Medicine of the older adult:. Continence, nutrition, skin and other geriatric syndromes

• Bladder and bowel: Urinary Incontinence in Older People | Nocturia | Constipation and Faecal Incontinence
• Nutrition and swallowing: Malnutrition and Weight Loss | Dehydration and Sodium Disorders | Dysphagia and Aspiration | Oral Health
• Skin and temperature: Pressure Ulcers | Skin Tears, Legs and Feet | Hypothermia and Heat Illness
• Other syndromes: Infection in Older People | Vision and Hearing | Pain Assessment | Sleep Problems | Elder Abuse and Self-neglect
• Revision: Geriatric Syndromes at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Continence, nutrition, skin and other geriatric syndromes — page 5 of the Medicine of the Older Person chapter. These everyday problems — incontinence, constipation, poor eating, swallowing problems, pressure ulcers, sensory loss and pain — matter enormously to older people's dignity and independence, and are often missed or dismissed as "just ageing". Most have treatable causes. Detailed urology and gastroenterology are in their own chapters; hyponatraemia is in the Endocrinology chapter on Sodium and Water.
Your four questions for every patient: Has anyone asked about bladder, bowels, eating, sleep and pain? Is there a treatable cause (infection, drugs, constipation, retention, poor teeth)? What is the simplest effective intervention? Is the person safe — at home, in their skin, and from abuse or neglect?

Urinary Incontinence in Older People

• Common — affects a third or more of older women and many older men; under-reported (embarrassment, thought to be "normal").
• Not a normal part of ageing — always assess.
• Transient (reversible) causes — "DIAPPERS":
  • Delirium.
  • Infection (symptomatic UTI).
  • Atrophic vaginitis or urethritis.
  • Pharmaceuticals — diuretics, alpha-blockers (women), sedatives, anticholinergics (retention and overflow), ACE inhibitors (cough), donepezil.
  • Psychological (depression).
  • Excess urine output (hyperglycaemia, hypercalcaemia, heart failure, fluid overload, caffeine).
  • Restricted mobility (can't get to the toilet in time).
  • Stool impaction (constipation).
• Types — stress, urge (overactive bladder — commonest in older people), mixed, overflow (retention — prostate, drugs, constipation, neurological), functional (mobility, cognition, environment) (see the Urology page).
• Assessment — history, bladder diary (3 days), urine dipstick only if symptoms (and culture), post-void residual (bladder scan), abdominal, pelvic and rectal examination, cognition and mobility, drug review.
• Management:
  • Treat reversible causes; prompted or timed toileting (especially with dementia), easy-to-remove clothing, commode or urinal near the bed.
  • Pelvic floor muscle training (stress), bladder training (urge), reduce caffeine, sensible fluid intake.
  • Vaginal oestrogen for urogenital atrophy.
  • Drugs for urge incontinence — mirabegron (not anticholinergic — check BP) or antimuscarinics with low brain penetration (e.g. trospium, solifenacin) — avoid oxybutynin in frail older people (confusion).
  • Continence products (pads) — for symptoms not curable, not instead of assessment.
  • Avoid indwelling catheters for incontinence alone — only for retention that can't be managed otherwise, or skin breakdown, or end-of-life comfort.

Nocturia

• Nocturia — waking at night to pass urine (two or more times is bothersome); causes poor sleep, falls (especially rushing to the toilet in the dark), fractures and fatigue.
• Causes:
  • Nocturnal polyuria — over a third of 24-hour urine produced at night (older people) — fluid redistribution from swollen legs when lying down (heart failure, venous disease, calcium channel blockers), evening fluids, caffeine, alcohol, obstructive sleep apnoea, diabetes, hypercalcaemia, diuretics taken late.
  • Reduced bladder capacity — overactive bladder, BPH, retention with overflow, bladder pain.
  • Sleep problems — waking for other reasons then voiding.
• Assessment — frequency–volume chart, urine glucose, U&E and calcium, check for heart failure and sleep apnoea, drug review.
• Management — reduce evening fluids and caffeine; take diuretics in the morning or early afternoon (or a late-afternoon loop diuretic for nocturnal polyuria); raise legs in the afternoon (oedema); treat BPH or overactive bladder; night lights and a commode or urinal by the bed; desmopressin is rarely appropriate in older people (hyponatraemia — avoid over 65 unless specialist and sodium monitored).

