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Hello, good evening everyone. Uh We're just having some technical issue with our speakers. Just give us like 23 minutes and we'll be back soon just trying to get in. Hello guys. Uh Thank you for joining us today. So my name is Shefali, I'm the president of Scape. So today we have our speaker um wa Khali and he going to talk about, about uh approach of geriatric uh patient. So just give us few minutes to set up the slides for us and uh we'll start soon. Thank you very much. Can, can everyone hear us? Can you just write in the chart if you can hear us, please? So, are you able to see the screen? Yes, we can. Ok. OK. Um I'm happy to start when, whenever everyone's ready we have. Yes, I can. I think we can start now. Thank you. Thank you. OK. Hello, everyone. Hi. My name is uh for Mustafa. I'm one of the fy two doctors working at West Suf Hospital. I did my f one in Hereford. I rotated in Geriatrics, general surgery and respiratory medicine and I'm presenting today on Geriatric medicine. So just a brief talk about how to approach geriatric patients and what the common presentations and what the common conditions that you need to uh consider when you have an elderly patient that presents. Uh Yeah, I'm saying I am going to start sharing. So just a brief introduction on what geriatric medicine is um means of older adults. So usually above the age of 65 because they have different complexities, different challenges um from geriatricians, it is quite crucial for enhancing patient outcomes. For example, when I was in general surgery, and we had patients that were possible candidates for emergency surgery with the geriatricians to s uh come and to see if they can. And this uh surgeons decide if they want to operate on the patient or not. But ultimately, the geriatricians are the ones that come in. And so whether this patient will be a good candidate for surgery. So we're going to talk about a few of the most common acute presentations in the elderly population. So, uti S pneumonia, sepsis and falls. So how can geriatricians help? Uh So older adults again, as expected present with more chronic diseases like diabetes, hypertension, heart failure, and geriatricians are trained uh to manage these comorbidities effectively. So they'll help us um manage their medications to decrease the risk of side effects. Uh We'll see how uh in the latest slide, we'll see how that's done and again, they help us prevent and intervene early when it comes to uh these conditions. So, vaccinations, screening for cognitive decline for risk assessments. Um These are all things that geriatricians are trained to uh treat again. Uh a bit of a questionnaire to get us warmed up. Uh These are common risk stratification scoring systems that are used in hospital uh mainly not just limited to geriatricians, but uh overall does an um you can use your mics to um read out or tell me what you think these uh scoring systems are used for or put it in the chart? Curb 65. Does anyone know what, what it's used for? Not sure how to check if the charts, if anyone's putting it in the charts. Um Yeah, anyone wanna take a guess on what co 65 is used for in hospital. Uh Someone said there is ac ap yeah. Community acquired pneumonia. Yeah, that's correct. So it's for pneumonia severity there is. Um So in primary care and GP, for example, we use uh CRB 65 without the Urea because obviously we don't have access to bloods. So uh we'll have a case later on that goes into a bit more detail about what CB 65 stands for. Uh Moving on to the next one. Glasgow Blatchford Co anyone know what that's used for? Someone say it bleeding risk. Yes. So it's to assess the upper gi bleeding severity. Rockwood clinical frailty scale. Uh No question there. It's just uh one of the more common um scales that we use to assess how frail, uh, an elderly patient is. So it goes from 1 to 9, if I'm not mistaken, or 1 to 5, uh, to so one being quite fit and well and five being severely frail. And it's one of the things that we take into account, uh, when assessing, uh, fitness for surgery, a single PTO T input and when assessing what we're targeting forms of treatment. Well, criteria. anyone know what that's used for? It's very common. It's used for two things, some say DV. TPE. Yeah, perfect, brilliant. Uh DVT and PE and has bled. I think there's a hint in the actual, uh, pneumonic or whatever it's called has bled. It is I'm going to put it down as risk of major bleeding. So if any patient, uh comes in is on an anticoagulant and you want to assess what the risk for major bleeding is, you, you know, you go through a call and if the risk is high, then you'd adjust the anticoagulation, possibly suspend it for the duration of their admission. Finding one of uh, C score is not something that I knew about before I started working. Does anyone know what it's used for guys? I was wondering if we can open you your mic so you can like talk freely. It's interactive. So if you guys want to do that would be appreciated. Thank you for following, for reading out the chat. See what's called, um, Yeah, I'm not sure if anyone