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That should be live. Now lie let me know if anything have Yeah, so yeah, stop, feel free to start whenever cool. I'll give it a couple more minutes guys and just see if anyone else is joining and then we'll get cracking. Ok? Um I think we'll get started. People are um trickling in but um we can start like with um introductions and stuff and then hopefully by the time we get into the swing of it people will have joined. Um So um my name's Ellie. Um I'm an f one doctor um working in the West Midlands at the moment. Um So I've just finished um my four months on respiratory medicine and I've just rotated onto trauma orthopedics um in a district general. So care of the elderly is something I'm doing quite a lot of at the moment. So hopefully I can give you like a good run through. Um So um just a little overview then of what we'll cover tonight. Um So acute confusion we'll do and we'll do falls, we'll do off legs inver commas and we'll discuss why it's in verticom. Um polypharmacy. Um And then we'll do um we'll just, we can just summarize at the end. Um So the way we'll do it, I, I'm sure you guys have been to these talks before, but if not, um and mainly we'll do it with um, MC Qs with one single best answer. Um I have also got um like an ay style case um to kind of walk, walk through. Um Now I'm not expecting you guys to like turn your cameras on and chat if you don't want to. That's completely fine. Um But there is a chat um optional medal. Um So what when we get to that bit, um you guys can just pop suggestions in the chat. I think that would probably be the easiest way to do it or um obviously please do talk out loud if you feel like it, but I'm absolutely won't be insisting on that. Um ok. Um So halfway through, I'll put up the QR code for feedback and I'll do it again at the end just to give you a bit of a chance to like pull it up on your phones. Um And I'm very happy um to be interrupted as we go through with questions. Um So like that's fine, don't be shy, put them in the chat or um unmute yourselves, um or you can save them to the end like whatever um you guys prefer. Um So we'll dive in then with um acute confusion. So, um an 87 year old lady has been admitted with a community acquired pneumonia overnight. She's become extremely agitated and is having visual hallucinations. She has not slept and is no longer oriented to time or place. Her past medical history is hypertension, chronic kidney disease stage two and arthritis. Her only regular meds are amLODIPine and paracetamol, which is or what is the most likely cause of her presentation. So I'll let you just digest um the options. Um I'll um, so I've not tried this before, but I'm gonna try and put it as a pole in the chat. Um, let's see if it works. If it doesn't, then we'll just go back to the, um, normal. Mhm. So I've popped the poll up. Um, now we don't know, we haven't tested this if you can see each other's, um, answers, like how many people are answering, but just have a go, um, and see what you guys think. So, I'll give you a few minutes to just, um, digest. Yes, I can see that most of you guys are answering. B which is correct. So it is most likely to be caused by, um, delirium. So, um, just before I explain, um, why that's the answer. Um, this is quite a common way for, um, a finals question to be phrased. So, what is the most likely, or, um, another one is like, what should you do first if we talk about management? So, I've just popped it in there just to get you guys familiar with the style. So because actually, like y it could, it could be um more than one of these, but what the most likely thing is, is delirium. Um So we'll talk about delirium in more detail on the next slide, but just um to kind of go through why it's not a few of the others. Um So a stroke, um if it was a stroke, you would be expecting um probably more of a motor or sensory deficit and you'd expect it to be normally unilateral. Um So this is not a typical presentation um in terms of the medication induced psychosis. So she's only taking amLODIPine and paracetamol. Um Neither of which are really associated with psychosis. And we, the question stem hasn't mentioned any new um medication. Um So unlikely and then schizophrenia and Charles Bonnet syndrome. Um It would be extremely unlikely for an 87 year old to have a first presentation of either of these. Um you know, they, she would have had this before and we would have then mentioned it in the past medical history. So, yeah, the answer is b delirium. So just to define delirium, then um it's an abrupt decline in cognitive function. Um and it follows a fluctuating course and this is really important. Um And by fluctuating, it can fluctuate within a day, it can fluctuate within a few days, even a couple of hours. Um And it, that is quite important that it will go up and down. So um the symptoms of delirium um so everything is altered, that's kind of the theme, altered something so altered perception. Um It's very common um