165

7 Comprehensive geriatric assessment 166

Demography 168

Functional anatomy and physiology 168Biology of ageing 168Physiological changes of ageing 169Frailty 170

Investigations 170Comprehensive geriatric assessment 170Decisions about investigation 170

Ageing and disease

M.D. Witham

Presenting problems in geriatric  medicine 171Falls 172Dizziness 173Delirium 173Urinary incontinence 175Adverse drug reactions 175Other problems in old age 176

Rehabilitation 176

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166

Insets (Wasted hand, kyphosis) From Afzal Mir 2003; (Senile purpura) Forbes and Jackson 2004; (Venous ulceration) Mosti 2012 – see p. 177.

PulseAtrial fibrillation

HydrationSkin turgor

Oedema

Erect and supineblood pressure

Postural hypotension

HearingWax

Hearing aidused

MuscleWastingStrength

8

2

3

4

5

6

Full systems examinationwith particular attention

to the above

Per rectumFaecal impactionProstate size/consistencyin menAnal tone

9

NutritionBody mass index

(Height calculated from arm demispan

or knee height to compensate for loss

of vertebral height)Recent weight loss, e.g. loose

skin foldsDentition/oral hygiene Joints

DeformityPainSwellingRange of movement

11

SkinWounds/ulcersInfectionSwelling

10

Gait and balanceGet up and go test(see opposite)Walking aid used

12

VisionVisual acuity

Glasses worn/presentCataract

7Cognitive functionMini-mental state examination

(see Ch. 10)

1

Measurement of knee height(see Ch. 5)

Severe kyphosis

Wasting of small muscles ofhands in rheumatoid arthritis

Cataract

Senile purpura

Venous ulceration

COMPREHENSIVE GERIATRIC ASSESSMENT

Comprehensive geriatric assessment

167

History• Slow downthepace.• Ensure the patient can hear.• Establishthespeed of onsetof

theillness.• Ifthepresentationisvague,

carryoutasystematic enquiry.• Obtainfulldetailsof:

all drugs,especiallyanyrecentprescriptionchangespast medical history,evenfrommanyyearspreviouslyusual function1. Canthepatientwalknormally?2. Hasthepatientnoticed

memoryproblems?3. Canthepatientperformall

householdtasks?• Obtain a collateral history:

confirminformationwitharelativeorcarerandthegeneralpractitioner,particularlyifthepatientisconfusedorcommunicationislimitedbydeafnessorspeechdisturbance.

Social assessmentHome circumstances• Livingalone,withanotherorin

acarehome.

Activities of daily living (ADL)• Tasksforwhichhelpisneeded:

domestic ADL:shopping,cooking,houseworkpersonal ADL:bathing,dressing,walking.

• Informal help:relatives,friends,neighbours.

• Formal social services:homehelp,mealsonwheels.

• Carerstress.

Domains of Comprehensive Geriatric Assessment.

Disease severity and comorbidity

Mentalhealth

andcognition

Supportnetworks and needs

Function and ability

12 Get up and go testTo assess gait and balance, ask the patient to stand up from a sitting position, walk 10 m, turn and go back to the chair. A normal performance takes less than 12 seconds.

Unsteady onstanding?

Difficulty rising? Unsteady gait? Unsteady onturning?

Unsteady onsitting down?

Team member Activity assessed and promotedPhysiotherapist Mobility, balance and upper limb functionOccupational therapist

ADL, e.g. dressing, cookingHome environment and care needs

Dietitian NutritionSpeech and language therapist

Communication and swallowing

Social worker Care needs and discharge planning, including organisation of institutional care

Nurse Motivation and initiation of activities; promotion of self-careEducationFeeding, continence, skin careCommunication with relatives and other professionalsAssessment of care needs for discharge

Doctor Diagnosis and management of medical problemsCoordinator of assessment, management and rehabilitation programme

Multidisciplinary team (MDT) roles

Examination• Thoroughtoidentifyall

comorbidities.• Tailored to the patient’s

staminaandabilitytocooperate.

• Includefunctional status:cognitivefunctiongaitandbalancenutritionhearingandvision.

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Fig. 7.1 Number of people aged 65 years and over projected in the world population.

Mill

ions

1600

1400

1200

1000

800

600

400

200

02010 2025 2050

Year

World

Developing countries

Developed countries

Sweeping demographic change has meant that olderpeople now represent the core practice of medicine inmany countries. A good knowledge of the effects ofageing and the clinical problems associated with oldage is thus essential in most medical specialties. Theolder population is extremely diverse; a substantialproportion of 90-year-olds enjoy an active healthylife, while some 70-year-olds are severely disabled bychronicdisease.Theterms‘chronological’and‘biologi-cal’ ageinghavebeencoined todescribe thisphenom-enon.Biological rather thanchronological age is takenintoconsiderationwhenmakingclinicaldecisionsabout,forexample,theextentofinvestigationandinterventionthatisappropriate.

Geriatric medicine is concerned particularly withfrail older people, in whom physiological capacity isso reduced that they are incapacitated by even minorillness. They frequently have multiple comorbidities,andacuteillnessmaypresentinnon-specificways,suchas confusion, falls or loss of mobility and day-to-dayfunctioning. These patients are prone to adverse drugreactions, partly because of polypharmacy and partlybecause of age-related changes in responses to drugsandtheirelimination(p.36).Disabilityiscommon,butpatients’ function can often be improved by the inter-ventionsofthemultidisciplinaryteam(p.167).

Olderpeoplehavebeenneglectedinresearchtermsand,untilrecently,wererarelyincludedinrandomisedcontrolledclinicaltrials.Thereisthuslittleevidenceonwhichtobasepractice.

DEMOGRAPHY

The demography of developed countries has changedrapidly in recent decades. In the UK, for example, thetotalpopulationgrewby11%overthelast30years,butthenumberofpeopleagedover65yearsroseby24%.Thesteepestriseoccurredinthoseagedover85–from600000in1981to1.5millionin2011–andthisnumberisprojectedtoincreaseto2.4millionby2026,whilsttheworking-age population (20–64 years) is expected togrowbyonly4%between2011and2026.Thiswillhaveasignificantimpactontheold-agedependencyratio,i.e.the number of people of working age for each personoverretirementage.Youngpeoplesupportoldermem-bers of the population directly (e.g. through livingarrangements)andfinancially(e.g.throughtaxationandpensioncontributions),sotheconsequencesofareducedratio are far-reaching. However, many older peoplesupport the younger population, through care of chil-drenandotherolderpeople.

