% of those aged >65 have two or more long-term health conditions.
How do older patients differ from younger patients?
NAMES is a helpful mnemonic:
• Non-specific presentations.
• Atypical presentations.
• Multiple pathologies and Multimorbidity.
• Erroneous attribution to symptoms of old age.
• Single illness can have serious consequences due to underlying frailty.
Presentation
Presentation of illness is often atypical in the elderly and therefore it is important to take a thorough history and perform a detailed examination of your patients. These patients will often have multiple pathologies, which make them complicated and mean that a holistic approach to their care is essential. This means formulating a broad differential diagnosis, and always thinking about their psychological, social, and functional status.
MDT
The MDT is the backbone to providing good care to the elderly, and is essential for both initial and longer-term management. The members of the MDT include physiotherapists, occupational therapists, speech and language therapists, dietitians, pharmacists, nurses, discharge coordinators, and social workers.
Common syndromes in the elderly: the six ‘I’s
Geriatric giants: the so-called geriatric giants are the major categories of impairment that appear in elderly people, especially as they begin to fail. These include immobility, instability, incontinence, and impaired intellect/memory.
The following are common presentations. It is important to remember that they are often a symptom of another illness—this should always be at the back of your mind when assessing an elderly patient:
1. Instability—falls.
2. Intellectual impairment—acute confusion/delirium, dementia.
3. Immobility.
4. Incontinence and constipation.
5. Iatrogenic—always consider drug side effects and polypharmacy as a cause for presentation.
6. Infections.
The physiology of ageing
Older people are more likely to become ill than younger people, and most of the older people who are ill have more than one illness. Older adults have greater vulnerability to acute stress than younger individuals due to age-related diminution of physiologic reserves. An acute insult or stressor may push one or more organ systems ‘over the brink’, resulting in organ failure. When one organ system fails, others often follow. Thus, when an older adult with several chronic medical conditions develops an acute illness, those organ systems that are seemingly unrelated to the presenting problem may lack the reserve to withstand the stresses of the acute illness. (See Table 11.1.)
Ageing (‘senescence’) theories broadly fall into two main categories: programmed ageing and accumulation of damage. These theories may interact with each other in a complex way. The following are just two important mechanisms suggested in the ageing process:
• Cell senescence and loss of telomeres: telomeres determine how many times a cell can divide. Their length is a hallmark of the ageing process, and they shorten every time the cell divides. This is evidence of the cell’s ‘biological clock’. In addition, free radical damage acts to accelerate telomere loss.
• Oxidative stress: occurs when the production of reactive oxygen species (ROS)—including free radicals—outweighs the protection available from antioxidants. Interaction of ROS with DNA can result in mutations and deletions. DNA damage accumulates over time, ATP production can decline, and cells begin to die (apoptosis).
Frailty
Frailty is a clinical syndrome characterized by an 
vulnerability to adverse health outcomes and is associated with mortality. Frail patients accumulate physiological deficits that make them less able to adapt to stressors such as acute illness. It is also associated with an rate of cognitive decline.
Care for frail older adults is frequently challenging, related to their disability and multiple chronic diseases. A MDT-based approach to care is often important in meeting the needs of frail, older adults.
A person is said to be frail if they meet three or more of following five characteristics.1
The frailty phenotype:
1. slowness (prolonged gait speed)
2. weight loss (unintentional)
3. weakness (reduced grip strength)
4. exhaustion (self-reported)
5. low physical activity.
Finally, the Clinical Frailty Scale2 is a rapid and easy-to-use frailty screening tool that provides a global score ranging from 1 (very fit) to 9 (terminally ill) to reflect the following domains: disability, mobility, activity, energy, and disease-related symptoms.
References
1. Fried LP, Tangen CM, Walston J, et al. (2001). Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 56(3):M146–56.
2. Clinical Frailty Scale (K. Rockwood): 
http://camapcanada.ca/Frailtyscale.pdf
Elderly care: in clinic
Find out before you attend a clinic what the theme of that clinic is. Read up before you go so that you can get more out of it. Remember, elderly care is a multidisease specialty, but in general, clinics will be related to one of the following themes:
Falls clinics
‘Falls’ are one of the most common presentations in elderly care medicine.
• One-third of people aged >65 and half of those >80 fall every year.
• Falls are usually multifactorial.
• Falls can result in death and disability.
