Level 2 of 6Must-remember

Acute illness in the older patient

Assess, manage and stay safe — enough on its own

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The card — assess, manage, caution

Assessment— look, ask, measure

A change in function is an acute illness until proved otherwise: "off legs", "failure to cope", "acopia" and "social admission" are not diagnoses and must never prevent a full search for a precipitant.
Collateral history first: establish the usual level of function and the chronicity of the change — hours to days points to delirium and acute illness, months of gradual decline to dementia or progressive chronic disease.
Ask what is actually being taken, not what is prescribed: one-third of patients over 65 take six or more medications and 5% take more than ten, and polypharmacy accounts in part for up to 6.5% of all iatrogenic hospital admissions.
Capillary glucose immediately: a value below 4.0 mmol/L is hypoglycaemia and mimics stroke, delirium and coma — treat it at once.
Count the respiratory rate yourself: a rate above 20 is an early, reliable sign of serious illness and is the observation most often not counted.
Read the blood pressure against the patient's own usual pressure: a systolic of 110 mmHg in someone who normally runs 170 mmHg is shock.
Temperature both ways: hypothermia, or a normal temperature in a patient who looks septic, because older people may not mount a fever with serious infection.
Screen for delirium with the 4AT (alertness; AMT4 of age, date of birth, place and current year; months of the year backwards from December; acute change or fluctuating course over 2 weeks still evident in the last 24 hours): a score of ≥4 suggests possible delirium, 1–3 possible cognitive impairment, 0 makes delirium unlikely.
Inattention is the defining feature of delirium: healthy adults repeat five to seven digits, a forward digit span of four or fewer indicates an attentional deficit, and many delirious patients manage three or fewer.
Know the three subtypes: hyperactive (agitated, hallucinating), hypoactive (quiet, sleepy, reduced intake — commoner in frailty, easily missed, poorer prognosis) and mixed, which is the commonest.
After a fall answer three questions: why did they fall (mechanism), what made them liable to fall (risk factors), and what did the fall do to them (consequences).
Separate syncopal from non-syncopal collapse with a collateral history: over 30% of patients who genuinely lose consciousness are unaware that it occurred, and absent protective arm response with facial injury suggests syncope.
Lying and standing blood pressure in every faller: lie for 5 minutes and measure, stand and measure within the first minute, repeat at 3 minutes — a fall of 20 mmHg systolic or 10 mmHg diastolic within 3 minutes (or 30 mmHg systolic in a hypertensive patient) is orthostatic hypotension.
Look for the long lie: a period on the floor implies rhabdomyolysis, hyperkalaemia, acute kidney injury, hypothermia, pressure injury and dehydration until excluded, and demands a creatine kinase.
Danger signs that change the plan: new focal signs, fluctuating conscious level or a scalp haematoma (chronic subdural haematoma); a shortened, externally rotated leg or inability to weight-bear; unexplained bruising or injuries of different ages.
Grade frailty, not chronological age, with the Clinical Frailty Scale 1–9 (1 very fit to 9 terminally ill) — but never use the word "frail" to justify inadequate investigation.