Lifeexpectancyinthedevelopedworldisnowpro-longed,eveninoldage(Box7.1);womenaged80yearscanexpecttoliveforafurther10years.However,ratesofdisabilityandchronicillnessrisesharplywithageingandhaveamajorimpactonhealthandsocialservices.In theUK, thereportedprevalenceofachronic illnessordisabilitysufficienttorestrictdailyactivitiesisaround25%inthoseaged50–64,butis66%inmenand75%inwomenagedover85.

Althoughtheproportionofthepopulationagedover65yearsisgreaterindevelopedcountries,two-thirdsofthe world population of people aged over 65 live indevelopingcountriesatpresent,andthisisprojectedto

Males Females

UK India UK India

At birth 79.1 65.1 83.0 67.2

At 60 years 22.8 16.7 25.5 18.9

At 70 years 15.0 10.9 17.1 12.4

At 80 years 8.7 7.5 9.9 8.0

7.1 Mean life expectancy in years, UK and India

rise to 75% in 2025. The rate of population ageing ismuch faster in developing countries (Fig. 7.1) and sotheyhavelesstimetoadjusttoitsimpact.

FUNCTIONAL ANATOMY AND PHYSIOLOGY

Biology of ageing

Ageing can be defined as a progressive accumulationthroughlifeofrandommoleculardefectsthatbuildupwithin tissues and cells. Eventually, despite multiplerepairandmaintenancemechanisms,theseresultinage-relatedfunctionalimpairmentoftissuesandorgans.

Many genes probably contribute to ageing, withthose that determine durability and maintenance ofsomatic cell lines particularly important. However,geneticfactorsonlyaccountforaround25%ofvarianceinhumanlifespan;nutritionalandenvironmentalfactorsdeterminetherest.

Amajorcontributiontorandommoleculardamageismade by reactive oxygen species produced during themetabolismofoxygentoproducecellularenergy.Thesecauseoxidativedamageatanumberofsites:• Nuclear chromosomal DNA,causingmutationsand

deletionswhichultimatelyleadtoaberrantgenefunctionandpotentialformalignancy.

• Telomeres,whicharetheprotectiveendregionsofchromosomeswhichshortenwitheachcelldivision

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becausetelomerase(whichcopiestheendofthe3′strandoflinearDNAingermcells)isabsentinsomaticcells.Whentelomeresaresufficientlyeroded,cellsstopdividing.Ithasbeensuggestedthattelomeresrepresenta‘biologicalclock’whichpreventsuncontrolledcelldivisionandcancer.TelomeresareparticularlyshortenedinpatientswithprematureageingduetoWerner’ssyndrome,inwhichDNAisdamagedduetolackofahelicase.

• Mitochondrial DNA and lipid peroxidation,resultinginreducedcellularenergyproductionandultimatelycelldeath.

• Proteins–e.g.thoseincreasingformationofadvancedglycosylationend-productsfromspontaneousreactionsbetweenproteinsandsugars.Thesedamagestructureandfunctionoftheaffectedprotein,whichbecomesresistanttobreakdown.

The rate at which damage occurs is malleable andthis is where the interplay with environment, particu-larly nutrition, takes place. There is evidence in someorganismsthatthisinterplayismediatedbyinsulinsig-nalling pathways. Chronic inflammation also plays animportantrole,againinpartbydrivingtheproductionofreactiveoxygenspecies.

Physiological changes of ageing

Thephysiologicalfeaturesofnormalageinghavebeenidentified by examining disease-free populations ofolderpeople, toseparate theeffectsofpathology fromthoseduetotimealone.However,thefractionofolderpeoplewhoagewithoutdiseaseultimatelydeclines toverylowlevels,sothatuseoftheterm‘normal’becomesdebatable.Thereisamarkedincreaseininter-individualvariation in function with ageing; many physiologicalprocesses deteriorate substantially when measuredacrosspopulations,butsomeindividualsshowlittleornochange.Thisheterogeneity isahallmarkofageing,meaningthateachpersonmustbeassessedindividuallyandthatonecannotunthinkinglyapplythesameman-agementtoallpeopleofacertainage.

Although some genetic influences contribute toheterogeneity, environmental factors, such as poverty,nutrition, exercise, cigarette smoking and alcoholmisuse,playalargepart,andahealthylifestyleshouldbeencouragedevenwhenoldagehasbeenreached.

Theeffectsofageingareusuallynotenoughtointer-ferewithorgan functionundernormalconditions,butreservecapacityissignificantlyreduced.Somechanges

Fig. 7.2 Features and consequences of normal ageing.

Respiratory system• Reduced lung elasticity and alveolar support• Increased chest wall rigidity• Increased V/Q mismatch• Reduced cough and ciliary action

CNS• Neuronal loss• Cochlear degeneration• Increased lens rigidity• Lens opacification• Anterior horn cell loss• Dorsal column loss• Slowed reaction times

Cardiovascular system• Reduced maximum heart rate• Dilatation of aorta• Reduced elasticity of conduit/ capacitance vessels• Reduced number of pacing myocytes in sinoatrial node

Endocrine system• Deterioration in pancreatic β-cell function

Renal system• Loss of nephrons• Reduced glomerular filtration rate• Reduced tubular function

Gastrointestinal system• Reduced motility

Bones• Reduced bone mineral density

Respiratory system• Reduced vital capacity and peak expiratory flow• Increased residual volume• Reduced inspiratory reserve volume• Reduced arterial oxygen saturation• Increased risk of infection

CNS• Increased risk of delirium• Presbyacusis/high-tone hearing loss• Presbyopia/abnormal near vision• Cataract• Muscle weakness and wasting• Reduced position and vibration sense• Increased risk of falls

Cardiovascular system• Reduced exercise tolerance• Widened aortic arch on X-ray• Widened pulse pressure• Increased risk of postural hypotension• Increased risk of atrial fibrillation

Endocrine system• Increased risk of impaired glucose tolerance

Renal system• Impaired fluid balance• Increased risk of dehydration/overload• Impaired drug metabolism and excretion

Gastrointestinal system• Constipation

Bones• Increased risk of osteoporosis

Clinical consequencesChanges with ageing

• •

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INVESTIGATIONS

Comprehensive geriatric assessment

Althoughnotstrictlyan investigation,oneof themostpowerfultoolsinthemanagementofolderpeopleistheComprehensive Geriatric Assessment, which identifiesalltherelevantfactorscontributingtotheirpresentation(p.166).Infrailpatientswithmultiplepathology,itmaybe necessary to perform the assessment in stages toallowfortheirreducedstamina.Theoutcomeshouldbea management plan that not only addresses the acutepresenting problems, but also improves the patient’soverallhealthandfunction(Box7.3).