• Falls are commonly indicative of an underlying issue whether they are age-related physiological changes, such as a reduction in vision, or a specific pathology, such as an infection.
• Falls are estimated to cost the NHS >£2.3 billion/year. Therefore, falling has an impact on quality of life, health, and healthcare costs.
Commonest risk factors for falls
• Acute medical illness (virtually anything in the elderly!).
• Visual impairment.
• Polypharmacy (more than four medications is a well-recognized risk factor).
• Impairment of balance/gait—vestibular or higher-level gait disorder.
• Cognitive impairment.
• Cardiovascular—postural hypotension/arrhythmias/heart disease.
• Neurological—TIA/CVA/sensory neuropathy.
• Environmental factors (poor lighting, slippery floors, uneven surfaces).
Taking a history
• Take a history of the fall from the patient, but if needed their friends, family, next of kin, or carers: where, what time, how, did anyone witness the fall, does the patient recall the events?
• Any head injury(ies)/other injuries (especially hips): did they lose consciousness? Any vomiting? Any pain/trauma sustained?
How many times they have fallen in last 12 months and any previous near misses?
Ask about:
• Symptoms before and after the fall: dizzy, palpitations, warning?
• Cardiac symptoms: e.g. chest pains, palpitations, (pre-)syncope.
• Symptoms of infection: especially urinary or chest.
• New weakness or change: in vision or speech.
• Medications: what are they on? What has been recently started?
Examination
Full examination including the following:
• Assessment for any injuries.
• Postural BPs (postural hypotension = >20 mmHg fall in systolic BP or >10 mmHg in diastolic BP, or if symptomatic).
• Functional: ask the patient to stand from a chair, walk a few steps, turn around, and sit back down (‘timed up and go’ (TUG) test).
• CVS: check pulse, assess for rhythm, and listen for murmurs (especially an ejection systolic murmur).
• Neurological: assess gait, identify any neurological defects, cerebellar dysfunction, visual impairment, and cognitive impairment.
Specific investigations
• Bloods: FBC, U&E, LFTs, TFTs, and bone profile.
• Check the creatine kinase if the patient has been on the floor for a significant period of time: rhabdomyolysis can cause AKI.
• Exclude infection: urine dipstick, midstream specimen of urine (MSU), and CXR.
• Cardiac: ECG, echocardiogram, postural BPs, tilt table test, 24+ hour ambulatory Holter monitor.
• Neurological: CT head—exclude subdural haemorrhage, look for evidence of new CVAs.
Honours
• Older patients can have a dampened white cell response or temperature so C-reactive protein (CRP) is a useful marker.
• Patients with catheters will frequently have positive urinalysis due to colonizing bacteria so correlation with the clinical picture and blood tests/investigations are often required.
Vertigo: sensation of movement in any direction
1. Benign paroxysmal positional vertigo (BPPV): extremely common. Caused by calcium debris within the posterior semicircular canal in the inner ear. Brief vertigo (<1 min) provoked by turning the head in a certain position, such as looking up, or rolling over in bed. Investigation of choice is the Dix–Hallpike manoeuvre. Treatment is a ‘particle repositioning manoeuvre’ such as the Epley manoeuvre which helps dislodge endolymphatic debris.
2. Vestibular neuronitis: acute onset lasting several days and self-limiting. Viral or post-viral inflammation affecting cranial nerve VIII.
3. Ménière’s: recurrent vertigo lasting hours that can be associated with hearing loss and tinnitus in one or both ears.
4. Vertebrobasilar insufficiency: brief vertigo when looking up.
5. Postural (orthostatic) hypotension: can be confused with BPPV. On the whole, patients experience a presyncopal sensation rather than vertigo. Orthostatic presyncope is not usually induced by rolling over in bed or lying down.
Falls prevention: multifactoral
Address the likely medical cause (Table 11.2) and manage appropriately. Other specific interventions include:
• review of medications
• hip protectors
• Ca2+ and vitamin D supplementation
• exercise and balance training
• home hazard modification
• community support
• sensory evaluation (vision, hearing, neurological).