Constipation and Faecal Incontinence

• Constipation — very common; causes:
  • Drugs — opioids, anticholinergics, iron, calcium supplements, calcium channel blockers (verapamil), antacids, diuretics.
  • Immobility, low fibre and fluid intake, lack of privacy or help to get to the toilet.
  • Metabolic — hypercalcaemia, hypothyroidism, hypokalaemia, diabetes.
  • Neurological — Parkinson's disease, stroke, dementia, spinal cord disease.
  • Colorectal cancer — a change in bowel habit needs investigation (FIT, colonoscopy) where appropriate.
• Faecal impaction — hard stool filling the rectum or colon; can cause overflow diarrhoea (liquid stool leaking around the impaction — don't give antidiarrhoeals), urinary retention, delirium, abdominal pain, bowel obstruction or stercoral perforation; rectal examination and abdominal X-ray (high impaction).
• Management:
  • Impaction — high-dose oral macrogol (disimpaction regimen), or rectal measures (glycerol or bisacodyl suppositories, phosphate or arachis oil enemas); then maintenance.
  • Maintenance — fluids, mobility, toilet routine (after meals — gastrocolic reflex), privacy, good positioning (footstool); osmotic (macrogol, lactulose) or stimulant (senna, bisacodyl) laxatives; avoid bulk-forming laxatives in immobile people with poor fluid intake.
  • Opioid-induced constipation — regular stimulant plus softener; peripheral opioid antagonists (naloxegol, methylnaltrexone) if resistant.
• Faecal incontinence — causes: impaction with overflow (commonest in frail older people), diarrhoea (infection, C. difficile, laxative excess, drugs), sphincter damage, neurological disease, dementia, immobility; assess with rectal examination; treat the cause; regular toileting; loperamide for loose stool once impaction and infection are excluded (see the Colorectal Surgery page).

Malnutrition and Weight Loss

• Malnutrition — about a third of older people admitted to hospital are malnourished or at risk; it causes weakness, falls, infections, poor wound healing, pressure ulcers and death.
• Screening — MUST (Malnutrition Universal Screening Tool) on admission and regularly:
  • BMI score (under 18.5 = 2; 18.5–20 = 1).
  • Unplanned weight loss in 3–6 months (over 10% = 2; 5–10% = 1).
  • Acute illness with no intake for over 5 days (2).
  • Total — 0 low risk, 1 medium, 2 or more high risk (refer to dietitian).
• Causes of weight loss in older people:
  • Medical — cancer, heart failure, COPD, CKD, hyperthyroidism, diabetes, malabsorption (coeliac), infection (TB), Parkinson's disease, dementia.
  • Psychological — depression, bereavement, anxiety, alcohol.
  • Mouth and swallowing — poor dentition, ill-fitting dentures, dry mouth, oral candida, dysphagia.
  • Drugs — metformin, digoxin, SSRIs, cholinesterase inhibitors, opioids (nausea, constipation), polypharmacy (taste changes, appetite).
  • Social — isolation, poverty, unable to shop or cook, lack of help with eating.
• Management — treat causes; food first (fortified foods, snacks, nourishing drinks), help with eating (red tray or protected mealtimes, assistance, appropriate cutlery), oral nutritional supplements, dietitian; protein about 1.0–1.2 g/kg/day; vitamin D.
• Refeeding syndrome — risk when feeding severely malnourished people (little or no intake for over 5–10 days): low phosphate, potassium and magnesium, fluid overload, arrhythmias — start feeding slowly, give thiamine and vitamin B, monitor electrolytes daily (NICE CG32).
• Artificial nutrition (NG or PEG) — decided individually; useful for temporary dysphagia (e.g. stroke recovery), not for advanced dementia (see page 3).

