The global elderly population is growing due to an increase in life expectancy. Older people with diminished functional and physiological reserves, multiple comorbidities, frailty, polypharmacy, risk of deterioration, hospitalisation and institutionalisation pose a challenge to clinical skills.
In the UK, people aged above 65 years comprise 16% of the population, consume 43% of the NHS budget and 71% of social packages.1 Two-thirds of all hospital beds are occupied also by the elderly. The older population is increasing especially the oldest old aged above 85 years.1 The management of geriatric conditions and syndromes remains a challenge to healthcare professionals. Dealing with elderly patients requires special skills in understanding and managing a variety of conditions.
This article elaborates some specialist geriatric secrets that every healthcare professional needs to be aware of in managing elderly patients.
Guard against clinical ageism
A patient’s chronological age (defined as number of years person has lived) is irrelevant in treatment decisions, and biological age (how well your body functions) is more important. Patients deserve to be treated regardless of their age. Even very elderly patients benefit from modern investigations and treatments including thrombolysis for stroke, acute coronary intervention for myocardial infarction, hip fracture surgery and life saving surgical interventions, anticoagulants, antiplatelets, antihypertensive, antidiabetic and osteoporosis drugs.
If a patient has reasonable mental and physician functioning, their physiological state will benefit from treatment. Even mentally ill patients deserve to be treated with respect. Do not underestimate the capacity of patients with dementia to understand and many have the ability to maintain a good quality of life in the society.
Doctors need to balance high quality care without age discrimination and at the same time avoid aggressive and futile interventions. Clinicians have to decide risks versus benefits, understand principles of mental capacity, consent, dealing with vulnerable elderly adult and end of life decisions.
Be a good historian
Communication may be difficult and a challenge in elderly patients. There could be several reasons such as impaired vision, hearing, speech problems, language difficulties, delirium and dementia. Physicians need to try to work out possible reasons and optimise communication. For example, try to learn how a hearing aid works so you can fix it by adjusting settings etc. Other ways to optimise communication is checking for wax in ears, using reading glasses, taking information from a carer/family member for patients with dementia. Basic things can help like talking slowly in front of patients in simple language, maintaining eye contact, writing things down, repeating and allowing them time to respond. Never write ‘poor historian’ in the notes.
Complexity, comorbidity and atypical presentation is often the rule
An elderly patient would usually have a mixture of acute disease, chronic disease and altered physiological reserve. Atypical presentations are common such as general deterioration, feeling unwell, found on the floor, confusion, unable to cope, reduced responsiveness, reduced mobility, reduced intake and falls.
Patients do not present disease in text book fashion hence old age medicine is complex. Acute disease is often masked and in disguise such as with falls. Confusion can be due to pneumonia, dehydration and hyponatremia.
There is also often failure to assess patients problems, failure to diagnose, failure to treat, with communication errors including medication errors. Sepsis can present as cold peripheries without fever or significant inflammatory response in blood tests. Feeling unwell’ or ‘inability to cope’ could be a presentation of an acute infection, exacerbation of underlying chronic disease (eg. chronic heart failure), drug side effect (eg. constipation) dehydration or serious malignancy. It is important to note that certain conditions are not pathological. Drowsiness is common and may not mean a brain problem. Nonpathological conditions in old age are neck stiffness, positive urine dipstick, basal crepts, reduced reflexes and reduced sensations.
In addition, speech disturbance or dysphasia in elderly patient is not always stroke, and sitting after meals slumping to one side does not mean a transient ischaemic attack (TIA).
‘I must have tripped’ means retrograde amnesia and may need further cardiac investigations. Frail older people may also appear postictal after syncope and take longer to recover because they are less able to compensate for brief cerebral hypoperfusion.
‘My problem is due to old age’
Many patients consider their problems to be due to old age alone and would take things for granted for several years. Examples are incontinence (elderly females may be embarrassed to discuss), falls, memory impairment, high blood pressure, breathlessness, and weight loss. However, proper assessment and management can improve conditions and quality of life not only for the patient but also the carers. Simple interventions can make big differences such as ear syringing, cataract surgery, using special shoes, walking aids, reducing medications, providing adaptations at home, improving incontinence and providing communication aids. It is useful to remember that observation skills of nurses and carers is important and may differ from that of the patient.
Comprehensive geriatric assessment (CGA) is key to good effective practice
Comprehensive geriatric assessment is an assessment of the patient by a team (geriatrician/experienced doctor, physiotherapy, occupational therapy, social worker, nurse, pharmacy, dietician, mental health team etc) followed by intervention and goal setting agreed with the patient and/or carers. It can be performed either in hospital, emergency department or in the community.2
CGA includes a holistic and complete medical assessment, medication review, patient’s functional health status, mood, cognition as well as information on social and environmental circumstances.
