Introduction of HCE

Introduction of HCE 9.4 million people over 65yrs in UK (approx 18% population) Non Specific presentations E.g. Are due to Homeostatic Failure confusion (delerium, demetia, infection, dysphasia, deafness “off legs” (CVA, confusion, MI, poor balance) Fall (confusion, off legs, poor vision etc) Mechanisms rely on each other – multiple pathology à less able to cope à failure e.g. drop in O2 should à increased ventiliation & CO but if angina, HF à pulmonary oedema à resp distress à decreased nutrition & dehydration à decreased CO & flow à delerium, renal failure etc Because of Multiple pathology IHD, HT, CVD, PVD, RVD, COPD, DM, Athritis (oesteo), vision (macular degeneration, glaucoma, cataracts), hearing, dementia, depression, parkinsons And Differential Challenge Poor support when needed most Social isolation Financial vulnerability Housing (cold, stairs, outside toilet) Rounded treatment of ALL failures à more successful cure Care Homes residential = w/o nursing, nursing = with Part 3 = residential for homeless Factors affecting institutionalisation Political (culture, society, family) Increasing age Living alone (social vulnerability) Disability (most commonly stroke à hemiparesis) Cognitive impairment (most commonly dementia) Alternatives Treat disease where possible (e.g. HF, parkinsons) Rehab after acute treatment (e.g. stroke) Disability management in the community (e.g. sheltered housing, adaptations) More effective links between hospital, GP, OT PT & district nurses On admission to care home Still under 1o care – full assessment before entry to assess capability, full diagnosis list allows treatment of all conditions to maximise function Medication review to reduce iatrogenic disease ALL ambulant residents on Ca2+, Vit D (help with fall prevention) End of life planning – ensures terminal care can be given in familiar setting Routine function monitoring – loss of function is a non specific presentation & needs review Examination of the Elderly Patient Gait Aided / unaided Foot drop Shuffling / striding, stable / unstable Difficulty in & out of chair? Parkinsonian? Multi-infarct? Face Parkinsonian (‘reptilian gaze’, immobility, fixed posture) Depression Hypothyroid, anamia, vitiligo Angular stomatitis (ill fitting dentures) Orofacial dyskinesia Ptosis (symmetrical = senile, unilateral = pathological / surgery) Basal cell carcinoma Facial palsy Joint disease Stiff neck Tentative handshake (rotator cuff atrophy, difficulty with sleeves) Stiff hips / knees Kyphosis & protruberant abdomen (osteoporosis) Self Neglect Dirty hand / face / body / clothes Evidence of incontinence Unshaven hair, unkempt Neglected nails Nutrition Obesity PEM (compare prev notes) Signs of recent weight loss / cachexia Hydration Conversation Appropriate? Good account of circumstances? Plausible? Dyspnoea Mood, emotional lability Speech – dysarthria, dysphasia, weak rapid Formal examination Extrasystoles – common and seldom significant Neglected breast cancer Displaced apex beat (chest deformity, also affects murmer radiation) Peripheral pulses – palpate & auscultate Abdomen – ribs tend to sit over pelvis (makes palpation difficult), faceal loading, distended bladder, kidneys Ankle jerks – usually present, plantar strike often works best