to have delusions or misperceptions. So for example, that they're being held against their will um or that they're somewhere that they're not. Um And hallucinations um quite distressing can be visual or auditory. Visual is more common, altered cognitive function. So that would be like a new confusion, which is what our lady in the stem had. Um She was no longer oriented to time or place um inattention. So what we mean by that is probably won't be able to have a proper conversation with. You probably won't be able to answer questions or focus on the radio or the tele like they would normally do um altered social behavior. Um So they might be shouting, they might be disinhibited. Um They might be pacing, um altered level of consciousness. So, um really, really common and one of the first things that you'll pick up is a sleep cycle disturbance. Um So very often people um who are suffering from delirium are awake at night and sleep in the day and that is really common. Um But they also might be really lethargic. Um it can go either way and then altered physical function. Um So you can have hyperactive or hypoactive delirium. Um So, generally, hyperactive is usually easier to spot and diagnose because it follows kind of what you classically think of as delirium, so very agitated, shouting, pacing, having all these delusions um or hallucinations. Um you will see a very active but distressed person hyperactive um is sometimes more subtle. So um someone can really like look like they've really shut down just sleep all the time, refuse oral intake. Um It can be quite commonly confused with either a stroke or depression actually. Um So they just really, you know, aren't engaging at all. Um You won't see the pacing or the um you know, the agitation. So it's important to remember that there's those two types, but also you can get a mixed picture just to make it easy for you. Um So you might well see um symptoms of both within delirium. So causes of delirium. Um So the way I like to think about this is I had um an elderly care consultant um on um an on call and he always says, um you know, ellie these patients delirious patients that are just crying out for the you, they're saying pinch me, pinch me. And I was like, what does he mean? But he means this um pneumonic and I find it really, really helpful when I'm thinking about um what are the key causes of delirium? And this is not an exhaustive list. And I'm going to say this quite a lot of times in this presentation. Um I can't, you know, you wouldn't want me to list everything exhaustively. So we're just gonna cov cover the really important ones. So pinch me is our mnemonic then to think about causes. Um, so pain, um, is really common, um, especially on a, in a patient with a background of dementia, um who, um, may not perceive or indeed communicate pain. Um Like you or I might, um, but, um, for example, um you might get somebody who fell down some stairs, has got lots of rib fractures that's extremely painful. Um And they may later go on to develop delirium if we don't um adequately control their pain infection is what everyone thinks of. I think when they think of delirium. So the classic is a urinary tract infection. Um but it can be any infection. So it's important not to just go straight for the uti um think about chest, um think about um cellulitis. You know, there's lots of other causes of infection, uh nutrition. So, especially if someone's coming into hospital with a new delirium. Um Are they getting adequate nutrition? Um wherever they're living, um poor nutrition um is a big cause constipation. Um This is a very, very common cause. Um And you know, when um you, you guys like start working, you'll see it all the time. Um It's really common, especially if someone's less mobile than usual to become quite constipated and that can lead to delirium hydration. Um So if someone's not adequately hydrated, um medications, there's lots of different medications, um, that can contribute. Um, new antibiotics is quite common but there's lots, um, you know, kind of the list is endless in terms of medications. So, when you're thinking about is it a medication? It's useful to look at if anything new has been started and then environment is one that's really common and really important that we probably don't think about enough. Um, so this is specifically, um, for, you know, kind of patients that are in hospital and then go on to develop delirium, you know, if they're in a bay with lots of loud, um other bay mates and things are really noisy, um that can be enough to trigger an episode of delirium. So those are the causes on the left. Um There are some risk factors as well which are important to be aware of. So someone's more likely um to experience delirium if they've had it before. Um Which makes sense if they're over 65. Um if they have dementia, if they have poor mobility. Um And that's partly because it can then go on to lead to some of the causes. So if someone's not very mobile, um their nutrition may be poor because they