knows, I will wait for another 23 seconds and reveal the answer and it's used for our cora. So any patient that comes in part of your history with, uh, all patients should be to go through the social history. See how much drinking they do and particularly in heavy drinkers. Uh, you want to assess the, see what going to check if they're at high risk for exhibiting alcohol withdrawal symptoms. So, c was called, is something that we use to monitor for symptoms of alcohol withdrawal. And if they are, if they're scoring high, then we use as particular drug uh to use to treat alcohol withdrawal. Does anyone know what that drug is? It acts on the same receptors as? Ok. Any guess. Ok, it is chlordiazePOXIDE or we call it PEX is the other name. It's a more common name, Pabx or chlordiazePOXIDE. We use it to treat alcohol withdrawal. So any patient who's doing an admission is a heavy drinker or we start on Cloze mono was called. Ok. Uh So a bit more interactive here. Uh So we have a case study. I would it would be nice if someone volunteers to go through uh the at assessment and tell me what they think the patient has, if not, I can read it out. So we have a patient. Oh, well, so any volunteers to go through it? Mhm. Ok. Guessing none. That's fine. Um So um yeah, answers in the chats. Fine. So we have Missus Smith, 82 years old presenting with increased confusion, worsening, lethargy over the past two days, she's got a background of hypertension type two diabetes and cognitive impairment. Uh, currently takes Ramipril for hypertension, Metformin for diabetes and Donepezil, one of the drugs used to treat Alzheimer's. So we'll start with an at assessment. So, on our assessment, you see that she's alert, she's talking to you in full sentences, but uh occasionally disoriented. So nothing particularly concerning there uh apart from being disoriented, but then again, she's come in with confusion. So expected um breathing respirate 22 slightly high oxygen, 92% on room air and chest sounds clear. I don't know if it was meant to sound clear. Ok? Yeah, chest sounds clear. Anything that you guys would do at this point. So she's got a respirator of 22 oxygen of 92% in room air and chest is clear. What action would you take doctor for? So basically the audience uh m is not working. So they're just typing up. I would just read it to interrupt you if this is OK for some reason we can that. Ok. That's fine. Thank you. Did someone say a urine test and someone um said V VBG and someone mentioned Martin mentioned give, give her some oxygen. OK? Yeah, all three are correct answers. But at this point of your at assessment, uh I would be more inclined to go sequentially. So, oxygen is 92%. So that's correct. You'd give her oxygen. So start her on. Well, so let's say 15 L of oxygen get her saturations up to, yeah, more than 94 to 98% here. One. Why? Because she doesn't have any thing in her history that indicates she's got COPD or any other disease, uh diseases where you'd be aiming for lower. So, yeah, so you start her on oxygen for now, urine test and BBg, we will come to next. So, moving on to. So you've put the oxygen on, she's picked up, picked up her oxygen, moving on to see uh heart rate 100 and 10 BPM. BP is 100/60 cap refill time, less than two seconds. What would you guys do at this point? So, in the chart, I see Rebecca, uh she mentioned about ABG and an X ray as well and yes, I agree. I agree. Actually, that's a very good point. Uh uh in breathing. Uh If someone's saturating low, you would do an x-ray to check if there's any uh consolidations on the ABG to see if they're oxygenating properly. You're doing ABG more. So in patients with uh COPD. So for this patient, there is no history of CO PD but you would still do it. Uh You can still do an E BG but in patients with CO PD, it's uh much more um I'd say yeah, much more appropriate to do an ABG because they are at risk of retaining and when a when a patient retains carbon dioxide, they can present as increased confusion. So that is a very good point. So for this patient. Mhm. Mhm. Sorry. Uh I mean they're writing in the chart, I'm just trying to read that and um they mentioned Rebecca mentions 250 mL fluid bullous. Uh And for Ken also, she mentioned about 500 to this Hartz Man, 15 minutes over 15 minutes. Yeah, that's fine. That's correct. Both are correct. Uh It just depends on how uh confident you are and depends on the comorbidities as well. So this patient is, does not have a background of heart failure. So you can, no one's gonna tell you off for starting off with 500 mils bolus, but the correct thing to do here is to give fluids. So uh yeah, perfect. So you give fluids to bring the BP up and take bloods like someone else said earlier, ABG VBG, you'll be testing for um uh infection markers. So full blood test FB EC RP, you take bloods at this point and yeah, it comes back, let's say raised inflammatory markers. So you've done, you've given the bolus the BP is improving now, moving on to D disability. So GCS is 14 BMS are normal and she is a bit confused. So you can think about doing a mini mental state exam to see how high they're