Comprehensive Geriatric Assessment is performedbyamultidisciplinaryteam(p.167).Suchanapproachwas pioneered by Dr Marjory Warren at the WestMiddlesex Hospital in London in the 1930s; her com-prehensiveassessmentandrehabilitationofsupposedlyincurable,long-termbedriddenolderpeoplerevolution-ised the approach of the medical profession to older,frail people and laid the foundations for the modernspecialtyofgeriatricmedicine.

‘Inpatient comprehensive geriatric assessment reduces short-term mortality and increases the chance of patients living at home in the long term.’

• Ellis G, Langhorne P. Br Med Bull 2005; 71: 45–59.

7.3 Comprehensive geriatric assessment

ofageing,suchasdepigmentationofthehair,areofnoclinicalsignificance.Figure7.2showsmanyfactorsthatareclinicallyimportant.

Frailty

Frailtyisdefinedasthelossofanindividual’sabilitytowithstandminorstressesbecause the reserves in func-tion of several organ systems are so severely reducedthatevenatrivialillnessoradversedrugreactionmayresult in organ failure and death. The same stresseswouldcauselittleupsetinafitpersonofthesameage.

Itisimportanttounderstandthedifferencebetween‘disability’, ‘comorbidity’ and ‘frailty’. Disability indi-cates established loss of function (e.g. mobility; seeBox7.13,p.176),whilefrailtyindicatesincreasedvulner-ability to loss of function. Disability may arise from asingle pathological event (such as a stroke) in anotherwisehealthyindividual.Afterrecovery,functionislargelystableandthepatientmayotherwisebeingoodhealth.Whenfrailtyanddisabilitycoexist,functiondete-rioratesmarkedlyevenwithminorillness,totheextentthat the patient can no longer manage independently.Similarly,comorbidity(thenumberofdiagnosespresent)is not equivalent to frailty; it is quite possible to haveseveraldiagnoseswithoutmajorimpactonhomeostaticreserve.

Unfortunately, the term ‘frail’ is often used rathervaguely,sometimesto justifyalackofadequateinves-tigation and intervention in older people. However, itcanbespecificallyidentifiedbyassessingfunctioninanumberofdomains.Twomainapproachestoevaluatingfrailty exist: measurement of physiological functionacrossanumberofdomains(e.g.theFriedFrailtyscore,Box7.2),orascorebasedon thenumberofdeficitsorproblems–forexample,theRockwoodscore.

Frailolderpeopleparticularlybenefitfromaclinicalapproach that addresses both the precipitating acuteillnessandtheirunderlying lossofreserves. Itmaybepossibletopreventfurtherlossoffunctionthroughearlyintervention; forexample,a frailwomanwithmyocar-dialinfarctionwillbenefitfromspecificcardiacinvesti-gationanddrugtreatment,butmaybenefitevenfurtherfromanexerciseprogrammetoimprovemusculoskele-tal function, balance and aerobic capacity, with nutri-tional support to restore lost weight. Establishing apatient’s level of frailty also helps inform decisionsregarding further investigation and management, andtheneedforrehabilitation.

*Varies between populations. Grip cutoff is 30 kg for men, 18 kg for women in US adults; 5 m walk time cutoff is 7 seconds in US adults for both sexes.

• Handgrip strength in bottom 20% of healthy elderly distribution*

• Walking speed in bottom 20% of healthy elderly distribution*• Self-reported exhaustion• Physically inactive• At least 6 kg weight loss within 1 year

Patient is defined as frail if 3 or more factors are present.

7.2 How to assess a Fried Frailty score

Decisions about investigation

Accuratediagnosisisimportantatallagesbutfrailolderpeoplemaynotbeable to tolerate lengthyor invasiveprocedures, and diagnoses may be revealed for whichpatients could not withstand intensive or aggressivetreatment.Ontheotherhand,disabilityshouldneverbedismissedasduetoagealone.Forexample,itwouldbea mistake to supply a patient no longer able to climbstairs with a stair lift, when simple tests would haverevealedosteoarthritisofahipandvitaminDdeficiency,for which appropriate treatment would have restoredhisorherstrength.Sohowdodoctorsdecidewhenandhowfartoinvestigate?

The patient’s general healthDoesthispatienthavethephysicalandmentalcapacitytotoleratetheproposedinvestigation?Doeshehavetheaerobiccapacitytoundergobronchoscopy?Willconfu-sion prevent her from remaining still in the magneticresonanceimaging(MRI)scanner?Themorecomorbidi-tiesapatienthas,thelesslikelyheorshewillbeabletowithstandaninvasiveintervention.

Will the investigation alter management?Would thepatientbefit for,orbenefit from, the treat-ment that would be indicated if investigation provedpositive?Thepresenceofcomorbidityismoreimportantthanageitselfindeterminingthis.Whenapatientwith

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whose mobility is limited by stroke, angina may onlypresentwhencoronaryarterydiseaseisadvanced,asthepatienthasbeenunabletoexercisesufficientlytocausesymptomsatanearlierstage.

Atypical presentationInfectionmaypresentwithdeliriumandwithoutclinicalpointers to the organ system affected. Stroke maypresentwithfallsratherthansymptomsoffocalweak-ness. Myocardial infarction may present as weaknessand fatigue, without the chest pain or dyspnoea. Thereasonsfor theseatypicalpresentationsarenotalwayseasytoestablish.Perceptionofpainisalteredinoldage,whichmayexplainwhymyocardialinfarctionpresentsinotherways.Thepyreticresponseisbluntedinoldagesothatinfectionmaynotbeobviousatfirst.Cognitiveimpairment may limit the patient’s ability to give ahistoryofclassicalsymptoms.

Acute illness and changes in functionAtypical presentations in frail elderly patients include‘failure to cope’, ‘found on floor’, ‘confusion’ and ‘offfeet’,butthesearenotdiagnoses.Thepossibilitythatanacute illness has been the precipitant must always beconsidered. To establish whether the patient’s currentstatusisachangefromhisorherusualleveloffunction,ithelpstoaskarelativeorcarer(byphoneifnecessary).Investigationsaimedatuncoveringanacuteillnesswillnot be fruitful in a patient whose function has beendeterioratingoverseveralmonths,butareimportantiffunctionhassuddenlychanged.

Multiple pathologyPresentations in older patients have a more diversedifferential diagnosis because multiple pathology isso common. There are frequently a number of causesfor any single problem, and adverse effects frommedicationoftencontribute.Apatientmayfallbecauseof osteoarthritis of the knees, postural hypotensiondue to diuretic therapy for hypertension, and poorvision due to cataracts. All these factors have to beaddressed to prevent further falls, and this principleholds true for most of the common presenting prob-lemsinoldage.

