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Symposium: Care of the elderly

Optimising the recognition of Lewy body dementia

25 May 2022Paid-up subscribers

Lewy body dementia is a heterogeneous condition that is often difficult to treat. It is associated with higher rates of neuropsychiatric symptoms, inpatient admission and carer stress, as well as shorter survival, than other dementia subtypes. Core clinical features are: fluctuating cognition with pronounced variations in attention and alertness; recurrent visual hallucinations; REM sleep behaviour disorder; one or more features of spontaneous parkinsonism. Recurrent visual hallucinations occur in up to 80% of patients.

Diagnosis and management of acute coronary syndrome

25 May 2022Paid-up subscribers

The term acute coronary syndrome (ACS) describes a range of conditions, including unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI), which are associated with a sudden reduction of blood flow to the heart. Its presentation is broad, and can include chest pain, cardiac arrest, haemodynamic instability, or cardiogenic shock. Urgent assessment of patients presenting with chest pain is crucial to the outcome as ACS treatment is time sensitive.

Diagnosing anxiety disorders in older adults can be challenging

25 Jan 2021Paid-up subscribers

In older adults, the prevalence of anxiety disorders is higher among those with other health problems, and those in hospital and care settings. A primary depressive disorder should be excluded whenever an older person presents with anxiety symptoms for the first time, and comorbid anxiety often indicates a more severe presentation of depression. Around four in five patients have a comorbid physical disorder. Medical conditions can mimic symptoms of, predispose to, or even directly precipitate an anxiety disorder, and may colour its symptomatology or limit treatment options.

Diagnosis and management of age-related macular degeneration

25 Jan 2021Paid-up subscribers

Age-related macular degeneration (AMD) is a cause of painless, gradual loss of vision. Epidemiological evidence suggests 4-8% of people aged over 65 years in the UK have visually significant AMD. Patients with suspected neovascular AMD (NvAMD) should be seen by ophthalmology within two weeks, and if the diagnosis and progressive disease are confirmed, treatment should commence within the same timeframe. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents cause regression of neovascularisation and reduce macular oedema. There is no treatment for dry AMD.

Identifying the cause of late life psychosis

23 Jan 2020Paid-up subscribers

Late life psychosis may be caused by organic conditions including: delirium, dementia, drug intoxication or withdrawal, or a general medical condition. In these situations there should be evidence of a temporal relationship between the psychosis and the underlying condition. Around 60% of older adults presenting with new onset psychosis have an identifiable underlying organic cause. If an underlying medical condition can be excluded, and there is no evidence to support a diagnosis of delirium or dementia, then the cause of psychosis may be functional. This is more likely if there is a family or personal history of mental illness.

Elderly onset RA: a diagnostic and therapeutic challenge

23 Jan 2020Paid-up subscribers

Elderly onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) with age of first onset 65 years or over. It comprises an acute onset proximal or large joint arthritis with a prominent systemic syndrome characterised by constitutional symptoms and a higher ESR than in the younger patient with RA. Investigations should focus on trying to establish the cause and ruling out differential diagnoses. They should include inflammatory markers, serum uric acid, full blood count, rheumatoid factor/anti-CCP antibodies, and X-rays of the affected joint as well as the hands and feet. The possibility of malignancy should always be borne in mind. NICE recommends urgent referral of all suspected cases.

Diagnosing and treating mood disorders in older people

05 Feb 2019Registered users

Depression in older adults is common. Depressive symptoms may be part of a recurrent depressive disorder or experienced for the first time in later life as a result of changes in risk and resilience factors. There is an association between cerebrovascular pathology, vascular risk factors and depression. Physical illnesses, particularly those associated with frailty, are also important risk factors for depression. Depression has a distinct presentation in late life and low mood may not be the predominant presenting symptom. Older patients may present with physical symptoms, apathy, cognitive symptoms, agitation, retardation, fatigue or weight loss.