scoring by keeping in mind that she's got a background of cognitive impairment. So, um yeah, so nothing, nothing for us to do at the moment to be able to normal, moving on to exposure, abdomen is soft. No tenderness is noted signs of possible dehydration. We've addressed that we've given her fluids and like someone said earlier, you do a urine dip and a urine M CNS. Um Yeah. So urine dip is one of the more quicker tests to tell you. Does the patient have increased white cell count increased? Uh Does she have blood in her urine? And for this patient, let's say for the sake of the case, she's got an increased white cell count and you send a urine M CNS and now you're thinking, ok, she's got increased white cell count and she's got possibly a UTI. Does anyone know what are the most common antibiotics used to treat UTI S or do we have a question? Is uh Rebecca mentioned, do we know if this confusion is different to her cognitive baseline? Yeah, it's a very good question actually. Um So part of your treatment and management for this patient would be to get a bit of collateral history. So uh to speak to whoever she's come in with or to speak to her care home, if she's in a care home or to speak to her family members to kind of establish the baseline because she's got a background of cognitive impairment. Uh You want to establish. Yeah. How long this confusion has been going on? How far off the baseline is she? Uh Yeah. So your collateral history is very helpful uh and very important in elderly in, in geriatrics because most of these patients come in very unwell uh unreliable historians. They can't, they can't tell you what's happened to them, they can't remember. So, collateral history is very important. Uh So good question in this case, let's say she is more confused than normal. Um Yeah, so going on to back to the case, uh we are going down the route that we think she's got a UTI and we are going to treat you with antibiotics. And does anyone know what the common antibiotics are? So, we do have some answers. Uh So Ken and um Rimsha mentioned Nitrofur and then Rebecca is trimethoprim and same nitrofur. Perfect. Yeah, those are the most common antibiotics of let's say the guidelines suggest to use nitrofurantoin and trimethoprim. Now it again comes down to a few demographic um factors. So we'll go through that again. You send a urine MC NS you, the results are not going to come back immediately, probably gonna take 2 to 3 days for the sensitivities, but you do wanna treat empirically in the beginning. So, yeah, so antibiotics wise, trimethoprim or nitrofurantoin again, depends on non pregnant women and pregnant. Well, in this case they're elderly. So I am expecting them to be non pregnant. Um So you can do trimethoprim or nitrofurantoin for three days if they're pregnant for the sake of completion, I put it in uh you would not use trimethoprim because as teratogenic in the first trimester, so you would use nitrofurantoin. Again, you can't use nitro furantoin if it's third trimester. So you depending on how far down pregnancy they are, you would use an antibiotic and you can use a mo uh Keflex. So, yeah, trimethoprim and nitrofurantoin if the, if the woman is pregnant, but she's asymptomatic. So you on a routine test, you've seen that she's grown um bacteria, then you treat it because she's pregnant. So you would either do nitrofurantoin depending on whether she's, you know, the first trimester last trimester and it would be a seven day course. So that's the difference between uh nonpregnant and pregnant women. So three days for nonpregnant uh or the elderly in this case. And if they're pregnant an extended course for men, you always go seven days. It does not matter if they are elderly or not. Uh So, trimethoprim or nitrofurantoin should be offered catheterized patients. Again, if, if it's a female catheterized patient and the symptomatic, you do a seven day course. If they're asymptomatic, you do not treat it. So, just to kind of uh revise what we've done in terms of antibiotics. So, trimethoprim and nitrofurantoin, nitrofurantoin. Uh again, you avoid it in pregnancy. But in the elderly you can do either or for three days if they're, if they're male, seven days, if they're female, three days, if they're catheterized symptomatic, seven days, if they're catheterized asymptomatic, no treatment. I hope that's clear. Any questions at this point. Uh, that is UTI S covered here, I think. Yeah. And, uh, yeah, you're in mcs. If it comes back down the line saying if the patient does not get better with the course or if the sensitivities come back, saying are the patients resistant to trimethoprim or resistant to nitrofurantoin, then you would obviously change the antibiotics discuss with microbiology and so on and so forth. So we see a lot of antibiotic resistance these days. So um you would adjust accordingly any questions so far. OK. I am gonna assume that's a no and move on to the second case. Uh We have Mister Johnson, 78 years old presenting with increased shortness of breath productive cough with green sputum and a fever over the past three days background of CO PD in hypertension