Around 60–70% of inpatients are aged >65. The Comprehensive Geriatric Assessment (CGA) (Box 31.1 and Figure 31.1) assesses the whole patient, and can reduce length of stay and institutionalization, and improve quality of life. Geriatric syndromes such as falls, delirium or immobility can be used to stream patients towards CGA interventions.

All the principles of early diagnosis and treatment apply as much to the frail older people as the young. However, assessment and management are harder because of:

• Non-specific presentations
• Communication barriers (requiring greater involvement of family, friends and carers)
• Multiple comorbidities
• More complex community care needs

To resolve this, CGA produces a list of medical and non-medical problems, which can be constructed by any or all the members of the multidisciplinary care team. Common problems include:

• Cognition: differentiate delirium from dementia; see http://guidance.nice.org.uk/CG103. Is further investigation required? If so does it need to happen now or in a clinic?
• Continence:
  • Urinary incontinence is common and often misdiagnosed as urinary tract infection, which can precipitate acute incontinence but is rarely the explanation for long-standing incontinence. Consider detrusor instability, retention, stress and functional incontinence. Consider bladder scanning. If there is no immediately obvious cause on admission, ensure the community services are aware this issue needs addressing, as treating incontinence improves quality of life and can reduce admission to long-term care.
  • Are you sure you know how to diagnose urinary tract infection? See Chapter 80 and also NICE guidance (http://www.nice.org.uk/guidance/CG40). An abnormal urinalysis does not necessarily indicated infection. Malodorous urine may reflect dehydration rather than urosepsis.
  • Bowels: frequency/stool type/constipation – a common cause of ‘coffee-ground vomitus’. A rectal examination is quicker, cheaper and usually more useful than an endoscopy or CT abdomen.

• Mobility: immobility, whether due to illness or institutionalization from hospital conservatism, can increase the risk of complications, such as chest infections and falls. All staff should seek opportunities to mobilize older people in hospital.

  Assess mobility by the ‘get up and go’ test. Check the patient is able to stand (if they can straight leg raise in bed, they should be able to stand) and walk. Usual footwear should be worn, and usual walking aid used. Ask the patient to stand up from a standard chair, and walk a distance of at least 3 m, then turn and get back to the chair. There is no need to time the test (although >11 s indicates higher falls risk). People who cannot ‘get up and go’ unaided are at increased risk of future falls.

• Mood: depression is common in ill health and worsens outcomes. Ask simple questions like ‘how is your mood?’. Note the patient's affect, and consider involving a mental health team if you are concerned about mood.
• Nutrition: ask about weight loss. What do they eat normally? Who shops/who cooks/who feeds? Are any modifications of food or drink required (e.g. pureed diet/thickened fluids)? Assess oral health: thrush/dentition/ulcers/dentures – do they fit?
• Activities of daily living. How do they transfer, for example in and out of bed? What aids to they need? Who washes/dresses? What about more advanced tasks: using a phone/driving? Minutes spent ascertaining this information up front and revising goals accordingly can save days later on in the patient journey.
• Medications: often medications are continued despite the original symptoms having subsided. Use a structured medication review process, for example STOPP/START criteria. Repeat offenders include the following which might be stopped/reduced:
  • NSAIDs (risk of GI bleeding/renal impairment)
  • Opioids (drowsiness/nausea/constipation)
  • Antihistamines (sedating)
  • Prochlorperazine (risk of extra-pyramidal side effects, ineffective for non-vestibular pathology)
  • Prophylactic antibiotics (there is little evidence that these prevent UTI; often increase resistance, making acute infection management more restrictive)
  • Anti-hypertensives (risk of postural hypotension)
  • Furosemide (risk of hypotension/fluid depletion/AKI: often erroneously started for dependent oedema)
• End-of-life care issues and ethics; is advance care planning indicated? Would you be surprised if this person was to die in the next 6–12 months? A third of frail older people discharged from AMU die within a year.

Once the initial assessment is complete, a problem list can be formulated (see Appendix 31.1 for an example). Anticipate future admissions. Often these are because of progressive disease, for example malignancy, severe heart failure, COPD or dementia. Other issues can be identified and addressed, such as:

• Incontinence, with referral to the relevant service.
• High falls risk. Management can include a falls care pathway for care homes/ambulance services to follow after a ‘recurrent faller’ has an event. This can guide what observations need to be done and which variance should prompt admission, as opposed to blanket admissions following all episodes.
• Risk of aspiration pneumonia in dementia. Discuss with family, community health professionals, care home staff that this is likely to recur. Address feeding issues (e.g. accepting spoon feeding with risk of aspiration) and avoid unnecessary speech and language therapy (SALT) assessments. Conveying the likely disease progression and prognosis can enable planning for end-of-life care.

Problem List

Multiple issues have been identified as probable contributors to the fall. Now that these have been clearly identified they can be individually addressed: either immediately or over time.