can't physically go and get their food, um they might be constipated. Um If you're not moving around much things don't move as, as much, they might not be hydrated again. They might, they can't go and get water or whatever they'd like to drink. Um and somebody with severe comorbidities um is also at much higher risk. Ok. So, investigation and management of delirium, basically the, the main say of it is you've got to work out why. So that's through your history and your examination. Um And then you would investigate based on what you think might be going on. Um And so, you know, you would do an infection screen. So a chest X ray send off a urine culture, um maybe a sputum culture. So you, you would do a really thorough kind of top to toe history and exam. And the only way to definitively manage delirium is to treat the underlying cause. But while we're kind of working on that, there are some supportive um things we can do to help manage delirium. So ideally um try and keep the same um doctors nursing team, um allied health professional kind of wider team that's looking after the patient, try and keep them the same if possible and just gently reorientate somebody. So we, we generally um encourage not to just, you know, if someone insists that, you know, um they're in prison, um you know, it's not helpful to kind of really, really argue with them just gently bring them back to where they are environmental adaptation. So in the carry the elderly ward in my trust, there's a massive clock in each bay. Um We encourage people to have their own familiar things from home, encourage visiting family and their medication. So it's really important to avoid unnecessary medication. We're gonna touch on this more when we discuss polypharmacy. Um, but it's also worth mentioning as well. Just, um, sedating medications are not helpful. Um, they often make delirium worse in the long term and we only really advocate the use of them if, um, someone's at risk for themselves or others. So, um, yeah, just to, just to be aware that kind of like Benzodiazepines or like Haloperidol generally, um isn't they're not really very useful? Ok. So we're gonna go on to an Aussie case study. Now. Um So for this, I if you guys are um able to kind of get involved, just pop things in the chat, um that would be great because it just makes it a little bit more um interactive. So this is the bit. So if you're doing an AY and you stood outside the station, this is what's on the wall for you to read. So you're an fy one working in the emergency department, an 80 year old male has presented following an unwitnessed fall and you are asked to take a history and perform an examination. So what key questions are you are going through your head when you're thinking about what you need to ask in this history. So I'll let you guys um have a little think but yet um any suggestions, nothing is a silly suggestion at all. Ok. Yeah, great. So, Yeah, absolutely. Before, during and after is the mainstay of a false history. That's great. Yeah, loss of consciousness. Absolutely. Um, we'll talk more about that but that's really, really important. Yeah, injuries. Perfect. Yeah. So you guys are thinking exactly the wrong along the right lines here. Um, yeah, great. So, those are some specific symptoms. I'll just read out, um, these in case anyone can't see the chat. So, um, incontinence, tongue biting or seizure like activity. So, absolutely. Um they are specific things that we should be asking about. So, um here we go. So um quite right then. So we want to think about before, during, after and then now, so before um I always ask this a good way of doing it is what were you doing when you fell? Um You know, were they gardening? Were they trying to stand up? What were they doing? And do they remember it? Um Cos that's really important because if they don't remember it, that's quite concerning. If they do remember it, then that's a really valuable source of information. And did they have any preceding symptoms? Um So things we would be thinking about are like palpitations. Did they have chest pain? Did they have a sudden headache? Um Did they feel um like sync presyncopal and did they lose consciousness? Then we want to think about the during. So we're thinking how they fell, which you guys quite rightly said in the, in the chat did they injure themselves? Um So a way of asking that as well is like, how did you land? Did you land on an outstretched hand? Um Did they fall backwards? Um And that can then help indicate, did they lose consciousness? Which is the next question cos sometimes people aren't sure, but the way they fell can give us quite a lot of clues. Um And this is helpful as well. If you've got someone there for a cholesterol history, you can bring them together. So if someone went down like a sack of potatoes, that indicates like a loss of consciousness and potentially syncope, if someone went stiff as a board and then fell, um we might be thinking about a seizure. Um If someone went onto an outstretched hand, are we