high-dose parenteral vitamin B supplements may be needed \200 Occasionally, the cause of delirium is not apparent. In such cases: \200 Initiate general supportive measures ( \202 uid, pressure care, nutrition, etc.) Continually re-examine and consider more advanced tests Competency Patients with delirium are not usually competent to direct treatment. The law al lows assessment and treatment in their best interests. This may include: \200 Holding wit hin a ward or hospital if a patient attempts to leave \200 Temporary physical restraint ( eg while drugs are administered) \200 Covert administration of essential drugs Clear expl anations should be given to staff and family of the need for such interventions, and their ethical and legal justi \201 cation. Document clearly in the medical notes why the team co nsiders that such measures are neces- sary. Reassess competence continually. Once the acute illness is over a \200\230Deprivation of liberty assessment \200\231 may be needed (see b \200\230Deprivation of Liberty Safeguards \200\231, p.657). DELIRIUM: NON-DRUG MANAGEMENT 241 Delirium: non-drug management Delirious patients feel ill, frightened, bemused, and disorie ntated. There are problems with attention, memory, and perception. Therefore do what you ca n to make life easier for the patient: \200 Provide a quiet environment free from worryin g sounds; appropriate clothes; quality lighting, at an appropriate level for the time of da y; a clock or outside view to aid orientation Optimize visual and auditory acuity by providing spectacles and hearing aids that work Reassure the patient repeatedly and calmly \200 Explain who you are, what you wish to do and con \201 rm understanding \200 Patients will sense a doctor \200\231s manner, partic ularly aggression or frustration. At all times appear relaxed, unhurried and pleasant \200 Use non-verbal communication: sit down, smile and appear friendly rather than professional Don \200\231t argue, or correct delusions \200\224 the product will be aggravation and lesser compliance Educate visitors who are heightening emotion \200\224 ask them to modify their behavior or even asked them to leave Explain to relatives, and enlist their help, in supervising, feeding, and bringing in items familiar to the patient Physical restraint Restraint is terrifying and has adverse mental and physical sequelae. It is only rarely needed, but is sometimes (inappropriately) used as a substitute for supervi sion and guidance by an experienced carer/nurse. In cases of severe aggression, where parenteral drugs are required, brief immobilization of the patient using the minimum force necessary may on balance be in the patient \200\231s b est interests. Recovery phase 2Patterns of recovery from delirium vary. Most patients recover com- pletely in a few days, some take much longer, but some never return to baseline cognitive and/or p hysical function. Delirium can \200\230unmask \200\231 a previ- ously unrecognized dementi a. In those whose functional status declines signi \201 cantly, remember that full recover y may take weeks or months \200\224 beware making irreversible decisions (eg home versus r esidential care) \200\224 before the \201 nal functional level is known. Once a patient is admitted, multiple barriers to discharge often appear: Carers and family will fear that recent deterioration will persist, and may resist discharge Care packages may be canceled, taking weeks to restart \200 Therapists may assess functio n as suboptimal in the unfamiliar hospital environment, judging that discharge is unsafe Therefore once the acute event has been diagnosed and treatment begun, encourage the team t o begin promptly to plan for home. Delay in discharge leads to increased prescription of ps ychotropic drugs, institutionalization and care home placement. 242 CHAPTER 9 Psychiatry Delirium: drug treatments Drugs are needed only when the agitation that accompanies deliriu m is: \200 Causing signi \201 cant patient distress \200 Threatening the safety of the patient or others \200 Interfering with medical treatment (eg pulling out of iv lines, a ggression preventing clinical examination) Having decided that drug treatment is in the patient \200\231s interests, remember that: \200 Drugs should complement, not replace, non-drug approaches \200 The correct dose is the minimum effective dose \200 The response (adverse and bene \201 cial) and prescripti on must be reviewed regularly It is preferable to use only one drug, starting at low dose, and increasing the dose increm entally at intervals of 30 \200\22360min Delirium can resolve quickly so avoid regular prescription \200\224 each dose should be as needed (prn). The relative merits of differing drug classes and drugs are debated, but a reasonable conse nsus is presented in b \200\230HOW TO Prescribe sedating drugs in delirium \200\231, p.243. In cases where behavior remains problematic, seek urgent advice from the local psychogeriatric team. DELIRIUM: DRUG TREATMENTS 243 HOW TO Prescribe sedating drugs in delirium Short-acting benzodiazepines (eg lorazepam) \200 Have recently replaced antipsychotics as \201 rst-line treatments. Useful if sleep disturbance is prominent, or for severe distre ss or agitation \200 Short-acting benzodiazepines are preferred, eg lorazepam orally (po) , im, or sublingual repeated as necessary/tolerated Dependence and tolerance is possible, so review regularly and discontinue as soon as possib le. Avoid inclusion on \200\230to take out \200\231 (TTOs) if possible Long-acting benzodiazepines are especially useful for the treatment of delirium caused by a lcohol or benzodiazepine withdrawal. Use chlordiazepoxide, in reducing dose In extreme cases only (eg severe distress/agitation, with imminent danger to self/others), consider giving a small intravenous dose of a short-acting benzodiazepine (eg midazolam), c arefully titrated to response. Monitor closely both clinically and with oximetry \200\224 the major risk is respiratory depression Typical antipsychotics (eg haloperidol) \200 Compared with low-potency antipsychotics, th ere are fewer side effects (eg sedation, hypotension, anticholinergic) Begin with a small dose, eg 0.5mg orally, as tablet or liquid, as required. Repeat doses after 1 \200\2232hr, and increase the dose size as needed and tolera ted. Total daily oral dose is usually 0.5 \200\2234mg \200 Response is idiosyncratic: som e patients are very sensitive to low dose, others only to very large doses In older people the half-life of haloperidol may be as long as 60hr. Dosing can be cumulati ve. Failure to titrate the dose correctly may render the patient semi-conscious for days The oral liquid formulation of haloperidol is colorless and odorless, aiding covert administration (eg in a drink) if required \200 In the very agita ted consider haloperidol 1 \200\2232mg im repeated after 1hr (approximately 2:1 oral to int ramuscular dose equivalence) The incidence of extrapyramidal side effects is high. Avoid haloperidol in dementia with Lewy bodies and in all causes of severe parkinsonism Atypical antipsychotics (eg olanzapine, risperidone) \200 The place of the newer atypical antipsychotic medications remains unclear, following concerns of increased risk of stroke Should be considered when response to other strategies is poor \200 Risperidone liquid ca n be diluted in water, black coffee, or orange juice \200 Risperidone 0.5mg has similar p otency to haloperidol 1mg Combination treatment Benzodiazepines and antipsychotic medicatio ns are sometimes combined in the management of delirium symptoms, generally under specialis t advice. Stopping treatment Once behavior has improved, consider stepwise dose reduction, aiming to stop the drug as soon as possible without prompting relapse. 244 CHAPTER 9 Psychiatry Confusion and alcohol It is an error to consider alcohol abuse as exclusively a disease of younger people. Even if the clinician remembers to ask about alcohol they are often deceive d by the patient who is embarrassed. Decreased alcohol metabolism means that older people s hould probably be recommended lower \200\230safe \200\231 drinking levels than younger adu lts. Decreased balance and cognitive reserve may mean that even very small doses of alcohol can have detrimental effects Alcohol withdrawal \200\224 occurs when habitual excess alcohol intake is stopped, eg when a patient is admitted to hospital. Agitation and confusion can occur along with physical s igns such as diarrhea, fever, and hypertension. Visual or tactile hallucinations or illusio ns can occur. Delirium tremens \200\224 severe form of alcohol withdrawal with a high mortality. There a re delusions, tremor, autonomic hyperactivity, and sometimes \201 ts. Wernicke \200\231s and ophthalmoplegia. May respond to prompt thiamine administration but many go on to develo p Korsakoff \200\231s. encephalopathy \200\224 triad of confusion, ataxia, Korsakoff \200\231s syndrome \200\224 irreversible brain damage caused by thiamine de \201 ciency, most commonly seen in alcoholism. May follow an episode of Wernicke \200\231s encephalopathy or develop gradually. Amnesia and confabulation occurs with lack of insight and apathy. Ataxia and tremor may also be found. Alcohol dementia syndrome \200\224 a dementia almost indistinguishable from Alzheimer \200 \231s can occur without the typical features of Korsakoff \200\223Wernicke syndrome. Managing alcohol withdrawal in hospital \200 Make the diagnosis \200 If necessary (not routinely \200\224 even heavy drinkers get withdrawal symptoms in about half of cases) use a decreasing dose schedule of benzodiazepine, eg chlordiazepoxide to control symptoms and behavior. Clomethiazole should not