uses Lisinopril laba and albuterol inhaler. And again, happy to have volunteers to do the at e if not, we'll talk through it and actions, uh you know, interventions on each stage. OK. Uh patients alert and responsive talking to you, airway is clear, can speak in full sentences, but he exhibits a slight cough while talking. So again, that kind of gives you a hint OK, we're probably thinking something to do with the lungs, uh moving on to be breathing. You see, the respirate is high 26 oxygen sats 88% on room air, decreased breath, sounds on auscultation and crackles in the right lower lung field. What are you going to do at this point? What are you going to do in terms of treatment? What are you gonna order and what do you expect to see? It's pretty much the same as last time, but it's a good practice to keep repeating. The Rebecca mentioned um is 15 L slash M and no rebreather A BGR and consider precourse. And then there's a chest X ray I mentioned and FBC. Yeah, perfect. I think that's covered everything. Uh Thank you, Rebecca and Rams. Um Yeah, so you would uh put them on oxygen 15 L nonbreath mask. Um Again, uh this patient, you do have a background of COPD, but uh you would want to aim for something higher than that. I should have probably put it down as 84%. But yeah, so you would uh put them on 50 m non rebreath mask and then titrate uh depending on the ABG results actually. So you do an ABG check if they're retaining. So you check the PH check if they're acidotic, you check the PCO two and you check the PO two. So that will tell you uh if they're being oxygenated enough. So in this patient let's say uh they're not, yeah, they're not retaining. So PC two is within normal ranges. So PCO two normally should be below six and PO two should be at least 10 and PH is between 7.35 to 7.45. Uh And uh so she mentioned oxygen CXR consolidation and calculates cur like score and also we should say the same thing uh SCB score C score. Yeah, exactly. Uh We are coming to that. I should have put it higher up. Perfect. Yeah, so you'd calculate the curb 65 score at this point um because you can hear crackles in the right lower lung feel. So you're thinking pneumonia and you wanna check how severe the infection is. So you do co 65. Perfect. Uh chest X ray would confirm your suspicion of pneumonia and moving on. So we've put them on 15 L of oxygen. We've done ABG. We've made sure we wanna make sure that they're not retaining. If they are retaining, then you go down. Uh that path there is uh different treatments for that. Uh for the sake of pneumonia. Let's say they're not retaining here. Uh Circulation, heart rate is 98 BP is 100 and 10/17 no signs of peripheral edema. Uh let's say slight signs of dehydration. So you would start them on some IV fluids, take some bloods like someone mentioned earlier on F PC using these C RPS and you'd uh yeah, wait for the results. It most likely will show you elevated uh increased inflammation markers. REMS mentioned if Sputum, then Sputum culture also COVID squab. Yes, perfect. Um Yeah, you probably do that at stage of B I'd say Sputum culture if the patients like because in the previous like I did say they have cough with green Sputum. So you spend Sputum culture for Sputum M CNS uh which will tell you what bugs are growing there and that will help target your antibiotic therapy better. So, similar to the last case, uh we would treat it empirically at first until that we have the sensitivities and then adjust the antibiotics to be more narrow. Um Perfect. That's very good. Actually, I missed that someone mentioned um like consider blood culture if it is uh peri pyrexic. Yeah. Where does that come? Uh exposure. Yeah. In e exactly. So blood cultures at, at the point of E you can do it at sea as well when you're bleeding them actually. So blood cultures to see if they're septic, septicemic everything. Yeah. All of this is going to help us uh treat the patient better in terms of antibiotics. Um Yeah. Blood culture sputum culture, chest X ray ABG, so on and so forth. D uh moving on to DGC S 15 signs of confusion, mild agitation, BMS 4.6. So BMS on the lower side. But um mm I wouldn't say hyperglycemic. So um you can be, you can be confident that it's not hypoglycemia, induced confusion. Gcs is 15. OK. That's contradicting anyways, uh moving on to de conduct a physical examination, you know, listen to their chest, which we've done already. Look, feel the abdomen, feel the calves. You find out that they've got a fever. So at this age, like I mentioned, you do blood cultures, uh give them some IV paracetamol, uh inspect the skin for rashes or any other signs of dehydration. Ok. So that's the A two assessment done. We've done. Yeah, we've given them oxygen, we've given, we've taken bloods, we've taken blood cultures, sputum cultures, we're given fluids if needed and moving on as everyone has said, we've gone through all of this. Uh You would, yeah, you start antibiotic therapy based on local guidelines for c and if obviously, if they had recent admission in the hospital, you consider the possibility of ha hospital acquired pneumonia. Uh Usually I think