Level 1 of 6Core
Acute illness in the older patient
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- A change in function is an acute illness until proved otherwise: "off legs", "failure to cope", "acopia" and "social admission" are not diagnoses. Take a collateral history first — hours to days of change points to delirium and acute illness, months of gradual decline to dementia or chronic disease.
- The four observations that change management: capillary glucose below 4.0 mmol/L is hypoglycaemia (mimics stroke, delirium, coma — treat at once); a respiratory rate above 20 is an early reliable sign of serious illness; read the BP against the patient's own usual pressure — systolic 110 mmHg in someone who normally runs 170 mmHg is shock; and hypothermia, or a normal temperature in a patient who looks septic, because older people may not mount a fever.
- Screen for delirium with the 4AT: a score of ≥4 suggests possible delirium, 1–3 possible cognitive impairment, 0 makes delirium unlikely. Inattention is the defining feature — a forward digit span of four or fewer indicates an attentional deficit. Know the subtypes: hypoactive (quiet, sleepy, reduced intake) is commoner in frailty, easily missed and has the poorer prognosis; mixed is the commonest.
- Every faller needs a 12-lead ECG and a lying-and-standing BP: lie 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 (30 mmHg systolic in a hypertensive patient) is orthostatic hypotension. Over 30% of patients who genuinely lose consciousness are unaware it occurred; absent protective arm response with facial injury suggests syncope.
- Look for the long lie: a period on the floor implies rhabdomyolysis, hyperkalaemia, acute kidney injury, hypothermia, pressure injury and dehydration until excluded — send a creatine kinase. A fall from 2 metres or less is the commonest mechanism of major trauma in older people: a standing-height fall in an anticoagulated 85-year-old is a major trauma presentation.
- 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; and unexplained bruising or injuries of different ages — approximately 1 in 10 older people experience abuse each month, so screen without the care-giver present.
Manage now— 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 — a problem list, not a single diagnosis.
- Oxygen to a target 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: under-filling causes acute kidney injury and over-filling pulmonary oedema.Doctor / Nurse
- Treat glucose below 4.0 mmol/L at once, remembering hypoglycaemia from a sulfonylurea or long-acting insulin recurs for many hours. In a child (glucose below 3.0 mmol/L; below 2.6 mmol/L in a neonate): 10% dextrose 2 mL/kg IV, recheck at 10 minutes, then a glucose-containing maintenance infusion; weight (kg) = (age in years + 4) × 2 for ages 1–10.Doctor / Nurse
- Pain relief is part of the delirium treatment: paracetamol 1 g orally or IV 6-hourly (adult under 50 kg: 15 mg/kg per dose, maximum 60 mg/kg in 24 hours; child 15 mg/kg per dose 6-hourly, maximum 60 mg/kg/24 h). Avoid NSAIDs in the frail — use topical NSAIDs or lidocaine patches. Opioids at a reduced starting dose with an antiemetic and laxative prescribed together; a fascia iliaca block for hip fracture minimises opiate use.
- Non-pharmacological measures are first line for delirium: spectacles on, hearing aids in, dentures in; clock and calendar in view; consistent staff, gentle lighting, family presence; do not move the patient between beds. Neither endorse nor challenge delusions, avoid urinary catheters, remove unnecessary cannulae and restraints, and mobilise early.
- Sedate only when the patient is a danger to themselves or others, or severely distressed by psychotic symptoms, and conservative measures have failed: check the QT interval before an antipsychotic and use the lowest dose. Antipsychotics sedate delirium, they do not treat it, and carry a boxed warning in dementia; benzodiazepines worsen confusion — reserve lorazepam for alcohol or benzodiazepine withdrawal.Doctor / Nurse
- Deprescribe on the day: hold antihypertensives and diuretics in the hypotensive or dehydrated; NSAIDs in acute kidney injury, GI 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.
- Do not dipstick urine to explain confusion in an over-65, and do not treat bacteriuria without specific urinary symptoms: as a screen in a confused patient without urinary symptoms sensitivity falls to 44%, up to 50% of women in nursing homes have asymptomatic bacteriuria, and treating that "UTI" is how the pneumonia, the infarct, the bleed and the subdural get missed.
| Drug (older adult, delirium) | Starting dose | Note |
|---|---|---|
| Haloperidol | 0.5 mg PO/IM | Avoid in Parkinson's / Lewy body |
| Risperidone | 0.25 mg PO (0.25–2 mg) | Stroke risk with vascular factors |
| Olanzapine | 1.25 mg PO daily | Sedating |
| Quetiapine | 12.5–25 mg PO | Preferred with parkinsonism |
| Lorazepam | 0.5 mg PO | Alcohol/benzodiazepine withdrawal only |
Refer / escalate
Escalate urgently for new focal signs, fluctuating conscious level, a scalp haematoma or head strike on an anticoagulant or antiplatelet (chronic subdural haematoma), a suspected hip or fragility fracture, a long lie with rhabdomyolysis or hyperkalaemia, hypotension persisting despite 250–500 mL boluses, delirium not settling despite treating the apparent precipitant, or unexplained bruising and injuries of different ages raising a safeguarding concern.
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