be used in older patients. Always prescribe B vitamins \200\224 either parenterally or orally (multivitamins plus some thiamine) Offer support SQUALOR SYNDROME 245 Squalor syndrome Also referred to as senile self-neglect (inappropriately derogatory) or Di ogenes syndrome. Clinical features \200 Affected people, usually elderly, live in conditions of severe sel f- neglect, are socially withdrawn, and lack insight into the unusual nature of their behavior s and effects on others Financial problems are rare \200 Homes are typically dirty, their upkeep neglected, and a re often the repository for hoarded garbage. This often causes distress and anxiety to neighbors, social and health professionals, much more so than to the patient themselves. Thus they come to t he attention of many agencies, health, social, and public (eg environmental health) The syndrome is not uncommon. Diagnosis is made when the clinical fea- tures listed exist, without major psychiatric illness (dementia, depression) to explain it. The best guess is t hat the syndrome is an unusual manifesta- tion of longstanding personality disorder, and th at isolated frontal lobe dysfunction commonly plays a part. Risk factors \200 Borderline personality ( \200\230eccentricity \200\231) \200 Early de mentia or depression \200 Recent bereavement (commonly spouse) \200 Lack of close famil y \200 Social isolation \200 Sensory impairment (often visual) Management \200 This should include identi \201 cation and treatment of contributing psy chiatric illness and secondary physical illness, eg malnutrition \200 Patients often decl ine ongoing social support. Psychiatric day care may maintain more mainstream behavior for a time, but relapse is common. Institutional care is a long-term solution, if accepted Usually such people are competent to decide to maintain their unusual lifestyle, and to decline offers of support Caring for them can be frustrating, but adverse consequences for the patient are often surprisingly few, and a watching brief is usually suf \201 cient, wi th prompt intervention when decompensation occurs 246 CHAPTER 9 Psychiatry Depression: presentation The most common psychiatric illness in older people. Probably 10 \200\22315 % prevalence over 65 years, severe in 3 % . Risk factors for depression include: Disability and illness (especially if serious) \200 Care home residents \200 Bereavemen t. Reactive depression is more common in older people, who suffer more bereavement, illness and other life events. The reaction may be understandable, but there is bene \201 t from treatment ( see b \200\230Bereavement \200\231, p.640) Social isolation \200 Chronic pain \200 Sensory impairment (eg hearing or sight) Comorb idity may mask or precipitate depression and may be: \200 Physical (Parkinson \200\231s, stroke, cancer, or post-acute illness) \200 Psychiatric (dementia) Depression is underdia gnosed in older people, for the following reasons: \200 Perception that depression carrie s a social stigma, so not volunteering symptoms Presentation with symptoms suggesting physical rather than psychiatric disease (eg weight loss rather than sadness) Perception that low mood is a normal part of ageing (eg \200\230Of course she is depressed \200\224 she is in a nursing home with chronic disability and pain \200\231) 2Have a low threshold for opportunistic screening. DEPRESSION: PRESENTATION 247 HOW TO Distinguish dementia from a depressive pseudodementia Pseudodementia is a severe depression that presents with poor memory and concentration and impaired functional capacity, eg for ADLs. Also known as dementia of depression. It is usually distinguishable from dementia, because: The history is often short and the onset relatively abrupt \200 Patients often complain a bout poor memory and are despairing \200 Assessment of cognition often results in \200 \230don \200\231t know \200\231 responses \200 Memories are often accessible with \200 \230hints \200\231 or cues from the assessor \200\224 they remain \200\230stored \200\231 There is often a past history of depression, or an identi \201 able precipitant The prognosis is variable. In some, mood and cognition respond to antidepressants. However, many go on to develop dementia, usually of Alzheimer type. Coexistence of depression and dementia \200 Both depression and dementia are relatively c ommon, and may coexist coincidentally Over 20 % of people with an early dementia may be depressed, suggesting a depressive reaction to the onset of dementia \200\224 especially common and u nderstandable if insight is preserved This is quite different from pseudodementia (where there is no actual dementia) General guidance \200 Treat depression whatever the cause \200\224 whether a \200\230tr ue \200\231 pseudodementia, or a combination of dementia and depression \200 Avoid mislabelling a dep ressed patient as