Approach to presenting problems in old ageFor the sake of clarity, the common presenting prob-lems are described individually, but in real life, olderpatients often present with several at the same time,particularly confusion, incontinence and falls. Theseshare some underlying causes and may precipitateeachother.

Theapproachtomostpresentingproblemsinoldagecanbesummarisedasfollows:• Obtain a collateral history.Findoutthepatient’s

usualstatus(e.g.mobility,cognitivestate)fromarelativeorcarer.Callthesepeoplebyphoneiftheyarenotpresent.

• Check all medication.Havetherebeenanyrecentchanges?

• Search for and treat any acute illness.SeeBox7.4.• Identify and reverse predisposing risk factors.These

dependonthepresentingproblem.

severe heart failure and a previous disabling strokepresentswitha suspiciousmass lesiononchestX-ray,detailedinvestigationandstagingmaynotbeappropri-ate if he is not fit for surgery, radical radiotherapy orchemotherapy. On the other hand, if the same patientpresented with dysphagia, investigation of the causewould be important, as he would be able to tolerateendoscopic treatment (for example, to palliate anobstructingoesophagealcarcinoma).

The views of the patient and familyOlderpeoplemayhavestrongviewsabouttheextentofinvestigationandthetreatmenttheywishtoreceive,andthese should be sought from the outset. If the patientwishes,theviewsofrelativescanbetakenintoaccount.If the patient is not able to express a view or lacksthe capacity to make decisions because of cognitiveimpairment or communication difficulties, then rela-tives’ inputbecomesparticularlyhelpful.Theymaybeabletogiveinformationonviewspreviouslyexpressedbythepatientoronwhatthepatientwouldhavewantedunder the current circumstances. However, familiesshould never be made to feel responsible for difficultdecisions.

Advance directivesAdvancedirectivesor‘livingwills’arestatementsmadebyadultsatatimewhentheyhavethecapacitytodecideabout the interventions theywouldrefuseoraccept inthefuture,shouldtheynolongerbeabletomakedeci-sions or communicate them. An advance directivecannotauthoriseadoctortodoanythingthat is illegaland doctors are not bound to provide a specific treat-mentrequestedif,intheirprofessionalopinion,itisnotclinicallyappropriate.However,anyadvancerefusaloftreatment, made when the patient was able to makedecisions based on adequate information about theirimplications, is legally binding in the UK. It must berespectedwhenitclearlyappliestothepatient’spresentcircumstances and when there is no reason to believethatthepatienthaschangedhisorhermind.

PRESENTING PROBLEMS IN GERIATRIC MEDICINE

Characteristics of presenting problems in old ageProblem-basedpracticeiscentraltogeriatricmedicine.Most problems are multifactorial and there is rarely asingleunifyingdiagnosis.Allcontributingfactorshavetobetakenintoaccountandattentiontodetailispara-mount. Two patients who share the same presentingproblem may have completely disparate diagnoses. Awideknowledgeofadultmedicineisrequired,asdiseaseinany,andoftenmany,oftheorgansystemshastobemanagedat thesametime.Thereareanumberof fea-turesthatareparticulartoolderpatients.

Late presentationMany people (of all ages) accept ill health as a conse-quenceofageingandmaytoleratesymptomsforlengthyperiods before seeking medical advice. Comorbiditiesmay also contribute to late presentation; in a patient

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Gait abnormality Probable cause

Antalgic Arthropathy

Waddling Proximal myopathy

Stamping Sensory neuropathy

Foot drop Peripheral neuropathy or radiculopathy

Ataxic Sensory neuropathy or cerebellar disease

Shuffling/festination Parkinson’s disease

Marche à petits pas Small-vessel cerebrovascular disease

Hemiplegic Cerebral hemisphere lesion

Apraxic Bilateral hemisphere lesions

7.6 Abnormal gaits and probable causes

• Muscle weakness• History of falls• Gait or balance abnormality• Use of a walking aid• Visual impairment• Arthritis

• Impaired activities of daily living

• Depression• Cognitive impairment• Age over 80 years• Psychotropic medication

7.5 Risk factors for falls

• Full blood count• Urea and electrolytes, liver function tests, calcium and

glucose• Chest X-ray• Electrocardiogram• C-reactive protein: useful marker for occult infection or

inflammatory disease• Blood cultures if pyrexial

7.4 Screening investigations for acute illness

important clues to an underlying diagnosis (Box 7.6).Commonpathologiesidentifiedincludecerebrovasculardisease(Ch.27),Parkinson’sdisease(p.1195)andosteo-arthritisofweight-bearingjoints(p.1081).OsteoporosisriskfactorsshouldalsobesoughtanddualenergyX-rayabsorptiometry (DEXA)bonedensity scanningconsid-ered in all older patients who have recurrent falls,particularly if they have already sustained a fracture(p.1065).

Prevention of falls and fracturesFalls can be prevented by multiple risk factor inter-vention (Box 7.7). The most effective intervention isbalance and strength training by physiotherapists; analternative with good evidence is tai chi training. Anassessment of the patient’s home environment forhazardsshouldbeundertakenbyanoccupationalthera-pist, who may also provide personal alarms so thatpatients can summon help, should they fall again.Rationalising psychotropic medication may help toreducesedation,althoughmanyolderpatientsarereluc-tanttostophypnotics.Ifposturalhypotensionispresent(defined as a drop in blood pressure of > 20mmHgsystolic or > 10mmHg diastolic pressure on standingfromsupine), reducingor stoppinghypotensivedrugsmay be helpful. Evidence supporting the efficacy ofotherinterventionsforposturalhypotensionislacking,butdrugs,includingfludrocortisoneandmidodrine,aresometimesusedtotrytoimprovedizzinessonstanding.Simple interventions, such as new glasses to correctvisualacuity,andpodiatry,canalsohaveasignificantimpactonfunctioninthosewhofall.

If osteoporosis is diagnosed, specific drug therapyshould be commenced (p. 1122). In patients in institu-tionalcare,calciumandvitaminD3administrationhas

Falls

Around30%ofthoseover65yearsofagefalleachyear,thisfigurerising tomore than40% in thoseagedover80.Althoughonly10–15%offallsresultinseriousinjury,theyarethecauseofmorethan90%ofhipfracturesinthisagegroup,compoundedbytherisingprevalenceofosteoporosis. Falls also lead to loss of confidence andfear,andarefrequentlythe‘finalstraw’thatmakesanolderpersondecidetomovetoinstitutionalcare.Man-agementwillvaryaccordingtotheunderlyingcause.