Dehydration and Sodium Disorders

• Older people dehydrate easily — reduced thirst, reduced kidney concentrating ability, diuretics, fear of incontinence (deliberately drinking less), cognitive impairment, dependence on others for drinks, swallowing problems.
• Signs — clinical signs are unreliable (dry mouth from mouth breathing, poor skin turgor with age); look at postural BP, urine output, weight, urea and sodium, creatinine rise.
• Hypernatraemia (sodium over 145) — almost always water deficit — frail, immobile, delirious people who can't drink; high mortality; correct slowly with oral water or IV 5% glucose (no faster than about 10 mmol/L in 24 hours) and treat the cause.
• Hyponatraemia (sodium under 135) — common in older people:
  • Drugs — thiazides, SSRIs, carbamazepine, PPIs, desmopressin, opioids.
  • SIADH — pneumonia, lung cancer, CNS disease, pain, nausea, drugs.
  • Low intake — "tea and toast" diet, beer potomania.
  • Heart failure, cirrhosis, hypothyroidism, adrenal insufficiency (steroid withdrawal).
  • Even mild chronic hyponatraemia causes falls, fractures, confusion and gait disturbance.
  • Assess volume status, paired serum and urine osmolality and urine sodium, TFTs and cortisol; avoid correcting chronic hyponatraemia by more than 8–10 mmol/L in 24 hours (osmotic demyelination) (see the Endocrinology chapter on Sodium and Water).
• Promoting hydration — regular drinks offered, preferred drinks, adapted cups, fluid charts when at risk, hydration rounds in care homes.
• Subcutaneous fluids (hypodermoclysis) — a useful option for mild dehydration in older people (care homes, end of life, difficult venous access).

Dysphagia and Aspiration

• Oropharyngeal dysphagia (difficulty starting a swallow) — coughing or choking when eating or drinking, wet voice after swallowing, food pocketing, drooling, prolonged mealtimes, recurrent chest infections, weight loss.
• Causes — stroke, Parkinson's disease, dementia (advanced), motor neurone disease, myasthenia gravis, myositis, head and neck cancer, drugs (sedatives, antipsychotics), delirium, frailty ("presbyphagia"), poor dentition.
• Oesophageal dysphagia (food sticking after swallowing) — strictures, cancer (progressive dysphagia with weight loss — urgent upper GI endoscopy), achalasia, pharyngeal pouch (regurgitation of undigested food, halitosis).
• Assessment — speech and language therapy bedside assessment; videofluoroscopy or FEES (fibreoptic endoscopic evaluation of swallowing) if needed; nurse swallow screen after stroke.
• Management:
  • Texture-modified food and thickened fluids — IDDSI framework (levels 0–7).
  • Positioning — sit upright (90°) for eating and 30 minutes after.
  • Small mouthfuls, slow pace, supervision, oral care.
  • Review medicines — liquid forms, avoid crushing unsuitable tablets.
  • Eating and drinking with acknowledged risks — when modified diets are refused or don't prevent aspiration and tube feeding isn't appropriate (e.g. advanced dementia, end of life) — focus on comfort and quality of life; document the decision.
• Aspiration pneumonia — right lower lobe most often (upright); oral bacteria; antibiotics per local policy; good oral hygiene reduces risk.
• Aspiration pneumonitis — chemical injury after vomiting (e.g. during reduced consciousness) — supportive; antibiotics only if infection develops.