also having dementia \200\224 the management and prognoses are very different Always screen for depression when assessing patients with cognitive disorders, including short-term memory loss alone 248 CHAPTER 9 Psychiatry Depression: clinical features Sadness Commonly denied, and not necessary in order to make a diagnosis of depression. Tearfulness is uncommon, especially in men. Also ask about bio- l ogical symptoms, anhedonia (inability to enjoy \200\224 ask \200\230What do you enjoy or look forward to? \200\231) and depressive thoughts (guilt, worthlessness, low self- esteem, self-blame, suicidal thoughts, hopelessness, and helplessness). Anorexia and weight loss Common to both depression and to serious physical illness. In the patient who presents in this way, without evidence of a physical cause after clinical exami nation and basic tests, it is a matter of judgment whether and when an antidepressant trial should begin, and whether more invasive tests should be delayed pending the results of tha t therapeutic trial. (See b \200\230HOW TO Manage weight loss in older patients \200 \231, p.357). Sleep disturbance Typically early morning wakening, but a full sleep history is useful, as early wakening may be appropriate, eg if sleeping during the day. Some older people do slee p much less than when younger \200\224 the key is whether they wake refreshed, or wake anx ious and fearful, keen to return to sleep but unable to do so (see b \200\230Sleep and ins omnia \200\231, p.176). Disturbance of behavior May include attention-seeking, aggression, irritability, cries for help (eg intentional falls), self-neglect, malnutrition, social withdrawal. Cognitive impairment Poor attention and concentration may result in impairments in several cognitive domains, typically memory. If severe, this may manifest as a \200\230depressive pseudodementia \200\231. Suicidal ideation and self-harm Should always be taken seriously, as completed suicide is r elatively common in older people, especially those with physical illness. Self- harm (eg dr ug overdose) may be medically trivial, but psychiatrically very serious, and should mandate psychiatric referral. Parasuicide \200\224 a \200\230cry for help \200\231 or \200\230m anipulative \200\231 self-harm event \200\224 is very rare; most older people who self-har m are at least moderately depressed. Physical slowness Exclude physical causes, including parkinsonism, cerebrovascular disease and hypothyroidism. May manifest as increased dependence or \200\230failure to cope \200 \231. May be severe, with very reduced mobility or total immobility \200\224 the depressed , bedbound, motionless, anorexic patient must be treated as an emergency. DEPRESSION: CLINICAL FEATURES 249 Somatization This expression of psychological problems as physical symptoms is common, as i s hypochondriasis (disproportionate concern over health). In the patient presenting with so matization or hypochondriasis, the risks are of failing to investigate and treat when a tru e physical illness is present, or conversely, of failing to appreciate that antidepressant treatment is actually what is needed. HOW TO Assess depression Depression rating scales For example, GDS ( see b Appendix, \200\230Glasgow Coma Scale \200\231, p.696), which is known to be valid in community and hospital settings, and mainta ins speci \201 city in mild to moderate dementia. Two or three simple questions can be effective screening tools. Simply asking \200\230Do y ou feel low? \200\231 has reasonable sensitivity and speci \201 city for depression. Psychiatric history and examination Physical history and examination Targeting evidence of physical illness contributing to or mimicking depression, and contraindications to drug tre atments. Cognitive assessment screen For example, MMSE, clock-drawing test. Is there coexisting cogn itive impairment? If so, does it improve with treatment for depression?, ie pseudodementia (see b \200\230HOW TO Distinguish dementia from a depressive pseudodementia \200\231 , p.247). Blood tests \200 FBC (anemia leading to lethargy; high mean corpuscular volume (MCV) in alcohol excess) \200 ESR (malignancy, vasculitis) \200 B 12 and folate (low le vels may contribute to depression, or result from anorexia) U,C + E (uraemia, dehydration) \200 Calcium (hypercalcaemia leading to depression, fatigu e) \200 Thyroid function (hypo- and occasionally hyperthyroidism may present as depression) Liver function (malignancy, alcohol excess) 250 CHAPTER 9 Psychiatry Depression: non-drug management Depression is undertreated as well as underdiagnosed. Treat ment should be started promptly, its intensity (eg drug dose) increased as needed, and cont inued until the likelihood of relapse off treatment is low. Supportive treatment \200 Includes counseling and relief of loneliness \200 Treat physi cal symptoms and pain \200 Address rational anxieties, eg \201 nancial, housing, physic al dependency \200 Consider stopping contributory drugs ( B -blockers, benzodiazepines, levodopa, opiates, steroids) Psychotherapy As effective as antidepressants for mild-to-moderate depression, and may be p referred by some. May complement drug treatment in resistant cases. Cognitive behavioral th erapy has the most evidence. Is resource intensive and often limited availability and/or lo ng waiting lists. Electroconvulsive therapy (ECT) ECT offers a safe, rapid, and reasonably certain response i n cases where: \200 Rapid response is necessary \200 Patients with depression have been intolerant to or have not responded to drug treatment When depression is very severe and manifests as psychosis, severe physical retardation, depressive stupor, or food/ \202 uid refusal Relative contraindications include coronary, cerebrovascular, and pulmonary disease. Specialist referral Consider psychogeriatric assessment if: \200 Treatment is unsuccessfu l after 6 \200\2238 weeks \200 Depression is severe, eg with delusions \200 The diagnos is is unclear, eg when depression and signi \201 cant cognitive impairment coexist A patient is refusing treatment or otherwise threatening self-harm \200 There are questio ns of competency \200 ECT is being considered Further reading NICE Depression: the treatment and management of depression in adults (upda te) ( 2009 ) online: M http://guidance.nice.org.uk/CG90/QuickRefGuide/pdf/English . This page intentionally left blank 252 CHAPTER 9 Psychiatry Depression: drug treatments Drug treatment is generally effective, well tolerated, and non- addictive, although patients often believe otherwise. 2There is signi \201 cant stigma ass ociated with taking antidepressants, which is more prevalent in older age populations, and this may need to be explored and addressed. General \200 In reactive depression, consider saying \200\230This won \200\231t stop you feeling sad, that \200\231s understandable, but it will help you to cope better with those feelings \200\231 Inform the patient that response takes time but is usual \200 No antidepressant class has been shown to be more effective, so choice depends on side effects, speed of onset, response to previous treatment, drug intera ctions and associated conditions, eg anxiety or pain Selective serotonin reuptake inhibitors For example: citalopram or sertraline \200 Now ge nerally the \201 rst class of antidepressant prescribed \200 Compared with tricyclic an tidepressants such as amitriptyline, they are less sedating, have fewer anticholinergic and cardiotoxic side effects, fewer drug interactions, and are much safer in overdose Symptomatic response commonly starts after 2 weeks but may take up to 8 weeks Common side effects include gastrointestinal symptoms (nausea and diarrhea), postural hypotension, anxiety, and restlessness, and hyponatraemia. Hyponatr aemia is usually moderate (Na > 125mM) and asymptomatic, and especially common in combinati on with diuretics Rarely causes serotonin syndrome (see b \200\230Neuroleptic malignant syndrome \200\231, p.169) Start at low doses to minimize side effects, and build up as needed to give a useful response If there is no response to an adequate dose of one SSRI, there is little point trying another. Instead, switch class Tricyclic antidepressants For example: amitriptyline, nortriptyline \200 Much less prescr ibed than previously \200 They still have a role, for example: If anticholinergic effects are desirable (urge incontinence) \200 When there is neuropath ic or other pain that may respond to its coanalgesic effect In depression resistant to other drugs The secondary amines (eg nortriptyline) are preferred, causing less orthostatic hypotension than tertiary amines (eg amitriptyline, imipramine). Anticholi nergic side effects are less troublesome if doses start low and are increased weekly DEPRESSION: DRUG TREATMENTS 253 Serotonin and noradrenaline reuptake inhibitors (SNRIs) For example: venlafaxine. \200 Fo r severe depression, or when poor response to SSRIs after 6 weeks \200 Also useful for an xiety and obsessive compulsive disorder \200 May cause less orthostatic hypotension than the SSRIs, but other side effects similar Serotonin antagonist For example: mirtazapine \200 An atypical antidepressant which tends to cause weight gain (so may be particularly useful in malnourished) It has fewer anticholinergic side effects, but is more sedating than tricyclics (so conside r when a degree of sedation is desirable) \200 Also less commonly complicated by hyponatr aemia than SSRIs Monoamine oxidase inhibitors For example: moclobemide \200 Occasionally used, under exper t guidance, but dietary and drug interactions are problematic Treatment should be continued for up to a year. If depression has been severe and/or recurrent, consider continuing inde \201 nitely Stopping drugs Withdrawal reactions (anxiety, mania, delirium, insomnia, gastrointestinal s ide effects, headache, giddiness) may occur if drugs are stopped abruptly after 8 weeks or more. Therefore reduce dose gradually, over 4 weeks. In those on long-term treatment, reduc e over several months. Switching drugs \200\230Cross-tapering \200\231 is generally advised, ie the incremental r eduction of the \200\230old \200\231 drug, and incremental increase of the \200\230new \200\231 drug usually over 2 \200\2233 weeks. Rarely, a wash-out period between drugs is re quired (eg before MAOIs). 