Chapter 8: The elderly patient

The ageing (over 65 years) are the fastest growing section of the Australian population. The number of ‘old-old’ (over 85 years) is increasing at an even faster rate.¹ Life expectancy has risen to 84.4 years for women and 80.3 for men.²

The over-65s in 2014 made up 15% of the Australian population. It is expected that this group will make up at least 20% of the population in 2031. A similar trend is expected in the US with 18% in 2040.²

The over-65s use twice the number of health services per head of population. They account for 25% of all hospital costs and 75% of all nursing home costs. They represent 29.6% of all general practice consultations.³ Many are affected by multisystem disease. All are affected to a greater or lesser extent by the normal physiological changes of organ ageing.

Ageing is characterised by the following:¹

• decrease in metabolic mass

• reduction in the functional capacity of organs

• reduced capacity to adapt to stress

• increased vulnerability to disease

• increased probability of death

Age-associated deterioration occurs with hearing, vision, glucose tolerance, systolic blood pressure, kidney function, pulmonary function, immune function, bone density, cognitive function, mastication and bladder function.

One of the main contributing factors is the problem of disuse. Encourage exercise, especially walking and water aerobics.

Degenerative cardiovascular disease emerges with ageing according to the following approximate guidelines:

Deterioration in health and the ‘masquerades’

Unexpected illness, including mental confusion (one of the major hallmarks of disease in the elderly), can be caused commonly by any of the so-called masquerades outlined in CHAPTER 17:

• depression

• drugs, including alcohol, anticholinergics

• diabetes mellitus

• anaemia

• thyroid disease

• urinary tract infection

• neurological dilemmas

  • – Parkinson disease

  • – cerebrovascular accident

• infections (e.g. bronchopneumonia)

• neoplasia

• giant cell arteritis/polymyalgia rheumatica

Common significant management disorders encountered in the elderly include:

• hypertension

• ischaemic heart disease and heart failure

• depression

• diabetes (type 2)

• dementia

• social and physical isolation

• osteoarthritis

• disorders of the prostate

• urinary incontinence

• locomotive (lower limb) disorders

  • – neurological

  • – peripheral neuropathy

  • – ataxia

  • – claudication due to vascular insufficiency

  • – other peripheral vascular disease

  • – claudication due to spinal canal stenosis

  • – sciatica/nerve root paresis

  • – osteoarthritis: hips, knees, feet

  • – foot disorders (e.g. ingrown toenails)

  • – leg ulceration

  • – sarcopenia (loss of muscle mass)

Important problems affecting the elderly are presented in FIGURE 8.2.

The ‘classic’ triad⁴

Be mindful of the classic triad:

This can represent non-specific signs of acute illness, particularly infection. Aggressive antibiotic treatment is worth considering while awaiting the results of culture or clinical developments.

A clinically significant feature in some elderly patients is the raising of the pain threshold and changes in homeostatic mechanisms, such as temperature control. Consequently, these patients may have an abnormal response to diseases such as appendicitis, pyelonephritis, internal abscess, pneumonia and septicaemia. There may be no complaints of pain and no significant fever but simply general malaise and abnormal behaviour, such as delirium, agitation and restlessness.

The elderly patient especially requires considerable support, understanding, caring and attention from a GP who can instil confidence and security in a patient who is likely to be lonely, insecure and fragile. This means taking time, showing a genuine interest and a modicum of humour, and always leaving detailed instructions.

One of the best ways to generate a good relationship is through home visits. The value of home visits can be considered under the precepts of the Royal Australian College of General Practitioners.⁵

1. Assessment, both initial and continuing: ‘You don’t know your patient until you’ve visited their home’.

2. Continuing care:

   • security to the patient

   • support for ‘caring’ family

   • effective monitoring/intervention role

   • effective liaison with patient/family

   • checking medication

Home visits can be considered in three categories:

1. an ‘unexpected’ visit (especially to a new patient)

2. a patient-initiated but routine request for a ‘check-up and tablets’

3. the regular call—usually 2 to 4 weeks

These home visits are a ‘security gesture’ to the patient—evidence that they are supported in their desire to remain independent for as long as possible in their own home (FIG. 8.1). They strengthen the patient–doctor relationship as a position of trust, which is of special importance to frail, elderly people feeling increasingly insecure and threatened.

