Associated problems

Depression can occur early in dementia and requires intervention. Demented patients are vulnerable to superimposed delirium which is often due to:

urinary tract infection

• other febrile illness

• prescribed medication

drug withdrawal

Delirium should be suspected if a stable patient becomes acutely disturbed. Medication 8

Demented patients often do not require any psychotropic medication. Antidepressant drugs can be prescribed for depression. Tacrine appears to be ineffective but donepezil (5-10 mg/day) is promising in delaying progression. To control psychotic symptoms or disturbed behaviour probably due to psychosis: haloperidol 1.5-10 mg (o) daily or thioridazine 25-50 mg (o) 1 to 4 times daily To control symptoms of anxiety and agitation use: oxazepam 15 mg (o) 1 to 4 times daily but benzodiazepines should be used only for short periods as they tend to exacerbate cognitive impairment in dementia.

Paraphrenia

Paraphrenia is that condition where the symptoms and signs of paranoid psychosis appear for the first time in the elderly. In this non-psychotic mental illness, the patient, who is usually an elderly female, presents with paranoid delusions such as a feeling of being watched or persecuted. These are usually associated with visual and hearing problems.

Falls in the elderly

Falls in the elderly are a major problem as 30% of people over the age of 65 experience at least one fall per year with 1 in 4 of these having significant injury. About 5% of falls result in fracture. 9 The main causes are:

• neurological, e.g. cerebrovascular disease

• sensory impairment, e.g. visual, vestibular

• cardiovascular, e.g. postural hypotension

• musculoskeletal, e.g. arthritis, foot disorders

• cognitive and psychological conditions, e.g. dementia, delirium

• medication/drug related, e.g. sedatives, alcohol

• physiological changes, e.g. gait disorders

• environmental factors, e.g. slipping or tripping

• combinations of the above

The most significant clinical risk factors for falls have been shown to be visual impairment, impaired general function, postural hypotension, hearing impairment, drug usage especially sedatives, decreased lower limb strength, and impaired balance and gait.

Assessment

The history should embrace the above causes and risk factors. In particular a description of the fall by a witness, the perceived dysfunction at the time of the fall and whether there was loss of consiousness is particularly important.

The physical examination should include cardiac function, neurological status including the mini-mental function test and the musculoskeletal system including assessment of gait. The 'get up and go' test (Table 8.4) is useful. As special investigations (especially for those proving difficult to evaluate) consider full blood examination and ESR, blood sugar, urea and electrolytes, thyroid function tests, cardiac investigations e.g. ambulatory ECG monitoring, ambulatory blood pressure monitoring, vestibular function testing, and CT scans or MRI scan. 10

Management and prevention

Steps should be taken to correct any medical disorders and risk factors. It is appropriate to refer to a multidisciplinary team including occupational therapists and physiotherapists. Assessment of circumstances in the home is very helpful. This may lead to reducing environmental hazards and providing walking aids.

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