Acute illnessFalls are one of the classical atypical presentations ofacute illness in frail people. The reduced reserves inolderpeople’sneurologicalfunctionmeanthattheyarelessabletomaintaintheirbalancewhenchallengedbyan acute illness. Suspicion should be high when fallshave suddenly occurred over a period of a few days.Commonunderlyingillnessesincludeinfection,stroke,metabolic disturbance and heart failure. Thoroughexaminationandinvestigationarerequired(seeBox7.4).Itisalsoimportanttoestablishwhetheranydrugwhichprecipitatesfalls,suchasapsychotropicorhypotensiveagent, has been started recently. Once the underlyingacuteillnesshasbeentreated,fallsmaystop.

BlackoutsAproportionofolderpeoplewho‘fall’have,infact,hadasyncopalepisode.Acollateralhistoryfromawitnessisofutmost importance inanyonefallingover;peoplewholoseconsciousnessdonotalwaysrememberhavingdone so. If loss of consciousness is suggested by thepatientorwitness,itisimportanttoperformappropriateinvestigations(pp.554and1157).

Mechanical and recurrent fallsAmongst patients who have tripped or are uncertainhow they fell, those who have fallen more than oncein thepastyearand thosewhoareunsteadyduringa‘getupandgo’test(p.167)requirefurtherassessment.Patients with recurrent falls are commonly frail, withmultiple medical problems and chronic disabilities.Obviously,suchpatientsmaypresentwithafallresult-ing from an acute illness or syncope, but they willremain at risk of further falls even when the acuteillness has resolved. The risk factors for falls (Box 7.5)should be considered. If problems are identified withmuscle strength, balance, vision or cognitive function,thecausesofthesemustbeidentifiedbyspecificinves-tigation, and treatment commenced if appropriate.Careful assessment of the patient’s gait may provide

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been shown to reduce both falls and fracture rates,througheffectsonbothbonemineraldensityandneuro-muscularfunction.Theyarenoteffectiveinthosewithosteoporosislivinginthecommunity,inwhombisphos-phonatesarefirst-linetherapy.

IntheUK,governmentpolicyandNationalInstituteforHealthandClinicalExcellenceguidelines(www.nice.org.uk)forfallspreventionhaveledtothedevelopmentof specific Falls and Fracture Prevention Services inmanypartsofthecountry.

Dizziness

Dizzinessisverycommon,affectingatleast30%ofthoseagedover65yearsincommunitysurveys.Dizzinesscanbedisablinginitsownrightandisalsoariskfactorforfalls. Acute dizziness is relatively straightforward andcommoncausesinclude:• hypotensionduetoarrhythmia,myocardial

infarction,gastrointestinalbleedorpulmonaryembolism

• onsetofposteriorfossastroke• vestibularneuronitis.

Althougholderpeoplemorecommonlypresentwithrecurrent dizzy spells and often find it difficult todescribe the sensation they experience, the most effec-tive way of establishing the cause(s) of the problem isneverthelesstodeterminewhichofthefollowingispre-dominant(evenifmorethanoneispresent):• lightheadedness,suggestiveofreducedcerebral

perfusion• vertigo,suggestiveoflabyrinthineorbrainstem

disease(p.1167)• unsteadiness/poor balance,suggestiveofjointor

neurologicaldisease.In lightheaded patients, structural cardiac disease

(suchasaorticstenosis)andarrhythmiamustbeconsid-ered,butdisordersofautonomiccardiovascularcontrol,suchasvasovagalsyndromeandposturalhypotension,are the most common causes in old age. Hypotensivemedicationmayexacerbatethese.Furtherinvestigationandtreatmentaredescribedonpage1157.

Vertigo in older patients is most commonly dueto benign positional vertigo (p. 1158), but if other

Predisposing factors

• Old age• Dementia• Frailty

• Sensory impairment• Polypharmacy• Renal impairment

Precipitating factors

• Intercurrent illness• Surgery• Change of environment or

ward• Sensory deprivation (e.g.

darkness) or overload (e.g. noise)

• Medications (e.g. opioids, psychotropics)

• Dehydration• Pain• Constipation• Urinary catheterisation• Acute urinary retention• Hypoxia• Fever• Alcohol withdrawal

7.8 Risk factors for delirium

• Individualised or group strength and balance training, or tai chi

• Rationalisation of medication, especially psychotropic drugs• Correction of visual impairment, particularly cataract

extraction• Home environmental hazard assessment and safety

education• Calcium and vitamin D supplementation for those in

institutional care

• Gillespie LD, et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2012, Art. no. CD007146.

• Cameron ID, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, 2010, Art. no. CD005465.

7.7 Evidence-based interventions to prevent falls in older people

brainstem symptoms or signs are present, MRI of thebrain is required to exclude a cerebello-pontine anglelesion.

Delirium

Delirium is a syndrome of transient, reversible cogni-tive dysfunction. It is very common, affecting up to30%ofolderhospitalinpatients,eitheratadmissionorduring their hospital stay. It is associated with highrates of mortality, complication and institutionalisa-tion, and with longer lengths of stay. Risk factors areshown in Box 7.8. Its pathophysiology is unclear; itmay in part be due to the effect of increased cortisolreleaseinacuteillness,oritmayreflectasensitivityofcholinergic neurotransmission to toxic insults. Oldertermsfordelirium,e.g.acuteconfusionortoxicconfu-sional state, lack diagnostic precision and should beavoided.

Clinical assessmentAssessmenthastwomaingoals:firstly,toestablishthediagnosis of delirium; and secondly, to identify allof the reversible precipitating factors to allow optimaltreatment.

Delirium may be missed unless routine cognitivetestingwithanAbbreviatedMentalTest,CLOXtestormini-mental state examination (MMSE; p. 234) is per-formed.Deliriumoftenoccursinpatientswithdemen-tia, and a history from a relative or carer about theonsetandcourseofconfusionisneededtodistinguishacutefromchronicfeatures.TheConfusionAssessmentMethod (Box7.9) is auseful tool todiagnosedeliriumaccurately and to differentiate the condition fromdementia.

Morethanoneoftheprecipitatingcausesofdelirium(Fig. 7.3) is often present. Symptoms suggestive of aphysicalillness,suchasaninfectionorstroke,shouldbeelicited.Anaccuratedrugandalcoholhistoryisrequired,especially to ascertain whether any drugs have beenrecentlystoppedorstarted.