it's amoxiclav and you try titrate it according to the Sputum M CNS. And if with this patient, they're on bronchodilators, Laba and Albuterol. So you would reevaluate if they need to be, if they're wheezy on examination, you consider if they need nebulizers to help with their breathing and so on. Uh Rimsha mentioned uh in C we do ECG as well. Yeah. Yeah, that's correct. Actually, uh heart rate is 98. You want to, yeah, you can check ECG is, should be done. If they're tachycardic. Uh Yeah, we would check if there's any abnormalities on there, if there's any new onset af uh secondary to infection and treated accordingly. Um, yeah, I think that's, I think we've covered everything in terms of pneumonia. Um, antibiotic treatment. Go according to the guidelines, use micro guide. I think it's called something else now. Um And do your at e sequentially and like you said, chest X ray and ecg blood cultures, et cetera. Any other questions? I think everyone's been very good actually, so far. Um I should have had, I should have had a slide with the C 65 score. Well, um ok, I think it might have been on my other side. Let me see. But ok, anyways K 65 score uh should be calculated for any patients you suspect with pneumonia and it will tell you whether the patient needs to be an inpatient to treat them or an outpatient or you can treat them with oral antibiotics or IV antibiotics. So curb 65 C for confusion, U for urea, more than seven R for respiratory rate and B for bun I think blood urea nitrogen and if they're more than 65. So depending on the score. So each if the, if the positive infusion, they get one for that, if the urea from the blood is high, another one for that respiratory rate in this patient would have been high. So another one for that for this patient, the curb 65 would have been, well, I don't have the urea but the 78 is a one for one for confusion, one for more than 65 1 for respiratory rate. And depending on the bloods, you would do the others and treat them accordingly. So it's helpful if you're the GP and you have a patient that comes in like this and you can see if uh you can treat it with oral antibiotics or do you have to send them in to, to get treated with IV. So that's co 65. And my final case is yes, before I start any other questions about UTIs and pneumonia or anything else that I might have missed out? So I can see in the chart and she uh he wrote like B dash BP. So B SBP. Can you elaborate today tomorrow, please? B dash BP for sure what that means? BP. No, he may. 000, the co 65 B is BP. Exactly. Exactly. Exactly. Yeah, my bad. Uh Yeah, cause yeah. So there's confusion, urea respiratory rate and B for BP. Not one. The bun is actually you. Ok. Thank you, Ken. Um Yeah. So moving on to case study three, we've got Missus Baker, 85 years old brought to the clinic and also found on the floor of the living room. Reported feeling dizzy before she fell has pain in her right hip but did not lose consciousness during the fall. She's got a background of hypertension, previous falls and takes Lisinopril and Alendronate. Um So how would you manage this patient? Does anyone know what Alendronate is? It's a very common drug in geriatrics, especially for patients with false four bone issues. Any guesses. So we have done uh he replied, uh bisphosphonate and then they go bones and then we have Rebecca says used for osteoporosis and can't remember the mechanism. Um And then Marriam also say the same things. Yeah, perfect. Uh It's all correct. So they are uh from the bisphosphonate group of drugs. They are used in osteoporosis and they basically increase bone resorption if I'm not mistaken. So increases bone density basically and is used for osteoporotic patients. And yeah, you would start any patient who is more than 75 I think and is a has had a fall in the past. There is a high risk of having a fall. You would start them on bone protection, which is Alendronate 1st 1st line. And I, one of the important things to know about Alendronate is it's one of those drugs that uh we have to advise the patient on how to take it. So it's taken on an empty stomach 30 minutes uh before any meal and advised to sit up and drink it with a big glass of water cause it can cause uh severe esophageal reaction, esophagal reaction, heartburn, et cetera. Um Yeah. So be careful, I advise the patients on how to take it. But yeah, on protection, uh continued. So this, this is, I wouldn't, I'm not going to do an at assessment for this patient, but just uh a discussion about what you need to do for this patient. Um, in terms of management. So you want to get detailed history, ask about any recent changes in health status, medications or living conditions, circumstances of the fall if, um, directly from the patient, if they're communicating or from, uh, anyone who is with them, took care home next of kin. Where and when did the fall occur? What was she doing? Did she lose consciousness? Was there a loss of balance? Did she trip? Did she hit her head? All of these important questions? And it is gonna guide you on your management any previous falls, uh, circumstances, frequency injuries. Again, this