If the patient is being supported by a spouse or relative, the doctor can provide continuous reassurance and support to all concerned as well as their continual assessment, both physical and mental. Finally, the home visit may become part of the terminal care of a dying patient, something that is very important to the elderly patient. Home visits can enhance the quality of life, both physical and mental, of an ageing person.

Forbes points out that at least one in three elderly people feel lonely.⁶ It is more likely to affect the ‘old-old’, widows and widowers, and those affected by disability. They may tend to stay indoors, troubled by depression, agoraphobia, social phobia, sensory impairment or incontinence of urine or faeces.

Possible signs of loneliness include:

• verbal outpouring

• drab clothing

• dependence on television

• body language with a ‘defeated’ demeanour

• prolongation of visit including holding on to one’s hand

Ellard⁷ has written a most interesting paper, based on a compendium of complaints by the elderly about their doctors, on behaviour that upsets the elderly:

• having a consulting room with slippery steps, poor lighting and inadequate handrails

• keeping them waiting

• having low soft chairs in the waiting room and surgery

• being overfamiliar, with addresses such as ‘Pop’ or first names for elderly females

• shouting at them on the assumption that they are deaf

• appearing rushed and keen to get the consultation over quickly

• forgetting their psychosocial problems and concentrating only on their physical problems (i.e. not treating the whole person)

• forgetting that they have several things wrong with them and using a different priority list from theirs

• failing to ask patients to give their understanding of what is wrong

• omitting to give printed patient education hand-outs about their problems and medications

• omitting to explain how the medication will work

• treating them as though they would have little comprehension of their health and treatment

• failing to respect their privacy, such as not knocking before entering the examination room

• failing to provide appropriate advice on various social services such as meals on wheels and other support groups

• failing to re-evaluate carefully their health and medication

• failing to take steps to reverse any deterioration in their health, including reluctance to refer

The initial consultation should include a thorough clinical examination on the traditional lines of history, physical examination and selective laboratory investigation. At regular intervals during continuing care this careful assessment may need to be repeated.

History

The medical history may be difficult to obtain and the help of a family member is recommended. The use of questionnaires, which can be completed at leisure at home with the help of family members, is most helpful as complementary to the medical interview.

Important specific areas to focus on are:

• previous medical history and hospitalisation

• immunisation status

• medications, prescription and OTC drugs

• alcohol intake, smoking

• problem list of complaints

• dependence on others

• members of household

• household problems

• comforts: heating, cooling, bedding, etc.

• ambulation/mobility/use of frame or stick

• meals: diet

• hygiene: bathing

• toileting: continence

• teeth: condition, ?dentures

• vision

• hearing (always ask about this)

• systems review, especially:

  • – genitourinary function

  • – gastrointestinal

  • – cardiorespiratory

• locomotion, including feet

• nervous system, ?falls, giddiness, loss of balance, faints

• emotional and mental health

• evidence of depression

• history of bereavement

• history of abuse by carers, family members

• financial/insurance status

A thorough family history and psychosocial history is of prime importance. At all times concentrate on a general assessment of the patients’ ability to communicate by evaluating mental status, comprehension, hearing, vision, mood and speech.

Physical examination

The routine for the physical examination is similar to that of the younger adult but certain areas require more attention. The elderly patient expects to be examined adequately (especially having blood pressure measured) but requires appropriate dignity. It is recommended that the practice nurse supervises dressing and undressing and prepares the patient for examination.