A full physical examination should be performed,notinginparticular:

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Fig. 7.3 Common causes and investigation of delirium. All investigations are performed routinely, except those in italics. *Tend to present over weeks to months rather than hours to days. The chest X-ray shows consolidation in pneumonia. The CT scan shows a cerebral haemorrhage. (COPD = chronic obstructive pulmonary disease; CRP = C-reactlve protein; MI = myocardial infarction; SSRI = selective serotonin re-uptake inhibitor; UTI = urinary tract infection)

Infection

Metabolicdisturbance

Toxic insult

Acuteneurologicalconditions

Hypoxia

PneumoniaUTISkin: cellulitis, abscessGram-negative sepsis

Full blood count, CRPChest X-rayUrinalysis and cultureOthers as appropriate: sputum,blood cultures, wound swabs

Digoxin level if prescribed

Urea and electrolytesPlasma calciumCapillary blood and plasma glucoseLiver function testsThyroid function testsB12 and folate

CT brain: only when intracraniallesion is suspected (focal neurologicalsigns, recent fall or head injury) or noother physical cause of delirium isidentifiedLumbar puncture: only if meningitis orencephalitis is suspected

Pulse oximetry (arterial blood gases if low)Chest X-rayECG

Acute renal impairmentHyponatraemia/hypernatraemiaHypercalcaemiaHypoglycaemiaHepatic encephalopathyThiamin deficiencyHypothyroidism*B12 deficiency*

Any drug but particularly• Anticholinergics• Digoxin• Opiates• Psychotropics• High-dose corticosteroidsWithdrawal of alcohol, opiate, SSRIor benzodiazepine

Acute strokeSubdural haematomaEncephalitis or meningitisSeizure (post-ictal)Space-occupying lesion, e.g. tumour

Pulmonary embolismPneumoniaPulmonary oedemaCOPD exacerbationAcute MI

Talk to the patient and assess:

• Cognition (e.g. MMSE, p. 234). A normal score makes delirium unlikely.

• Inattention. Can the patient converse with you? If in doubt, give 6–7 digits (between 1 and 9) to remember and repeat back to you; failure suggests inattention.

• Conscious level. Alert, hyper-alert or drowsy?• Thinking. Is speech rambling? Does it make sense? Is the

patient hallucinating?

Obtain a collateral history (e.g. from carer, nurse or general practitioner):

• What is the patient normally like?• Has there been a sudden deterioration, e.g. over a few days?• Does confusion fluctuate through the day?

Consider the diagnosis. Delirium is present if there is:

Acute deterioration in cognition, which fluctuates over time AND Evidence of inattentionWITH EITHER Evidence of disorganised thinkingOR Altered level of consciousness (either drowsy/stupor/coma or hyper-alert/agitated/irritable)

7.9 How to make a diagnosis of delirium: the Confusion Assessment Method (CAM)

• pyrexiaandanysignsofinfectioninthechest,skin,urineorabdomen

• oxygensaturation• signsofalcoholwithdrawal,suchastremoror

sweating• anyneurologicalsigns.

Arangeof investigationsareneededto identifythecommoncauses(seeFig.7.3).

ManagementSpecifictreatmentofallof theunderlyingcausesmustbe commenced as quickly as possible. However, thesymptoms of delirium also require specific manage-ment. To minimise ongoing confusion and disorienta-tion, the environment should be kept well lit and notundulynoisy,withthepatient’sspectaclesandhearingaidsinplace.Goodnursingisneededtopreserveorien-tation, prevent pressure sores and falls, and maintainhydration,nutritionandcontinence.

Theuseofsedativesshouldbekept toaminimum,astheycanprecipitatedelirium.Inanycase,manycon-fused patients are lethargic and apathetic rather thanagitated. Sedation is very much a last resort, and isappropriate only if patients’ behaviour is endangering

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themselvesorothers.Smalldosesofhaloperidol(0.5mgtwicedaily)aretriedorallyfirst,andthedoseincreasedif the patient fails to respond. Sedation can be givenintramuscularly only if absolutely necessary. In thosewith alcohol withdrawal or Lewy body dementia(p.252),areducingcourseofabenzodiazepineshouldbeprescribed.Inothercases,benzodiazepinesshouldbeavoided,astheymayprolongdelirium.

The resolution of delirium in old age may be slowand incomplete. Many patients fail to recover to theirpre-morbidlevelofcognition.Deliriummaybethefirstpresentationofanunderlyingdementiaandisalsoariskfactorforsubsequentdementia.

Urinary incontinence

Urinaryincontinenceisdefinedastheinvoluntarylossof urine and comes to medical attention when suffi-ciently severe to cause a social or hygiene problem. Itoccursinallagegroupsbutbecomesmoreprevalentinoldage,affectingabout15%ofwomenand10%ofmenagedover65.Itmayleadtoskindamageifsevereandcanbesociallyrestricting.Whileage-dependentchangesin the lower urinary tract predispose older people toincontinence, it is not an inevitable consequence of

Fig. 7.4 Assessment and management of urinary incontinence in old age. See also page 472 and NICE guideline on the Management of Incontinence in Women: www.nice.org.uk. (UTI = urinary tract infection)

Urinary incontinence

Overflow(i.e. residual

volume > 100 mL)Surgical relief ofobstruction (e.g.prostatectomy)

Intermittentcatheterisation

if no obstruction

StressPelvic floor

muscle trainingSurgical

intervention ifunsuccessful

If still incontinent:• Establish the pattern of urinary loss (diary is helpful)• Measure residual urine volume (by ultrasound)• Assess for vaginal prolapse and atrophic vaginitis (women)• Assess prostate by rectal examination (men)

Address contributory factors:• UTI• Severe constipation• Drugs, e.g. diuretics• Hyperglycaemia• Hypercalcaemia• Restricted mobility• Acute confusion

UrgeBladder

retrainingAntimuscarinic

drugs, e.g.solifenacin,tolterodine

ageingandrequiresinvestigationandappropriatetreat-ment.Urinaryincontinenceisfrequentlyprecipitatedbyacuteillnessinoldageandiscommonlymultifactorial(Fig.7.4).

Initial management is to identify and address con-tributoryfactors.Ifincontinencefailstoresolve,furtherdiagnosisandmanagementshouldbepursued,asdes-cribedonpage472.• Urge incontinenceisusuallyduetodetrusor

over-activityandresultsinurgencyandfrequency.

• Stress incontinenceisalmostexclusivetowomenandisduetoweaknessofthepelvicfloormuscles,whichallowsleakageofurinewhenintra-abdominalpressurerises,e.g.oncoughing.Itmaybecompoundedbyatrophicvaginitis,associatedwithoestrogendeficiencyinoldage,whichcanbetreatedwithoestrogenpessaries.

