| 🧠 Acute Confusional State / Delirium |
- Acute onset and fluctuating confusion.
- Inattention, disorientation, altered consciousness.
- Hyperactive: agitation, hallucinations, distress.
- Hypoactive: drowsy, withdrawn, quiet - easily missed.
- Common triggers: infection, pain, constipation, urinary retention, dehydration, hypoxia, drugs, metabolic disturbance, alcohol withdrawal, environmental change.
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- Clinical diagnosis using 4AT or CAM plus collateral history.
- Check glucose, oxygen saturation, pain, constipation and bladder retention.
- FBC, U&E, calcium, CRP, LFT; cultures/imaging guided by clinical signs.
- Medication review: anticholinergics, benzodiazepines, opioids, steroids, antihistamines, sedatives.
- Consider CT head only if head injury, focal neurology, anticoagulation, seizure or unexplained reduced consciousness.
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- Treat underlying cause: infection, pain, dehydration, constipation, urinary retention, hypoxia, drug toxicity.
- Non-drug measures first: reorientation, glasses/hearing aids, sleep hygiene, mobilisation, hydration, family presence, calm lighting.
- Avoid restraints and unnecessary catheters/cannulas.
- Use antipsychotic only if severe distress or risk of harm and non-drug measures fail; use low dose and review frequently.
- Avoid haloperidol in Parkinson’s disease/Lewy body dementia; seek specialist advice.
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| 🧠 Acute Stroke / TIA |
- Sudden face droop, arm weakness, speech disturbance or visual loss.
- May present as fall, confusion, dizziness, dysphagia or reduced mobility in older adults.
- Posterior circulation stroke: vertigo, ataxia, diplopia, dysarthria, vomiting.
- Risk factors: AF, hypertension, diabetes, prior stroke/TIA, vascular disease.
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- Use FAST or validated stroke screen.
- Check glucose immediately to exclude hypoglycaemia mimic.
- Urgent CT head to distinguish haemorrhage from infarct.
- CT angiography/perfusion imaging if thrombectomy considered.
- ECG for AF; bloods including FBC, U&E, clotting, glucose.
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- Immediate stroke team referral.
- Consider IV thrombolysis if eligible and within local time window.
- Consider mechanical thrombectomy for large vessel occlusion if eligible.
- Aspirin after haemorrhage excluded and thrombolysis plan clarified.
- Swallow screen before oral intake.
- Manage BP, glucose, temperature and oxygenation according to stroke pathway.
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| 🦴 Hip Fracture / Neck of Femur Fracture |
- Fall with hip, groin or thigh pain.
- Unable to weight bear.
- Shortened, externally rotated leg may be present.
- May be subtle in dementia, delirium or impacted fracture.
- High risk of delirium, pneumonia, pressure injury, VTE and deconditioning.
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- AP pelvis and lateral hip X-rays.
- MRI if hip fracture suspected despite negative X-rays; CT if MRI unavailable within 24 hours or contraindicated.
- FBC, U&E, clotting, group and save, ECG, CXR only if clinically indicated.
- Assess anticoagulants and reversible surgical delays.
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- Analgesia early; consider fascia iliaca block.
- Orthogeriatric and trauma/orthopaedic pathway.
- Operate on the day of or day after admission if medically optimised.
- Correct reversible issues promptly: dehydration, anaemia, electrolytes, heart failure, arrhythmia, anticoagulation plan.
- Pressure area care, delirium prevention, nutrition, VTE prophylaxis and early mobilisation.
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| 🫀 Acute Coronary Syndrome in Older Adults |
- Chest pain, pressure or tightness may occur.
- Atypical features common: breathlessness, collapse, delirium, fatigue, nausea, epigastric discomfort or falls.
- Higher risk with diabetes, CKD, frailty and prior vascular disease.
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- 12-lead ECG within 10 minutes if suspected.
- Serial high-sensitivity troponins.
- U&E/eGFR to guide antithrombotic dosing.
- CXR/echo if heart failure, murmur or alternative diagnosis suspected.
- Assess bleeding risk, frailty, cognition and goals of care without denying evidence-based treatment solely due to age.
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- Aspirin loading unless contraindicated.
- ACS pathway: PCI for STEMI where appropriate; risk-stratified NSTEMI care.
- Oxygen only if hypoxaemic, shocked or severe distress.
- Careful use of nitrates/opioids due to hypotension/delirium risk.
- Anticoagulant and antiplatelet dosing must consider renal function, weight and bleeding risk.
- Cardiology and geriatric input for complex frailty/multimorbidity decisions.
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| 🦠 Sepsis in Older Adults |
- May present without fever: confusion, falls, reduced mobility, poor intake, incontinence or functional decline.
- Classical features: fever/hypothermia, tachypnoea, tachycardia, hypotension.
- Sources: pneumonia, UTI, biliary sepsis, skin/soft tissue infection, intra-abdominal infection, line/device infection.
- Frailty and immunosuppression increase deterioration risk.
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- NEWS2 and clinical judgement.
- Blood cultures if sepsis suspected before antibiotics if this does not delay treatment.
- FBC, U&E, CRP, lactate, glucose, LFT.
- Urine testing only interpreted with symptoms/signs - asymptomatic bacteriuria is common.
- CXR, abdominal imaging or CT depending on suspected source.
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- Sepsis pathway if high-risk features.
- Prompt antibiotics according to likely source and local guidance.
- IV fluids if hypotensive/hypoperfused, but reassess frequently due to heart failure/CKD risk.
- Oxygen if hypoxaemic.
- Source control: drain abscess, remove infected line, relieve obstruction.
- Escalate to ICU if shock, rising lactate or organ failure, aligned with patient wishes/escalation plan.
