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SECTION TWO
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Older people
87
Box 7.1
The introduction: observation as they enter; greeting
Cadence and interest
Position and comfort of patient
Vision, hearing, cognition
Environment
Autonomy and respect
Use of multiple sources of information
Interview versus interrogation
live independently and lowers their physiological
reserve. Frailty can be measured formally using a
variety of scales, which take into account day- today functioning, energy levels and need for support.
A clear correlation exists between increasing frailty
and increasing mortality, which makes it a more
useful indicator of prognosis than chronological age
alone.
History taking: points to note
History
Taking a good history is always essential, but it
requires particular sensitivity in older people. The
practical aspects of ensuring that patients have their
hearing aids and glasses and teeth in are essential to
optimizing the history- taking process. Sitting on the
same level as the patient will support a patient who
may also lip read. Some patients may need written
questions. Frailer patients may not tolerate lengthy
histories or being bombarded with questions and
they may tire easily.
Some patients may rely on a carer or family
member to support with communication but ensure
that everyone is involved in the conversation.
Ask the patient’s permission to clarify something
with a carer and by positioning yourself closer to
the patient physically so that they feel involved.
Some patients with cognitive problems may not
remember much about their medical history, but
they may still be able to tell you what matters
most to them, how they spend their day and who is
important to them.
It is useful to establish what the patient likes to
be called because this is often not what is written
on their record. Most of the communication skills
required to support history taking in older people are
transferable to ALL patients and will hone historytaking skills generally (Boxes 7.1 and 7.2)
Comprehensive geriatric assessment
This is an assessment tool used by the MDT to ensure
that all aspects of a person’s life have been assessed
and that management plans reflect the outcome of
this assessment and are patient focused. Geriatricians
work closely with all members of the MDT, which
Box 7.2
Can the patient see and hear you?
Is behaviour normal?
Is language normal?
Does the patient understand your role as a doctor?
Is the patient at ease, or in pain?
Is there evidence of support from family or friends?
Box 7.3
Physical and mental assessment key areas:
Sleep
Falls and mobility
Appetite and weight
Continence
Skin
Pain
Memory
Mood and energy levels
Medication
Vision, hearing and dentition
incorporates nurses, physiotherapists, occupational
therapists, pharmacists, speech and language therapists,
dieticians and social workers. The assessment may
take place over a number of ward rounds or days as it
involves collating a lot of information.
The comprehensive geriatric assessment (CGA)
tool is an evidenced- based and well- validated
intervention for older and frailer people. At its core
are five main areas of focus:
1. Physical health assessment.
2. Mental health assessment.
3. Functional assessment.
4. Social assessment.
5. Environmental assessment.
Each member of the team can contribute to any
of the key areas, but doctors and nurses generally
focus on the physical and mental health assessments.
Physiotherapists and occupational therapists will
assess the functional and environmental issues
and a social worker will be involved in the social
assessment. Combining information from the full
team ensures that appropriate medical and social
care can be implemented.
The physical and mental health assessment
will need to ensure that the key ‘geriatric giants’
(immobility and falls, pressure ulcers, cognitive
problems and incontinence) are assessed. Getting
into the habit of doing this at an early stage in your
career is essential to the future care of older and/or
more frail patients (Box 7.3).
Older patients should be examined in the same
way as younger patients, but there are some key
additional areas to focus on to ensure a robust
assessment has been completed and these are
highlighted in each section.
Observations during the introduction
Comprehensive geriatric assessment
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7
Older people
Comprehensive geriatric
assessment—physical health
Sleep
It is worth noting how well a patient feels he sleeps.
What time does he go to sleep and how long does
he sleep? Is his sleep interrupted or does he sleep
‘badly’? Does he have frequent nightmares or
terrors? Is his sleep disturbed by pain or needing to
go to the toilet?
Good sleep is increasingly recognized as an
important contributor to optimal physical and
mental wellbeing. Disturbances in sleep can have
an impact on concurrent medical issues, mood,
energy levels and even memory. The link between
poor sleep and poor cognition is gaining evidence,
but being sleep deprived will have an impact on
concentration and thinking in any person.
Nightmares and night terrors may be associated
with Parkinson’s disease and Lewy body dementia.
Overnight pain must be explored and addressed.
Frequent nocturia can be a sign of prostatism in men
or may represent bladder instability, overflow or
infection in either sex, all of which may be alleviated
by advice around drinking habits, further physical
assessment and medication, as needed. A person who
gets up at night may be at increased risk of falling, so
the assessment and management of simple issues like
pain and continence may reduce the risk of falls and
their associated complications.
Falls and bone health
Entire clinics are now devoted to assessing patients
who ‘fall’, such is the impact of this seemingly simple
event on morbidity and mortality. It is therefore
important to ask if a person has fallen in the last year
and how many times? Information about the pattern
of any previous falls can be helpful: frequency,
relationship to posture, activity or time of day, prewarning and residual symptoms following the fall,
and any avoiding steps taken by the patient should
be ascertained. The absence of any warning implies a
sudden event, usually neurological or cardiovascular
in nature.