Randomised trials have shown that a CGA can improve function, quality of life, reduce length of hospital stay, reduce readmission and institutionalisation rate. In terms of effect size, CGA is as effective and worthwhile as thrombolysis for myocardial infarction.
This requires working and taking into account the views of other members of the multidisciplinary team and full involvement of carers in planning and delivering healthcare for elderly individuals.
Importance of functional assessment
Patients may have difficulties in washing, dressing, using the toilet, walking, using the stairs, feeding themselves, using laundry, and public transport. It may be difficult to determine which of these need active intervention/rehabilitation and which need observation/palliation. Functional assessment can help.
One of the simplest method is to use a clinical assessment scale such as Barthel Index (BI) scale. It can help in maximising the gains from medical/ surgical treatments. Elderly patients deteriorate quickly functionally after an illness and take longer to recover and serial BI can be a guide for progress. Many patients would require referral to multidisciplinary team to get benefit from therapy services for rehabilitation.
Age related loss of muscle mass, strength and function is called sarcopenia3 and is undergoing extensive research as treatment of sarcopenia can avoid frailty, disability and adverse clinical outcomes.
‘Social admission’ is usually a myth
When an older person is admitted to the hospital acutely, there are often multiple and complex medical and social factors which contribute to the crisis. The diagnosis of social admission should not be done without a detailed assessment of patients clinical and social problems.
Admission to hospital gives a chance to explore the severity of medical conditions, drugs and treatments. If assessed carefully, it is likely that a doctor would find several ways to relieve symptoms, improve function and improve patients ‘social’ problems. Examples are managing polypharmacy, managing atypical presentations of conditions, correction of silent biochemical abnormalities, improving mood, cognition, nutrition, adaptations and carer support at home. For a significant number of older persons, advancing age is associated with increased vulnerability to stressor event called frailty4 predisposing them to falls, disability, hospital admission or institutional care.
Learn to recognise and manage ‘confusion’
Those patients who cannot give a good history or have ‘confusion’ could be suffering from one of the four Ds—delirium, dementia, depression or drug effect.
Delirium is common amongst older persons requiring hospital admission. It is acute onset of confusion with disorganised thinking, inattention, incoherent speech or altered level of consciousness. It fluctuates in course and can be due to common acute illness, eg. UTI, pneumonia, drugs (opiods, anticholinergic, steroid etc), electrolyte disturbance, hypoxia, and alcohol. Even simple conditions such as urinary retention and faecal impaction can cause delirium, which improves on correcting the cause.
Cognitive impairment is a contributory factor and hence delirium and dementia may coexist. Delirium patients are at high risk of adverse outcomes so it should be recognised early and treated quickly and appropriately. Patients can become agitated (hyperactive) or become more quiet (hypoactive delirium) and the diagnosis of hypoactive delirium may be difficult to differentiate from dementia. Treatment of delirium is to avoid the precipitating factor and treat the underlying illness.
Agitated patients would need lorazepam and haloperidol should be avoided if possible. Screening instruments such as CAM (Confusion Assessment Method) or 4AT scale can be used to proactively identify the condition.
Training of hospital and care home staff is important. Good holistic care includes regular toileting, control of pain, optimising environment such as lightening, reducing noise, using spectacles, hearing aids, photos, clocks, reducing disruption to the environment, avoiding catheter and stopping certain drugs to proactively prevent delirium.
Dementia is often suspected for the first time when patient is admitted to the hospital for another reason. This is chronic progressive brain disorder with various cognitive deficits such as short term memory loss, language or word finding difficulties, personality change, inability to concentrate, solve problems, complete a task, disorientation and visuospatial difficulties impacting on ADLs.
Depression is not a part of ageing, but can be easily missed causing delayed recovery but is reversible with early recognition and medication.
Drug-related presentations are common
More than 60% of elderly patients are on regular medications, with 50% taking more than four drugs. Some 17% of hospital admissions are adverse drug related.5 In the elderly, 88% of adverse drug related admissions are preventable (24% in the young). Common drug-related presentations include confusion, constipation, postural hypotension, falls, bleeding. Although patients may have several medical reasons for polypharmacy, there may be failure to review and failure to discontinue medications.
Also be aware of potential ‘prescribing cascades’. An example is when a patient with arthritis is given a NSAID that causes hypertension so they are prescribed calcium blockers. This causes ankle swelling so they are prescribed diuretics. This then can cause a fall and fracture.