Table 11.2 Causes of falls
| CNS |
• Balance and gait impairment:
• Visual impairment
• Cranial nerve VIII problems—vestibular neuritis, BPPV
• Neuropathy
• Acute confusion/delirium
• Epilepsy/fits
• Stroke/TIA
• Parkinson’s
• Cerebellar syndromes
|
| CVS |
• Hypotension (postural, MI, bleeding)
• Arrhythmias (brady/tachy, broad complex/narrow) complex)
• Valve problems—AS
• Vasovagal
• Carotid sinus hypersensitivity
• Situational syncope (cough, micturition, defecation)
|
| GI |
• Diarrhoea
• Dehydration
• GI bleeding
|
| MSk |
• Unstable joints
• Osteomalacia
|
| Metabolic |
• Hypo/hyperthyroidism
• Addison’s (hypotension)
• Cushing’s (myopathy, hypokalaemia)
• Hypoglycaemia (?diabetes)
|
| Iatrogenic/drug causes |
• Benzodiazepines (sedation)
• Antihypertensive medications
• Antiarrhythmics
• Tricyclic antidepressants (TCAs), do not forget alcohol!
|
Continence clinics
• Incontinence is common among older people. It can have a major adverse impact on their quality of life. In fact, it is associated with an increase in mortality and morbidity.
• One in five women and one in ten men over the age of 65 suffer from incontinence.
• 1% of the NHS budget is spent on incontinence (£500 million).
Normal changes with ageing predispose to incontinence
• Age-related changes.
• Vaginal atrophy.
• Reduced bladder contractility.
• Weak pelvic floor musculature.
• Unable to postpone voiding.
• Prostatic hypertrophy.
Reversible causes of incontinence (Table 11.3) can be remembered with the following mnemonic (DIAPERS):
• Drugs/delirium
• Infection
• Atrophic urethritis
• Psychological
• Excess fluid output
• Reduced mobility
• Stool impaction.
Types of urinary incontinence
• Stress: involuntary urine leakage on effort or exertion or on sneezing or coughing.
• Urgency: involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay).
• Mixed: involuntary urine leakage associated with both urgency and exertion, effort, sneezing, or coughing.
• Overactive bladder syndrome: defined as urgency that occurs ± urge urinary incontinence and usually with frequency and nocturia.
Table 11.3 Diseases causing incontinence
| Acute (often reversible) |
Chronic (likely established) |
| Excessive diuresis (drugs, hyperglycaemia, hypercalcaemia) |
Stroke |
| Atrophic senile vaginitis |
Dementia |
| Mechanical (constipation) |
Poor mobility |
| Psychological |
Benign prostatic hyperplasia (BPH) |
| Delirium |
Drugs |
| Iatrogenic (diuretics, oversedation, anticholinergics) |
Nerve damage |
Management of incontinence
History
• What type is it?
• Any urogenital or neurological symptoms?
• Altered bowel habit?
• Mobility.
• Toilet accessibility.
• Past surgery.
Examination
As appropriate: abdominal, rectal (PR) exam including anal tone (essential), examination of perineum to assess for vaginal atrophy and prolapse.
Investigations
This varies but in general rule out simple causes:
• UTI—urine MC&S, U&E, glucose.
• Retention—perform a bladder scan initially and then kidney ultrasound scan.
• Drugs.
• Constipation.
• Voiding record.
• Urodynamic studies.
• Cystoscopy.
Management
• Pelvic floor exercises for stress incontinence.
• Timed voiding and regular toileting for dementia patients.
• Advise to avoid stimulants, e.g. tea, coffee, and soft drinks.
• Intermittent self-catheterization for overflow incontinence.
• Drug therapy: β3 adrenoceptor agonist (e.g. mirabegron), desmopressin for detrusor instability, alpha blockers for BPH, anticholinergics (but best to avoid in the elderly).
• Treat the cause.
• MDT approach.
• Surgery if required.
Memory clinics
Dementia is common in old age. The risk of developing dementia rises with increasing age: >30% of people over the age of 85. There are currently an estimated 1 million people with dementia in the UK, and it is on the increase as the population ages.
Features
• Memory loss, particularly short-term memory.
• Communication and language impairment.
• Loss of ability to focus and pay attention.
• Reasoning and judgement impaired.
• Visual perception deficits and hallucinations.
Types
• 60% Alzheimer’s dementia.
• 20% vascular dementia.
• 10% dementia with Lewy bodies.
• 5% frontotemporal dementia (Pick’s disease).
• 5% other dementias (e.g. vitamin B12 and thyroid deficiencies, Creutzfeldt–Jakob disease (CJD), and Huntington's disease).