thinking about mechanical force? So it's really important to think about exactly how it happened and then afterwards, um you want to think um So how did they get up? Did they do it? Could they get themselves up? If not? Did they need help? Um And how much, how long they were on the floor? Um Does anyone know why we care about that? You can just pop it in the chat if you know, why do we care about the length of time on the floor? Yeah, perfect. Um rhabdomyolysis. Yeah. Um So that would be um rhabdomyolysis caused by um breakdown of muscles. Um And we care about that um because that can cause a really dreadful, um, acute kidney injury, um, which can make someone kind of life threateningly unwell. Um, did they have any symptoms following the fall? So we're thinking pain, but also, as someone quite rightly said in the, um, chat, if we're thinking about seizures, were they postictal, were they confused? Um, did they still have chest pain? That's really important. And then how do they feel now? Um, so are there any lasting symptoms? Are they still confused? Are we worried about concussion? Um But also that's kind of when I um would kind of start to think about any preceding illness. So, how are you feeling? Now, do you have a cough? Um How long have you had that? Is this actually like an infective cause? And that's when I would always um just do a very quick systems review. Um, you know, you might have been given something in the history that you want to tap into a system in more detail. But if up to this point, you haven't really, that would be your, your chance to do it um past medical history then. So there's some um conditions that are particularly relevant that I would always think about asking um by name as well as just saying, like, do you take any regular um meds for anything? Have you been in hospital? So any cognitive impairment, um any cardiovascular conditions? So, um do they have heart failure? Do they have an arrhythmia that we know about, um, Parkinson's disease. Um So that, that kind of come as a two reasons why we might, we always want to know about that is the first is the orthostatic hypertension that comes with it. And that's because in Parkinson's, you have an autonomic dysfunction. But also, um generally people with Parkinson's have a very classic gait. You've probably heard of it, the shuffling gait. So they take very small steps and they tend to tip forward as they walk and it's really common for them to then tip all the way to the floor. So Parkinson's is very um high risk um for falls and then sensory impairment. So that, again, that's got lots of um factors. So we're thinking, um you know, visually can they see where they're going with this mechanical because they didn't see um an obstacle. Um Have they got hearing or vestibular problems? Have they actually got vertigo? Um That's why they fell um under sensory, we can also think about peripheral neuropathies. So actually have they got um really terrible um peripheral neuropathy and they just can't feel the floor with their feet. Um So these are things that I would be thinking about asking specifically and then drug history. Um So it's great to ask this. Um Again, there's a couple that I would ask if I remembered. Um So anything sedating. So, do they take any Benzos? So, do they take diazePAM for a bad back? Um or anxiety diuretics um are really common, they can kind of cause you to um drop your BP. Um So, are they on furamide um antidepressants? Um they can cause um an orthostatic hypertension as can anticholinergics and then steroids. Um So, steroids, um they are less commonly cause um a postural hypotension, but they really do cause muscle weakness, especially long term use. So, they're another one to be aware of and actually, like certainly, um, on my acute medicine shifts, I've seen quite a few falls secondary to long term steroid use. So a good one to be aware of. So this is, um, perhaps not the kindest pneumonic, but it is really helpful. Um If you're, you know, in an ay or if you do long cases at your med school and you think, oh, my goodness. I cannot think of what to, what to ask. Splatted is quite helpful. Pneumonic. Um, I had to use it in my finals when I panicked. Um, so worth bearing in mind. So it's all the stuff we've already talked about, but it just uses it to help. So, um, symptoms, any previous falls, that's always really useful. Um, because actually, um, we know that people that have had falls before are far more likely to fall again location. So where we've talked about that we've talked about activity, any trauma sustained. So, um, that's quite a nice way to remind you to check and time. Um, you know, was this immediately after taking tablets? And is it the tablet that's the, um, culprit? Is it food? Is it, um, postprandial hypertension? Um, were they getting up? Um, and then the drug history? So that's just a, um, useful prompt. Um, you know, if all else fails and your mind goes blank, it is quite useful. Um, and then just thinking about investigations. So I went too