Practice nurse

• Prepares for examination

• Helps with questionnaire

• Records weight and height

• Takes temperature, pulse and respiration

• Checks audiometry (if hearing problem)

• Checks ocular tension (if appropriate)

• Prepares cervical smear tray for female patient (if relevant)

Doctor

The following areas should be examined:

• general appearance, including skin, hair and face (evaluate nutritional status)

• mental state examination (see FIG. 8.3)

• eyes: visual acuity

• ears: simple hearing test; auroscopic examination

• oral cavity, including teeth and gums

• neck especially thyroid

• lungs: consider peak flow meter

• pulse and blood pressure (repeat)

• heart; breasts

• abdomen; hernial orifices

• spine

• lower limbs: joints; circulation; feet including nails

• gait

• men: rectal examination; scrotum and testes

• women: cervical smear if appropriate

‘Rules of 7’ for assessment of the non-coping elderly patient

If your elderly patient presents with non-specific symptoms, unexpected deterioration in health and/or an inability to cope with the activities of daily living, consider the checklist precented in TABLE 8.1 in your assessment. Apart from confusion, other non-specific symptoms include drowsiness, poor concentration, apathy, fatigue/weakness/tiredness/lethargy, anorexia, nausea, weight loss, dyspnoea, immobility, ‘stuck in bed or chair’, stumbles or falls. It is also important to consider infections including pneumonia and the masquerades (see CHAPTER 17). Dementia symptoms should be investigated as soon as possible.

The mini-mental state examination

Evidence of memory difficulty remains the best single indicator of dementia and should always be evaluated by formal memory testing. However, memory problems may be due to factors other than dementia, and demonstrating failure in other areas of cognitive functioning (language, spatial ability, reasoning) is necessary to confirm the diagnosis of dementia.⁸ A number of screening tests are available but the mini-mental state examination (MMSE), particularly the Folstein MMSE depicted in FIGURE 8.3, is commonly used and is the recommended test to use.

Another, somewhat simpler test is the ‘Quick 10-step cognitive impairment test’ (see TABLE 8.2).^9,10

The clock-face drawing test

This relatively simple test provides a ready qualitative screening test to differentiate normal elderly from patients with cognitive impairment, particularly dementia.¹¹

Method

• Give the patient a blank, A4-sized piece of paper.

• Ask the patient to draw the face of a round clock and put the numbers in their correct positions on the face of the clock to represent the hours (see FIG. 8.4).

• Ask the patient to draw in the hands of the clock, indicating 10 minutes after 11 (or some other suitable time) (see FIG. 8.4).

• Repeat the instructions if the patient does not understand them.

Scoring system

• A closed circle is drawn—3 points

• Numbers are in the correct position—2 points

• All correct numbers are included—2 points

• Clock hands are placed in the correct position—2 points

The maximum score is 9. A low score indicates the need for further evaluation and does not establish the criteria for dementia, being a pointer only.

Laboratory investigations

The laboratory tests should be selected according to the evaluation of the patient and to costs versus potential benefits.

Recommended investigations for suspected dementia include:^8,12

• kidney function

• hepatic function

• thyroid function

• full blood screen

• blood glucose

• serum electrolytes (especially if on diuretics)

• serum calcium and phosphate

• urinalysis

• serum vitamin B12 and folate

• serum vitamin D

• syphilis serology (consider HIV)

• chest X-ray

• neuroimaging: computed tomography (CT), especially non-contrast CT, or magnetic resonance imaging (MRI) (preferably)

• positron emission tomography (PET) scan or single photo emission computed tomography (SPECT) scan—for further information

As GPs, we are often called to assess abnormal behaviour in the elderly patient, with the question being asked, ‘Is it dementia?’ or ‘Is it Alzheimer’s, doctor?’.

There are many other causes of behavioural changes in people over the age of 65 years and dementia must be regarded as a diagnosis of exclusion. The clinical presentation of some of these conditions can be virtually identical to early dementia.

