CONFUSION AND FALLS – BANE OF THE ELDERLY
Due to the ageing process, memory and cognitive function deteriorates leading to confusion and the musculo-skeletal system become weak with poor balance, leading to falls. Effect of ageing is usually not enough to interfere with organ function under baseline state, but may reduce reserve capacity sufficiently so that stress of a minor illness or introduction of a new drug to be enough to precipitate a problem. These could result from accumulation of factors such as poor diet, or accelerated by lack of exercise, smoking or alcohol.
When a person loses memory gradually or has mobility problems over a period of time, it could be normal due to ageing. But if confusion occurs acutely or if the person falls due to no apparent reason, there has to be some underlying problem needing investigation. When assessing an elderly patient with confusion or falls, it is difficult to know whether they had been precipitated by an acute illness, untill it is established that the present state of the patient is a change from his or her usual level of function. Common causes of confusion and falls in the elderly are dehydration, faulty heart rhythm and urinary tract infection.
Usual reasons for falls in elderly are simple trips or accidents, dizziness, blackouts and low blood pressure, collapse due to acute illness and musculo-skeletal problems such as poor balance, Parkinson’s and stiff and painful hip or knee. As a result of a fall, if they suffer a hip fracture, this will lead to a loss of confidence and fear of walking. Bone breaks when it is subjected to high velocity force. If it breaks as a result of minimal impact or no force at all, it is termed pathological fracture, commonest cause of which is osteoporosis, where density of the bone is reduced. Prime sites of these fractures are hip, wrist and vertebrae.
In large section of the elderly, cause of fall may not be immediately obvious. Such patients are often frail, with multiple medical problems and chronic disabilities. It has been demonstrated that reversal of risk factors such as usage of multiple drugs (poly pharmacy), lowering of blood pressure (hypotension) and poor balance and control of Parkinsonism and osteoarthritis, reduces the risk of a subsequent fall. Poor mobility shares many of the causes of falls and appropriate interventions to manage risk factors will improve mobility.
Dizziness, light headedness and unsteadiness due to change of posture, moving of head or neck, with or without blackout, palpitation, tinitus or fall are common presentation. If there is blackout, cardiological investigation and if there is tinitus, ENT investigation needs to be done. Acute dizziness may be caused by stroke involving posterior part of the brain or inflammation of balance organ in the ear (vestibular neuronitis). However, old people often present with recurrent dizzy spells, finding it hard to describe the sensation they experience. Lowering of blood pressure on change of position (Postural Hypotension) such as on getting up from sitting or lying, causes dizziness and may result in a fall. Old people are advised not to stand up quickly from bed, but first to sit on bed and then rise up. Similarly when wearing trousers they must do it seated or leaning against a wall. Light headedness and unsteadiness on movement of the head and neck suggests restricted neck (cervical spondylosis).
Acute confusion usually result from simple problems rather than complex medical issues. It occurs when the brain is unable to perform its usual functions, for which it requires the supply of water, oxygen and sugar, all these being supplied through blood pumped from the heart. Therefore not only these entities should be adequate, but also pumping action of the heart should be normal in power and rhythm. When water is deprived, brain cells shrink and when oxygen and sugar are deprived they could perish. Not surprisingly, most common causes of acute confusion are dehydration, faulty heart beats and low sugar levels.
Confusional states cause impairment of mental functions with varying degrees of level of consciousness and loss of memory to recent events, which leads to disorientation to time and place. Slowing of mental and physical activity will lead to apathy and depression in many, and anxiety and agitation in others. Other causes are metabolic disturbances such as kidney and liver failure producing high urea content in blood, chronic lung disease or chest infection leading to low level of oxygen content in blood, low body temperature in those in cold countries, lowered blood pressure following heart attack or septicaemia, mini strokes, brain bleeds and epilepsy, vitamin and thyroid deficiency and drugs like sedatives.
Urinary tract infection is a common cause of confusion and collapse in the elderly. Enlarged prostate in men resulting in accumulation of urine in bladder and post-menopausal changes in women, give rise to recurrent urinary tract infection. It manifests with frequency of urination and fever, and if left unattended can end up with septicaemia. Incontinence of urine is common in those over 75 years, often predisposing to urinary tract infection, which in turn would cause incontinence by initiating the feeling of urgency to pass urine.
When a person suffers acute confusion or falls, baseline monitoring is done first, such as pulse, blood pressure, temperature, oxygen saturation, finger blood for sugar, urine dipstick test and electrocardiograph (ECG). These will eliminate any problems arising out of irregular heart beats, low body temperature, low oxygen level and low blood glucose. Next infection screen is done by sending blood for full blood count and inflamatory marker, urine and blood for the detection of causative organisms and X-ray of chest, and metabolic screen is done by sending blood for kidney, liver and thyroid function and vitamin B12 level. Finally full neurological examination to be performed, and if necessary CT scan of the brain. Giving intravenous fluid drip to these patients as initial step, will not go wrong. On recovery they are rehabilitated by counselling, encouragement to regain their life style and providing them physiotherapy and occupational therapy service and appliances for support for mobilisation. Aim is to reduce the impact of disability which causes loss of day-to-day function.
Prevention of further episodes of confusion or falls is important. As stated above, the main cause of these is dehydration, and elderly should be encouraged to take plenty of fluids to avoid trouble. As for faulty heart rhythm, unfortunately ECG taken on their arrival at hospital in many of them are normal. Similarly in those with low blood pressure causing it, may record a normal reading at hospital. These people should be monitored 24/7 using Halter machine worn in the body, which gives the true picture of any abnormality.