254 CHAPTER 9 Psychiatry Suicide and attempted suicide Older people, especially men, have a higher risk of completed (rather than attempted) suicide. Following an attempted suicide, further attempts \200 \224 and successful suicide \200\224 are common. Risk factors include being male, single (ie unmarried, divorced/separated, or widowed), soc ially isolated, having \201 nancial problems, having made previous attempts, and recent b ereavement. Unlike younger people, the substantial majority of older people who attempt sui cide are psychiatrically unwell at the time of the attempt; most are depressed. Many seek c ontact with medical services prior to the attempt, although they may not express depressive or suicidal thoughts at that visit. Suicidal behaviors may be overt or covert. Overt behaviors include: Intentional drug overdoses (opiates, antidepressants, paracetamol, benzodiazepines; more common in women) Self-injury (hanging, shooting, jumping, drowning; more common in men) Covert suicide is relatively more common in older people, and includes \200 Social withdr awal \200 Severe self-neglect \200 Refusal of food, \202 uid, or medication This may manifest in subtle ways that encourage extensive investigation to exclude physical illness, while the psychiatric problem goes unrecognized and untreated. Suicidal ideation is more common in institutional settings (acute and rehabilitation hospit al wards, and care homes) and in people with acute or chronic physical illness. Risk factor s here include depression, chronic pain, sleep disturbance, functional impairment, drug abu se, and psychotropic drug prescription. At their mildest, suicidal ideas manifest as common and relatively benign doubts about whether life is worth living. At their most worrying, t hey are carefully considered, well formulated and strongly held beliefs that death is prefe rable to life, and how that could be achieved. Assessment of the \200\230severity \200\231 of an attempt requires an effort to determine perceived risk from the patient \200\231s perspective at the time of the attempt. This may not parallel the medical seriousness. Consider: \200 Degree of planning versus impulsivit y \200 Likelihood of interruption during attempt \200 Reaction to interruption to attem pt (disappointment or relief?) \200 Suicide note and its contents \200 Planning for fut ure (eg making of will, contents of suicide note) \200 Personal view of suicide as a reas onable \200\230life choice \200\231 Specialist referral . Always in cases of attempted sui cide, suicidal ideation or \200\230covert suicide \200\231. Probably not in cases of non-p ersistent or poorly formulated views that life is not worth living. 255 Chapter 10 Cardiovascular The ageing cardiovascular system 256 Chest pain 258 Stable angina 260 HOW TO Rationalize antianginals in older patients 261 Acute coronary syndromes 262 Myocardial infarction 266 Hypertension 268 Hypertension: treat ment 270 HOW TO Use antihypertensives in a patient with comorbid conditions 271 Arrhythmia: pr esentation 272 Arrhythmias: management 274 Atrial \201 brillation 276 Atrial \201 brill ation: rate/rhythm control 277 Atrial \201 brillation: stroke prevention 278 HOW TO Discuss warfarin for AF 280 HOW TO Use digoxin 281 Bradycardia and conduction disorders 282 Common arrhythmias and conduction abnormalities 28 6 Heart failure: assessment 288 HOW TO Investigate a patient with suspected heart failure 289 Acute heart failure 291 Chronic heart failure 292 Dilemmas in heart failure 294 HOW TO Manage the heart failure see-saw 295 Diastolic heart failure 296 Valvular heart disease 298 Peripheral oedema 300 Preventing ven ous thromboembolism in an older person 302 Peripheral vascular disease 304 HOW TO Measure ABPI 305 Gangrene in peripheral vascular disease 306 Vascular secondary prevention 308 256 CHAPTER 10 Cardiovascular The ageing cardiovascular system Advanced age is the most potent risk factor for cardiovasc ular disease. This vulnerability stems from: Cumulative exposure to risk factors (extrinsic ageing) \200 This was looked at in more de tail in the WHO MONICA project (see b \200\230Further reading \200\231, p.256), which look ed at coronary risk factors in 38 populations across 