Geriatrics for Juniors 2017

A group of seven of us from the Leicestershire team went to this conference yesterday. It was really well organised and there were some very informative talks. The full programme can be viewed here. There is also lots of good feedback and views on the event on Twitter using the hashtag #G4J17.

Some personal learning points that I took away are:

Delirium

  • 48 hours of delirium increases mortality by 11%
  • Delirium may not be preventable, but there are modifiable risk factors, including constipation.
  • The 4AT tool is really easy and quick to use to identify delirium.
  • Patients will not always tell you about hallucinations they have been having. So as not to miss delirium, patients should be screened for hallucinations – normalise them.
  • When explaining delirium to relatives, it can be useful to use the term “turbulance” to explain the fluctuating state.
  • The RCN is running a delirium champions programme.

The Ageing patient and ITU

As we don’t send patients directly to ITU from our community hospital wards, I thought that this talk may have been of limited interest to me. It didn’t take long for me to realise, however, that a lot of the points that were being made could be applied to the situation where we are considering escalating a patient’s care from community hospital to an acute environment. The main tips I acquired are:

  1. Start by assuming that the patient is for escalation.
  2. Think about what escalation can offer the patient compared with what can done for them in the current setting.
  3. Understand how ageing has affected the individual patient.
  4. Identify what the patient would want. Explore their pre-morbid state and what their thoughts have been in the past.
  5. Remember that escalation has possible side effects, including death!

Geriatrics in the ED.

Tips:

  • Communicating with patients that have hearing impairment: put your stethoscope in their ears and talk into it!
  • Try to avoid cognitive bias – I need to do some reading about this.
  • It is OK not to know something, for example, a diagnosis, always present your findings.
  • Time is a useful diagnostic tool.

Parkinson’s disease

  • Triad of motor symptoms:
    • Bradykinesia – can tested for by looking at rapid alternating movements.
    • Cogwheel rigidity – this is often better tested by getting the patient to perform a distracting movement with the other arm.
    • Tremor – Resting, pill rolling, unilateral.
  • Other symptoms include:
    • Loss of sense of smell.
    • Constipation.
    • Sleep disturbance – often involves shouting out or violent movements. Ask the bed partner.
  • If you suspect a diagnosis of Parkinson’s and a patient is fit to be discharged home, then let them go home and arrange follow-up in PD clinic.
  • Rotigotine is a dopamine agonist and can cause delirium.
  • When making changes to PD medication, review the patient daily and get them reviewed by the Parkinson’s team.
  • The safest antiemetics for use with patients with Parkinson’s are ondansetron and domperidone.

Dementia

  • About 20% of patients who have ischaemic stroke will develop vascular demetia within 6 months following the event.
  • Dementia with Lewy bodies often causes hallucinations.
  • Rule out metabolic causes for confusion with blood tests including thyroid function and vitamin B12.
  • Medication review is important – reduce the anticholinergic burden.

Falls

  • About 30% of people aged over 65 will fall within a year.
  • About 70% of falls have multifactorial causes.
  • Medication review is important:
    • Antianginals may cause hypotension and may not be required if the patient is less active than previously.
    • Review sleeping tablets – the risks of these often outweigh the benefits.
  • Be proactive in assessing falls risks – these may be present in patients who have not presented with a fall.
  • It is OK to reduce or stop medication.

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