Honours
Many people with Lewy body dementia are very sensitive to the older typical neuroleptic medication (e.g. haloperidol), which can lead to severe side effects and even death.
Atypical antipsychotics (e.g. risperidone and quetiapine) are better tolerated but beware of QT prolongation.
Important things to exclude in patients with memory impairment
• Systemic infection including common infections (chest and urine) and rarer causes (e.g. HIV, neurosyphilis).
• Cerebral infection/inflammation— LP to exclude infection, e.g. encephalitis/neoplasm.
• Vasculitis—suggested by elevated CRP/ESR, and antinuclear antibody (ANA).
• Alcohol-associated dementia.
Diagnosis and assessment of dementia
History
• Take as much of a history from the patient as possible, but you will also need a comprehensive collateral history from family and friends.
• Deterioration may be gradual (e.g. Alzheimer’s), stepwise (e.g. vascular), or abrupt (e.g. stroke).
Features
• Unable to retain new information, and short-term memory loss.
• Unable to manage complex tasks, e.g. paying bills and shopping.
• Communication and language impairment, e.g. inability to hold conversation and word-finding difficulties.
• Behavioural changes, e.g. aggression, irritability, irrational judgement, and wandering.
• Neglect of self-care, e.g. grooming, washing, and toileting.
• Recognition, e.g. failure to recognize, friends, and family.
• Agnosia: failure to recognize familiar people, places, and objects.
• Apraxia: failure to carry out complex, coordinated movements (e.g. buttoning a shirt).
Physical examination
• Look for signs of Parkinsonism, thyroid disease, vascular disease, and neuropathy.
• AF, peripheral vascular disease (PVD; vascular dementia).
• Cognitive and mental state examination:
• Exclude delirium (e.g. 4AT test, Confusion Assessment Method).
• Exclude depression.
• Measure cognitive function, e.g. Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Addenbrooke’s Cognitive Examination (ACE).
Appropriate investigations
• Bloods to exclude infection or metabolic dysfunction.
• CT/MRI brain—excludes other cerebral pathologies, and helps detect vascular changes.
• Review of medication in order to identify and minimize use of drugs, including over-the-counter products that may adversely affect cognitive functioning (see STOPP/START Toolkit1).
• Electroencephalography (EEG) if concerned about seizures, and potentially a LP.
• Urinary incontinence, abnormal gait, and marked cerebral atrophy in the context of cognitive decline suggest ‘normal pressure hydrocephalus’, which is treatable.
Management of dementia
General approaches include:
• memory clinics
• day centres and support groups
• dementia nurse specialists
• aim to promote and aid independence
• minimize major changes such as moving home
• simplify medications and aid with a dosette box
• (lasting) power of attorneys, wills, and CPR status are all important for when the patient is unable to make decisions for themselves
• support for family and carers is very important.
Reference
1. Gallagher P, Ryan C, Byrne S, et al. (2008). STOPP (Screening Tool of Older Persons’ Prescriptions) & START (Screening Tool to Alert Doctors to Right Treatment): Consensus Validation. Int J Clin Pharmacol Ther 46(2):72 –83.
The acute assessment of the geriatric patient: ED and on the wards
Common acute presentations in elderly patients on both the wards and in the ED are confusion and reduced mobility. Both of these two presentations are usually a sign of underlying illness and should be taken seriously.
Acute confusion and delirium
Confusion Assessment Method
1. Acute confusion and fluctuating course
Is there an acute change from the patient’s baseline cognition as reported by family/carer/healthcare provider? Does this fluctuate over time?
2. Inattention
Does the patient have difficulty focusing on a topic or are they easily distracted? Can the patient count back from 10, or spell WORLD backwards?
3. Disorganized thinking
Does the patient have rambling or incoherent speech? Do they unpredictably switch from topic to topic?
4. Altered level of consciousness
Is the patient’s level of consciousness hyperalert (agitated), drowsy, stuporous, or comatose?
A diagnosis of delirium requires the presence of features 1, 2, and either 3 or 4.
Delirium is a fluctuating syndrome defined by acute brain dysfunction resulting in disturbance of consciousness, change in cognition, and a reduced ability to sustain attention, precipitated by peripheral stressors/insults such as infection, hypoxia, metabolic abnormalities, stroke, and drug effects.