• Overflow incontinenceismostcommonlyseeninelderlymenwithprostaticenlargement,whichobstructsbladderoutflow.In patients with severe stroke disease or dementia,

treatmentmaybe ineffective, as frontal cortical inhibi-tory signals to bladder emptying are lost. A timed/promptedtoiletingprogrammemayhelp.Otherthaninoverflow incontinence, urinary catheterisation shouldneverbeviewedasfirst-linemanagement,butmayberequiredasafinalresortiftheperinealskinisatriskofbreakdownorqualityoflifeisaffected.

Adverse drug reactions

Adversedrugreactions(ADRs)andtheeffectsofdruginteractions are discussed on pages 24–28. They mayresultinsymptoms,abnormalphysicalsignsandalteredlaboratorytestresults(Box7.10).ADRsarethecauseofaround5%ofallhospitaladmissionsbutaccountforupto20%ofadmissionsinthoseagedover65.Thisispartlybecause older people receive many more prescribeddrugs than younger people. Polypharmacy has beendefinedastheuseoffourormoredrugs;thisshouldbeavoided if possible, but is not always inappropriatebecause many conditions, such as hypertension andheart failure, necessitate the use of several drugs, andolderpeoplemayhaveseveralcoexistingmedicalprob-lems(Box7.11).However,themoredrugsthataretaken,thegreatertheriskofanADR.Thisriskiscompoundedbyage-relatedchangesinpharmacodynamicandphar-macokineticfactors(pp.18–21),andbyimpairedhomeo-static mechanisms, such as baroreceptor responses,plasmavolumeandelectrolytecontrol.Olderpeoplearethusespeciallysensitivetodrugsthatcancauseposturalhypotension or volume depletion (see Box 7.10). Non-adherencetodrugtherapyalsoriseswiththenumberofdrugsprescribed.

TheclinicalpresentationsofADRsarediverse,soforanypresentingprobleminoldagethepossibilitythatthepatient’s medication is a contributory factor shouldalwaysbeconsidered.Failuretorecognisethismayleadtotheuseofafurtherdrugtotreattheproblem,makingmattersworse,whenthebettercoursewouldbetostoporreduce thedoseof theoffendingdrugor tofindanalternative.

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Factor Intervention required

Health conditionUnderlying disease, e.g. stroke, osteoarthritis

Medical or surgical treatment

ImpairmentSymptoms or signs of the condition, e.g. hemiparesis, visual loss

Medical or surgical treatment

Activity limitationResultant loss of function, e.g. walking, dressing

Rehabilitation, assistance, aids

Participation restrictionResultant loss of social function, e.g. cooking, shopping

Adapted accommodationSocial services

7.13 International classification of functioning and disability

• Hypothermia p. 104• Under-nutrition p. 120• Dementia p. 250• Infection pp. 296 and 306• Fluid balance problems p. 439• Heart failure p. 546• Hypertension p. 606• Dizziness and blackouts pp. 554 and 1157• Atrial fibrillation p. 564• Diabetes mellitus p. 806• Peptic ulceration p. 872• Anaemia p. 1001• Painful joints p. 1069• Bone disease and fracture pp. 1120 and 1071• Stroke p. 1231

7.12 Other presenting problems in old age

• Multiple pathology• Poor patient education (see Box 2.20, p. 35)• Lack of routine review of all medications• Patient expectations of prescribing• Over-use of drug interventions by doctors• Attendance at multiple specialist clinics• Poor communication between specialists

7.11 Factors leading to polypharmacy in old age

from that in younger individuals. These are listed onpage178.

REHABILITATION

Rehabilitationaims to improve theabilityofpeopleofallagestoperformday-to-dayactivities,andtorestoretheir physical, mental and social capabilities as far aspossible. Acute illness in older people is often associ-atedwith lossof theirusualability towalkorcare forthemselves, and common disabling conditions such asstroke, fractured neck of femur, arthritis and cardio-respiratorydiseasebecomeincreasinglyprevalentwithadvancingage.

Disability is an interaction between factors intrinsictotheindividualandthecontextinwhichtheylive,andboth medical and social interventions are needed toaddressthis(Box7.13).Doctorstendtofocusonhealthconditionsandimpairments,butpatientsaremorecon-cerned with the effect on their activities and ability toparticipateineverydaylife.

Regularreviewofmedicationsisimportantinprevent-ingADRs.Thepatientorcarershouldbeaskedtobringallmedicationforreviewrather thanthedoctorrelyingon previous records. Those drugs that are no longerneededorarecontraindicatedcanbediscontinued.

Other problems in old age

There is a vast range of other presenting problems inolderpeopleandtheypresenttomanymedicalspecial-ties. End-of-life care is an important facet of clinicalpractice in old age and is discussed on page 290.Relevant sections in other chapters are referenced inBox7.12.

Within each chapter, ‘In Old Age’ boxes highlighttheareasinwhichpresentationormanagementdiffers

Drug class Adverse reaction

NSAIDs Gastrointestinal bleeding and peptic ulcerationRenal impairment

Diuretics Renal impairment, electrolyte disturbanceGoutHypotension, postural hypotension

Warfarin Bleeding

ACE inhibitors Renal impairment, electrolyte disturbanceHypotension, postural hypotension

β-blockers Bradycardia, heart blockHypotension, postural hypotension

Opiates Constipation, vomitingDeliriumUrinary retention

Antidepressants DeliriumHyponatraemia (SSRIs)Hypotension, postural hypotensionFalls

Benzodiazepines DeliriumFalls

Anticholinergics DeliriumUrinary retentionConstipation

(ACE = angiotensin-converting enzyme; NSAID = non-steroidal anti-inflammatory drug; SSRI = selective serotonin re-uptake inhibitor)

7.10 Common adverse drug reactions in old age

Further information and acknowledgements

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• Re-assessment.Thereisongoingre-evaluationofthepatient’sfunctionandprogresstowardsthegoalsbytherehabilitationteam,thepatientandthecarer.Interventionsmaybemodifiedasaresult.

Multidisciplinary team workingThe core rehabilitation team includes all members ofthe multidisciplinary team (p. 167). Others may beinvolved, e.g. audiometry to correct hearing impair-ment,podiatryforfootproblems,andorthoticswhereaprosthesisorsplintingisrequired.Goodcommunicationandmutualrespectareessential.Regularteammeetingsallow sharing of assessments, agreement of rehabilita-tiongoalsandinterventions,evaluationofprogressandplanning for the patient’s discharge home. Rehabilita-tion isnotwhen thedoctororders ‘physio’or ‘ahomevisit’,andtakesnofurtherrole.