Sinister symptoms associated with falling include
loss of consciousness (although, notoriously, this
is poorly reported), focal neurological deficit,
features of seizure, chest pain, palpitations or
other cardiorespiratory symptoms. The most useful
clinical investigation in ‘older fallers’ is to watch
them walking; however, they may also need medical
investigations to exclude cardiovascular problems
such as a 24- hour ECG tape or a tilt test and brain
imaging if a neurological cause is suspected.
It is also important to establish any previous
injuries from a fall, especially any broken bones. Any
patient who has had a previous fracture from a fall
will need an assessment of bone health, including an
assessment of vitamin D and calcium and potentially
bone mineral density analysis.
Falls prevention programmes constitute a key part
of local public health initiatives and entail education
around falls, trip hazards and exercise programmes.
Key areas of examination
A focus on the cardiovascular and neurological
systems and observation of the person walking are
both aspects of any falls assessment (Box 7.4).
Cardiovascular examination in older patients
does not differ from that in younger adults, but a
number of important factors need to be taken into
account. Brady- arrhythmias and tachy- arrhythmias
are common in sick, older patients and may lead to
cardiovascular collapse, despite similar heart rates
being well tolerated in the young. The increase in
heart rate in response to stress (e.g. exercise, illness
or pyrexia) is reduced in advanced old age, and
this may be exacerbated by medications such as β-
blockers and other anti- arrhythmics. Pauses in heart
rhythm caused by combinations of anti- arrythmic
drugs and underlying ischaemic changes may result
in sudden collapse and syncope.
A lying and standing (or sitting) blood pressure
is extremely useful but may not be obtainable in
the more disabled patient. Postural hypotension,
defined as a drop in systolic blood pressure of
more than 20 mmHg on standing, is a considerable
cause of morbidity in old age; often it is caused or
exacerbated by medications. The sitting or standing
blood pressure should be measured immediately
prior to and then 1, 3 and 5 minutes after changing
position. The guidelines for managing blood
pressure in older people now reflect the increased
morbidity associated with hypotension and postural
hypotension and a more relaxed approach to blood
pressure management might be the less risky option
in very frail or very elderly patients (a systolic blood
pressure of up to 160 might be more tolerable than
repeated falls or impacts on cerebral blood flow
resulting from significant postural hypotension).
Heart valves, especially the aortic valve, can
become less mobile, exacerbated by calcification.
Known as aortic sclerosis, this is characterized by a
non- radiating ejection systolic murmur, heard loudest
in the aortic area. Some patients may present with
aortic stenosis as a cause of their fall and this may be
amenable to surgical intervention, depending on their
overall general health. Degeneration and calcification
of the mitral valve can result in either apical ejection
murmurs or the more common pansystolic mitral
regurgitant murmur (see Chapter 13).
The formal assessment of the peripheral nervous
system by examining muscle bulk, tone, power,
sensation and tendon reflexes is something the
inexperienced clinician often finds difficult. In
older, disabled patients, about whom judgements
concerning normality and abnormality may be
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Box 7.4
Premonitory
The causes of falls in elderly people
Forerunner of acute, usually infectious, illness
Medication
Multiple drug therapy
Psychotropic drugs
L- dopa
Antihypertensives
Postural hypotension
Drugs
Alcohol
Cardiac disease
Autonomic failure/dysfunction
Neurological disease
Neurocardiogenic syncope
Multiple strokes
Transient ischaemic attack
Parkinson’s disease
Cerebellar disease
Epilepsy
Age- related loss of postural reflexes
Spastic paraparesis (usually owing to cervical
spondylosis)
Peripheral sensory or motor neuropathy
Situational and postprandial syncope
Cardiovascular disease
Carotid sinus syndrome
Brady- and tachyarrhythmia: second- degree and
complete heart block, sick sinus syndrome, atrial and
ventricular tachyarrhythmias
Structural abnormalities: valvular stenosis and
regurgitation, hypertrophic obstructive cardiomyopathy
Myocardial infarction and ischaemia
Musculoskeletal disease
General muscle weakness (e.g. owing to systemic
malignancy)
Muscular wasting caused by arthritis
Unstable knee joints
Myopathy (e.g. osteomalacia)
Miscellaneous
Drop attacks
Hypoglycaemia
Cervical spondylosis
Alcohol
Elder abuse (e.g. physical mistreatment)
Poor vision
Multisensory deprivation:
– deafness
– poor vision
– labyrinthine disorder
– peripheral neuropathy
more subjective, this can be especially difficult. As
with all clinical skills, such judgement is acquired
only with practice. As part of this assessment, it is
useful to ask the patient to hold his upper limbs fully
extended and supinated, at shoulder height, with his
eyes closed. Observe for pronator drift, which is a
sign of pyramidal weakness. The reflexes should be
examined in the normal manner. It is not uncommon
for the ankle jerks to be diminished or hard to elicit
in very old people but, as with all clinical signs, this
should be viewed in the context of other findings
and not in isolation.
