Falls, delirium, dementia, polypharmacy, frailty, continence, and comprehensive geriatric assessment.
21 topics · 31 linked questions
Falls and Fall Prevention
Falls are the most common cause of injury-related death in people over 75 in the UK, requiring a multifactorial risk assessment and individualised intervention programme.
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Key Facts
One in three adults over 65 falls each year; one in two over 80
Falls are the most common cause of injury-related death in people >75 in the UK
NICE CG161 recommends multifactorial falls risk assessment for all older people presenting with a fall or at risk of falling
Lying and standing blood pressure must be measured in all falls assessments (postural drop ≥20mmHg systolic)
Hip protectors reduce hip fracture risk in nursing home residents who are at high risk of falls
Overview
Key Facts
Falls in older people are rarely due to a single cause. A comprehensive multifactorial assessment is essential to identify and address modifiable risk factors.
Epidemiology
One in three people >65 falls each year; increases to one in two >80
Falls cause >250,000 fractures per year in the UK
Approximately 30% of falls result in injury; 5% result in fracture
Hip fracture: approximately 66,000 per year in the UK; 30-day mortality ~8%
Annual NHS cost of falls in older people: approximately £2.3 billion
Balance and mobility assessment is a core component of falls evaluation and geriatric assessment, using validated tools to identify gait and balance impairments and guide targeted interventions.
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Key Facts
Gait and balance impairment is the single strongest predictor of future falls in older adults
Timed Up and Go (TUG): stand from chair, walk 3m, turn, return, sit down; >12 seconds suggests increased fall risk
30-second Chair Stand Test: functional lower limb strength; <8 stands is below normal for >65
Tinetti Performance-Oriented Mobility Assessment (POMA): gait (12 points) + balance (16 points); <19 = high fall risk
Short Physical Performance Battery (SPPB): combines balance, gait speed, and chair stands (0-12); <10 = increased disability risk
Gait speed <0.8 m/s is associated with increased mortality and frailty
Dual-task testing (walking while performing cognitive task) identifies those at highest fall risk
Overview
Key Facts
Balance and mobility assessment should be performed for all older adults at risk of falls or presenting with mobility difficulties. It informs targeted exercise prescriptions and intervention planning.
Epidemiology
Gait speed declines approximately 1-2% per year after age 60
Balance impairment is present in approximately 30% of people >65
Gait and balance disorders are the second most common cause of falls (after environmental hazards)
Reduced mobility is strongly associated with institutionalisation and death
Aetiology
Balance and mobility impairment in older adults is usually multifactorial:
Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event, identified using validated tools and managed through comprehensive geriatric assessment.
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Key Facts
Frailty affects approximately 10% of people >65 and 25-50% of people >85 in the UK
Comprehensive Geriatric Assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, functional, and social capabilities of a frail older person to develop a coordinated care plan.
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Key Facts
CGA is the gold standard for assessment and management of frail older people in hospital and community settings
Meta-analysis evidence (Ellis et al. 2011, 2017): CGA increases the likelihood of being alive and in own home at 12 months (NNT = 13)
CGA reduces mortality (OR 0.76), institutionalisation, functional decline, and length of stay
CGA should be delivered in a dedicated geriatric unit where possible (associated with best outcomes)
Goal-setting is a key component: patient-centred goals guide the management plan
CGA is process-driven (not just a one-off assessment) with regular review and adaptation
Overview
Key Facts
CGA is one of the most evidence-based interventions in medicine for improving outcomes in frail older adults. It is both an assessment tool and a management framework.
Epidemiology
Approximately 30-50% of hospital inpatients >65 would benefit from CGA
Acute frailty units using CGA have improved outcomes compared to standard care
CGA is recommended by NICE for all frail older people admitted to hospital
Aetiology
CGA addresses the multifactorial nature of illness and decline in older adults, recognising that a single disease model is inadequate.
Pathophysiology
Frail older adults have reduced physiological reserve
Delirium is an acute, fluctuating disturbance of consciousness and cognition caused by an underlying medical condition, affecting up to 30% of hospitalised older adults and associated with increased mortality.
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Key Facts
Delirium affects up to 30% of hospitalised older adults and 50-80% of ICU patients
4AT is the recommended rapid screening tool (NICE NG103, Sign 157); score ≥4 suggests delirium
Three subtypes: hyperactive (agitation), hypoactive (most common, worst prognosis, often missed), mixed
Always reversible in principle - identify and treat the underlying cause; use the mnemonic PINCH ME (Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment)
Avoid antipsychotics unless patient is at risk of harm; if essential, use haloperidol 0.5-1mg (avoid in Lewy body/Parkinson's - use lorazepam 0.5-1mg)
Predisposing factors: age >65, dementia, severe illness, hip fracture, visual/hearing impairment
Dementia is a progressive syndrome of cognitive decline affecting approximately 900,000 people in the UK, with Alzheimer's disease being the most common cause, requiring early diagnosis, acetylcholinesterase inhibitors, and comprehensive support.
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Key Facts
Dementia affects approximately 900,000 people in the UK; projected to exceed 1 million by 2025
Polypharmacy is the concurrent use of multiple medications, commonly defined as 5 or more regular drugs, with deprescribing being the planned, supervised withdrawal of inappropriate medications to improve outcomes.