Oral Health

• Poor oral health causes pain, poor eating, malnutrition, aspiration pneumonia, social embarrassment and delirium (pain).
• Common problems — tooth decay and gum disease, ill-fitting or lost dentures, dry mouth (drugs — anticholinergics, diuretics; Sjögren's; dehydration; mouth breathing; oxygen therapy), oral candida (inhaled steroids, antibiotics, dentures, diabetes), ulcers, mouth cancer (non-healing ulcer or white or red patch — urgent referral).
• Mouth care — part of daily care in hospital and care homes: brush teeth twice daily with fluoride toothpaste, clean and remove dentures at night (label them!), moisturise lips and mouth (saliva substitutes), check the mouth regularly (Mouth Care Matters).
• Denture-related — denture stomatitis (candida under dentures — antifungals and clean dentures), angular cheilitis.
• Dental access — domiciliary dentistry for housebound and care home residents.

Pressure Ulcers

• Pressure ulcers — localised damage to skin and underlying tissue from pressure (and shear) over bony areas — sacrum, heels, hips, buttocks, elbows, ears, back of the head; also under devices (masks, tubes, catheters, splints).
• Risk factors — immobility, frailty, malnutrition, dehydration, incontinence (moisture), reduced sensation (diabetes, stroke, spinal injury), poor circulation, sedation, delirium, dementia, long lie, acute illness, surgery.
• Risk assessment — on admission (within 6 hours) and regularly — Purpose-T, Waterlow or Braden scores, plus skin inspection (NICE CG179).
• Categories — 1 (non-blanching redness), 2 (partial-thickness skin loss or blister), 3 (full-thickness skin loss — fat visible), 4 (bone, tendon or muscle exposed), unstageable, deep tissue injury (see the Plastic Surgery page).
• Prevention — "SSKIN":
  • Surface — pressure-redistributing mattress and cushion.
  • Skin inspection — regularly.
  • Keep moving — repositioning (at least every 6 hours; every 4 hours if high risk), heel offloading.
  • Incontinence and moisture — barrier creams, prompt cleaning.
  • Nutrition and hydration.
• Treatment — relieve pressure, wound care (tissue viability nurse), nutrition, treat infection (cellulitis, osteomyelitis — sepsis), debridement, pain relief; surgery rarely.
• Safeguarding — some severe pressure ulcers may indicate neglect and need reporting per local policy.

Skin Tears, Legs and Feet

• Ageing skin — thinner, drier, more fragile, slower healing; steroids and anticoagulants worsen this.
• Skin tears — from minor trauma (moving and handling, knocks) — clean, realign the skin flap, use non-adherent dressings or skin closure strips (not sutures), mark the direction of the flap, protect limbs (padding, long sleeves).
• Dry skin and itch (asteatotic eczema) — very common in winter; emollients and soap substitutes; consider other causes of itch (iron deficiency, CKD, liver disease, thyroid, drugs, scabies — especially in care homes, bullous pemphigoid — itchy tense blisters in older people).
• Leg ulcers — venous (commonest), arterial, mixed; check ABPI before compression (see the Vascular Surgery page).
• "Red legs" — bilateral red legs are rarely cellulitis — usually venous (stasis) eczema, lipodermatosclerosis or oedema; true cellulitis is usually one-sided, hot, spreading and with systemic upset.
• Chronic oedema — heart failure, venous insufficiency, low albumin, drugs (calcium channel blockers), immobility ("dependency oedema" — chair-bound), lymphoedema; leg elevation, compression (after ABPI), skin care, mobility.
• Foot problems — thickened nails (onychogryphosis), corns, bunions, poor footwear — all increase falls; podiatry; diabetic foot checks.