It is essential to observe the walking or gait pattern
wherever possible in someone who has fallen over.
This may reveal subtle evidence of hemiparesis,
poor balance or the furniture- clutching gait of
the patient with long- standing mobility problems.
When observing the gait, always have someone walk
alongside the patient to offer a helping hand in case
he stumbles or falls. Occasionally patients claim
that they are capable of carrying out activities when
in reality they cannot. Always check the feet for
chiropody problems (e.g. onychogryphosis), which
cause a ‘painful’ or antalgic gait.
Further tests of balance are often carried out by
physiotherapists and, combined with the physical
examination, creates a picture as to the most likely
cause of the fall and stratifies the risk of a person
falling again. Balance tests such as the Tinetti test
(a person is assessed standing and sitting from a
chair and then walking a set distance whilst gait
is observed) and the ‘Timed Up And Go’ (TUAG
test—a person is asked to stand from a chair,
walk 3 metres and sit back down again) provide
objective evidence that can be used to create
a management plan for falls prevention. These
tests can be reassessed to show improvement and
progress. Strength and balance exercises are a key
intervention in any falls prevention programme and
there is good evidence to show that this intervention
has a positive impact.
Appetite and weight
Does the person enjoy his food? Does he eat a varied
diet? Is food provided by an outside agency and
delivered to the door (‘meals on wheels’) or made
by carers during the day? Has he lost weight?
Like sleep, food and nourishment form an essential
part of human survival. People who rely on food
being provided may not like what is served and
people with absent teeth or dentures may manage
only softer diets. Taste and smell may change as
we age and this may impact on how much food is
enjoyed. Loss of weight occurring in the presence
of good oral intake should prompt a thorough
investigation for an underlying cause, such as a
malignancy. Loss of weight may have an impact on
muscle bulk and therefore balance, which in turn
may increase the risk of fall. Low sun exposure from
being housebound may have an impact on vitamin D
levels and, combined with a diet low in calcium, this
also increases the risk of fall and fracture.
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Older people
Key areas for examination
The older patient should be weighed at every visit.
As in younger patients, nutritional assessment
includes estimation of the body mass index (BMI):
weight (kg)/height (m2). Because of osteoporotic
vertebral collapse and other age- related changes,
height may reduce in the old and so trends in weight
are a more useful benchmark. The ‘Malnutrition
Universal Screening Tool’ or ‘MUST’ is used to
screen for nutritional status in the acute care setting
and ensures that anyone who requires nutritional
support can be identified in a timely manner. It
incorporates BMI, disproportionate weight loss and
the presence of acute illness to establish a risk score,
which can then trigger further dietetic review.
Abdominal examination may be limited by
patients’ orthopnoea, kyphoscoliosis or other
disabilities. However, always try to perform an
appropriate assessment. If abdominal examination
is limited by such disabilities, the patient will also
find it difficult to lie supine for investigations,
such as computed tomography (CT) scanning or
colonoscopy.
Continence
Sensitive questioning of bowel and bladder habits
is an important skill to learn and may take some
practice. Ask whether the person has to go to the
toilet frequently during the day or night? Does he
ever have accidents and leak urine or does he wear
a pad to support this? Can he tell when he needs
to go to the toilet? Does he have to rush before
it comes out? Are his bowels regular? Is the stool
sometimes too hard to come out or like rabbit
pellets? Again, these build up a picture of whether
someone can control his bowel and bladder and
whether there may be potentially reversible
pathology.
Incontinence should not be regarded as a normal
part of ageing and is more specifically associated with
sphincteric damage, loss of neurological control mechanisms, especially in dementia or stroke, and with severe disability, chronic illness and frailty. Amongst the
institutionalized older population, as many as 50%
may suffer urinary and/or faecal incontinence.
When taking a history of urinary or faecal
incontinence, try to differentiate between loss of
ability to control voiding and failure to identify or
reach an acceptable place for elimination. Find out
how socially disabling the incontinence has become:
many patients become isolated or afraid to go out
because of the associated anxiety and potential
embarrassment.