Risks of adverse effects need to be balanced with the benefits during prescribing. Consider drug-disease, drug-drug interactions, quality of life and expected survival of the patient. Review all medications regularly, eg. steroids, clopidogrel, PPI drugs and do not be reluctant to discontinue unnecessary drugs.
The STOP-START tool6 is a screening tool to review medications for inappropriate combination (STOP) and for recommended treatments (START) and is a reliable comprehensive tool to optimise patients’ treatment.
Check if a patient is taking chewable preparations or sitting upright for osteoporosis drugs. Timing of medication is also essential for Parkinson’s drugs. Provide written information to the patient and carers about their condition and medications.
Also remember any herbal and over the counter medications taken by the elderly. Examples of herbal drug interactions include:
- Atrial fibrillation patient on warfarin develops bleeding after Gingko Biloba
- Grapefruit juice increased drug levels of felodipine for hypertension causing dizziness.
Important pharmacokinetic and pharmacodynamic considerations in the elderly are highlighted in Table 1.
Transient ischaemic attacks (TIA) usually do not cause episodic loss of consciousness
Some patients clearly recall losing consciousness. Some do not remember falling and mention that they were sitting/standing and fell to the ground—this is a clue that this is likely a cardiovascular cause, postural hypotension, hypoglycaemia or abnormal biochemistry. Do not diagnose this as TIA without a focal neurological deficit on history and examination as this would lead to unnecessary investigations and treatments. Underlying cardiac disease, abnormal ECG or history from witness account are further clues towards proper diagnosis as TIA is still commonly misdiagnosed and wrongly referred to rapid access TIA clinic to local hospital.
|TABLE 1. PHARMACOKIENTICS AND PHARMACODYNAMICS|
|Pharmacokinetic (what body does to drug)|
|Pharmacodynamic (what drug does to body)|
Understand and manage the Geriatric Giants
Conditions such as incontinence, immobility, instability and falls, impaired mental function are common, presentations as the final pathway for many medical illnesses in old age. They may present alone or together, may present in atypical manner and usually are difficult to diagnose and treat. They require careful assessment to identify the underlying acute illness or exacerbation of chronic disease together with age-related physiological deterioration.
The doctor needs to understand the cause of patient’s urinary incontinence rather than trying to deal with catherisation only. Proper assessment including history, drug history, urinalysis, residual volume bladder scan, frequency volume charting is necessary. Drugs are available which can improve symptoms and quality of life.
A single fall can be due to acute illness, eg. pneumonia, stroke, low blood pressure or accidental injury. Recurrent falls are often due to underlying medical problems and some of them can be treated. Ask how many times they have fallen in last 12 months. Falls are often multifactorial, eg. fall due to combination of osteoarthritis, quadriceps wasting, old stroke, diabetic neuropathy, drugs, poor vision and loose carpet. Many falls can be prevented in the elderly.
Those with recurrent falls need multifactorial risk assessment by the multidisciplinary team and referral to specialist geriatric team/falls clinic. Basic assessment of recurrent fallers that should be done includes history, medication review, abbreviated mental test, vision, lying standing blood pressure check, cardiovascular and neurological examination, Get up and Go Test, ECG and basic blood tests. Getup and Go Test is a screening test for gait and balance disorders and can differentiate suspected conditions such as stroke, peripheral neuropathy, parkinsons disease, arthritis, foot drop and cerebellar disease.
Dizziness can be a symptom of many conditions
A proper history is the clue for diagnosis and could be subdivided into:
- Lightheadedness: postural—postural hypotensio; independent of posture—hypoglycaemia, cardiac arrhythmia
- Vertigo (sensation of movement)—BPPV, Menieres Disease, vestibular neuronitis, cerebellar disease
- Fuzzy all the time—diffuse cerebrovascular disease, drugs eg. antiepileptics.
Dizziness may be multifactorial eg poor vision plus peripheral neuropathy, postural hypotension, cerebrovascular disease and drugs.
With increasing life expectancy and a rising elderly population the demands on healthcare services are likely to increase. It is important that staff dealing with elderly patients have adequate training and expertise to recognise and manage their complex comorbid conditions.
A comprehensive geriatric assessment, multidisciplinary team working, and involvement of carers in decision making is necessary. A more holistic approach is needed in geriatric medicine than general medicine. Assessing and managing elderly care issues is not only challenging but rewarding.
Dr Abhaya Gupta, Consultant Physician Elderly care, Glangwili hospital, Carmarthen
Conflict of interest: none declared.