21 countries for a decade This showed that not all risk factors increased with age \200\224 male smoking decreased (although not female) and cholesterol showed a small downwards trend. Body mass i ndex (BMI) increased for both sexes \200 Thus, it is not inevitable, and can be modi \201 ed by behavior, eg athletes who continue to exercise into older age may show fewer sig ns of cardiovascular ageing than an un \201 t younger person Disease acquisition \200 Often occult \200 Affected by risk factor accumulation Intrinsic ageing The relative contributions of these factors to the clinical picture are un clear. Table 10.1 addresses the three important questions: \200 What are the common chang es with age? \200 How does that impact on function? \200 What are the clinical implicat ions? Further reading Evans A , Tolonen H , Hense HW , et al . ( 2001 ). Trends in coronary risk factors in the WHO MONICA Project . Int J Epidemiol 30 : S35 \200\223 S40 . THE AGEING CARDIOVASCULAR SYSTEM 257 Table 10.1 An overview of age-related changes and their effects Age-related change Impact on function Clinical implications Intimal thickening probably predisposes to atheroma Systolic pressure peak increases, causing hypertension Proximal arteries become thicker, dilated, elongated and less elastic Systolic hypertension common in older patients Increased peripheral vascular resistance (variable) CXR may show enlarged aortic knuckle \200\230unfolding \200\231 of the aorta First degree heart block and bundle branch block common Slower conduction from SA node and through the conducting system Fibrosis and fat in \201 ltration of the sinoatrial (SA) node and conducting system Left axis deviation more frequent More vulnerable to clinically signi \201 cant bradyarrhythmias Less able to mount a tachycardia, so less reliable sign of acute illness Decreases capacity for cardiac output \200\224 largely compensated for at rest, but limits response to stress Maximum heart rate falls by 10 % at rest and 25 % during stress A degree of cardiac enlargement seen on CXR is normal. Worse with hypertension, so always c heck BP and treat as needed Increases cardiac \201 lling pressures and allows compensation for drop in heart rate Left ventricular wall thickens as myocyte size increases Predisposes to AF Left atrial size increases due to alterations in cardiac \201 lling Decreased cardiac reserve to stress \200\224 may become haemodynamically compromised in re sponse to acute illness earlier than younger patients Contractility preserved at low stimulation, but with stress cannot increase meaning (along with heart rate factors) that cardiac output cannot be increased Myocardial contractility impaired at high demand Increased circulating catecholamines with down regulated receptors (especially B adrenergic ) Impairs ability to mount a stress response As above, this table \200\224 decreased cardiac reserve to stress More prone to heart failure Contributes to reduced cardiovascular reserve to stress Varies considerably between individual older patients \200\224 unchanged in those used to exercise, up to 60 % reduction in un \201 t Impaired oxygen consumption on exercise 258 CHAPTER 10 Cardiovascular Chest pain A common complaint in all settings. May be primary symptom (presenting to GPs an d general medical take) or mentioned only in response to direct questioning. Also occurs du ring inpatient stays for other reasons. There are very many causes, the majority of which become more common with age. Many are ben ign, but some are serious and even life threatening, so a thorough and sensible approach is needed. Common conditions not to be missed include: cardiac pain; pleuritic pain due to pulmonary i nfarction or infection; peptic pain (including bleeding ulcers); pain from dissecting aorti c aneurysm and pneumothorax (especially in COPD). Other possibilities include: muscular pain (eg after unaccustomed exertion); costochondriti s (local tenderness at sternal joint); pain from injury (eg after a fall); referred pain fr om the back and neck (eg osteoarthritis) and referred pain from the abdomen. Differentiating these depends on accurate history taking and careful examination, both of w hich can be more of a challenge in older patients. Presentation may be atypical, and the pa tient may have many other problems so teasing out which are the important symptoms can be d if \201 cult (experience improves the ability to \200\230feel \200\231 your way around th e history). 