The clinical features of early dementia include:

• poor recent memory

• impaired acquisition of new information

• mild anomia (cannot remember names)

• personality change (e.g. withdrawn, irritable)

• minimal visuospatial impairment (e.g. tripping easily)

• inability to perform sequential tasks

The differential diagnosis for behavioural changes apart from dementia include several other common and important problems (which must be excluded) and can be considered under a mnemonic for dementia (see TABLE 8.3).¹²

All these conditions should be considered with the onset of deterioration in health of the elderly person. Even apparently minor problems—such as the onset of deafness (e.g. wax in ears), visual deterioration (e.g. cataracts), diuretic therapy, poor mastication and diet, urinary tract intercurrent infection, boredom and anxiety—can precipitate abnormal behaviour.

It is important to keep in mind the possibility of abuse of the elderly, especially where there is a family history of abuse of members. The issue is as important as child and spouse abuse. Over one million elderly people are estimated to be the victims of physical or psychological abuse each year in the US.⁴ We should keep in mind the occasional possibility of Munchausen syndrome by proxy. General practitioners should be alert to signs and symptoms of abuse and consider referral to an Aged Care Assessment/Service worker, e.g. ACAT team, Guardianship Tribunal or other responsible person or service. Ensure patient confidentiality and take care signing or witnessing forms for family members. Mandatory reporting law may vary from state to state.

The main differential diagnosis of dementia is depression, especially major depression, which is termed pseudodementia. The mode of onset is one way in which it may be possible to distinguish between depression and dementia. Dementia has a slow and surreptitious onset that is not clear-cut, while depression has a more definable and clear-cut onset that may be precipitated by a specific incident. Patients often have a past history of depression. Those with dementia have no insight; those with depression have insight, readily give up tasks, complain bitterly and become distressed by their inability to perform normal enjoyable tasks. It is vital to determine the cause of dementia.

In response to cognitive testing, the typical response of the depressed patient is ‘don’t know’, while making an attempt with a near-miss typifies the patient with dementia (see TABLE 8.4).

It is vital to detect depression in the elderly as they are prone to suicide: ‘Nothing to look back on with pride and nothing to look forward to.’ The middle-aged and elderly may not complain of depression, which can be masked. They may present with somatic symptoms or delusions.

Note that depression occurs commonly in people with dementia, especially in the early stages.

Dementia (chronic organic brain syndrome)¹³

The incidence of dementia increases with age, affecting about 1 person in 10 over 65 years and 1 in 5 over 80 years. It doubles every 5 years from age 65 and is uncommon under 60 years. The important causes of dementia are:

• degenerative cerebral diseases, including

  • – Alzheimer disease (about 60%)

  • – dementia of frontotemporal type (up to 10%)

  • – dementia with Lewy bodies (up to 10%)

• vascular (15%)

• alcohol excess (5%)

• Parkinson disease-associated dementia

Note: Mixed dementia should be considered.

Other causes of dementia:

• AIDS dementia

• corticobasal degeneration

• cerebral tumours

• Creutzfeldt–Jakob disease

• Pick disease

• neurosyphilis

• amyloidosis

• normal pressure hydrocephalus

In Alzheimer disease, there is insidious onset with initial forgetfulness progressing to severe memory loss (see FIG. 8.5). In frontal dementias the earliest manifestations are personality change and alteration of behaviour, including social dysfunction. Dementia with Lewy bodies is characterised by any two of visual hallucinations, spontaneous motor Parkinsonism and fluctuations in the mental state. Vascular dementia usually starts suddenly and is accompanied by focal neurological signs with evidence of cerebrovascular disease.

The characteristic feature of dementia is impairment of memory. Abstract thinking, judgment, verbal fluency and the ability to perform complex tasks also become impaired. Personality may change, impulse control may be lost and personal care deteriorate.

Risk factors for dementia include:

• family history

• increasing age

• late-onset depression

• hypothyroidism

• Down syndrome

• history of head injury

• HIV/AIDS

• generalised atherosclerosis

• Parkinson disease

• Aboriginal and Torres Strait Islander people

Differential diagnosis of dementia includes:

• normal cognitive impairment of ageing

• delirium

• major depression

• acquired brain injury

• drug abuse

• amnestic disorder

• various medical conditions (e.g. anaemia, thyroid/endocrine disorders)

The DSM-IV (TR) criteria for dementia are presented in TABLE 8.5 and clinical clues suggesting dementia in TABLE 8.6.