Delirium is common and affects 40–65% of older patients in hospital, but often goes unrecognized. It is associated with mortality, length of hospital stay, complications, and hospital costs. Delirium strongly predicts future new-onset dementia and accelerates existing dementia. (See Table 11.4 for differences between delirium and dementia.)
A common assessment of confusion which is used in the ED and which you will need to know for your exams and for when you start as a junior doctor is the AMTS score.
Common causes of delirium
Delirium can be remembered by the following mnemonic (DELIRIUM):
• Drugs e.g. CNS-acting drugs, anticholinergics.
• Electrolyte and metabolic disturbance.
• Lack of drugs e.g. withdrawal of alcohol.
• Infection.
• Reduced sensory input (blindness/deafness/darkness).
• Intracranial conditions e.g. stroke, meningitis, subdural.
• Urinary retention/constipation.
• Myocardial conditions e.g. MI, heart failure, arrhythmias.
Table 11.4 How to distinguish delirium from dementia
| Feature |
Delirium |
Dementia |
| Timing/onset |
Acute |
Chronic |
| Precipitating illness |
Common |
Uncommon |
| Reversibility |
Reversible (usually) |
Irreversible |
| Short- and long-term memory |
Poor memory |
Poor short-term memory (long-term memory usually preserved until late) |
| Fluctuations |
Hour-to hour fluctuations |
Little variation/lability |
| Agitation and aggression |
Common |
Uncommon in early stages |
| Conscious level |
Usually affected |
Normally unaffected |
| Hallucinations |
Common |
Uncommon in early stages |
| Motor signs |
Tremor, myoclonus, asterixis |
Late stages only |
Management of delirium
• People with delirium commonly, but not always, need to be admitted.
• Treat the underlying cause.
• Correct electrolyte disturbances and glucose levels.
• Orient patient to date and place daily, provide clocks and calendars.
• Environment—low noise, low lighting at night, minimize transferring within and between wards, or changes in environment.
• Mobilize early and regularly.
• Ask family or friends to support the patient. Education of the families and carers is important.
• If a patient is confused enough to be removing cannulae or other lines, a SC needle sited in between the shoulder blades is often a good temporary measure to enable at least 2 L of hydration/day.
• Stop offending medications, e.g. discontinue benzodiazepines, anticholinergics, antihistamines, and meperidine.
• Treat any pain—start with paracetamol, use low-dose opiates 
titrate up the ‘pain ladder’ as required.
• Check for urinary retention, which is a not uncommon cause of pain and delirium. Treat constipation. Avoid urinary catheters if possible.
• Ensure use of usual glasses, hearing aids, or other adaptive equipment. Ensure the patient can see your mouth to aid in lip reading and expressions. Optimize lighting.
• Attempt non-pharmacological strategies first.
• If sedation is required for safety: antipsychotic medications should be used with caution—start at low doses and carefully titrate up, while closely monitoring for adverse events.
• Haloperidol 0.25–0.50 mg PO/IM.
• Risperidone 0.25–0.50 mg PO.
• Quetiapine 12.5 mg PO.
• Olanzapine 2.5 mg PO/buccal.
• Benzodiazepines are not recommended.
Mental capacity
Capacity is assumed unless proven otherwise. Assessment is based on the Mental Capacity Act (MCA) (2005).
The existence of capacity requires four criteria to be present:
• The patient can understand the information given to them.
• The patient can weigh up the information given to them.
• The patient can retain the information.
• The patient can communicate their decision.
Take all practical steps to support decision-making (e.g. hearing aids, glasses, interpreter, and family). If the patient lacks capacity, any actions must be in their best interest, and the least restrictive option. If a patient lacks capacity and is being hospitalized for a period, then a Deprivation of Liberty Safeguarding (DoLS) order will need to be completed as per the MCA. Contact psychiatry liaison services for support.
Mental Health Act (1983)
• Section 5 (2): allows detention for up to 72 hours. Completed by foundation year 2 doctor and above. Form 12 has to be completed and submitted to the duty hospital manager.
• Section 2: allows detention for up to 28 days and is not renewable. Completed by a social worker and two registered medical practitioners.
Patient has fallen
Much of this topic was covered in the section on falls in the clinic setting (see 
pp. 235–236) and is very relevant to inpatients as well as outpatients. All the same rules apply for a patient who has fallen prior to admission or who has fallen on the ward. As a junior doctor you will regularly be called to assess a person who has fallen. A thorough history and examination is required to assess for both a cause and possible consequences of the fall including injury (especially head injury and hip fractures).