2It may be the last symptom mentioned in a long list, however, mention of chest pain should always trigger a careful assessment. History \200 Is this a new symptom? (may suffer from chronic angina) \200 If not, is it any different from the usual pain? (intensity, pattern) \200 What is the nature of the p ain? (pleuritic, heavy, tight. This is often hard to do, and hand gestures can help \200 \224 a clenched \201 st for a heavy pain, a stabbing action for a sharp pleuritic pain) \200 Where is it located? (including radiation) \200 How acute is the onset and what is the duration? \200 Are there any associated symptoms? Patients with cognitive impairment can be particularly dif \201 cult to assess, but allowing free conversation may reveal sym ptoms, followed by closed questions that may prompt appropriate answers. Family members may have noted signs or symptoms and are an invaluable aid to assessment, eg clutching the che st after walking. Remember that cardiac symptoms may differ for each patient and they will describe the pain in their own terms. Many older adults with ischaemia will deny \200\230pain \200\231 and i nstead describe \200\230discomfort \200\231. Some will just experience weakness, dyspnoea, or nausea. Examination \200 How does the patient look? A sweaty, clammy patient needs urgent and exhaustive assessment, whereas a patient drinking tea and chatting is less likely to ha ve a devastating condition What are the basic observations? CHEST PAIN 259 Signs of shock alert to a serious condition \200\224 IHD, pulmonary infarction, dissection, sepsis, blood loss \200\224 but remember these may be late signs and are less useful in older patients. The patient may usually be hypertensive, so a BP of 120/80 may be very low for them; they may be on a B -blocker, so unable to mount a tachycardia, etc. Temperature may be raised in sepsis \200 Low oxygen saturation always needs explaining (u nless chronic) and may indicate an intrapulmonary problem Is the jugular venous pressure (JVP) elevated? (heart failure) \200 Look at the chest wal l for shingles, bruising and localized tenderness \200 Different blood pressures in the a rms may indicate dissection (but may also occur with atheroma) Listen to the heart \200\224 are there any new murmurs (dissection or infarction) or a rub (pericarditis)? Listen to the lungs \200\224 is there consolidation (sepsis) or a rub (consolidation or infarction)? Look at the legs \200\224 is there any clinical DVT? Investigations Some tests can be less useful in older patients, and should be individually tailored to the patient. Sending off every single test on all patients with chest pain will only lead to confusion. \200 ECG \200\224 should be done on the majority of patients wi th chest pain. Remember the baseline ECG may well be abnormal in an elderly person, and com parison with old traces is extremely useful. If your patient has a very abnormal ECG (eg le ft bundle branch block (LBBB)) it is useful to give them a copy to carry with them CXR \200\224 looking for lung abnormalities and widening of the mediastinum. Remember that the aorta often \200\230unfolds \200\231, so a careful look at the contours of the aortic arch and/or comparison with old \201 lms is needed to assess possible disse ction. Remember that a patient can look fairly well in the early stages of aortic dissectio n Blood tests \200\224 basic hematology, biochemistry, and in \202 ammatory markers are oft en useful. Remember that in acute blood loss, the hemoglobin may not drop immediately, and that an elderly septic patient may take a day or two to develop an elevated white cell coun t and CRP Troponin \200\224 useful in a patient with suspected cardiac chest pain (for risk strati \201 cation). It is NOT a useful test if you do not think this is cardiac pain \200\224 th ere are many false positives that will only cause confusion D-dimer \200\224 only useful if negative in cases of suspected thromboembolism. There are a huge number of causes of a positive d-dimer (including old age itself); a positive result does not imply the diagnosis of PE Further tests (eg CT thorax for suspected dissection, exercise testing for angina, lung perfusion scans for thromboembolism, etc.) depend on clinical factors 2Always attempt to explain a chest pain \200\224 both for the patient and future clinician s. A \200\230diagnosis \200\231 of non-cardiac chest pain is rarely helpful. 260 CHAPTER 10 Cardiovascular Stable angina Coronary artery disease is clinically evident in 20 % of those > 80 years. Ma nagement is often suboptimal. It is unacceptable to leave a patient with symptoms, however frail, until all available options have been looked at, and it has been proven (by trying i t) that a certain treatment cannot be tolerated. A stepwise, slow introduction of tablets a llows insight into adverse effects and may require multiple clinic visits. Symptom diaries can assist with this process. Stable angina Risk factor reduction \200 Cholesterol and BP less likely to be lowered in older patients, but the risk reduction is equal if not greater than for younger subjects \200 Diabetic control is less likely to be tight, in part due to justi \201 able concerns about the dangers of hypoglycaemia