Hypothermia and Heat Illness

• Hypothermia (core temperature under 35°C) — older people are at risk because of reduced shivering and temperature sensation, immobility, cold homes (fuel poverty), hypothyroidism, sedatives, alcohol, sepsis, falls with long lies.
• Features — confusion, drowsiness, slurred speech, bradycardia, AF, J waves on ECG, hypotension, low glucose or high glucose; use a low-reading thermometer.
• Management — handle gently, remove wet clothes, passive and active external rewarming (warm blankets, warm air), warm IV fluids; look for causes (sepsis, hypothyroidism, hypoglycaemia, drugs, stroke); rewarm slowly in chronic hypothermia (about 0.5–1°C per hour); severe cases — ICU.
• Prevention — warm homes (at least 18°C), winter fuel support, Cold Weather Alerts, regular checks on isolated people.
• Heat illness — older people are at high risk in heatwaves (reduced sweating and thirst, heart disease, diuretics, anticholinergics, antipsychotics, dementia, living alone):
  • Heat exhaustion — dizziness, weakness, nausea, headache, temperature under 40°C — cool, fluids.
  • Heat stroke — temperature over 40°C with confusion, seizures or coma — emergency: rapid cooling, fluids, ICU.
  • Prevention — Heat-Health Alerts, keep cool, drink regularly, review diuretics and anticholinergics, check on vulnerable people.

Infection in Older People

• Atypical presentations — confusion, falls, reduced eating, drowsiness, incontinence, worsening of chronic conditions; fever may be absent (a rise of 1.1°C from baseline or temperature over 37.8°C — or a low temperature — may be significant); WCC may be normal.
• Urinary tract infection — over-diagnosed in older people:
  • Don't use urine dipsticks in people over 65 (asymptomatic bacteriuria is very common and doesn't need treatment) (UKHSA).
  • Diagnose on symptoms — new dysuria, new frequency or urgency, new incontinence, suprapubic pain, visible haematuria, fever with no other source, plus new or worse confusion (with other features).
  • Send urine culture before antibiotics; treat per local guidelines (nitrofurantoin or pivmecillinam — check kidney function).
  • Catheterised patients — don't dipstick; change the catheter before taking a sample and treat only if symptomatic.
  • Unnecessary antibiotics cause C. difficile, resistance and AKI.
• Pneumonia — commonest serious infection; aspiration risk; may present with confusion and tachypnoea without cough; CURB-65 (age 65+ scores 1).
• Other infections — cellulitis, infected pressure ulcers, intra-abdominal (diverticulitis, cholecystitis — little tenderness), infective endocarditis, prosthetic joint infection, shingles (postherpetic neuralgia more common), C. difficile, norovirus and influenza outbreaks in care homes, TB reactivation.
• Vaccination — annual influenza, pneumococcal (65 and over), COVID-19 boosters, shingles (Shingrix — per current UK schedule), RSV vaccine (UK programme for people around 75 and older adults — per current schedule).

Vision and Hearing

• Visual impairment — common causes: cataract, age-related macular degeneration (wet — sudden distortion, urgent anti-VEGF; dry — gradual), glaucoma, diabetic retinopathy, uncorrected refractive error (simply needing new glasses).
• Consequences — falls, isolation, depression, loss of independence, delirium, Charles Bonnet hallucinations; affects driving.
• Action — regular eye tests (free over 60 in the UK), cataract surgery (reduces falls), low vision aids, good lighting, certification as sight-impaired (access to support).
• Hearing loss (presbyacusis — high-frequency, both ears) — very common; also wax impaction (treatable), noise damage, drugs (aminoglycosides, loop diuretics).
• Consequences — isolation, depression, communication problems in clinics and hospital, misdiagnosis of confusion; hearing loss is a major modifiable risk factor for dementia.
• Action — check for wax, refer to audiology, hearing aids (and make sure they're worn, charged and brought into hospital), communication tips (face the person, reduce background noise, speak clearly — don't shout, use a pocket talker or written notes).
• Dual sensory loss — especially disabling; specialist support.