Faecal incontinence is relatively rare in well, older
men but is principally associated with severe chronic
disability or cognitive impairment. In women, it is
relatively more frequent but still rare. It may result
from pelvic floor weakness. In both sexes, it may
occur with carcinoma of the rectum, diverticular
Box 7.5
Faecal incontinence (ball- valve effect, with spurious
Intestinal obstruction
Restlessness and agitation in the confused (but faecal
Retention of urine
Rectal bleeding
Bowel perforation (termed ‘stercoral perforation’, rare)
Box 7.6
Pelvic floor weakness
Sphincter defects from injury in childbirth
Pelvic floor neuropathy
Urinary tract infections
Bedridden state with immobility
Dementia and delirium
Neurological disease, e.g. stroke, myelopathy
Autonomic neuropathy
disease, laxative abuse and excess, faecal overloading
with impaction and neurogenic bowel. Constipation
severe enough to cause faecal impaction is not
uncommon and may have serious consequences
(Box 7.5). This is often iatrogenic caused by the use
of opiate analgesia, iron supplements or calcium
channel blockers; if of recent onset, it should be
investigated appropriately.
Faecal impaction may cause
diarrhoea)
impaction never causes confusion)
Common causes of urinary incontinence in the
older person
Key areas for examination
The indications for digital rectal examination are
the same as for younger patients, but this may not
be feasible or appropriate, particularly in the very
disabled or frail, older patient.
As part of the examination there should be an
assessment of the prostate gland, evaluation of the
pelvic floor muscles and culture of a mid- stream
specimen of urine. An incontinence chart kept for
a few days may suggest a recognizable pattern of
urinary and/or faecal incontinence. The specialist
help of a continence adviser is often useful. Causes of
urinary incontinence are shown in Box 7.6. It is rarely
useful to dip a urine sample to look for infection.
If a urinary infection is suspected from symptoms
and examination, then a culture should be taken and
antibiotics commenced as appropriate. Urine dips
should be reserved in the context of acute kidney
injury and to check for hematuria and proteinuria.
Older people frequently have ‘positive’ urine dips
with asymptomatic bacteria and are treated with
antibiotics erroneously.
Skin
Older skin is thinner, less elastic, bruises more easily
and takes longer to heal. As such, multiple attempts
Figure 7.1 Superficial pressure ulcers.
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at phlebotomy may cause considerable distress. Most
patients and families will tell you about any ‘sores’. It
is worth checking how frequently the nurses attend
to dress any skin lesions. Ask about painful sores,
which may keep a person awake all night. Ask him
if he thinks the sore has changed, become smelly or
started leaking?
Skin breakdown in the form of pressure ulcers
is a surrogate marker of inadequate support and
care because this reflects that a person is not being
provided with enough care to ensure clean, dry
and pressure- free skin. New pressure ulcers should
prompt safeguarding procedures to investigate how
better to support this person’s care.
About 80% of pressure ulcers are superficial (Fig.
7.1). They occur mainly in dehydrated, immobile
and incontinent patients exposed to sustained pressure. People with impaired sensation or with diabetes are especially vulnerable. Decubitus ulcers are
always potentially preventable but will occur in any
setting if skin care is disregarded. Any superficial ulcer will deepen if the pressure is not relieved. Deep
ulcers (Fig. 7.2) are formed when localized high
pressure applied to the skin cuts off a wedge- shaped
area of tissue, usually adjacent to a bony prominence.
Older people can frequently develop leg ulcers as
a result of poor venous return or poor arterial blood
supply (50% are owing to venous stasis (Fig. 7.3),
10% to arterial disease and 30% to 40% are of mixed
origin). Some of these can be very resistant to healing and this can then have an impact on mobility,
pain and sleep. Prolonged sitting in a chair with infrequent exercise can exacerbate skin breakdown,
which may have originally been caused by a relatively minor insult. Pressure bandaging can be used
to support venous return, but only in the presence of
an adequate arterial blood supply.
Good skin care depends on fastidious nursing
and close observation. Healthy skin requires
good nutrition, careful positioning, alertness to
potential pressure burdens as well as careful
SECTION TWO
Older people
Figure 7.2 Deep pressure ulcers.
Figure 7.3 Leg ulcers.
cleaning and drying routines. An alternatingpressure air mattress (APAM) in which horizontal
air cells (Fig. 7.4) inflate and deflate over a short
cycle, constantly supporting the patient, provides
periods of low pressure at all pressure sites, and
good protection.
Key areas for examination
A general assessment of a person’s skin can reveal
a host of clues to his general health. Wrinkles
are mainly owing to past exposure to ultraviolet
light and hence are not usually seen in covered
areas. The skin of the elderly bruises easily (senile
purpura); some people have skin like transparent
tissue paper, described as papyraceous, especially
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ABPI
Ankle systolic pressure
Brachial systolic pressure
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Older people
Figure 7.4 An alternating- pressure air mattress (APAM).
Pain
Concerns about pain may have been explored
within other topics. Older people may normalize
pain or regularly medicate it and therefore not
think it relevant. When asking about pain it is worth
checking when a person last felt ‘pain free’ and how
effective any painkillers are at reducing or clearing
pain completely. This might be an opportunity
to establish if he uses alcohol to medicate pain or
whether he uses other over-the-counter (OTC)
medications or topical agents.