In this section we will look at causes of immobility—i.e. the patient has been admitted because he/she is not able to cope at home due to sudden or insidious onset of immobility (see Table 11.5). In the elderly, once again, this is often multifactorial and a symptom of the underlying disease.
Table 11.5 Causes of immobility
| Pain |
Weakness |
Psychological |
Iatrogenic |
|
Bone pain
Fractures
Osteoporosis
Paget’s disease
Malignancy |
Endocrine
Hypo/hyperthyroidism
Cushing’s disease |
Dementia + depression |
Oversedation |
|
Joint pain
Arthritis:
OA
RA
Pseudogout and gout |
Metabolic
Electrolyte disturbance—calcium
Dehydration |
Fear and anxiety of recurrent falls |
Parkinsonism (drug induced) |
|
Muscular pain
PMR
Polymyositis |
Haematological: always think about anaemia in elderly patients |
|
Hypotension |
|
Soft tissue pain
Pressure sores
Foot problems |
Neurological: stroke and Parkinson’s |
|
Bed rest |
Rehabilitation
Rehabilitation is provided by the MDT, and this will be discussed at greater length later in the section on discharge planning (see pp. 250–251). It is important that the MDT, in conjunction with the patient, set goals that can be worked towards. The rehab process consists of:
• recognition of potential (rehabilitation team assessment particularly by physiotherapists and occupational therapists)
• rehabilitation goal setting
• re-ablement (interventions)
• resettlement
• readjustment.
The Barthel Index—a standardized rehabilitation measurement tool
This measures independence across ten daily living activities, including dressing, grooming, and walking, with a score ranging from 0 (dependent) to 20 (independent).1
Reference
1. Mahoney FI, Barthel D (1965). Functional evaluation: the Barthel Index. Md State Med J 14:56–61.
The holistic approach/‘comprehensive geriatric assessment’
The elderly care ward round
Every elderly patient should have a ‘comprehensive geriatric assessment’ (CGA) during their admission. This is a multidimensional, multidisciplinary, holistic assessment of an older person that determines and addresses their medical, psychological, social, functional, and environmental needs. It encompasses joint medical, nursing, therapy, and social care services around the diagnoses and decision-making.
Randomized controlled trials show that CGA leads to better outcomes, including reduced mortality, improved function, improved quality of life, reduced hospital admission, and reduced readmission rates which is becoming even more relevant with the financial pressures placed on the NHS.
A CGA should include:
• medical diagnoses and treatment
• review of medications and concordance with drug therapy
• information about social circumstances including details of carers, social support, finances, and social services
• assessment of cognitive function and mood
• assessment of functional ability
• home environmental assessment
• formulating goals specific to the patient and agreed with the patient, their relatives, and carers.
Simplify the pill box/prescribing in the elderly
Polypharmacy
Polypharmacy and the adverse effects of drugs are common in the elderly. Up to 30% of hospital admissions are the result of adverse drug events and almost a third of inpatient complications occur due to medications.
Common adverse drug events include delirium, urinary retention, orthostatic hypotension, metabolic derangements, e.g. hyponatraemia, bleeding due to anticoagulants or antiplatelets, and hypoglycaemia related to diabetic medications. GI side effects, including nausea, anorexia, dysphagia, and constipation, are also common.
It is particularly important to ensure that a complete and accurate list of medications is obtained in older patients. Hospital pharmacists, care homes, and their GPs can be helpful sources of information.
Tips on taking a drug history in elderly patients
• Ask the patient or family to bring in all their medication.
• Include allergies and intolerances in the drug history.
• A telephone call to the GP will help confirm what medications are actually taken or prescribed.
• A discharge letter from a recent admission will often be a very useful source.
There are greater pharmacological challenges for the elderly due to:
• wasting of muscle tissue
• fat accumulation
• 
weight and body water
• cardiac output
• intestinal motility
• impaired renal function ( glomerular filtration rate)
• impaired homoeostasis
• liver blood flow and oxidation/reduction (phase I metabolism).
Drug metabolism, absorption, and elimination all change as a patient gets older. Doses in the elderly therefore need to be carefully monitored. Doses of some commonly prescribed medications with narrow therapeutic windows (e.g. gentamicin, digoxin, and vancomycin) will need to be carefully monitored and the dose adjusted to account for reduced renal function and metabolism in older patients.
