Chapter 39. Care of the elderly
The proportion of the population that is over the age of 70 is rising.
Old age may bring a combination of factors rendering the old person especially vulnerable to an acute breakdown in their capacity to cope:
• Social isolation
• Poor housing
• Low income
• Precarious functional capacity
• Dependency on others.
Many old people are fiercely proud and independent and may fail to recognise or acknowledge their increasing vulnerability.
Negative attitudes to old age (ageism) must be avoided by healthcare professionals.
The nature of acute illness in old age
Acute illnesses in old people often fail to present with convenient and characteristic symptoms or physical signs:
• A myocardial infarct may not present with crushing central chest pain but rather with a fall, acute onset of mental confusion or simply breathlessness
• Acute infections may fail to mount the response of an immune reaction (raised white cell count) or a raised body temperature.
Acute illnesses in old people arise in the context of a general background of failing health such as:
• Memory loss and impairment of intellect. The elderly brain is especially susceptible to the toxic effects of any acute illness, so that acute onset of mental confusion may be a presenting symptom
• Failing eyesight or hearing
• Increase in postural sway so that acute illnesses may present as falls
• Impaired central control of bladder function so that acute illnesses may present with urinary incontinence
• Perhaps most importantly, an accumulation of other diseases; for example, a fairly trivial acute illness may arise in a person already compromised by heart failure and further limited by impaired mobility following an operation for a fractured neck of femur.
Acute illnesses in old people often arise in a situation of precarious social circumstances in which the support network for the individual is already stretched.
The paramedic called to an emergency must be aware that an apparently minor illness in an old person can have very different consequences from the same illness in a young person.
Major health problems in old age
Intellectual disorder
In simple terms, intellectual disorder is of two types: due to disease outside the brain (extrinsic) and due to intrinsic brain disease (dementia).
Extrinsic causes
Mental impairment may be caused by:
• Drugs
• Infections
• Hypoxia
• Dehydration
• Electrolyte disorders
• Disturbances of carbohydrate metabolism
• Renal or hepatic failure
• Hypothyroidism and vitamin B 12 and folate deficiency (rare)
• Head injury.
The intellectual dysfunction associated with these extrinsic causes is usually short-lived, unless there is co-existing intrinsic brain disease.
Two cardinal features distinguish this type of mental disorder from dementia:
• Acute onset (and usually rapid resolution)
• Disturbed or fluctuating conscious level.
Intrinsic causes
Dementia is a pathological state characterised by diffuse loss of brain tissue. When brain tumour and other focal conditions have been excluded, the usual causes are Alzheimer’s disease, multifocal vascular disease and a mixture of the two. Dementia also occurs in Parkinson’s disease, Huntington’s chorea and other rarer brain diseases.
Alzheimer’s disease is a slowly progressive disease with a 10-year course on average. Most cases appear in the 8th and 9th decades.
Vascular brain disease, also called multiinfarct dementia, occurs in hypertensive patients who suffer progressive loss of brain tissue, with or without focal neurological signs. Many of these patients die from cardiac disease or stroke.
The history
Patients may give a very misleading history of the illness as they are unable to assess their current state, but may be able to talk convincingly and positively of their past life. Be very wary of patients who make even the slightest lapse from consistency of accuracy in answering questions and seek information from relatives who have watched them over a period of time.
Eventually a crisis occurs, which carers can no longer accept and this fracture of sound support may masquerade as a medical emergency.
Indicators of intellectual disorder in the elderly
• An increased use of the telephone, especially in the middle of the night
• Frequent losses of key, pension books, money, jewellery
• Accusations that others have stolen these
• Burning out kettles
• Leaving the gas on unlit
• Resistance to bathing and changing clothes
• Changes in sleep–wake patterns
• Soiling of clothes and neglect of personal appearance
• Leaving the house and getting lost
• Repeatedly asking the same question
• Misidentifying or failing to identify near relatives
• Speaking of the past as if it were the present and of dead people, e.g. parents, as if they were still alive.
Immobility
Immobility can be defined as an inability to occupy space (the life-space, ranging from anywhere in the world to the confines of an upstairs bedroom).
What are the consequences of immobility?
Loss of choice:
• Being able to go where we want to be and thus be able to do what we want to do
• Being alone or with others
• Having the TV on or off (look around any hospital ward or old people’s home).
Loss of capability:
• Getting to the toilet in time, answering the door or getting upstairs
• Social responsiveness
• Worsening physical dependency.
An old person’s world may thus contract and after becoming housebound, he (or more often she) then becomes restricted to the lower half of the house and eventually perhaps to one room.
Barriers to maintaining mobility in old age
Physical barriers (often more than one):
• Joint problems, especially osteoarthritis of knees and hips
• Neurological deficit: impaired balance, stroke, Parkinson’s disease
• Previous falls
• Sensory deprivation: deafness, impaired vision
• Cardiovascular and respiratory diseases.
Mental barriers:
• Reduced expectations of an active life
• Loss of adaptability and creativity
• Introversion with reduced social contact
• Anxiety and fear of going out (or of allowing others to).
Social barriers:
• Retirement brings with it dangers of reduced social contact and a drop in income
• Living alone: an epidemic problem in ageing women
• Nowhere to go – insufficient outside interests or activities.
Incontinence
Anyone can become incontinent if not able or not allowed to have access to proper toilet facilities. The elderly are more vulnerable because of poor mobility and frequency and urgency of micturition. Any acute illness is likely to be associated with deterioration in continence but usually, this is transient. Any change of environment such as admission to hospital may also lead to a temporary period of incontinence.
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