Musculoskeletal pain is common amongst
older patients and may represent underlying
osteoarthritis or other inflammatory arthropathies. A
multidisciplinary approach to managing this type of
pain may allow for the use of non- pharmacological
agents, assessment of joint mobility and supportive
measures, such as exercises and orthotic appliances.
Many people have a complex relationship
with pain and trying to alleviate years of pain is a
significant challenge. The role of patient- driven goals
and wishes allows some focus on the management
plan, e.g. ‘I want to be able to sleep better’ or ‘I want
to be able to see my family for the day’.
Figure 7.5 Transparent ‘papyraceous’ skin. The surface has been
broken by trivial trauma.
on the backs of the hands and the forearms
(Fig. 7.5). The skin around the eyes may show
yellow plaques—Dubreuilh’s elastoma. Some
solar- induced changes to be aware of include
keratoacanthoma, basal cell carcinoma, squamous
cell carcinoma and malignant melanoma. The
most common skin lesion noted is the small red
Campbell de Morgan spot, a benign lesion seen
most often on the trunk and abdomen.
Examination should include sensory (neuropathic
ulcers) and vascular (ischaemia and varicose veins)
examinations of the lower limbs. Measure the ankle
and brachial blood pressures using a Doppler meter
and sphygmomanometer cuff, the Doppler meter
being used instead of a stethoscope at the feet. The
ankle–brachial pressure index (ABPI) is calculated
using the formula:
=
An ABPI of 1.0 is normal; an ABPI below 1.0 may
indicate arterial disease. An ABPI <0.8 indicates
a compromised distal circulation, and so pressure
bandaging for leg ulceration should be avoided.
Key areas for examination
An examination of the large joints, shoulders,
hips and knees to look for acute or chronic
changes is required to establish the cause of any
potential musculoskeletal pain. Older people
may present with acute pain on chronic changes
and acute inflammatory arthropathies, which
can have a significant impact on mobility and
functioning. Again the physiotherapists may be
able to support some of this examination and
suggest some non- pharmacological treatment for
it. Exercise, good positioning and use of ultrasound
can have a significant impact on the experience of
musculoskeletal pain and reduce tablet burden.
Dementia
Cognitive problems are not a part of normal ageing.
Our memory and our capacity for learning changes
over the years, but dementia is a pathological
process producing a clinical syndrome. In the UK
currently, one-third of all persons over 65 years of
age will die with a dementia diagnosis and 20% of
all over 80 years of age have dementia (meaning
80% do not).
People with dementia are disproportionately
represented in health care settings. At any one
time in the UK, 25% of all hospital beds nationally
are occupied by a person with dementia. Good
knowledge around the assessment and care of people
with dementia is essential if high-quality care is to be
provided to this group of patients.
Not all patients will remember or know that they
have dementia, but it is important to ask a person for
a view on their memory. They may understand that
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Older people
93
other people are bothered about their memory even
if they are not. It is important to establish the type
of dementia a person has. It would not be acceptable
to document a general ‘cancer’ diagnosis. The length
of history and any behavioural or psychological
symptoms, such as hallucinations, agitation and day/
night reversal, are important as they often incur a
significant burden on carers.
Delirium
The old terminology of ‘acute confusional state’ is
now obsolete and a focus on correct diagnosis and
treatment of patients presenting with cognitive
problems is essential.
Delirium is an acute neuropsychiatric disorder
occurring in response to a wide range of biological
and environmental insults. It is a lot more common
in people with dementia and is therefore often
overlooked or considered as part of the normal
progression of a dementia diagnosis. Delirium is
extremely common in older patients presenting
to hospitals acutely and is associated with a high
mortality rate.
Delirium causes an acute change in cognition
associated with clouding of consciousness and
changes in attention. A person may present as hyper-
alert and over attentive to surroundings or hypo-
alert and under attentive to surroundings. People
can often swing between the two states of arousal.
Patients with delirium can be difficult to care for on
an acute hospital ward and this can lead to negative
perceptions around caring for this group of patients.
However, delirium can be a deeply distressing
experience and all health care staff should be trained
to advocate and support this very vulnerable group
of patients.
Delirium is rarely caused by a single pathology
and half of all patients will have multiple triggers for
their delirium, which can occur more commonly in
the context of cognitive frailty (previous delirium,
known dementia, cerebrovascular pathology).
Triggers may be apparently minor, such as a
new environment, unfamiliar routines, sleep
deprivation, pain and constipation (Box 7.7). Good
delirium management relies on early recognition,
identifying those at most risk and addressing
potential causes in turn. Simple interventions,
such as ensuring good sleep hygiene and allowing
a familiar carer to stay in the hospital, can make
a big difference on the impact of delirium on a
person.
