General Internal Medicine and Geriatric Medicine
Core concepts
The geriatric giants are falls, immobility, incontinence and intellectual impairment. Falls: assess gait, vision, medications (sedatives, antihypertensives, anticholinergics), postural blood pressure, syncope, vitamin D and bone health. Syncope: reflex (vasovagal, carotid sinus), orthostatic, cardiac (arrhythmia, structural) - and always consider seizure. Delirium is acute, fluctuating and inattentive, hyperactive or hypoactive; find the cause - infection, constipation, urinary retention, pain, medication, metabolic derangement, environment - and treat non-pharmacologically first. Dementia is insidious and progressive: Alzheimer's, vascular, Lewy body (fluctuations, visual hallucinations, parkinsonism, neuroleptic sensitivity) and frontotemporal. Capacity: assume it is present; assess understanding, retention, weighing and communication; if lacking, act in best interests. Polypharmacy: review anticholinergic burden and use STOPP/START criteria; avoid benzodiazepines, long-acting sulfonylureas, NSAIDs and anticholinergics where possible. Pressure ulcers: risk assessment, offloading, nutrition. Continence: exclude urinary infection, constipation and drugs first. Older people often present atypically - with confusion, falls or immobility rather than fever or pain.
Traps
Calling delirium dementia. Missing urinary retention or faecal impaction as the cause of agitation. Prescribing antipsychotics first line for delirium (reserve for severe distress). Assuming a patient lacks capacity because they refuse treatment.
Rule of thumb
New confusion in an older person is delirium until proven otherwise: look for the trigger before adding a sedative, and reassess after treating it.