The many guises of dementia can be considered in terms of four major symptom groups:¹⁴

1. Deficit presentations—due to loss of cognitive abilities, including:

   • forgetfulness

   • confusion and restlessness

   • apathy (usually a late change)

   • self-neglect with no insight

   • poor powers of reasoning and understanding

2. Unsociable presentations—based on personality change, including:

   • uninhibited behaviour

   • risk taking and impulsive behaviour

   • suspicious manner

   • withdrawn behaviour

3. Dysphoric presentations—based on disturbed mood and personal distress, including:

   • depression (hopeless and helpless)

   • irritability with emotional outbursts

   • lack of cooperation

   • insecurity

4. Disruptive presentations—causing distress and disturbance to others, including:

   • aggressive, sometimes violent, behaviour

   • agitation with restlessness

The problem occasionally results in marked emotional and physical instability. It is sad and difficult for relatives to watch their loved ones develop aggressive and antisocial behaviour, such as poor table manners, poor personal cleanliness, rudeness and a lack of interest in others. Sometimes severe problems, such as violent behaviour, sexual promiscuity and incontinence, will eventuate.

There is always the likelihood of accidents with household items such as fire, gas, kitchen knives and hot water. Accidents at the toilet, in the bath and crossing roads may be a problem, especially if combined with failing sight and hearing. Such people should not drive motor vehicles.

Without proper supervision they are likely to eat poorly, neglect their bodies and develop medical problems, such as skin ulcers and infections. They can also suffer from malnutrition and incontinence of urine or faeces. The median time to death after diagnosis is 3 years.

Management of suspected dementia

Exclude reversible or arrestable causes of dementia:

• full medical history (including drug and alcohol intake)

• mental state examination: select from several tools, e.g. Montreal Cognitive Assessment

• physical examination

• investigations (see Laboratory investigations, above, and CHAPTER 45)

• psychometric assessment

Management of dementia

Refer to a specialist to confirm the diagnosis and provide ongoing shared care. There is currently no cure for dementia—the best that can be offered to the patient is tender, loving care.

Education, support and advice should be given to both patient and family. Legal issues should be discussed such as enduring power of attorney, enduring guardianship and advanced care planning. Multidisciplinary evaluation and assistance are needed. Regular home visits by caring, sympathetic people are important. Such people include relatives, friends, GPs, district nurses, home help, members of a dementia self-help group, religious ministers and meals on wheels. People with dementia tend to manage much better in the familiar surroundings of their own home and this assists in preventing behaviour disturbance. Encourage the person to exercise, eat well and stay socially connected.

Special attention should be paid to organising memory aids, such as lists, routines and medication, and to hygiene, diet and warmth. Adequate nutrition, including vitamin supplements if necessary, has been shown to help. Provide ongoing support to carers.

Driving

Driving is a problem, especially as many are reluctant to give up their licence. Those with mild dementia are more likely to cause road accidents. In some states it is compulsory for doctors to report patients who are unfit to drive. If uncertainties arise or a patient is recalcitrant, refer to the local Road Traffic Authority. In Sweden it is recommended that those with moderate to severe dementia should not drive.

Comorbidity/associated problems¹⁵

The behavioural and neuropsychiatric problems are a major management issue. Depression can occur early in dementia and requires intervention. Demented patients are vulnerable to superimposed delirium, which is often due to:

• urinary tract infection

• other febrile illness

• prescribed medication

• drug withdrawal

Delirium should be suspected if a stable patient becomes acutely disturbed.