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Key Facts
Polypharmacy (≥5 medications) affects approximately 50% of people >65 and >70% of care home residents in the UK
Appropriate polypharmacy is necessary for multimorbidity; problematic polypharmacy occurs when the risks outweigh benefits
Adverse drug reactions (ADRs) account for 6-7% of hospital admissions in older adults
STOPP/START criteria (v2, 2015): evidence-based screening tool for potentially inappropriate medications (STOPP) and potential prescribing omissions (START)
Beers Criteria: American Geriatrics Society list of potentially inappropriate medications in older adults
Anticholinergic burden: cumulative effect of anticholinergic drugs increases falls, delirium, and cognitive impairment risk
NICE NG56: recommends structured medication review for all people with multimorbidity, especially those on ≥10 medications
Deprescribing should be gradual, patient-centred, and monitored for withdrawal effects
Overview
Key Facts
Medication review and deprescribing are essential components of managing older adults with multimorbidity. The goal is to optimise medications, reduce harm, and improve quality of life.
Epidemiology
50% of >65s take ≥5 medications; 20% take ≥10
ADRs cause 6-7% of hospital admissions in older adults (preventable in ~50%)
Falls related to polypharmacy: 1.5-2× increased risk
Care home residents: average 7-8 regular medications
Urinary incontinence affects approximately 30-50% of older adults, with stress, urge, overflow, and functional subtypes requiring targeted investigation and management including behavioural therapies and pharmacotherapy.
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Key Facts
Urinary incontinence affects 30-50% of community-dwelling older adults and >50% of care home residents
Types: stress (weak pelvic floor), urge/overactive bladder (most common in elderly), overflow (retention), functional (mobility/cognition), mixed
NICE NG123: behavioural therapies (bladder training, pelvic floor exercises) are first-line for all types
Antimuscarinics for urgency/OAB: oxybutynin 2.5-5mg BD-TDS (avoid in elderly due to cognitive effects) - prefer solifenacin 5-10mg OD or tolterodine 2-4mg MR OD
Mirabegron 50mg OD (β3 agonist): alternative to antimuscarinics with fewer cognitive side effects (preferred in elderly)
Post-void residual >100ml suggests overflow incontinence (retention with overflow)
Incontinence causes significant psychosocial impact: depression, social isolation, falls, skin breakdown, carer burden
Overview
Key Facts
Urinary incontinence is common but not inevitable in ageing. It is often under-reported and under-treated. Many cases are modifiable with appropriate assessment and intervention.
Epidemiology
Prevalence: 30-50% community-dwelling >65; >50% in care homes
More common in women (stress incontinence) but urge incontinence is equally common in both sexes in old age
Constipation affects up to 50% of older adults and care home residents, requiring identification of reversible causes and a stepwise approach to laxative therapy, with particular attention to medication-related and secondary causes.
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Key Facts
Constipation affects 20-30% of community-dwelling older adults and up to 50% of care home residents
Rome IV criteria: <3 spontaneous bowel movements per week with straining, hard stools, or incomplete evacuation
Common causes in elderly: medications (opioids, anticholinergics, calcium, iron), immobility, dehydration, low fibre, hypothyroidism, hypercalcaemia, colorectal cancer
NICE CG99: first-line laxatives include macrogol (Movicol) and osmotic or stimulant laxatives
Opioid-induced constipation: co-prescribe laxatives prophylactically (senna + docusate); consider naloxegol 25mg OD if standard laxatives fail
Faecal impaction can cause overflow diarrhoea (often misdiagnosed), delirium, urinary retention, and incontinence
Always exclude colorectal cancer in patients with new-onset constipation over 60 (change in bowel habit >4 weeks + rectal bleeding → 2-week wait)
Bristol Stool Chart types 1-2 indicate constipation; aim for type 3-4
Overview
Key Facts
Constipation in older adults is often multifactorial and requires a systematic approach to identify and address reversible causes before escalating laxative therapy.
Epidemiology
20-30% of community-dwelling >65; up to 50% in care homes
More common in women and with increasing age
A common reason for GP consultation and A&E attendance
Aetiology
Medications: opioids (most common drug cause), anticholinergics, calcium supplements, iron, antipsychotics, tricyclic antidepressants
Step 2 - Osmotic: macrogol (Movicol) 1-3 sachets daily (NICE first-line for most patients); lactulose 15-30ml BD (alternative)
Step 3 - Stimulant: senna 15-30mg ON; bisacodyl 5-10mg ON
Combination: often needed; senna + docusate (softener + stimulant)
Faecal impaction: high-dose macrogol (Movicol 8 sachets/day for up to 3 days) for soft impaction; glycerine suppositories or phosphate enema for rectal loading; manual evacuation under sedation if necessary
Opioid-induced constipation: prophylactic senna + docusate; if refractory: naloxegol 25mg OD (peripherally acting μ-opioid receptor antagonist) or methylnaltrexone 12mg SC
Prucalopride 1mg OD (5-HT4 agonist): for chronic constipation when two laxatives have failed (specialist initiation)
Linaclotide 290mcg OD: for IBS-C if standard laxatives fail
Surgical/Interventional
Manual evacuation: for hard faecal impaction in rectum
Transanal irrigation: for neurogenic bowel
Surgery: very rarely needed; subtotal colectomy for refractory slow-transit constipation (specialist)
Referral Criteria
Red flags for malignancy: 2-week wait (NICE NG12)
Failed two laxatives over adequate trial: specialist referral
Malnutrition affects approximately 3 million people in the UK and sarcopenia affects 10-30% of community-dwelling older adults, both contributing significantly to frailty, falls, and mortality.