Managing arrhythmias in coronary artery disease

23 Jan 2019Registered users

A detailed history is essential in patients with coronary artery disease (CAD) to elucidate red flag symptoms necessitating urgent specialist assessment. Red flags include syncope and presyncope, particularly in patients with concomitant left ventricular systolic dysfunction. Palpitations with severe chest pain and breathlessness also warrant urgent assessment. Undiagnosed atrial fibrillation (AF) is common in older populations. LVEF of 35% or less is a predictor of increased risk of sudden death. All patients with CAD should therefore undergo assessment of LVEF, usually by transthoracic echocardiography.

Timely diagnosis of vascular dementia key to management

23 Jan 2018Paid-up subscribers

Vascular dementia is the second most common type of dementia, after Alzheimer’s disease, and accounts for 15% of cases. The core diagnostic features include cognitive impairment in at least two domains (orientation, attention, language, visuospatial function, executive function, motor control and praxis), which affect social or occupational function, together with evidence of cerebrovascular disease (focal neurological signs or neuroimaging). Crucially there should be a temporal relationship between cerebrovascular disease and the onset of cognitive changes.

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018Registered users

Pulmonary rehabilitation is a multifaceted programme of exercise and education that aims to improve breathlessness, exercise capacity, and quality of life, and aid self-management. Patients with chronic respiratory failure, those on long-term or ambulatory oxygen and patients with anxiety and depression can all benefit from rehabilitation. It is one of the most beneficial and cost-effective treatments for COPD and should be considered a fundamental component of disease management rather than an option.

Depression is linked to dementia in older adults

23 Jan 2017Registered users

Depression and dementia are both common conditions in older people, and they frequently occur together. Rather than a risk factor, depression with onset in later life is more likely to be either prodromal to dementia or a condition that unmasks pre-existing cognitive impairment by compromising cognitive reserve. The distinction between depression and early dementia may be particularly difficult. Detailed histories obtained from patients and their relatives as well as longitudinal follow-up are important. 

 

Special reports

Diagnosing and managing dementia in primary care

25 Sep 2019Paid-up subscribers

In patients with suspected dementia, the history should cover cognitive, behavioural and psychological symptoms, and the impact symptoms have on daily life. A physical examination is necessary to look for any focal neurological signs and to exclude any visual or auditory problems. Baseline blood tests should be carried out. A medication review should be undertaken as many commonly prescribed drugs have anticholinergic effects which can exacerbate cognitive impairment. A brief cognitive screening test should be performed before referral to a memory clinic.

Tailor BP targets to the older patient with hypertension

25 Jun 2018Paid-up subscribers

The prevalence of hypertension increases with age and older people are likely to benefit more from BP reduction because of their high baseline cardiovascular risk. However, older people are a very heterogeneous group and a single BP target will not be appropriate for all. Current evidence is based on ambulatory or healthy older populations as patients with significant complex conditions were not represented in randomised clinical trials. 

 

Editorials

Abstinence and heavy drinking raise risk of dementia

24 Sep 2018Paid-up subscribers

The risk of dementia in old age is greater in individuals who abstain from alcohol and those who consume more than 14 units per week from midlife than for those who drink moderately, according to findings from a large prospective cohort study. For those drinking > 14 units/week, a 7 unit increase in weekly alcohol consumption was associated with a 17% increase in the risk of dementia.

Anticholinergic drugs and risk of dementia

25 Jul 2018Paid-up subscribers

Antidepressant, urological and anti-parkinsonian drugs with definite anticholinergic effects are associated with an increased risk of incident dementia up to 20 years after exposure, a UK nested case-control study has found. The study authors conclude: 'Clinicians should continue to be vigilant with respect to the use of anticholinergic drugs, and should consider the risk of long-term cognitive effects, as well as short-term effects, associated with specific drug classes when performing their risk-benefit analysis.'

 

Photoguide

Skin conditions affecting the elderly

21 Mar 2013

 • Actinic keratoses • Asteatotic eczema  • Bowen’s disease  • Seborrhoeic keratoses  • Basal cell carcinoma  • Varicose eczema

Skin conditions in the elderly

01 Jun 2009Registered users

  • Entropion
  • Seborrhoeic warts
  • Dupuytren's contracture
  • Erythema ab igne
  • Hallux valgus
  • Chondrodermatitis nodularis chronica helicis