Rehabilitation outcomesThereisevidencethatrehabilitationimprovesfunctionaloutcomes in older people following acute illness,stroke and hip fracture. It also reduces mortality afterstroke and hip fracture. These benefits accrue fromcomplex multi-component interventions, but occupa-tional therapy to improve personal ADLs and indivi-dualised exercise interventions have now been shownto be effective in improving functional outcome intheirownright.

Further information and acknowledgements

Websiteshttp://profane.coPrevention of Falls Network Earth: focuses on

the prevention of falls and improvement of postural stability in older people.

www.americangeriatrics.orgAmerican Geriatrics Society. Education, careers vignettes from geriatricians, advocacy and clinical guidelines.

www.bgs.org.ukBritish Geriatrics Society: useful publications on management of common problems in older people and links to other relevant websites.

www.eugms.orgEuropean Union Geriatric Medicine Society. Research, position papers and educational resources.

www.iagg.infoInternational Association of Gerontology and Geriatrics. Promoting care of older people and the science of gerontology globally; research, policy and educational resources.

www.knowledge.scot.nhs.uk/effectiveolderpeoplecare.aspxCollates and summarises the Cochrane evidence for best practice in the health care and rehabilitation of frail older people.

Figure acknowledgementsPage 166 insets(Wasted hand, kyphosis)AfzalMirM.Atlasof

clinicaldiagnosis.2ndedn.Edinburgh:Saunders;2003;copyrightElsevier;(Senile purpura)ForbesCD,JacksonWF.Clinicalmedicine.3rdedn.Edinburgh:Mosby;2004(p.438,Fig.10.101);copyrightElsevier;(Venous ulceration)GiovanniMosti,ClinicsinPlasticSurgery,2012,39(3):269–280,Figure1;copyright©2012ElsevierInc.;allreproducedwithpermission.

Mobility

Independent = 3 Needs help = 2 Wheelchair independent = 1 Immobile = 0

Stairs

Independent = 2 Needs help = 1 Unable = 0

Transfers (e.g. from bed to chair)

Independent = 3 Needs minor help = 2 Needs major help = 1 Unable = 0

Bladder

Continent = 2 Occasional incontinence = 1 Incontinent = 0

Bowels

Continent = 2 Occasional incontinence = 1 Incontinent = 0

Grooming

Independent = 1 Needs help = 0

Toilet use

Independent = 2 Needs help = 1 Unable = 0

Feeding

Independent = 2 Needs help = 1 Unable = 0

Dressing

Independent = 2 Needs some help = 1 Completely dependent = 0

Bathing

Independent = 1 Needs help = 0

The total score reflects the degree of dependency; scores of 14 and above are usually consistent with living in the

community; scores below 10 suggest the patient is heavily dependent on carers.

7.14 How to assess rehabilitation needs using the Modified Barthel Index (20-point version)

The rehabilitation processRehabilitation is a problem-solving process focusedonimprovingthepatient’sphysical,psychologicalandsocialfunction.Itentails:• Assessment.Thenatureandextentofthepatient’s

problemscanbeidentifiedusingtheframeworkinBox7.13.Specificassessmentscales,suchastheElderlyMobilityScaleorBarthelIndexofActivitiesofDailyLiving(Box7.14),areusefultoquantifycomponentsofdisability,butadditionalassessmentisneededtodeterminetheunderlyingcausesortheinterventionsrequiredinindividualpatients.

• Goal-setting.Goalsshouldbespecifictothepatient’sproblems,realistic,andagreedbetweenthepatientandtherehabilitationteam.

• Intervention.Thisincludestheactivetreatmentsneededtoachievetheestablishedgoalsandtomaintainthepatient’shealthandqualityoflife.Interventionsincludehands-ontreatmentbytherapistsusingafunctional,task-orientatedapproachtoimproveday-to-dayactivities,andalsopsychologicalsupportandeducation.Theemphasisonthetypeofinterventionwillbeindividualised,accordingtothepatient’sdisabilities,psychologicalstatusandprogress.Thepatientandcarer(s)mustbeactiveparticipants.

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Environmental and nutritional factors in disease

• Environmental factors in disease p. 102• Thermoregulation p. 104• Energy balance p. 122• Vitamin deficiency p. 127

Infectious diseases

• Problems with antimicrobial therapy p. 154• Fever p. 296• Infectious diarrhoea p. 306

Clinical biochemistry and metabolism

• Hyponatraemia and hypernatraemia p. 439• Management of hyperlipidaemia p. 458

Kidney and urinary tract disease

• Incontinence p. 473• Acute kidney injury p. 483• Renal replacement therapy p. 491• Urinary infection p. 512

Cardiovascular disease

• Congestive cardiac failure p. 551• Atrial fibrillation p. 566• Angina p. 595• Myocardial infarction p. 599• Atherosclerotic vascular disease p. 602• Hypertension p. 610• Aortic stenosis p. 622• Endocarditis p. 626

Respiratory disease

• Respiratory function p. 648• Obstructive pulmonary disease p. 677• Respiratory infection p. 686• Interstitial lung disease p. 714• Thromboembolic disease p. 724• Pleural disease p. 731

Endocrine disease

• The thyroid gland p. 755• Gonadal function p. 766• The parathyroid glands p. 770• Glucocorticoids p. 779• Spontaneous hypoglycaemia p. 784• The pituitary and hypothalamus p. 795

Diabetes mellitus

• Diagnosis of diabetes mellitus p. 806• Diabetes management p. 828

Alimentary tract and pancreatic disease

• Endoscopy p. 850• Acute abdominal pain p. 863• Oral health p. 864• Gastro-oesophageal reflux disease p. 868• Peptic ulcer disease p. 875• Malabsorption p. 883• Constipation p. 918

Liver and biliary tract disease

• Liver disease p. 980• Gallbladder disease p. 988

Blood disease

• Haematological investigations p. 1001• Anaemia p. 1034• Haematological malignancy p. 1047• Haemostasis and thrombosis p. 1056

Rheumatology and bone disease

• Use of oral NSAID p. 1079• Osteoarthritis p. 1085• Gout p. 1090• Joint and bone infection p. 1094• Osteoporosis p. 1124

Neurological disease

• Neurological examination p. 1139• Dizziness p. 1158• Epilepsy p. 1185

Other

• Prescribing p. 36• Genetic disease and counselling p. 64• Immune senescence p. 82• The critically ill older patient p. 204• Poisoning p. 208• Medical psychiatry p. 238• Cancer p. 271• HIV infection p. 410• Skin changes p. 1254

7.15 Index of ‘In Old Age’ boxes