fast. Um, do you guys wanna pop any investigations that you would think about doing for someone that's fallen in the chat? I know I have showed you a quick glance but, um, just pop a few in the chat. See we can go through them. No. Ok. You guys are less keen on this one. so we'll just go ahead and talk through it. So I don't know how you guys have been taught to structure your investigations. So if we go, we, you know, this is still an oy station. Um, you've had, you know, 5 to 7 minutes to take your history and the examiner may stop you and ask you a couple of questions. Investigations is a really common, um, thing that they probably will want to talk about. So I was always taught, um, to structure my investigations like this and I've, um, continued to do it like through med school and now working and I find it really helpful. So you've got bedside bloods slash laboratory tests, imaging and specials. And I always kind of divide up my investigations this way, I find it very useful and it kind of shows as well. Um You know, if you use this, it shows an examiner that you are thinking it through, you're not just kind of like spouting random things. So bedside, um vital signs, you can always do vital signs, lying and standing BP in a fall that is essential. You need to know if there's a postural drop, blood glucose. Um So are they hypoglycemic? Um Is that why they fell? And an ecg? So you want to think about arrhythmias there? Um You wouldn't do a urine dipstick. Um But you can send a urinary culture just, just a spot question. Does anyone know why we won't do this and care of the elderly? No. Gosh, I hope I'm not putting you all to sleep. Um So the reason we don't do a urine dipstick is because pretty much um most people over the age of 65 have an asymptomatic um bacteria in their urine. So it will light up saying there's nitrite and leucocytes. Um but we don't need to treat that unless it's causing them symptoms. So, in people over the age of 65 you treat UTI S based on clinical signs and you would send the culture um to guide your antibiotics, but you never do a dipstick unless you're looking for something else. So if you're looking for blood protein, you can, but if it's for uti I then you don't um bloods then. So you think about your FB CCR P? So you think about infection ene? Um Have they got, um, have they been on the floor for quite a long time? Have they got an AK I um, have they got a metabolic abnormality? That's why they found clotting. Um So particularly thinking about injuries, especially if they're on blood thinners. Um Vitamin B12 and folate. So, um this is always really useful if they're, especially if they're then also confused, but also, um you know, if they are deficient, they could have neuropathies, muscle weakness, thyroid um that comes in under the confusion screen. Um But again, also, you know, um it could make someone more prone to falling and cultures if you think there's an infection imaging. Um So chest X ray um very useful if you're looking for an infection. Um But also, um if you're concerned over like a new breathlessness, um or if you think it's heart failure, any bony injuries, you would do an X ray at least. Um It's always worth thinking that if, if the X ray is clear, but there's clearly, you know, there's swelling. Um there's a, there's a clear injury you can then do act um and a CT head. So there's lots of guidelines about when to do a CT head. And in what time frame. So things that would earn you a CT head in an hour um would be um reduced G CS. Um any signs of um bleeding and you're, you're on a blood thinner. Um So any signs of like a basal skull fracture, things that would earn you um A CT head in eight hours. So an unwitnessed fall on blood thinners that would um head injury and then subsequent vomiting. So there's um I won't go through the whole list, but there are some really good guidelines on, on nice about who gets act and when and then special tests. So if you think that somebody might have heart failure, an echo is really useful. Um If you think it was an arrhythmia, you could do a 24 hour holter. Um you know, anything you can think of, I always think in these, you know, that obviously this isn't like a list that you have to follow if you can justify your investigation, that's fine. The examiner's happy, it's much better to come up with something a bit weird but justify it and just reel off a list and then not and not really say why you're doing it because the examiner will always want to think, see that you're thinking. Um So yeah, you could come up with literally anything as long as you can justify it, then you can happen. Ok. So then just thinking about causes of falls. So most falls are multifactorial. It's unusual for a fall to be just one thing, just one pure thing that's caused a fall. Um So that's worth bearing in mind. But the way we look at kind of causes of falls is intrinsic. Um So, some essentially like a condition for that person. Um and then extrinsic, which is anything going on around them. So, um things