Pain Assessment

• Chronic pain affects about half of older people living at home and more in care homes — commonly osteoarthritis, back pain, neuropathy, leg ulcers, post-herpetic neuralgia.
• Under-reporting — older people may not complain ("expected at my age", fear of addiction, not wanting to be a burden); ask about "aches" or "discomfort" too.
• Assessment in people who can communicate — numerical or verbal rating scales, faces scales; site, nature, impact on function, sleep and mood.
• Assessment in people with dementia or who can't communicate — observe behaviour:
  • Abbey Pain Scale — vocalisation, facial expression, change in body language, behavioural change, physiological change, physical changes.
  • PAINAD — breathing, vocalisation, facial expression, body language, consolability.
  • Signs — grimacing, guarding, moaning, restlessness, aggression during care, withdrawal, reduced appetite, new confusion.
• Treatment — regular paracetamol (often first step and may reduce agitation), topical NSAIDs, cautious opioids (see page 4), non-drug approaches (heat, positioning, physiotherapy, distraction); review effect.

Sleep Problems

• Normal ageing — earlier bedtime and waking, lighter sleep, more night waking, daytime naps.
• Causes of insomnia — pain, nocturia, breathlessness (heart failure, COPD), depression and anxiety, caffeine and alcohol, drugs (steroids, beta-blockers, SSRIs, diuretics at night), restless legs syndrome (iron deficiency, CKD, drugs), obstructive sleep apnoea (snoring, daytime sleepiness), dementia (sleep–wake reversal), noisy hospital wards.
• REM sleep behaviour disorder — acting out dreams (punching, kicking) — early sign of Parkinson's disease or Lewy body dementia.
• Management — treat causes; sleep hygiene (regular routine, daylight exposure, limit daytime naps, avoid caffeine and alcohol in the evening); CBT for insomnia; avoid hypnotics (falls, confusion) — short-term melatonin if needed.
• In hospital — reduce noise and light at night, cluster care to avoid waking patients, eye masks and ear plugs.

Elder Abuse and Self-neglect

• Abuse of older people — a single or repeated act, or lack of appropriate action, within a relationship of trust, causing harm or distress (WHO). Types (Care Act 2014):
  • Physical, psychological, sexual, financial or material (commonest reported — scams, misuse of money or property), neglect and acts of omission, discriminatory, organisational (poor care in institutions), domestic abuse, modern slavery, and self-neglect.
• Warning signs — unexplained or patterned bruises and injuries, fractures inconsistent with the story, pressure ulcers, malnutrition, dehydration, poor hygiene, missed medicines, fearfulness, withdrawal, sudden changes in finances, a carer who won't let the person speak alone.
• Risk factors — dementia, dependency, social isolation, carer stress, carer substance misuse or mental illness, history of family violence.
• Action — see the person alone, document carefully (body maps, photographs with consent), ensure immediate safety, and raise a safeguarding concern with the local authority (adult safeguarding); involve police if a crime; respect the wishes of people with capacity where possible (but share information if others are at risk or it's in the public interest).
• Self-neglect — not caring for personal hygiene, health or surroundings (including hoarding) — assess capacity (including executive capacity — "can say but can't do"), mental health, cognition; multi-agency approach; respect autonomy while managing risk.
• See the Psychiatry chapter on Safeguarding.

Geriatric Syndromes at a Glance

Spot the Diagnosis

Exam-style Scenarios

1. An 83-year-old woman in a care home has new urinary incontinence and is more confused. She is on furosemide, oxybutynin and codeine. Her urine dipstick is positive for nitrites and leucocytes, but she has no urinary symptoms or fever.
Answer: Transient incontinence and delirium — probably not a UTI.

• Don't treat the dipstick (asymptomatic bacteriuria); look for other causes — constipation (codeine, oxybutynin), retention (bladder scan), drug effects, dehydration, other infections.
• Stop oxybutynin; review codeine and furosemide timing; treat constipation.
• Prompted toileting; reassess cognition and continence once causes are treated.

2. A 79-year-old man has lost 8 kg over 6 months and eats very little. He lives alone since his wife died a year ago. BMI 18.
Answer: Unintentional weight loss with high malnutrition risk (MUST 4).