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Key Facts
Malnutrition affects approximately 3 million people in the UK; >30% of hospital admissions in older adults are malnourished
MUST (Malnutrition Universal Screening Tool): should be used on all hospital admissions and care home residents (NICE CG32)
Prevalence: sarcopenia affects 10-30% of community-dwelling >60; up to 50% in hospitalised older adults
Protein intake: older adults need 1.0-1.2 g/kg/day (higher than younger adults); 1.2-1.5 g/kg/day if acutely ill
Resistance exercise is the most effective intervention for sarcopenia; combined with adequate protein
Oral nutritional supplements (ONS): Fortisip/Ensure; improve nutritional status and reduce mortality in malnourished patients
Refeeding syndrome: risk in severely malnourished patients when refeeding; monitor phosphate, potassium, magnesium
Overview
Key Facts
Malnutrition and sarcopenia are interrelated conditions that significantly worsen outcomes in older adults. Both are modifiable with appropriate nutrition and exercise.
Epidemiology
Malnutrition: ~3 million affected in the UK; 30% of hospital admissions
Sarcopenia: 10-30% of community-dwelling >60; increases with age
Both contribute to frailty, falls, functional decline, and mortality
Malnutrition costs the NHS approximately £20 billion/year
Osteoporosis is a systemic skeletal disease characterised by low bone density and microarchitectural deterioration, causing approximately 500,000 fragility fractures per year in the UK.
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Key Facts
Osteoporosis affects approximately 3 million people in the UK; causes ~500,000 fragility fractures/year
Defined by DEXA T-score ≤ -2.5 at hip or spine; osteopenia: T-score -1.0 to -2.5
Fragility fracture = fracture from standing height or less; hip, spine, and wrist most common
Vitamin D (800-1,000 IU daily) + calcium (1,000mg total daily intake): recommended with bisphosphonate therapy
Denosumab 60mg SC 6-monthly: if bisphosphonates contraindicated/not tolerated (FREEDOM trial)
Fracture Liaison Service (FLS): secondary fracture prevention; all fragility fracture patients should be assessed
Overview
Key Facts
Osteoporosis is often called the 'silent disease' as it is typically asymptomatic until a fracture occurs. Secondary fracture prevention is critical as the risk of further fracture is highest in the first 2 years.
Epidemiology
~3 million people affected in the UK
~500,000 fragility fractures/year: hip (~66,000), vertebral (~120,000), wrist (~70,000)
1 in 2 women and 1 in 5 men >50 will have a fragility fracture
Annual cost to NHS: ~£4.4 billion
Aetiology
Primary: postmenopausal (oestrogen deficiency) and age-related
Hip fracture is a common and serious injury in older adults with approximately 66,000 cases per year in the UK, requiring surgery within 36 hours and comprehensive orthogeriatric care to reduce mortality.
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Key Facts
Hip fracture affects approximately 66,000 people/year in the UK; predominantly older women with osteoporosis
30-day mortality: approximately 8%; 1-year mortality: approximately 30%
NICE NG124: surgery within 36 hours of admission (improves outcomes and reduces mortality)
Intracapsular fractures: hemiarthroplasty (displaced) or cannulated screws (undisplaced) in fit patients; total hip replacement if independently mobile and cognitively intact
Extracapsular fractures: dynamic hip screw (DHS) for intertrochanteric; intramedullary nail for subtrochanteric/reverse oblique
Orthogeriatric care (shared care with geriatrician from admission): reduces mortality by 30% and LOS
Best Practice Tariff (BPT) standards: surgery <36h, orthogeriatric assessment <72h, bone protection, falls assessment, physio from day 1
All patients should receive bone protection and falls prevention - secondary fracture prevention is critical
Overview
Key Facts
Hip fracture is one of the most common reasons for emergency hospital admission in older adults and is associated with significant morbidity and mortality. Rapid surgery and comprehensive geriatric care are essential.