is also going to tell you how to manage this patient and if they need to be seen by any other specialist functional status again, yeah, assess his ability to perform activities of daily living, tells you what the patient's baseline is like. So it will they tell you if the patient is frail and is like, you know, prone to fall in or if this is something that's never happened before? Are they able to, uh, cook for themselves? Are they able to shop for themselves, et cetera? So we, we have Grimshaw and she mentioned esophagal, uh, erosion and also social history, for example. Alcohol. Yes. Yeah. Yeah, that, that's, that's a very good, uh, part of detailed history. So you want to rule out if the fall was due to intoxication? So that's some of the question that you asked them. Uh, part of the detailed history. Um, yeah, so you do the normal clocking medications review. So in the elderly, uh, any slight change in medication can have, um, much more of a drastic effect on them compared to someone who's 40 50 30. So you want to check, review all these side medications for side effects or any, anything that's been changed recently, um, to see if there's any cause there that could have caused the fall. So, diuretics, antihypertensives, sedatives, antihypertensive y cause it could have been a drop in BP. Another thing I'd add there is probably diabetic, uh, drugs. It could have been, uh, hypo, for example, I want to check if they're adherent again, um, whether they're taking their medications, uh, physical examination. Your a to assessment, you're checking BP. More important in patients with fall is, uh, your orthostatic reading. So, what we call a lying standing BP to check if there is a significant drop when they, when they're sitting and when they stand up, uh, what we call symptomatic, uh, postural hypertension, uh, anything, any difference, a difference of more than 20 millimoles of mercury, uh, in BP would be classified as postural hypertension and you would treat that heart rate and temperature. Ecg is very important when it comes to assessing patients who've had falls. Why? Because they could have had a cardiac event, heart blocks. Um Mr, so ECG S are important in that sense. Neurological examination, very important uh to check for any signs of neurological deficits. Have they had a tia, have they had a stroke, any weakness, any altered sensation? Have they had mus any muscular weakness that could indicate towards, you know, and what's it called cervical degeneration, et cetera. Uh So false assessment, you, it's a bit more thorough uh compared to your normal at assessment. So vital signs, lying, standing BP, neurological exam, uh complete neurological assessment, uh musculoskeletal assessment. You want to check for any injuries particularly to the hip and they, they can have suffered uh like a feur fracture. And in if they've hit their head when they fell, you want to check for any bruises. Do you want to uh request a ct of their head to see if there's any hemorrhages? There, you assess their coordination, you assess their balance and walking gait assessment. It's all of this. You build a picture when you assess someone who's had a fall. Uh you check their past medical history, et cetera. So anything else that I'm missing out? Yeah, patient. Mhm. Sorry. Sorry. We have Marion uh in the chart. She mentioned that DA L SBP. Yeah. Uh Yeah, that is a BP, orthostatic readings, lying, standing BP. And you want to rule out postural hypertension, as we mentioned, anything more than 20 millimoles you treat it. Uh, the drugs commonly used. Does anyone know what drugs we use to treat? Postural hypertension? There's two more, two very common drugs, there's others, but it's one or the other. Any guesses. Bye. Yeah. Yeah. I, ok. No guesses. Uh, so midodrine is one of them. Fludrocortisone is another that you use, uh to treat postural hypertension. Uh, if one doesn't work, you can use both at the same time and up titrate it to see if that helps with the BP. Uh Another question would have been, yeah, in terms of medications, review, what medications would you, uh, be looking to review? So if there are any anticoagulants and they have any bruises, you might consider suspending that until they've had their CT head because they might be bleeding or if they have an AKI, for example, because of dehydration, uh, you wanna stop nephrotoxic drugs. So some very common nephrotoxic like Metformin, if they're diabetic uh Ramipril ace inhibitors, I think they are. Yeah. Mm Antihypertensives if they're found to be on the lower side. So if the patient has postural hypertension, then you would stop antihypertensives conclusion for this for. So I contributing factors. Yeah. So like we said, when you, when you build the picture, you kind of, you ticking boxes, you're like, ok, so it's not cost you hypertension. So, dizziness from medication is less likely muscle weakness. Uh is another thing you want to rule out environmental hazards because they have tripped and so on and so forth. So, intervention and plan medical management address any underlying medical issues, any infection. I mean, it doesn't have