Management— do this, in order

Treating the precipitating factors is the treatment of delirium, and they may be multiple — assess immediately for sepsis, drug and alcohol intoxication or withdrawal, hypoglycaemia and other metabolic disorders, then work systematically through the rest.
Oxygen: target saturations of 92–96%, or 88–92% where there is a risk of hypercapnic respiratory failure.
Fluids in 250–500 mL boluses of balanced crystalloid or 0.9% sodium chloride with reassessment between each — respiratory rate, saturation, lung bases, jugular venous pressure — never a litre run in freely, because under-filling causes acute kidney injury and over-filling pulmonary oedema.Doctor / Nurse
Glucose below 4.0 mmol/L is treated at once, remembering that hypoglycaemia from a sulfonylurea or long-acting insulin recurs for many hours.Doctor / Nurse
Pain relief is part of the delirium treatment: paracetamol 1 g orally or intravenously 6-hourly is the mainstay, but in an adult weighing under 50 kg reduce to 15 mg/kg per dose, maximum 60 mg/kg in 24 hours.
Opioids may be given at a reduced starting dose, titrated in small increments, with an antiemetic and a laxative prescribed at the same time; tramadol has less addiction potential but is contraindicated in seizure disorders and used cautiously with SSRIs and SNRIs.Doctor / Nurse
Regional anaesthesia (fascia iliaca block) for hip fracture minimises opiate use where a trained operator is available.Doctor
Non-pharmacological measures are first line for delirium: spectacles on, hearing aids in with working batteries, dentures in; clock and calendar in view; personal objects and photographs; consistent staff; gentle lighting; lower alarm volumes; earplugs at night; family presence; and do not move the patient between beds.
Neither endorse nor challenge delusions and hallucinations, re-orientate without arguing, attend to hydration, nutrition, bowels and bladder, avoid urinary catheters, remove unnecessary cannulae and restraints, and mobilise early.
Use a sedative or antipsychotic only when the patient is a danger to themselves or others, or is severely distressed by psychotic symptoms, and conservative measures have failed; use the lowest dose that controls symptoms and check the QT interval before starting an antipsychotic.Doctor / Nurse
Starting doses in an older adult: haloperidol 0.5 mg orally or intramuscularly; risperidone 0.25 mg orally (range 0.25–2 mg); olanzapine 1.25 mg orally daily; quetiapine 12.5–25 mg orally (preferred where parkinsonism is present); lorazepam 0.5 mg orally reserved for alcohol or benzodiazepine withdrawal.Doctor / Nurse
Deprescribe on the day: hold or reduce antihypertensives and diuretics in the hypotensive or dehydrated; NSAIDs in acute kidney injury, gastrointestinal bleeding or heart failure; metformin in acute kidney injury, sepsis or before contrast; sulfonylureas after any hypoglycaemia; anticholinergics, antihistamines, tricyclics and sedatives in delirium; and any drug started or changed in the preceding two weeks that could explain the presentation.Doctor
Postural hypotension — treat the cause and use the non-drug measures: elevate the head of the bed to 30 degrees, teach counter-manoeuvres (leg crossing and squeezing, buttock, thigh and calf clenching, standing slowly), give a 500 mL bolus of water drunk within 5 minutes which raises blood pressure for around 90 minutes, and consider abdominal binders (effective in about half of patients) and full-length grade 2 compression stockings (below-knee stockings are unhelpful); fludrocortisone and midodrine are the licensed drugs, both risking supine hypertension.Doctor / Nurse
Prevent the next fall and fracture: exercise incorporating lower-limb strength and balance training (multimodal group exercise and Tai Chi), colecalciferol 800 units (20 micrograms) daily with a total calcium intake of 1–1.5 g/day, home environment assessment, medication review, cataract surgery for the first cataract and cardiac pacing for carotid sinus hypersensitivity.
Where a child is involved: obtain a weight or use weight in kg equal to (age in years + 4) multiplied by 2 for children aged 1–10 years; treat hypoglycaemia (glucose below 3.0 mmol/L, or below 2.6 mmol/L in a neonate) with 10% dextrose 2 mL/kg intravenously, recheck at 10 minutes, then start a glucose-containing maintenance infusion; paracetamol is 15 mg/kg per dose 6-hourly to a maximum of 60 mg/kg in 24 hours.Doctor / Nurse
Structure the whole assessment as a Comprehensive Geriatric Assessment — disease severity and comorbidity, mental health and cognition, support networks and needs, and function and ability — treating problems in parallel as a problem list, not a single diagnosis.
Establish what the patient wants and document capacity for the specific decision — can they understand, retain and weigh the information and communicate a choice — and reassess after any clinical change such as a resolving delirium.
If the patient is not improving the diagnosis is probably wrong or incomplete: look for a second precipitant (retention, impaction, pain, untreated hypoxia), reconsider chronic subdural haematoma, stroke, non-convulsive status epilepticus and alcohol or benzodiazepine withdrawal, and review the drug chart again because last night's sedation may now be the problem.