Epidemiology
~66,000 hip fractures/year in the UK
Mean age: 83 years; 75% are women
30-day mortality: ~8%; 1-year mortality: ~30%
Only 50% regain pre-fracture level of independence
Annual cost: ~£2 billion
Aetiology
Low-energy fall (standing height) in the context of osteoporosis (most common scenario)
High-energy trauma in younger patients (road traffic collision)
Pathophysiology
Intracapsular (subcapital/transcervical - within joint capsule): disrupts blood supply to femoral head (retinacular vessels) → risk of avascular necrosis (AVN) and non-union
Garden classification: I-II (undisplaced); III-IV (displaced)
Extracapsular (intertrochanteric/subtrochanteric - outside capsule): blood supply intact; lower AVN risk; heals well with fixation
Subtrochanteric: higher mechanical forces; may be associated with bisphosphonate use (atypical fracture)
Clinical Presentation
Typical Presentation
Older adult after a fall (usually low-energy)
Pain in hip/groin (may be referred to knee)
Unable to weight-bear
Shortened and externally rotated leg (displaced fracture)
Pain on axial loading and log-roll
Occult Hip Fracture
Pain on weight-bearing but X-ray appears normal
May be ambulant
Requires MRI (gold standard) or CT if MRI not available
Red Flags
Pathological fracture (minimal/no trauma, known malignancy)
Bilateral fractures or fracture in young patient (metabolic bone disease, malignancy)
Neurovascular compromise (rare)
Signs of long lie: pressure injury, rhabdomyolysis, hypothermia, dehydration
Differential Diagnosis
Diagnosis
Key Features
Investigation
Pubic ramus fracture
Groin pain, can weight-bear (usually), tenderness over pubic ramus
Pelvic X-ray
Peri-prosthetic fracture
Previous hip replacement, fall
X-ray
Soft tissue injury
Pain but normal imaging, can weight-bear
Clinical, imaging if needed
Pathological fracture
Minimal trauma, bone lesion on X-ray
X-ray, CT, biopsy
Septic arthritis
Fever, hot swollen joint, unable to move hip
Aspiration, blood cultures
Diagnosis / Investigation
Bedside
Hip examination: shortened, externally rotated limb, pain on log-roll
Observations: HR, BP, temperature
ECG (pre-operative)
Cognitive screen (4AT for delirium; AMT for baseline cognition)
Lying/standing BP if possible
Fluid and nutritional assessment
Bloods
FBC, U&Es, LFTs, bone profile, clotting
Group and save/crossmatch
CRP (baseline)
CK if long lie (rhabdomyolysis)
Vitamin D
Imaging
AP pelvis + lateral hip X-ray: first-line imaging
MRI hip: gold standard for occult fracture (X-ray normal but clinical suspicion)
CT hip: alternative if MRI not available or contraindicated
CXR: pre-operative assessment
Special Tests
NHFD (National Hip Fracture Database): all patients entered
Pre-operative anaesthetic assessment
Echocardiography if significant murmur or cardiac history
Vertebral fractures are the most common osteoporotic fracture, yet only one-third are clinically diagnosed, causing significant pain, kyphosis, and functional decline in older adults.
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Key Facts
Vertebral fractures are the most common osteoporotic fracture; approximately 120,000/year in the UK
Only one-third are clinically diagnosed (two-thirds are incidental or unrecognised)
Height loss >4cm or kyphosis should prompt investigation for vertebral fractures
Thoracolumbar junction (T11-L1) is the most common site
Vertebral fracture assessment (VFA) via DEXA or spinal X-ray: identifies compression fractures
Management: analgesia, early mobilisation, physiotherapy, bone protection (alendronate 70mg weekly)
Vertebroplasty/kyphoplasty: for acute painful fractures not responding to conservative treatment (evidence equivocal; NICE IPG12)
One vertebral fracture increases the risk of further vertebral fracture by 5× ("vertebral fracture cascade")
Overview
Key Facts
Vertebral fractures are under-diagnosed and under-treated, yet they are a major cause of pain, disability, and further fracture risk in older adults.
Epidemiology
~120,000 vertebral fractures/year in the UK
Only ~33% clinically diagnosed (most are incidental findings)
Female:male ratio 2:1
Prevalence increases with age: 20% of women >70, 35% of women >80
Aetiology
Osteoporosis (primary cause in older adults)
Minimal or no trauma (spontaneous in severe osteoporosis)
Parkinson's disease is a progressive neurodegenerative disorder affecting approximately 150,000 people in the UK, characterised by bradykinesia, rigidity, and rest tremor, managed with levodopa as the mainstay of treatment.
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Key Facts
Parkinson's disease affects approximately 150,000 people in the UK; prevalence increases with age (1-2% >65)
Cardinal features: bradykinesia (must be present) + at least one of: rest tremor, rigidity
Levodopa (co-careldopa/co-beneldopa) is the most effective symptomatic treatment; start when symptoms affect quality of life
NICE NG71: do not delay levodopa to prevent motor complications; refer to specialist before starting treatment
Non-motor symptoms are common and disabling: depression, constipation, REM sleep behaviour disorder, anosmia, cognitive impairment, orthostatic hypotension
Never abruptly stop Parkinson's medications (risk of neuroleptic malignant-like syndrome / parkinsonism-hyperpyrexia)
Avoid dopamine-blocking drugs: metoclopramide, haloperidol, prochlorperazine (worsen Parkinson's); use domperidone for nausea
Falls are common in Parkinson's disease: multifactorial (postural instability, freezing, orthostatic hypotension, cognitive impairment)
Overview
Key Facts
Parkinson's disease is the second most common neurodegenerative disease after Alzheimer's. Management is complex, requiring specialist input and multidisciplinary care.