Dementia and Parkinson disease

A feature of Lewy body dementia, Parkinson disease is a very difficult yet common problem. One problem is that medication affects the mental processes. Lewy body dementia is extremely sensitive to the typical antipsychotics—typical agents should not be prescribed.¹⁶ Quetiapine is the agent of choice. The choice of drugs is critical to care, so referral to an experienced team which can provide a good neuropsychiatric assessment is advisable. The best option appears to be the administration of:

• levodopa to maximum dose

• quetiapine at night

Medication¹⁵

Demented patients often do not require any psychotropic medication. Antidepressant drugs can be prescribed for depression. Citalopram is effective in treating agitation but tricyclic antidepressants (TCAs) tend to aggravate confusion.¹⁶ Benzodiazepines are effective for short term use in agitated behaviours. The cholinesterase inhibitors donepezil, galantamine and rivastigmine appear to delay progression of dementia to a modest extent only. There appears to be no differences between the available agents. Beware of drugs that aggravate such as anticholinergics, opiates, TCAs, frusemide, prednisolone and salbutamol.¹⁶

Available drugs for Alzheimer disease

Cholinesterase inhibitors

• donepezil 5 mg (o) nocte for 4 weeks, increase to 10 mg nocte as tolerated

• galantamine prolonged release 8 mg (o) daily for 4 weeks, increase to 16 mg daily or 24 mg if tolerated

• rivastigmine 1.5 mg (o) bd for 2 weeks, increase gradually up to 6 mg bd as tolerated

  or

• rivastigmine 4.6 mg transdermal daily for 4 weeks, then 9.5 mg daily as tolerated

Aspartate (NMDA) antagonist

• memantine (Ebixa) 5 mg (o) mane for 1 week → 5 mg bd week two → 10 mg bd from week 4

Based on double-blind randomised trials of the two drugs donepezil and rivastigmine and using Cochrane data,^15,17 the following points emerge:

• only modest improvement overall

• greatest improvement with higher doses

• higher doses less well tolerated

• long-term efficacy unknown

• clinical effectiveness in severe disease has not been demonstrated¹⁸

The newer agent memantine appears to have similar outcomes and can be used in combination.

Using evidence-based medicine criteria on numbers needed to treat (see CHAPTER 13), the evidence shows that 13 patients must be treated with rivastigmine 6–12 mg/day for 6 months for one patient to display clinically meaningful improvement.^18,19

To control psychotic symptoms or disturbed behaviour probably due to psychosis:²⁰

• olanzapine 2.5–10 mg (o) daily

  or

  risperidone 0.25–2 mg (o) bd, increasing to maximum of 2 mg daily

  To control symptoms of anxiety and agitation use:

  oxazepam 7.5 mg (o) one to three times daily

Benzodiazepines should be used only for short periods (maximum 2 weeks) as they tend to exacerbate cognitive impairment in dementia.

Complementary therapy¹⁵

As yet there is insufficient evidence for the efficacy of complementary medicines such as Ginkgo biloba,²¹ vitamin E²² and other antioxidants in treating (alleviating symptoms in) dementia, despite some epidemiological evidence, especially in the case of vitamin E. However, we should encourage our patients in preventive healthy lifestyle strategies, such as optimal nutrition rich in essential vitamins and exercise. Deficiencies of folate, vitamin B12 and vitamin D should be treated.

This suggested program is based on the research work of Dr Michael Valenzuela.²³

• Healthy blood pressure—‘a healthy heart means a healthy brain’—the strongest evidence for dementia prevention.

• The three keys:

  1. physical: walking 30–60 minutes 3–4 times a week, plus strength exercises, balance and stretching exercises—reportedly known to enhance brain cell growth, brain cell interconnections and angiogenesis

  2. mentally stimulating activities

  3. social activities in company that are both fun and rewarding.

• Alcohol control: avoid binge drinking and always promote a safe intake, i.e. 1–2 standard drinks with a meal for 3 days a week.

• Diet—Mediterranean in style, oily fish 2–3 times a week (consider Chia seed), 2 fruits and 5 vegetables daily.