Mood/mental state
Some questions about mood are also important. Do
you feel down or sad about life? Do you have things
to look forward to in life? What does the future look
like? Do you ever get lonely at home?
Loneliness amongst older people is common
and associated with poorer outcomes across the
physical and mental health spectrum. Increasingly
Box 7.7
Changes in environment
Sleep deprivation
Pain
Constipation
Medication (new or stopped)
Infection
Ischaemia
Electrolyte abnormalities
Urethral catheter insertion
(50% have multiple causes; 20% no cause is found)
the pressure of jobs, childcare and housing means
that many older people no longer have the support
of their wider family members to keep them busy
and supported. Some older people view a trip to
the hospital or clinic as a social event and may be
reluctant to go home. Establishing this as a key
concern can trigger local befriending services and
social prescribing to increase contact with other
people and groups, which may in turn improve
mood and health generally.
Asking about a person’s perception of his energy
levels can provide some insight into his level of
frailty. Higher levels of frailty are associated with
low perceived energy levels and fatigue. People
may describe themselves as having no ‘get up and
go’ which may be physical (deconditioned weaker
muscles, after acute illness) or mental (low mood
and lack of motivation, cognitive problems). With
experience, these conversations can dovetail into
more detailed exploration of a patient’s expectations
and wishes around his health and an opportunity to
document this more formally as an advanced care
plan.
Causes of delirium
Key areas for examination
All older patients attending a hospital or acute
health care setting should have some form of
screen for memory problems and cognitive testing.
Nowadays the 4AT has largely superseded the use
of the abbreviated mental test score because it is
able to pick up both likely dementia and delirium.
The 4AT is a well-validated tool for initial cognitive
assessment that also tests for conscious level and
alertness and is a more robust test of attention (using
the months of the year backwards) (Table 7.2). It
can be performed by any health care staff and is
short enough to do during ward rounds.
If the initial screening indicates that longerterm cognitive problems may be present, then
more formal cognitive assessments should be
undertaken. This is rarely useful to do in an acute
hospital setting and may be done better in a
follow- up clinic.
The ‘clock test’ can be used as an indicator
of underlying cognitive problem in the ward
environment. A single fault in this test alone is
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Older people
Table 7.2 The ‘Four As’ Test (4AT) for delirium and cognitive
impairment. AMT4, Abbreviated Mental Test with
four questions
[1] Alertness
This includes patients who may be markedly drowsy (e.g.
difficult to rouse and/or obviously sleepy during assessment)
or agitated/hyperactive. Observe the patient. If asleep,
attempt to wake with speech or gentle touch on shoulder.
Ask the patient to state his name and address to assist
rating.
Normal (fully alert, but not agitated, throughout
testing)
Mild sleepiness for <10 seconds after waking,
then normal
Clearly abnormal 4
0
0
[2] AMT4
Age, date of birth, place (name of the hospital or building),
current year.
No mistakes 0
1 mistake 1
2 or more mistakes/untestable 2
[3] Attention
Ask the patient: ‘Please tell me the months of the year in
backwards order, starting at December’. To assist initial
understanding one prompt of ‘what is the month before
December?’ is permitted.
Achieves 7 months or more correctly 0
Starts but scores <7 months/refuses to start 1
Untestable (cannot start because unwell, drowsy,
inattentive)
2
[4] Acute change or fluctuating course
Evidence of significant change or fluctuation in: alertness,
cognition, other mental function (e.g. paranoia, hallucinations)
arising over the last 2 weeks and still evident in last 24 hrs.
No 0
Yes 4
4AT score
Source: www.the4AT.com © MacLullich A, Ryan T, Cash H.
associated with an increase in mortality at 1 year.
The patient is presented with a drawn circle, about
10–15 cm in diameter, and asked to fill in the
numbers of a clock face (Fig. 7.6). Abnormalities
may be caused by visual impairment, agnosia
(owing to right parietal lobe lesions) or cognitive
impairment. This test is easily reproducible and less
influenced by cultural and language problems than
the abbreviated mental test score (AMTS) or minimental test examination (MMSE). There are many
more comprehensive tests of cognition, all of which
can be equally useful, provided they cover the key
areas of cognitive function, short- term memory, longterm memory, attention, language, higher executive
function and orientation. It is useful to practise with
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1
2
3
4
5
6
7
8
Figure 7.6 Clock- face drawing.
some of these tests because they can initially appear
long and cumbersome, but with time will become
easier to perform.
One of the key issues that people with dementia
and delirium have problems with is communication.