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| 💧 Dehydration / Electrolyte Disturbance / AKI |
- Poor intake, dizziness, falls, confusion or reduced urine output.
- Postural symptoms, dry mouth, tachycardia or hypotension.
- May be caused by infection, heat, diarrhoea/vomiting, diuretics, ACEi/ARB, NSAIDs, SGLT2 inhibitors.
- Hypernatraemia suggests water deficit and is high risk in frailty.
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- U&E, creatinine/eGFR, glucose, calcium, magnesium.
- Urinalysis if renal/infection differential.
- Fluid balance, weight, lying/standing BP if safe.
- Bladder scan if AKI or retention suspected.
- ECG if potassium disturbance.
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- Correct fluid deficit cautiously and reassess frequently.
- Use oral/subcutaneous/IV fluids depending on severity and swallowing ability.
- Hold nephrotoxic or volume-depleting medicines where appropriate.
- Correct sodium/potassium slowly and safely according to severity.
- Treat underlying cause and monitor urine output/renal function.
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| 🚽 Acute Urinary Retention |
- Lower abdominal pain, agitation or new delirium.
- Inability to void or overflow incontinence.
- Palpable bladder may be absent in obesity or dementia.
- Triggers: BPH, constipation, anticholinergics, opioids, infection, immobility, neurological disease.
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- Bladder scan.
- U&E/creatinine if prolonged retention, high residual or AKI concern.
- Urinalysis/culture only if infection symptoms or systemic illness.
- Review constipation and medicines.
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- Catheterise if significant painful retention or renal compromise.
- Monitor post-drainage urine output; watch for post-obstructive diuresis.
- Treat constipation and review anticholinergic/opioid burden.
- Alpha-blocker if likely BPH and appropriate.
- Trial without catheter / urology follow-up according to local pathway.
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| 🧍 Falls and Fragility Fractures |
- Fall, collapse or “found on floor”.
- Pain, bruising, head injury, fracture or inability to mobilise.
- Long lie may cause rhabdomyolysis, pressure injury, hypothermia and AKI.
- Cause may be syncope, postural hypotension, infection, stroke, hypoglycaemia, arrhythmia or medication effect.
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- Collateral history: witnessed? loss of consciousness? prodrome? time on floor?
- ECG, lying/standing BP if safe, glucose, FBC, U&E, CK if long lie.
- CT head if head injury with anticoagulation, neurological signs or guideline indications.
- X-ray painful areas; hip imaging if unable to weight bear.
- Medication review: sedatives, antihypertensives, diuretics, anticholinergics.
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- Treat injuries and pain promptly.
- Investigate cause, not just consequence.
- Mobilise early with physiotherapy/OT where safe.
- Falls prevention: vision, footwear, strength/balance, home hazards, bone protection.
- Osteoporosis assessment and fracture prevention after fragility fracture.
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| 🍬 Hyperosmolar Hyperglycaemic State |
- Older person with type 2 diabetes, severe dehydration and marked hyperglycaemia.
- Confusion, weakness, falls, seizures or coma.
- Often triggered by infection, stroke, MI, steroids, poor intake or missed medication.
- Ketosis absent or mild; acidosis not dominant.
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- Glucose often ≥30 mmol/L.
- Serum osmolality usually ≥320 mOsm/kg.
- Blood ketones mild/absent and pH usually >7.3.
- U&E, creatinine, VBG, infection screen, ECG.
- Assess corrected sodium and hydration deficit.
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- Use local JBDS/HHS pathway.
- Careful IV 0.9% sodium chloride, slower correction than DKA.
- Insulin often delayed until fluids have started lowering glucose unless significant ketonaemia.
- Monitor osmolality, sodium, potassium and fluid balance closely.
- VTE prophylaxis unless contraindicated.
- Treat trigger: infection, MI, stroke, drugs or dehydration.
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| 🫁 Aspiration / Pneumonia in Frailty |
- Cough, breathlessness, fever or pleuritic pain may be absent.
- Commonly presents as delirium, falls, reduced mobility or poor intake.
- Aspiration clues: coughing with meals, wet voice, dysphagia, stroke, Parkinson’s disease, dementia.
- May cause hypoxia, sepsis or decompensated heart failure.
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- Oxygen saturations, respiratory rate and NEWS2.
- CXR if suspected pneumonia, but early CXR may be normal.
- FBC, U&E, CRP, blood cultures if septic.
- Swallow assessment if aspiration risk.
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- Antibiotics according to local CAP/aspiration pathway if bacterial pneumonia suspected.
- Oxygen if hypoxaemic and fluids if dehydrated, with careful reassessment.
- Speech and language therapy/swallow plan if dysphagia.
- Positioning, oral care, nutrition and mobilisation.
- Escalation plan discussion if recurrent aspiration or advanced frailty.
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| 💊 Medication Toxicity / Polypharmacy Crisis |
- Falls, delirium, bradycardia, hypotension, AKI, bleeding, hypoglycaemia or sedation.
- Common culprits: benzodiazepines, opioids, anticholinergics, digoxin, insulin/sulfonylureas, antihypertensives, diuretics, anticoagulants, NSAIDs.
- Risk increased by CKD, dehydration, low body weight and recent prescribing changes.
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- Medication reconciliation with pharmacy/carer/GP record.
- U&E/eGFR, glucose, ECG.
- Drug levels where relevant: digoxin, lithium, anticonvulsants.
- Check INR if warfarin; anti-Xa/DOAC timing if relevant locally.
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- Stop or hold offending medicines where appropriate.
- Treat toxicity: glucose for hypoglycaemia, naloxone for opioid toxicity, vitamin K/PCC for major warfarin bleeding, digoxin Fab for life-threatening digoxin toxicity.
- Adjust doses for renal function and frailty.
- Deprescribing review before discharge.
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