Epidemiology
~150,000 affected in the UK; ~18,000 new diagnoses/year
Prevalence: 1-2% of >65; mean age of onset: 65 years
Male:female ratio 1.5:1
Young-onset Parkinson's: <50 years (~5-10%)
Aetiology
Idiopathic (most common)
Loss of dopaminergic neurons in the substantia nigra pars compacta
Lewy bodies: α-synuclein protein aggregates (hallmark pathology)
Genetic: LRRK2, SNCA, Parkin, PINK1, GBA mutations (5-10% familial)
Risk factors: age, male sex, pesticide exposure, head trauma, family history
COMT inhibitors: entacapone 200mg with each levodopa dose, opicapone 50mg OD (adjunct to levodopa)
Motor fluctuations (wearing off/dyskinesia):
Add COMT inhibitor, MAO-B inhibitor, or dopamine agonist
Adjust levodopa dose/frequency
Amantadine 100mg BD-TDS for dyskinesia
Advanced therapies: apomorphine SC infusion, levodopa-carbidopa intestinal gel (LCIG/Duodopa), deep brain stimulation (DBS)
Non-motor management: treat depression (SSRIs, SNRIs), orthostatic hypotension (midodrine, fludrocortisone), constipation (macrogol), dementia (rivastigmine - only AChEI licensed for PDD)
Surgical/Interventional
Deep brain stimulation (DBS): subthalamic nucleus or GPi; for motor fluctuations/dyskinesias despite optimised medication; improves motor function by ~50%
Focused ultrasound thalamotomy: emerging for tremor-predominant PD
Referral Criteria
All suspected PD: refer to specialist (neurologist or geriatrician with PD interest) before starting treatment (NICE NG71)
Complex motor fluctuations: specialist review
Advanced therapies: specialist PD centre
Cognitive decline: dementia assessment
Falls: falls prevention service + PD specialist review
Prognosis
Life expectancy: reduced by approximately 2-5 years compared to age-matched population
Motor complications (wearing off, dyskinesia): develop in 50% within 5 years of levodopa
Dementia: develops in ~80% of patients over 20-year course
Falls: affect >60% of PD patients; leading cause of hospital admission
Aspiration pneumonia: leading cause of death in advanced PD
Quality of life significantly impacted by non-motor symptoms
Individual prognosis varies widely; tremor-predominant has better prognosis than postural instability-gait difficulty (PIGD) phenotype
Pressure ulcers are localised injuries to the skin and underlying tissue, usually over a bony prominence, caused by sustained pressure, affecting approximately 700,000 people per year in the UK and largely preventable.
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Key Facts
Pressure ulcers affect approximately 700,000 people/year in the UK; cost NHS £3.8 billion annually
Most are preventable: regular repositioning, pressure-relieving devices, nutrition, skin assessment
NICE CG179: recommends risk assessment with validated tool (Waterlow, Braden) on admission and ongoing
Grading (EPUAP/NPUAP): Category 1 (non-blanchable erythema) to Category 4 (full-thickness tissue loss including bone/tendon)
Common sites: sacrum, heels, ischial tuberosities, greater trochanters, occiput
Pressure ulcers are a significant cause of morbidity, pain, and reduced quality of life. Prevention is far more effective and cost-effective than treatment.
Epidemiology
~700,000 affected per year in UK
Prevalence: 4-10% of hospital patients; up to 30% in care homes
Annual NHS cost: ~£3.8 billion (accounts for 4% of total NHS expenditure)
Category 2 and above are reportable as clinical incidents
Aetiology
Sustained pressure over bony prominence
exceeds capillary closing pressure (~32mmHg)
tissue ischaemia
necrosis
Shear forces: layers of tissue slide against each other (e.g. sliding down in bed)
Friction: skin dragged across surface
Moisture: maceration from incontinence or perspiration
Pathophysiology
Pressure > capillary closing pressure
microvascular occlusion
tissue hypoxia
ischaemia-reperfusion injury
cellular death
ulceration
Necrosis occurs from deep tissues outward ("iceberg" phenomenon - visible damage often underestimates deep tissue injury)
Reperfusion injury on release of pressure: reactive hyperaemia (blanching normal; non-blanchable = tissue damage)
Biofilm formation in chronic wounds impairs healing
Clinical Presentation
Category Classification (EPUAP/NPUAP)
Category 1: Non-blanchable erythema of intact skin
Category 2: Partial-thickness skin loss (dermis exposed); shallow open ulcer or blister
Category 3: Full-thickness skin loss (subcutaneous fat visible; bone/tendon NOT visible)
Category 4: Full-thickness tissue loss (bone, tendon, or muscle exposed)
Unstageable: obscured by slough or eschar (cannot assess depth)
Deep tissue injury: purple/maroon localised area; intact skin with underlying damage
End of life care for older adults requires recognition of dying, symptom management, personalised care planning, and support for patients and families, guided by principles of comfort, dignity, and individual choice.
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Key Facts
~500,000 people die each year in England; >80% of deaths are in people >65
Recognising dying is a clinical skill; use validated tools and clinical judgement (e.g., the Surprise Question: 'Would I be surprised if this patient died in the next 12 months?')
NICE NG31 (Care of Dying Adults): individualised care plan within hours of recognising dying
Preferred place of death: approximately 70% of people prefer to die at home; only ~25% do; ~46% die in hospital
Syringe driver (CSCI): continuous subcutaneous infusion for patients unable to take oral medication; mix medications as per local compatibility chart
Clinically assisted hydration: assess individually; not routinely started or continued in last days of life if not providing benefit
Communication: honest, compassionate conversations with patient and family about prognosis, treatment limitations, and goals of care
Overview
Key Facts
Good end of life care is a core competency for all doctors. It requires clinical skill in recognising dying, managing symptoms, and communicating sensitively with patients and families.