Communication is a two- way process that involves
understanding and comprehension as well as the
production of appropriate speech. Difficulties with
either or both of these processes can mean that a
person may not be able to make his needs heard
or met which, in turn, can lead to considerable
frustration. Communication problems can be
considered in terms of:
disorders of language (dysphasia)
disorders of articulation (dyspraxia, dysarthria)
disorders of voice (dysphonia) or of fluency
(dysfluency)
Dysphasia, that is difficulty in encoding and
decoding language, is usually associated with a left
hemisphere lesion (see Chapter 16). Dyspraxia
is difficulty initiating and carrying out voluntary
movements, for example of the tongue, and hence
can affect speech. Dysarthria has many causes,
including local factors in the mouth and dentition,
stroke, Parkinson’s disease and other neurological
disorders. Dysphonia, an abnormality of the quality
of the voice (e.g. hoarseness), can be owing to anxiety,
vocal abuse, local disease of the larynx and pharynx
or hypothyroidism. It is common after throat surgery
and intubation. Dysfluency (stammer) is found in
people of all ages.
Careful assessment of language and cognition
should provide some pointers as to cause. Ensuring
that all staff are able to identify and optimize
communication with this person is everyone’s duty
and this can be supported with input from the speech
and language therapists and specialist dementia and
delirium nurses.
Medication
The number of comorbid conditions that many
older people now accumulate over a lifetime means
that the old saying ‘a pill for every ill’ now incurs
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Box 7.8
Current medications
Previous hospital and family doctor medications
Treatment from ‘alternative’ practitioners
Self- medication
Past bad experiences with medicines
Other non- drug treatments
Medicines kept in the home
Compliance and help: dosette box; nurses; carers
a considerable tablet burden. Asking people about
their medicines may reveal those that they place
faith in and those that they may admit to skipping on
occasion. It is worth checking what medication has
been started recently and what medication they have
been unable to tolerate (this may differ from a true
allergy to the drug). Some medications are started to
alleviate the side effects of other drugs (anti- platelet
agents and gastric protection, for example) and it is
important to establish the use of OTC medication
and topical agents, such as transdermal non- steroidal
analgesia as there will still be some central absorption
of these drugs (Box 7.8).
‘Polypharmacy’ is the term used to describe the
use of multiple medications in one person. It is
associated with an increase in falls risk as well as
other impacts on appetite, sleep and functioning. The
antidote to this is ‘rationalizing medication’, a key
process during CGA. Rationalizing is not simply the
removal of drugs but rather a careful assessment of
each drug’s impact, risks and benefits ensuring that
older people are on the most effective combination
of drugs conducive to a good quality of life.
Areas to cover in a treatment history
Box 7.9
Acute
Retinal detachment
Vascular (central retinal artery/vein thrombosis)
Angle- closure glaucoma
Chronic
Cataract
Macular degeneration
Open- angle glaucoma
Diabetic retinopathy
aid batteries last less than a week so will have run
out by the end of the average hospital stay. Many
people do not like wearing their hearing aids because
of discomfort and feedback and the use of ‘hearing
loops’ or headsets may be more acceptable.
Few elderly people have their original dentition
and many rely on the use of ‘false plates’. These
require considerable care to ensure they are clean
and infection free. Any weight loss may render plates
loose, which can cause pain and ulceration within
the mouth. All of these issues may affect the types of
food a person enjoys and sometimes the inventive use
of blended and fortified foods is required to ensure
that all nutritional components are included in a
person’s diet. A dietician can support this process.
Glasses, false teeth and hearing aids are easily
lost in the hustle and bustle of busy hospitals.
These seemingly minor irritants can have disastrous
consequences for the patient who may now not be
able to see his meals, hear staff asking him questions
or chew the food provided.
Common causes of acute and chronic loss of vision
Key areas for examination
Some drug side effects will become apparent during
general examination, e.g. thin, papery, easily bruised
skin of long- term steroid use or gynaecomastia seen
in men taking spironolactone. A close inspection of
tablet boxes, the date of issue and a pill count will
also provide an insight into concordance. The same
can be done for medication aids in which daily doses
of tablets are provided in pre- filled, weekly packs
(dosette boxes).
Vision, hearing and teeth
Changes in vision are inevitable with advancing
age and most people will become long- sighted
from middle age onwards as the muscles of the
eye and lens shape change. Cataracts are also seen
in all ageing lenses to a greater or lesser extent and
can have an impact on the quality of vision. These
changes will occur earlier in patients with diabetes.
Not being able to see to read or distinguish faces can
be a lonely place.
Hearing loss of higher frequencies is almost
inevitable owing to presbycusis, an age- related
degeneration of the cochlear hair cells. Hearing
Key areas for examination
Check what type of glasses a person is wearing, their
condition and when he wears them. Visual acuity
should be assessed and any loss of vision noted,
together with the history of development of the
visual disorder. Acute and chronic causes of loss of
vision should be considered during the examination
(Box 7.9).
Age- related loss of periorbital fat may give the
eyes a sunken appearance; this may be severe enough
to cause drooping of the upper lid (ptosis) and
redundant skin at the lateral borders. The loss of fat
can also cause the lower eyelid to curl in (entropion)
and irritate the cornea, causing redness and watering
(epiphora) or to fall outwards slightly (ectropion). A
whitish rim around the iris (arcus senilis) is a zone of
lipid deposition around the periphery of the cornea.