Caution— what harms

Do not dipstick urine to explain confusion in an over-65: sensitivity is about 77% with urinary symptoms but falls to 44% as a screen in a confused patient without urinary symptoms, and Public Health England guidance (2018) advises against dipsticks in this population.
Do not treat bacteriuria without specific urinary tract symptoms: up to 50% of women in nursing homes have asymptomatic bacteriuria (6–16% in non-care-home women aged 65–90), a long-term catheter is almost always positive, and treating that "UTI" is how the pneumonia, the infarct, the bleed and the subdural get missed.
Absence of fever, tachycardia or pain does not exclude serious disease: the febrile response may be absent, the tachycardic response is limited by reduced maximum heart rate and beta-blockade, and neuropathy blunts visceral pain so that myocardial infarction may be painless and present as weakness and fatigue.
A "normal" creatinine may conceal significant renal impairment because low muscle mass produces less creatinine; a GFR of 50–60 mL/min — half the young adult value — may be regarded as normal over 80, and creatinine clearance must be calculated before prescribing anything renally excreted.Not available at your setup — Renal function (creatinine/urea).
Do not chase an oxygen saturation of 99%: 92–95% may be physiologically normal in an older patient, but equally do not be reassured by 93% in someone visibly working to achieve it.
A raised D-dimer in a patient who has fallen and bruised means nothing — bruising, infection and inflammation all raise it, and the test is most useful when normal.
Antipsychotics sedate delirium, they do not treat it: there is no evidence they treat delirium, no medication has consistently been shown to prevent it or improve length of stay or mortality, the drugs are themselves deliriogenic, and they carry a boxed warning in older patients with dementia with increased mortality compared with placebo.
Benzodiazepines are not first-line sedation because they worsen confusion — limit them to delirium caused by alcohol or benzodiazepine withdrawal, the other exceptions being Parkinson's disease and Lewy body dementia where antipsychotics are hazardous.
Escalating sedation is not a treatment for undiagnosed delirium, and in children haloperidol should not be used under 12 years without paediatric specialist agreement while promethazine is contraindicated below 2 years because of the risk of fatal respiratory depression.
Avoid NSAIDs in the frail older patient: they precipitate acute kidney injury, gastrointestinal haemorrhage, fluid retention and worsened heart failure, compounded by concurrent antiplatelet or anticoagulant therapy — use topical NSAIDs or lidocaine patches instead.
Do not accept "generalised atrophy and small-vessel change" as the diagnosis on a CT head — these are background findings of age; where a fall involved no head strike, no neurological signs and no anticoagulation, careful observation over 48–72 hours is a reasonable alternative to scanning.Not available at your setup — CT scan.
Anaemia is not a normal age-related change and always requires explanation — iron deficiency, chronic disease, B12 deficiency, myelodysplasia — while a high haemoglobin may simply reflect dehydration.
A fall from 2 metres or less is the commonest mechanism of major trauma in older people ("silver trauma"): a standing-height fall in an anticoagulated 85-year-old is a major trauma presentation, not a minor injury.
Ask about abuse and screen without the care-giver present: approximately 1 in 10 older people experience abuse each month, two-thirds of older people with dementia have been abused, fewer than 1 in 20 cases are reported, and misuse of medicine in either direction — excessive sedation and inadequate analgesia — is itself physical abuse.

Refer / escalate

Escalate or transfer urgently for new focal neurological signs, fluctuating conscious level, a scalp haematoma or head strike on an anticoagulant or antiplatelet (chronic subdural haematoma), a suspected hip or other fragility fracture, a long lie with rhabdomyolysis or hyperkalaemia, hypotension persisting despite 250–500 mL fluid boluses, delirium that does not settle despite treating the apparent precipitant, or unexplained bruising and injuries of different ages raising a safeguarding concern.

The card — assess, manage, caution

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