Prescribing tips for the elderly
• Is it indicated?
• Can it be stopped?
• Start low and go slow.
• Monitor renal and liver function more closely.
• Monitor therapeutic doses and serum levels (digoxin, gentamicin, lithium).
• Drugs to be regularly reviewed and discontinued if no longer indicated.
• Educate the family and patient. Use medication summaries.
• Convert to once a day or modified release if possible.
• Try to use one medication that does the same thing as two, e.g. ACEI in heart failure and hypertensive patients.
• Consider a monitored dosage system.
The following medications are potentially hazardous in the elderly and need to be prescribed with caution:
CVS
• Aspirin: high risk of GI bleed/ulcers.
• Warfarin: bleeding.
• Beta blockers in combination with verapamil or diltiazem may result in symptomatic heart block.
• Digoxin in impaired renal function: potential for digitoxicity and arrhythmias.
• Diuretics: may exacerbate gout, hyponatraemia, and hypo/hyperkalaemia.
CNS
• Benzodiazepines can worsen confusion, cause falls, and impair balance.
• Antimuscarinics and some anticonvulsants can worsen confusion.
• Avoid TCAs in dementia—risk of worsening cognitive impairment.
• TCAs exacerbate glaucoma, are proarrhythmic, and can cause constipation as well as urinary retention.
• Selective serotonin reuptake inhibitors (SSRIs) can cause hyponatraemia.
• Antimuscarinics and metoclopramide worsen Parkinsonian symptoms.
Drugs that cause falls (‘BOSS VAN’)
• Benzodiazepines
• Opiates, e.g. codeine and morphine
• Sedating antidepressants, e.g. TCAs
• Sleeping tablets, e.g. zopiclone
• Vasodilators, e.g. nitrates, nicorandil, calcium channel blockers
• Antihistamines (sedating), e.g. chlorphenamine
• Neuroleptics, e.g. phenytoin, carbamazepine.
GI
• Avoid NSAIDs in peptic ulcer disease or GI bleeds.
• Drugs that cause constipation: antimuscarinics, TCAs, calcium channel blockers, and opioids.
Respiratory
• Long-term steroid use can cause GI ulcers, and systemic corticosteroid/Cushingoid features.
• Nebulized ipratropium may exacerbate glaucoma.
MSk
• NSAIDS: bleeding, bruising, GI disease, exacerbate heart failure, and hypertension.
Urological
• Antimuscarinics, e.g. oxybutynin, are associated with an risk of constipation, confusion, cognitive impairment, urinary retention, and glaucoma.
How to initiate warfarin
• Explain why warfarin is needed.
• Discuss risks vs benefits with patient.
• Explain about frequent blood tests and monitoring initially.
• Explain that some medications interact with warfarin, e.g. tetracyclines, more so in the elderly.
• Avoid vitamin K-rich foods, e.g. spinach.
• Inform them that alcohol will affect levels.
• Follow local hospital policy for the initial dosing of warfarin, but for most elderly patients 5 mg, 5 mg, then check INR on the third day is a safe approach.
• Initially it is important to check INR daily, then alternate days until a pattern becomes clearer.
• Give them the yellow booklet with indications for being on warfarin and their treatment schedule.
End of life and palliative care
Withholding treatment
The benefits and burdens of treatment need to be reviewed when death is imminent. It is important to recognize when the patient is in the terminal phase of their life and help make it as peaceful and dignified as possible. The palliative care team should be involved early and spiritual needs should also be addressed.
Verification of death
Check for and document the following assessments:
• Pupils fixed and dilated.
• No pulses palpable for 1 min.
• No heart sounds heard for 1 min.
• No breath sounds heard for 3 min.
• Time of death.
• Persons present.
• No response to painful stimulus/unresponsive.
• Whether next of kin/family informed or not.
Certification of death
This is an important duty and a legal requirement. A funeral cannot be arranged without it and it also provides important statistics for disease surveillance and public health. Always ask a senior before issuing a death certificate with regard to cause of death. Be as precise as possible regarding the cause, e.g. ischaemic heart disease rather than cardiac failure. Old age is an acceptable cause of death in the very elderly person who has had a non-specific decline and treatable causes have been excluded (see Fig. 11.1).