The visual fields should always be assessed. It
is common to see irregular, asymmetrical pupils
owing to previous iridotomy. Pupillary responses
are normal in the well, older patient, but stroke and
medication may cause abnormal size and responses.
Abnormalities, such as Horner’s syndrome, and
palsies of the third, fourth and sixth cranial nerves
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Older people
are relatively common in the elderly, related to
stroke and neoplastic disease. Funduscopy should be
attempted wherever necessary but may be difficult
in the presence of cataracts.
Look in the ears for wax or evidence of infection
(an easily missed source) and ensure hearing aids are
clean and not blocked and have fresh batteries.
Look in the mouth for moisture and the
condition of the tongue. There are classic signs seen
in tongues, such as the beefy red tongue of vitamin
B12 deficiency or the white plaques of candidiasis
infection, but the tongue may also be coated and
dry. Check dentition and note the state of dentures.
A dry, coated tongue is not conducive to the
enjoyment of food and simple measures such as
cleaning the tongue, mouth and dentures can lead
to improved oral intake.
Social history
Although the multidisciplinary team will build a
detailed picture of ‘normal life’ for the person being
assessed, it is important that a social history is taken
to support this.
Ask what type of housing a person lives in and
whether he owns it. Who else is in the property?
Does he ever leave the house and when? Does he
have to navigate stairs? Does he have a downstairs
toilet? Getting up and down stairs can be a precarious
exercise for someone who is frail and lacking in
muscle strength.
Activities of daily living can be subdivided into
personal (washing, grooming, toileting, dressing,
feeding and continence) and domestic (shopping,
cooking, laundry, housework). Many people will still
participate in ‘extended’ activities, such as using a
mobile phone, getting on public transport, managing
finances, etc. This can be formally recorded using
The Barthel index (Table 7.3).
Support networks may be formal, provided
through social care, or paid for privately; or informal,
through family, friends and neighbours. When
someone depends on the arrival of another person to
get washed and dressed or to be provided with a drink
and meal it is easy to understand how precarious
this arrangement might be and how vulnerable this
person is to even a minor change in the timetable (a
late carer, a forgotten drink or insufficient time to
provide the full meal). Some hospital admissions are
described as purely ‘social,’ but it is always important
to find out what has broken down in the support
to cause admission. It might be that a change in
someone’s underlying health condition means that a
fragile arrangement is no longer sufficient.
Review of systems
The use of the comprehensive geriatric assessment
means that there is usually little left to be explored
on review of systems. The only notable omission
Table 7.3 The Barthel ADL Index (total score 20)
Item Categories
Bowels 0 = incontinent (or needs to be given an
enema)
1 = occasional accident (once per week)
2 = continent
Bladder 0 = incontinent/catheterized, unable to
manage
1 = occasional accident (max once every 24 hr)
2 = continent (for over 7 days)
Grooming 0 = needs help with personal care
1 = independent face/hair/teeth/shaving
(implements provided)
Toilet use 0 = dependent
1 = needs some help but can do something
alone
2 = independent (on and off, dressing, wiping)
Feeding 0 = unable
1 = needs help cutting, spreading butter, etc.
2 = independent (food provided in reach)
Transfer 0 = unable—no sitting balance
1 = major help (one or two people, physical),
can sit
2 = minor help (verbal or physical)
3 = independent
Mobility 0 = immobile
1 = wheelchair independent (includes corners)
2 = walks with help of one (verbal/physical)
3 = independent (may use any aid, e.g. stick)
Dressing 0 = dependent
1 = needs help, does about half unaided
2 = independent, includes buttons, zips, shoes
Stairs 0 = unable
1 = needs help (verbal, physical), carrying aid
2 = independent
Bathing 0 = dependent
1 = independent (may use shower)
The Barthel Index should be used as a record of what a patient does, not as a
record of what he was able to do previously. The main aim is to establish the
degree of independence from any help, physical or verbal, however minor and for
whatever reason. The need for supervision means the patient is not independent.
Performance over the preceding 24– 48 hours is important, but longer periods are
relevant. A patient’s performance should be established using the best available
evidence. Ask the patient or carer, but also observe what the patient can do.
Direct testing is not needed. Unconscious patients score 0 throughout. Middle
categories imply that the patient supplies over 50% effort. Use of aids to be
independent is allowed.
may be questions around respiratory symptoms. This
might also be the opportunity to ask about what
bothers a person most and what he expects or hopes
to happen. Given that older people frequently have
many pathologies, it is useful to establish what their
priority is. What input would he most value? It may
not necessarily align with that of their health care
practitioners and finding this out can lead to more
satisfying patient interactions.
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