Epidemiology
~500,000 deaths/year in England
80% in people over 65
Most common causes of death in elderly: dementia, heart disease, cerebrovascular disease, respiratory disease, cancer
Place of death: hospital ~46%, home ~25%, care home ~22%, hospice ~6%
Aetiology
End of life care is needed for patients dying from any cause, including:
Cancer (predictable trajectory)
Organ failure: heart failure, COPD, renal failure (unpredictable trajectory with acute exacerbations)
Frailty/dementia (gradual decline)
Pathophysiology
Dying is a physiological process: progressive organ failure
Common symptoms in the last days: pain, agitation, respiratory secretions, nausea, dyspnoea
Reduced consciousness is normal in the dying process
Advance care planning is a voluntary process of discussion about future care between a person, their family, and healthcare professionals, enabling patients to express preferences and make legally binding advance decisions.
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Key Facts
Advance care planning (ACP) is a voluntary process of discussion about future care preferences and goals
Advance Decision to Refuse Treatment (ADRT): legally binding under the Mental Capacity Act 2005; must be written, signed, and witnessed if refusing life-sustaining treatment
Lasting Power of Attorney (LPA) for health and welfare: legal authority to make decisions on behalf of someone who lacks capacity; must be registered with the Office of the Public Guardian
DNACPR (Do Not Attempt Cardiopulmonary Resuscitation): a clinical decision but should involve patient/family discussion; documented on ReSPECT form in most of England/Wales
ReSPECT process: recommended summary plan for emergency care and treatment; replaces standalone DNACPR forms
ACP discussions should be initiated early, when the patient has capacity - not left until crisis
NICE NG97, NG31: recommend ACP discussions for patients with dementia and at end of life
ACP does not include euthanasia or assisted dying (which remain illegal in England and Wales)
Overview
Key Facts
Advance care planning gives patients a voice in their future care, especially when they may lose the capacity to make or communicate decisions. It is a process, not a one-off event.
Epidemiology
Only ~4% of the UK population have an ADRT
~10% have a registered health and welfare LPA
ReSPECT forms now in use across most of England and Wales
ACP is particularly important for: dementia, cancer, progressive neurological disease, frailty, COPD, heart failure
Aetiology
ACP is needed because:
Many patients lose capacity before death (dementia, stroke, delirium, ICU admission)
Without ACP, decisions are made by clinicians acting in patient's best interests (which may not align with patient's actual wishes)
Reduces unwanted hospital admissions and interventions at end of life
Pathophysiology
Not applicable (ethical/legal framework rather than pathological process). However, ACP is underpinned by the Mental Capacity Act 2005 which provides the legal basis for advance decisions and proxy decision-making.
Clinical Presentation
When to Discuss ACP
At diagnosis of life-limiting illness
When moving to care home
After significant deterioration or hospital admission
When Surprise Question answer is "No" (would not be surprised if died in 12 months)
At patient's request
During routine reviews for long-term conditions
Components of ACP
Patient's values, beliefs, and preferences
Understanding of their condition and prognosis
Preferred place of care and death
Specific treatment preferences (e.g. hospital admission, ICU, ventilation)
What matters most to the patient
Naming a spokesperson/proxy
Red Flags
Patient expressing strong views about future treatment without documented plan
Conflict between family members about patient's wishes
Patient with progressive illness and no ACP in place
Healthcare professional making decisions without exploring patient's wishes
Differential Diagnosis
Document
Legal Status
Scope
Advance statement
Not legally binding
General wishes and preferences
ADRT
Legally binding (if valid and applicable)
Specific refusal of treatment
LPA (health and welfare)
Legally binding when registered
Proxy decision-making
ReSPECT form
Clinical recommendation
Summary emergency care plan
DNACPR
Clinical decision
CPR decision only
Diagnosis / Investigation
Bedside
Capacity assessment (see Capacity Assessment topic): does the patient have capacity to make this decision now?
Review of existing documents (ADRT, LPA, ReSPECT)
Discussion with patient about values, wishes, and preferences
Discussion with family/carers (with patient's consent)
Bloods
Not applicable
Imaging
Not applicable
Special Tests
Not applicable (ACP is a communication process, not a diagnostic process)
Management
Non-pharmacological
Initiate conversation: use open questions; explore what the patient understands about their condition
Discuss: values, preferences, fears, goals of care, preferred place of death
Document: in clinical records; create/update ADRT if requested; complete ReSPECT form
Review regularly: ACP is a process; preferences may change over time
Involve: family/carers (with consent), GP, specialist team, palliative care
Support: written information, time to reflect, opportunity to revisit
Key Legal Documents
Advance Decision to Refuse Treatment (ADRT):
Must be made when patient has capacity
Must specify the treatment being refused and circumstances
Must be written, signed, and witnessed if refusing life-sustaining treatment
Can be overridden by a more recent decision or if patient had capacity at the time
Cannot request treatment (only refuse it)
Lasting Power of Attorney (LPA) for Health and Welfare:
Appoints a proxy (attorney) to make decisions when patient lacks capacity
Must be registered with the Office of the Public Guardian
Attorney must act in patient's best interests
Can include authority for life-sustaining treatment decisions
ReSPECT form:
Recommended Summary Plan for Emergency Care and Treatment
Completed with patient (or those close to them if lacking capacity)
Includes CPR decision, clinical recommendations, patient preferences
Travels with the patient (home, ambulance, hospital)
Pharmacological
Not applicable
Surgical/Interventional
Not applicable
Referral Criteria
Complex ACP discussions: palliative care specialist
Mental capacity assessment under the Mental Capacity Act 2005 is a legal and clinical skill requiring assessment of whether a patient can understand, retain, weigh, and communicate a specific decision at a specific time.