• Early dementia

• Benign senescent forgetfulness

• Depression

• Anxiety

• Acquired brain injury

• Physical illness

This ‘popular’ term is also referred to as ‘age-related memory loss’ or ‘mild cognitive impairment’ of ageing. Features include:

• short-term forgetfulness

• inability to find the right word

• embarrassment about shortcomings

• feeling dithery

• inability to find items stored away

• forgetting to pay accounts

It is debatable whether these are truly benign cognitive impairment or early features of dementia.²⁵

The risk of suicide increases with age in males. The risk factors for late life suicide are:²⁵

• male

• single

• recent bereavement

• social isolation

• recent relocation

• poor pain control

• feeling helpless/hopeless

• anhedonia

• indicating a wish to die

• recent alcohol abuse

The principles of treatment include supportive care, regular visits, CAT team, interpersonal psychotherapy, cognitive behavioural therapy and family support/interventions.

Paraphrenia, known as ‘late onset’ schizophrenia, is that condition where the symptoms and signs of paranoid psychosis appear for the first time in the elderly. In this apparent non-psychotic mental illness, the patient, who is usually an elderly female, presents with paranoid delusions, such as a feeling of being watched or persecuted and even hallucinations. These are usually associated with visual and hearing problems. Treatment is with an antipsychotic agent, e.g. risperidone or olanzapine.

Sarcopenia is degenerative loss of skeletal mass, strength and possibly function as a result of ageing, illness, sedentary lifestyle and poor diet. Features of significant frailty include poor hand grip strength, slow walking speed, exhaustion with activity and susceptibility to infection and falls. Treatment strategies include exercise, especially resistance training, protein supplements in diet, Vitamin D and reduction in polypharmacy.

TABLE 8.7 presents the diagnostic strategy model. Falls in the elderly are a major problem as 30% of people over the age of 65 experience at least one fall per year, with 1 in 4 of these having significant injury. About 5% of falls result in fracture.²⁷ In 2002 in Australia, there were approximately 1200 deaths in people over 75 years of age following falls, which were responsible for 90% of hip fractures and 50% of vertebral fractures.

Assessment

The history should embrace the above causes and risk factors. In particular, a description of the fall by a witness, the perceived dysfunction at the time of the fall and whether there was loss of consciousness are particularly important.

The physical examination should include cardiac function, neurological status (including the mini-mental function test) and the musculoskeletal system (including assessment of gait). The ‘get up and go’ test (see TABLE 8.8) is useful.

As special investigations (especially for those proving difficult to evaluate), consider full blood examination and erythrocyte sedimentation rate (ESR), blood sugar, urea and electrolytes, vitamin D, thyroid function tests, cardiac investigations (e.g. ambulatory electrocardiogram [ECG] monitoring, ambulatory blood pressure monitoring), vestibular function testing, and CT scans or MRI scans.²⁸

Management and prevention

Steps should be taken to correct any medical disorders and risk factors. It is appropriate to refer to a multidisciplinary team that includes occupational therapists and physiotherapists. Assessment of circumstances in the home is very helpful. This may lead to reducing environmental hazards and providing walking aids. Exercise training and medication reduction are also important strategies. (See www.racgp.org.au/redbook, section 5.2: Falls and physical activity.)

Ageing is associated with increased rates of adverse drug reactions.¹ The rate of adverse drug reactions for a single medication rises from about 6% at age 20 years to about 20% at age 70 years.

For fewer than six medications taken concurrently, the rate of adverse drug reactions is about 6%. For more than six medications taken concurrently, the rate of adverse drug reactions jumps to 20%.¹ Approximately 15% of elderly patients admitted to hospital are suffering adverse drug reactions. Most adverse drug reactions are type A (dose related) rather than type B (idiosyncratic).²⁹

Factors predisposing to adverse drug reactions in the elderly¹

Most adverse drug reactions in the elderly are entirely predictable. Most are merely an extension of the pharmacological action of the drug (e.g. all antihypertensives will reduce blood pressure and have the capacity to cause hypotension and falls in a person with impaired baroreceptor function or poor homeostasis in their vascular tree). Very few adverse reactions are idiosyncratic or unexpected.