to be medication. Only an infection can cause a fall. Many of times we have patients with uti with pneumonia like the other two cases that come in with a fall. So you treat the infection that well, then again treat the fall. Uh, geriatrics, PTO T very, very important, uh, physiotherapy and occupational therapy. Uh, no patient goes home without being assessed by PT and OTP T to improve mobility and reduce fall risk ot or more to do with. Do you need any modifications at home? So grab bars, improved lighting. Do they need a walker? Do you need a walking stick? Um, another thing that we do for geriatric patients is do they, are they coping at home? Do they need help at home? So, do you need to arrange for a package of care for someone to come in twice a day or three times a day to, uh, help them at home and regular follow ups for these patients? So Grimshaw mentioned ruling out non accidental injury. Yeah, that is another thing you want to rule out. So, um, hm I didn't think about that actually. So, um, one does she mind expanding on what we're looking for there. It's a bit of a learning experience for me as well. Ria, does that mean, uh, any signs of abuse at home? Is that what she means? Like domestic abuse or self-harm? I might have put her in the spotlight there. It's because uh yeah, it's very, I mean, it is something that you want to keep in mind but it's very uncommon for you to come across patients that um yeah, mentioned like bruises at a normal sites. Yes, she thinks it's as uh abuse and yeah, yeah, yeah, or any false alarm about. And uh I think Soha mentioned about sign of neglect negligence. Exactly. Exactly. Actually, that's a very good point. Um Yeah, so signs of negligence uh especially if they're in, they're in a care home. Uh You would have what we call safeguarding risks. So safeguarding against the carer. So yeah, like Kim mentioned, uh you want to assess for any bruises that might trigger an alarm. So um not in the side of the fall. So, and if you see them, you raise concerns uh in involved the safeguarding team. That could be, yeah. Uh we have a lot of patients that are have safeguarding concerns raised and which then indicates a change of placement, a different care home and going down that line. Thank you. It's actually a very good point that I missed out. It's good teaching for me. So that is all from my side in terms of the common geriatric things. I've tried to keep it brief, obviously, you have sepsis. Uh but then again, sepsis, you treat it the normal sepsis six. And it's nothing new in terms of uh uh geriatrics. But I think geriatrics, the, the different approach in terms of geriatrics is, you know, you know, your collateral history is really important. Your PTO T input is really important, your safeguarding concerns, like I mentioned is very important. Uh medications review is very important. So geriatrics is different from that point of view. Um Delirium again, uh delirium, all these patients can put on delirium. So any patient with a background of cognitive impairment uh can go into delirium because of UTI S because of pneumonia because of hypercapnia. So you treat the underlying cause and you treat the delirium. And yeah, if patient does not have a background of cognitive impairment and comes in with confusion, then once you've treated the course, you might consider referring them to a memory clinic or an Alzheimer's clinic, a dementia clinic to get assessed there. So yeah, that's all any other questions from uh anyone else? Thank you, everyone. Uh Everyone's actually been very good, very good input. Good questions for me. It's, it's how I've learned from this myself. Um Yeah, the floor is yours. Thank you, Shefali for reading out the answers from the chat. Thank you very much, Doctor Khaled. It was very helpful and I hope everyone find it very helpful. So if you have any questions, you can write on the chart. And in the meantime, I'll send out the feedback form so you can fill it out for your certificate. So can someone let me know if you got the certificate? Is it visible or not? It is visible? And I would just like to mention uh so on 13 October, we'll have our next talk on assessing and handling intoxication. So and in the meantime, if you have any questions for Doctor Khaled, uh please go for it. I give it a few more minutes or seconds. Yeah. Yeah. And I think um sorry to pop back in. I was just reading through the chat as Maram mentioned, a false alarm is uh one of the things that ot uh would consider would suggest to the team for patients who are recurrent risk of falls. So very good uh suggestion there. Everyone's good at geriatrics. Cool. I think there's no further questions. I would appreciate it. Uh People filled out the feedback form. OK? Thank you so much. Uh Doctor K for your session. We get to learn so much and um thank you everyone who joined us for our talk and I hope to see you for the next one and I'm just gonna close and this uh chart will be in the video as well. So you will get to see back and forth later. So we'll be we'll upload it in our me. Thank you. Thank you. Thank you very much. Good evening everyone. Bye bye.