Cremation forms
You must have looked after the patient in their terminal illness to complete this form. The form asks for your details, what your role was, how long you looked after the patient, and when was the last time you cared for the patient prior to their death. It also asks for the cause of death as would be issued on the death certificate, a summary of events that led to the patient’s death.
Geriatrics: in exams
Specific geriatric assessments in OSCEs
Assessment of cognition
• Introduce yourself, establish rapport/patient’s name and age.
• Explain you are going to test their memory and that some of the questions you ask them may seem silly to them. Apologize for this.
• Conduct the Abbreviated Mental Test Score (maximum 10 points):
1. How old are you?
2. What is your date of birth?
3. What time is it?
4. Can you remember the following address? 42 West Street (repeat question at the end).
5. What year is it?
6. What place is this?
7. What is my job? What is that person’s job? (recognizing two people)
8. Can you tell me when World War I started/finished?
9. What is the name of the monarch?
10. Can you count backwards from 20 to 1?
Each answer scores 1 point. A score of 8 or less is abnormal.
• Summarize and elicit any concerns from the patient.
• Present your findings and management plan to the examiner.
NB: this is a screening tool to establish if someone is confused; if positive, a more detailed assessment is then required—you should say this to the examiner when presenting your findings at the end of the station. You can explain that an example of this is the MMSE or the MoCA tool but you will not be required to do this in an examination scenario. You may be required to know what the different elements are:
The MoCA assesses several cognitive domains
• Short-term memory recall
• Visuospatial abilities
• Executive functions
• Phonemic fluency
• Verbal abstraction
• Attention, concentration, and working memory
• Language
• Orientation to time and place.
Discharge planning and functional status assessment
• Explain that you want to discuss issues surrounding their discharge home following admission (e.g. after a stroke when the patient’s needs and mobility may have changed significantly).
• Establish the patients’ ideas and concerns when returning home.
• Ask about the home environment (e.g. stairs, bathrooms, kitchen, etc.).
• Assessment of activities of daily living: what is the patient able to do for themselves? Ask specifically about:
• washing
• dressing
• mobility and walking aids
• transferring (e.g. bed to chair)
• stairs
• cooking
• feeding
• continence issues.
• Ask about support required on discharge:
• Carers (for help with washing and dressing).
• Single-level accommodation (if stairs are an issue).
• Shopping (delivery can be arranged).
• Cooking (‘meals on wheels’ are available).
• Continence (commode in bedroom or continence pads).
• Nutrition: the Malnutrition Universal Screening Tool (MUST) is a predictor of malnutrition. There are multiple causes of weight loss due to inadequate nutrient intake. These include social (e.g. living alone, poverty, isolation), psychological (e.g. depression, dementia), medical (e.g. cancers, dysphagia), and pharmacological issues.
• Explain that there will be a MDT to help the patient prepare for discharge, which may involve social services, occupational therapists, and physiotherapists, amongst other specialist services.
• Ask the patient about any other concerns.
• Summarize.
• Present your findings and management plan to the examiner.
Formal functional scores exist that you would use to assess the patient, but you would not be expected to formally assess this in an examination. One example is the Barthel Index that focuses on reflecting the degree of independence.1 A higher score is associated with a greater likelihood of coping and living at home with a degree of independence following hospital discharge. Ten variables are scored out of a maximum of 20.
Assessment of depression in elderly patients
• Introduce yourself.
• Ask about how the patient is feeling.
• Explain that you are going to ask some questions to assess their mood.
• The Geriatric Depression Scale (GDS) screening tool is used to identify depressive symptoms in the elderly.2 It consists of 15 yes/no questions. This is a quick test which takes 5–10 min. Scoring:
• 0–4: no depression.
• 5–10: mild depression.
• 11+: severe depression.
• Ask about deliberate self-harm and suicide: if the patient expresses any intent to harm themselves you must conduct a full suicide assessment.
• Be aware of pseudo-dementia in the elderly: the response ‘I cannot remember’ may indicate some degree of cognitive impairment but also may be a symptom of depression for instance.
• Ask if the patient has any particular concerns.
• Summarize.
• Present your findings and management plan to the examiner.
References
1. Mahoney F. Barthel D (1965). Functional evaluation: the Barthel Index. Md State Med J 14:61–5.
2. Yesavage JA, Brink TL, Rose TL, et al. (1982). Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 17(1):37–49.