The five mechanisms of adverse drug reactions in the elderly are:

1. Drug–drug interaction. For example, beta blockers given concomitantly with digoxin increases the risk of heart block and bradycardia. Alcohol used in combination with antidepressants increases the risk of sedation.

2. Drug–disease interaction. For example, in the presence of kidney impairment, tetracyclines carry an increased risk of kidney deterioration.

3. Age-related changes leading to increases in drug plasma concentration. Decreased kidney excretion can extend the half-life of medication, leading to accumulation and toxicity.

4. Age-related changes leading to increased drug sensitivity. For example, there is some suggestion that the pharmacological response to warfarin, narcotics and benzodiazepines is increased in the elderly. Conversely, the pharmacological response to insulin, theophylline and beta-adrenergic blocking agents is thought to be decreased.

5. Patient error. Multiple medications can lead to patient error. The incidence and prevalence of dementia also increases with age. Other problems include failing eyesight and reduced manual dexterity.

Risk factors predisposing to medicine-related problems

Adverse drug effects in older people are influenced by multiple factors, with many exposed to more than one of these factors at a given time. Furthermore, their recovery from serious incidents such as a hip fracture is jeopardised, possibly ending in death.

Increasing the number of simultaneous medications increases the risk for all five mechanisms of adverse drug reactions.

In a study on adverse drug reaction in elderly patients the drugs most frequently causing admission to hospital were:³⁰

• psychotropics and hypnotics

• diuretics

• antihypertensives (including beta blockers)

• anti-Parkinson drugs

• anti-convulsants

• analgesics and NSAIDs

The main drugs contributing to falls were:³¹

• antidepressants

• benzodiazepines

• antipsychotics

• antihypertensives

• anti-Parkinson

• diuretics

• hypnotics

• sedatives

• anti-convulsants

Drug regimens should be kept as simple as possible to aid compliance and avoid or minimise drug interactions.

The elderly may need much lower doses of anxiolytics and hypnotics than younger patients to produce the same effect, thus rendering them more susceptible to adverse effects and toxicity. The elderly are especially liable to accumulate the longer-acting benzodiazepines.

In particular, any drug or combination of drugs with anticholinergic properties (e.g. tricyclic antidepressants, anti-Parkinsonian agents, antihistamines, phenothiazines and some cold remedies) can precipitate a central anticholinergic syndrome.¹⁴

The elderly are very prone to adverse effects to most of the more potent drugs, especially those for cardiac dysfunction and hypertension. Both ACE inhibitors and calcium channel blockers have been shown to produce a greater fall in blood pressure in elderly compared with younger subjects, presumably related also to a reduced homeostatic response.⁷

Starting medications¹⁵

The starting dose of a drug in the aged¹⁴ should be at the lower end of recommended ranges. Dosage increments should be gradual and reviewed regularly.

That is, start low, go slow and monitor frequently. It is important to individualise doses for the elderly with the simplest dosage regimen.

Minimising medication problems

• Write simple instructions on all prescriptions.

• Individualise doses for the elderly.

• Give patients a list of their medications.

• Ask them to bring the list and their medications at each visit.

• Update this list as necessary.

• Keep medication regimen as simple as possible.

• Consider a Dosette box or Webster pack for polypharmacy.

• At home visits use the opportunity to inspect medications.

• Observe for drug interactions and toxicity.

• Keep detailed records of all medications prescribed.

• Carefully review medication after discharge from hospital.

Other tips for medication in the elderly

• Obtain relatives/carers’ consent for medication, especially in the confused.

Dementia Australia. <www.dementia.org.au>, accessed January 2018.

National Prescribing Service (NPS). Balancing the benefits and harms of antipsychotic therapy. Prescribing Practice Review, 2011; (PPR 55).