MRCP Part 1 · MRCP Part 2 · PLAB 1 · UKMLA · MRCGP AKT · MSRA
Key Facts
Mental Capacity Act 2005 (England and Wales): legal framework for capacity assessment and best interests decisions
Capacity is decision-specific and time-specific: a person may have capacity for one decision but not another
Two-stage test: (1) Does the person have an impairment of, or disturbance in, the functioning of the mind or brain? (2) Does this impairment mean they cannot make the specific decision?
Four functional criteria: the person must be able to understand, retain, weigh/use, and communicate the information relevant to the decision
Principle 1: Assume capacity until established otherwise
Principle 3: An unwise decision does not equal lack of capacity
If a person lacks capacity, decisions must be made in their best interests (Section 4 MCA 2005)
IMCA (Independent Mental Capacity Advocate): must be instructed for serious medical treatment decisions or accommodation changes for unbefriended patients
Overview
Key Facts
Capacity assessment is a core clinical skill. All clinicians are responsible for assessing capacity for decisions within their scope of practice. It is a legal requirement under the Mental Capacity Act 2005.
Epidemiology
Approximately 2 million adults in England and Wales may lack capacity for some decisions
Capacity assessments are performed daily in hospitals, GP practices, and social care settings
Aetiology
Impairment or disturbance of the mind or brain may be caused by:
Dementia
Delirium
Brain injury (stroke, traumatic)
Learning disability
Severe mental illness (psychosis, severe depression)
Intoxication (alcohol, drugs)
Loss of consciousness
Pathophysiology
The Mental Capacity Act 2005 does not define capacity in pathological terms but in functional terms - it assesses what a person can do with the information relevant to a specific decision, not their diagnosis.
Clinical Presentation
When to Assess Capacity
When there is reason to doubt capacity for a specific decision
Before any medical treatment or intervention
When a patient refuses treatment
When a patient is making a decision with significant consequences
When advance care planning
When considering discharge destination
Five Principles of the MCA 2005
Assume capacity unless established otherwise
Support decision-making: take all practicable steps to help the person make their own decision (e.g. timing, location, communication aids, interpreter)
Unwise decisions are allowed: a person is not to be treated as lacking capacity merely because they make a decision others consider unwise
Best interests: any act done for a person who lacks capacity must be in their best interests
Least restrictive option: anything done must be the least restrictive of the person's rights and freedoms
Red Flags
Clinician assuming lack of capacity based on diagnosis alone (unlawful)
No documented capacity assessment before proceeding with treatment
Best interests decision made without consulting relevant people
Lack of capacity assumed because patient makes an unwise decision
Restraint used without proper legal framework (DoLS/LPS)
Differential Diagnosis
Scenario
Capacity Status
Action
Patient with capacity refuses treatment
Has capacity
Respect decision (even if clinicians disagree)
Patient lacks capacity, treatment in best interests
Lacks capacity
Proceed under best interests (MCA Section 4)
Patient lacks capacity, valid ADRT exists
Lacks capacity
Respect ADRT (if valid and applicable)
Patient lacks capacity, LPA exists
Lacks capacity
Consult attorney (who acts in best interests)
Unbefriended patient lacks capacity for serious decision
Lacks capacity
Instruct IMCA
Diagnosis / Investigation
Bedside
Stage 1: Is there an impairment of, or disturbance in, the functioning of the mind or brain? (e.g. dementia, delirium, brain injury, intoxication)
Stage 2 (if yes to Stage 1): Can the person:
Understand the information relevant to the decision? (presented in simple terms, including risks and benefits)
Retain the information long enough to make the decision? (even briefly is sufficient)
Weigh/use the information as part of the decision-making process? (balance pros and cons)
Communicate the decision? (by any means - speech, writing, signing, blinking)
Failure in any one of these four = lacks capacity for that decision
Bloods
May be needed to identify/treat reversible causes of impaired capacity (e.g. delirium workup)
Imaging
Not required for capacity assessment itself
May be relevant if investigating underlying cause
Special Tests
Cognitive assessment (AMT, MoCA, ACE-III) may inform but does not replace formal capacity assessment
Neuropsychological assessment: for complex cases
Management
Non-pharmacological
If person HAS capacity: respect their decision, even if it seems unwise; document assessment
If person LACKS capacity: make a best interests decision (Section 4 MCA)
Best Interests Decision (Section 4 MCA)
Consider all relevant circumstances
Consider whether the person will regain capacity
Involve the person as much as possible
Consider past and present wishes, feelings, beliefs, and values
Elder abuse affects approximately 500,000 older people in the UK at any time, requiring healthcare professionals to recognise, report, and respond to suspected abuse under safeguarding duties.
