Geriatric and General Internal Medicine
Comprehensive assessment
The comprehensive geriatric assessment - medical, functional, cognitive, psychological and social domains - improves outcomes more than any single intervention. Assess falls with a multifactorial review: medications (sedatives, antihypertensives, anticholinergics), vision, footwear, gait, arrhythmia and postural blood pressure.
Delirium, dementia and capacity
Delirium is acute, fluctuating and inattentive; the 4AT is a practical screening tool, and a score of 4 or more suggests delirium. Hypoactive delirium is most often missed. Search for pain, constipation, urinary retention, infection, drugs and environment; antipsychotics are only for distressing symptoms and never the first step. Dementia is chronic and progressive - do not attribute a new acute confusional state to dementia. Assume capacity unless proven otherwise; assess understanding, retention, weighing of information and communication of choice.
Polypharmacy and atypical presentation
Review medicines with STOPP/START criteria and consider anticholinergic burden. Older adults present atypically: myocardial infarction without chest pain, infection without fever, hypothyroidism as confusion, depression as weight loss.
Traps: overtreating hypertension and causing falls or AKI; prescribing benzodiazepines for delirium; missing that a fall was actually syncope from a bradyarrhythmia.
Rule of thumb: when an older patient deteriorates suddenly, review the drug chart before adding a new diagnosis - recently started drugs are a common cause of confusion, falls and AKI.