Care of the Elderly

Question 1

If a patient falls when getting out of bed, what does that indicate?

Answer 1

Postural hypotension

Question 2

If a patient falls and there is tongue biting and incontinence what does that indicate?

Answer 2

A seizure

Question 3

If the patient is either pale or flushed after the fall what does that indicate?

Answer 3

Vasovagal attack

Question 4

If the patient is confused after the fall what could that indicate?

Answer 4

Head injury

Question 5

If the patient had weakness or speech difficult after the event what does that indicate?

Answer 5

Stroke/TIA

Question 6

What medications may cause or help to identify the cause of a fall?

Answer 6

B-blockers - bradycardia
Diabetic medications - hypo
HTN drugs - hypotension
Benzodiazepines - sedation
Antibiotics - current infection

Question 7

What bedside investigations would you perform after a fall and why?

Answer 7

Observations (BP/HR/RR/Sats/Temp) - sepsis / bradycardia
Lying and standing blood pressure - orthostatic hypotension
Urine dipstick - infection / rhabdomyolysis (blood in urine)
ECG - bradycardia / arrhythmias / heart block
Cognitive screening - cognitive impairment
Blood glucose - hypoglycaemia secondary to poor intake

Question 8

What bloods would you perform after a fall and why?

Answer 8

Full Blood Count - anaemia / Infection
Urea and Electrolytes - dehydration / Electrolyte abnormalities, rhabdomyolysis
Liver function tests - chronic alcohol use
Bone profile - calcium abnormalities in malignancy or over supplementation

Question 9

What imaging would you do after a fall and why?

Answer 9

Chest X-ray - pneumonia
CT head - chronic or acute subdural / Stroke
Echo - valvular heart disease e.g aortic stenosis

Question 10

What are the differential diagnoses of the cause of a fall?

Answer 10

General - mechanical (always give a reason e.g. secondary to poor footwear/visual difficulties/polypharmacy
Cardiovascular - arrhythmias / orthostatic hypotension / bradycardia / valvular heart disease
Neurological - stroke / peripheral neuropathy
Genitourinary - incontinence / urinary tract infection
Endocrine - hypoglycaemia
Musculoskeletal - arthritis / disuse atrophy
ENT - benign paroxysmal positional vertigo / ear wax

Question 11

What are the two main types of delirium?

Answer 11

Hyperactive and hypoactive

Question 12

What are the symptoms of hyperactive delirium?

Answer 12

Agitation
Delusions
Hallucination
Wandering
Aggression

Question 13

What are the symptoms of hypoactive delirium?

Answer 13

Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention

Question 14

What bloods would you do in delirium?

Answer 14

FBC
U&E
LFTs
INR 
TFTs
B12 + folate/haematinics 
Glucose

Question 15

How do you treat delirium?

Answer 15

TREAT CAUSE
Supportive management
Environmental adaptation
Avoid medications

Question 16

What are the causes of a fractured neck of femur (NOF)?

Answer 16

Osteoporosis / osteopenia
Trauma – often falls in the elderly
Pathological fractures – primary bone tumours or metastatic deposits leading to fracture

Question 17

What would you find on examination of a fractured NOF?

Answer 17

Classically the affected leg is shortened, ABducted and externally rotated
Exacerbation of pain on palpation of the greater trochanter
Pain is exacerbated by rotation of the hip

Question 18

How long after admission should fractured NOF be treated?

Answer 18

Surgery needs to take place within 36 hours of admission.

Question 19

How are fractured NOFs classified?

Answer 19

Fractures are classified as extracapsular or intracapsular.
This is an important distinction because the management and risk of complications differ.
The main blood supply of the femoral head traverses under the capsule and along the femoral neck. As a result, the possibility of developing avascular necrosis of the femoral head is much more likely in intracapsular fractures (even more so in those involving displacement).

Question 20

What classification system is used to classify fractured intracapsular NOF?

Answer 20

Garden classification
Group I & II refer to undisplaced intracapsular fractures
Group III & IV refer to displaced intracapsular fractures

Question 21

What are the complications of fractured NOF surgery?

Answer 21

Infection
Bleeding
Increased risk of thromboembolic events – deep vein thrombosis / pulmonary embolism
Avascular necrosis of the femoral head

Question 22

What dementia is this?
Usually begin after the age of 60 (though there are “early-onset” cases, most of which involve genetics).
Can affect all areas of the brain: many functions and abilities can be impacted upon and eventually lost.
Most common presenting symptom is memory loss, with evidence of varying changes in planning, reasoning, speech and orientation.

Answer 22

Alzheimers

Question 23

What dementia is this?
Single infarct vascular disease: classically cognitive impairment (acutely or subacutely) following the event.
Functional deficits are often seen before memory impairment.
Mood disturbances and mood disorders are common in vascular dementia
Psychosis, delusions, hallucinations and paranoia can often be seen, especially in later stages.
Patients should be screened for depression and for signs of psychomotor retardation (often a more common feature than positive signs of depression).
Emotional lability can be prominent.

Answer 23

Vascular dementia

Question 24

What dementia is this?
Often involves visual hallucination and Parkinson-like symptoms.
If physical symptoms precede cognitive decline by more than a year, the diagnosis is often Parkinsons, with superimposed cognitive decline.
Fluctuation in cognitive ability is common.
At presentation, problems multitasking and performing complex cognitive actions are more likely to be issues than memory.
Sleep disorders are a common manifestation.

Answer 24

Lewy-body dementia

Question 25

What type of dementia is this?
Tend to present with one of three clinical pictures (or an overlap): changes in personality and behaviour (which may be labelled psychiatric), or as progressive language difficulty and aphasia.

Behavioural presentation

Altered emotional responsiveness, apathy, disinhibition, impulsivity. Progressive decline noted in interpersonal skills. Changes in food preference, more childlike amusements. Obsessions and rituals may also be noted.

Semantic presentation

Progressive decline in the understanding of word meanings. Speech may still be fluent, but there is difficulty in name-retrieval and use of less precise terms. Are unable to determine the meanings of common words when asked. This tends to develop into the inability to recognise objects, or familiar faces (prosopagnosia).

Non-fluent presentation

Progressive breakdown in the output of language. Speech takes effort and is not fluent. Generally display speech apraxia (poor articulation) or disorders of speech sound. There also tends to be impaired comprehension of sentences and an impact on literacy skills.

Answer 25

Fronto-temporal dementia