MRCP Part 1 · MRCP Part 2 · PLAB 1 · UKMLA · MRCGP AKT · MSRA
Key Facts
Elder abuse affects approximately 500,000 older people in the UK at any given time
Types of abuse: physical, psychological/emotional, financial, sexual, neglect, self-neglect, discriminatory, organisational/institutional, domestic abuse, modern slavery
Care Act 2014: places a duty on local authorities to make enquiries (Section 42) when an adult at risk may be experiencing abuse or neglect
Adult at risk (Section 42): has needs for care and support, is experiencing or at risk of abuse or neglect, AND is unable to protect themselves because of those needs
Healthcare professionals have a duty to report concerns about abuse to the local authority safeguarding team
Financial abuse is the most commonly reported type in community settings; neglect is most common in institutional settings
Risk factors for abuse: social isolation, dependency, dementia, mental illness, carer stress, substance misuse (carer)
Consent should be obtained before sharing information, but override consent if there is risk of serious harm to the person or others
Overview
Key Facts
Elder abuse is under-reported and under-recognised. All healthcare professionals have a responsibility to safeguard adults at risk.
Epidemiology
~500,000 older people in the UK affected at any time
Prevalence in community: 2-5%; in care homes: 15-25%
Financial abuse most common in community; neglect most common in institutions
Often perpetrated by family members, carers, or paid care staff
Under-reporting is significant: estimated only 1 in 24 cases reported
Aetiology
Perpetrator factors: carer stress, mental illness, substance misuse, financial dependence on victim, history of domestic abuse
Victim factors: dependency, social isolation, dementia/cognitive impairment, physical disability, communication difficulties
Situational factors: overcrowded living, poor institutional culture, inadequate staffing, lack of training
Pathophysiology
Not a pathological process but a pattern of harmful behaviour. The impact includes:
Rehabilitation in older adults is a goal-directed, multidisciplinary process aimed at restoring function and independence after illness or injury, underpinned by comprehensive geriatric assessment.
MRCP Part 1 · MRCP Part 2 · PLAB 1 · UKMLA · MRCGP AKT · MSRA
Key Facts
Rehabilitation is a goal-directed process enabling a person to reach their optimal physical, psychological, and social functioning
MDT approach is essential: geriatrician, physiotherapist, occupational therapist, SALT, dietitian, social worker, psychologist, nursing
Comprehensive Geriatric Assessment (CGA) underpins all rehabilitation programmes for older adults
Early mobilisation (within 24 hours of admission) reduces deconditioning, delirium, VTE, pressure ulcers, and length of stay
Goal-setting should be patient-centred, SMART (Specific, Measurable, Achievable, Relevant, Time-bound), and regularly reviewed
Common rehabilitation settings: acute hospital, community rehabilitation unit, intermediate care, home-based rehabilitation
Functional independence is the primary outcome measure; tools include Barthel Index (0-20/100) and Functional Independence Measure (FIM)
Deconditioning in hospital: older adults lose 5% of muscle strength per day of bed rest; 10 days of bed rest = 10 years of muscle ageing
Overview
Key Facts
Rehabilitation is a core function of geriatric medicine. It requires active patient participation, realistic goal-setting, and coordinated multidisciplinary input.
Epidemiology
Approximately 30-50% of hospitalised older adults experience functional decline during admission
10 days of bed rest in a healthy older adult leads to 14% loss of aerobic capacity and 10% loss of muscle strength
Intermediate care and rehabilitation services handle >500,000 episodes per year in England
Effective discharge planning is a structured process beginning at admission to ensure safe, timely transition from hospital to home or appropriate care setting, reducing readmissions and improving patient outcomes.
MRCP Part 1 · MRCP Part 2 · PLAB 1 · UKMLA · MRCGP AKT · MSRA
Key Facts
Discharge planning should begin at admission - not as an afterthought when the patient is medically fit
Estimated Date of Discharge (EDD) should be set within 24 hours of admission and communicated to patient/family
Discharge to Assess (D2A): model where patients are discharged when safe (not necessarily fully recovered) and assessed for ongoing needs in their usual environment
4 D2A pathways: 0 (simple discharge), 1 (home with support), 2 (rehabilitation/reablement facility), 3 (complex assessment for long-term care)
Delayed discharges cost the NHS approximately £300 million/year and harm patients through deconditioning and hospital-acquired complications
Medication reconciliation: essential at discharge; ensure accurate medication list, patient/GP letter, compliance aids if needed
Communication: discharge summary to GP within 24 hours; must include diagnosis, investigations, medication changes, follow-up plan
Red flags for unsafe discharge: unstable medical condition, unresolved safeguarding concerns, no safe living environment, unassessed capacity for discharge decision
Overview
Key Facts
Good discharge planning reduces length of stay, readmissions, and patient harm. It requires a multidisciplinary approach and close coordination with community services.
Epidemiology
~10-15% of hospital beds in England occupied by patients who are medically fit for discharge ("delayed transfers of care")
20-25% of older adults are readmitted within 30 days of discharge
Average excess LOS for delayed discharge: 7 days
Delayed discharge associated with increased mortality, functional decline, and hospital-acquired infection
Aetiology
Common reasons for delayed discharge:
Awaiting social care assessment/package
Awaiting care home placement
Awaiting community equipment/adaptations
Family/patient choice
Awaiting further NHS care (rehabilitation)
Safeguarding concerns
Pathophysiology
Prolonged hospital stay → deconditioning, nosocomial infection, delirium, falls, pressure ulcers, loss of independence
Hospital environment is disorienting for older adults (unfamiliar, noisy, disrupted sleep-wake cycle)
Each day of unnecessary hospital stay increases mortality risk and reduces functional recovery
Clinical Presentation
Discharge Planning Process
Admission: identify likely discharge needs; set EDD
During stay: daily MDT review; progress against goals; update EDD