• Look for causes — cancer (examination, bloods, FIT, chest X-ray, targeted tests), depression and bereavement, dentition, swallowing, alcohol, drugs, thyroid, diabetes, malabsorption.
• Dietitian, food first and supplements; help with shopping and cooking (social care, meals); social support for isolation.
• Treat depression if present (mirtazapine may help appetite); review weight regularly.

3. An 88-year-old woman is admitted after a stroke. She coughs when drinking water and has a wet, gurgly voice after swallowing.
Answer: Oropharyngeal dysphagia with aspiration risk.

• Nil by mouth until assessed; urgent speech and language therapy assessment; review medicines (alternative routes).
• Texture-modified diet and thickened fluids per SLT (IDDSI); upright positioning; supervised meals; oral care.
• Consider NG feeding for nutrition and medicines while swallowing may recover; monitor for aspiration pneumonia.

4. A 91-year-old man with dementia in hospital has a category 2 pressure ulcer on his sacrum and red, non-blanching heels. He is incontinent, eats little and spends most of the day in bed.
Answer: Pressure ulcers with high risk of further damage.

• SSKIN — pressure-relieving mattress, regular repositioning (every 2–4 hours), heel offloading boots, skin inspection, barrier creams and continence care, nutrition and hydration.
• Tissue viability input; wound dressings; look for infection; pain relief.
• Document; report per local policy (hospital-acquired pressure ulcers are patient safety incidents).

5. An 84-year-old woman with dementia attends with her son. She has bruises on both upper arms in a grip pattern, appears frightened and looks to her son before answering. He says she "falls a lot".
Answer: Possible physical abuse.

• See her alone; ask sensitively; examine fully; document injuries (body map, measurements, photographs with consent or best interests).
• Assess capacity and immediate safety; consider admission or a place of safety if at risk.
• Raise a safeguarding concern with the local authority; involve police if a crime is suspected; consider carer stress and support needs.

Key Points

• Incontinence is not normal ageing — look for transient causes (DIAPPERS).
• Bladder scan for retention; avoid oxybutynin; avoid catheters for incontinence alone.
• Nocturia causes falls — look for nocturnal polyuria, heart failure, sleep apnoea, drugs.
• Faecal impaction causes overflow diarrhoea, retention and delirium — always do a rectal examination.
• Screen nutrition with MUST; food first and help with eating; watch for refeeding syndrome.
• Hypernatraemia means water deficit; hyponatraemia often comes from drugs — correct both slowly.
• Coughing on drinks and wet voice — SLT assessment; IDDSI textures; upright positioning.
• Good mouth care reduces aspiration pneumonia and helps eating.
• Pressure ulcers — SSKIN; reposition and offload heels.
• Bilateral red legs are rarely cellulitis.
• Don't dipstick urine in over 65s; diagnose UTI on symptoms.
• Vision and hearing loss cause falls, isolation and apparent confusion — fix what can be fixed.
• Assess pain in dementia with the Abbey Pain Scale or PAINAD.
• Older people are vulnerable to cold and heat.
• Suspected abuse — see the person alone, document, safeguarding referral.

Guidelines and Further Reading

• NICE NG123: Urinary incontinence and pelvic organ prolapse in women; NICE CG97: Lower urinary tract symptoms in men
• NICE CG49: Faecal incontinence in adults; NICE CKS: Constipation
• BAPEN: Malnutrition Universal Screening Tool (MUST)
• NICE CG32: Nutrition support for adults
• International Dysphagia Diet Standardisation Initiative (IDDSI)
• Royal College of Physicians: Supporting people who have eating and drinking difficulties
• NICE CG179: Pressure ulcers — prevention and management
• UKHSA: Diagnosis of urinary tract infections — quick reference tool
• UKHSA: Cold Weather and Heat-Health Alerts
• British Pain Society and BGS: Guidance on the management of pain in older people
• Care Act 2014: Statutory guidance — adult safeguarding
• Health Education England: Mouth Care Matters
• BNF — for current doses