that we think about intrinsic, so, syncope, um dizziness, vertigo, we mentioned um seizures. Someone mentioned in the chat is very um very important um peripheral neuropathies. Um We've mentioned um autonomic dysfunction. So, um that could be Parkinson's disease. Um But there is also other things that are slightly less common. So, postural orthostatic tachycardia syndrome. So, pots that counts as autonomic dysfunction, um cognitive impairment, um side effects of drugs or alcohol. Um And it's important to just, you know, um people that are old can still um use recreational drugs or um be alcohol dependent. So certainly like just because someone's a little bit older, still think about that and then age related frailty um extrinsic factors then. So um poor, these are things that in their environment. So poor lighting, clutter, um pets and Children getting onto their feet. Um Have they recently moved their environment now? Really unfamiliar? Um Do they not have the right mobility aid or any? Um So those are the other things that you would start to think about as well. So this is just like um this is the QR code, I'll just give you a chance to um use it if you guys want to. Um cos I know like at the end it can be a bit of a rush. So if you um just pop that up there for you and we'll talk a bit more about the feedback at the end. But um just that's just like it's just there for you if you want it. Um But we'll probably move on in the interest of time, um, fairly quickly. Um Just while we're at this point. Um Any questions so far or are you guys happy? I'm gonna um take that as happy. Um So we'll move on. I'm just create setting the next pole in motion. So um act with another um M CQ. So I've popped the pole in and here is the question. So a 76 year old female presents to the emergency department with a two day history of being off legs following five days of diarrhea. She's usually mobile with a frame. She reports lethargy muscle weakness and feels really dizzy when she stands up on examination. She looks clinically dehydrated and has hyporeflexia. So her reflexes are not as good as they should be. Which abnormality in her blood test is the most likely cause for her symptoms. So, hypokalemia, hyperglycemia, hyponatremia, hypernatremia or hypercalcemia, sorry, they're quite difficult to say all in a row. So I'll let you guys um start voting. I'll just give you a few more minutes. OK. So I think responses is slowing down now. So um the answer is C hyponatremia. Um So low sodium um can cause um really terrible lethargy, um muscle weakness, um postural hypotension, which is what she's describing. Um feeling dizzy when she stands up. Um It's the only electrolyte abnormality that causes a true hyporeflexia. So that's your big um indicator in the history. Um It also um the other clue was the clinic, the diarrhea and then she looked clinically dehydrated. So this is a case of hypovolemic hyponatremia. Um, other, the other options, you know, are sensible. So hypokalemia that is certainly like a sa sensible one to think about because especially with this history of diarrhea. Um, but generally you would just get a little bit of muscle pain, a bit of abdominal pain. Um, it is actually quite unusual for someone to get symptomatic hypokalemia. It's normally picked up on a blood test like a routine one run by the GP. Um, it's unlikely, um, to be this bad and, um, you don't get a proper hyporeflexia either, um, in the same way that you do with hyponatremia hypoglycemia. Um, so if in the history, there'd been a comment about type one diabetes, type two diabetes, um, or impaired glucose tolerance, then you might go. Oh, is it, is it hypoglycemia? But you would expect to hear about, um, polydipsia and polyuria. Um, at least one of them really, um, in a question, them to make you think about that, we've talked about why it's hyponatremia, hypernatremia. Um, certainly one to think about because um you can get hypernatremic when you've lost lots of water or lost lots of salt. So the diarrhea history um kind of fits with that. Um But generally, um you would, you would get um like myoclonic jerks or you, you would feel really lethargic. Um and you can, you can get seizures. Actually, that's worth saying with both hypo and hypernatremia in, you know, severe severe cases, kind of the worst case scenario are seizures and then a coma. And that's why um you know, we do treat it as a medical emergency when it's really severe. Um But yeah, in hypernatremia, you'd be thinking about things like myoclonic jerks and then hypercalcemia um is your classic bone stones, Crohn's and psychic bones. Um So, um pain in your bones. Um If you think about like kidney stones, abdominal pain, depression, that's none of this is really mentioned in the in the. So let's talk about off legs. What do we mean by off legs? So off legs can really mean two things. So it's really important to clarify what we mean. So for example, you know, you're working on the medical take and you get the referral from Ed and it's f you know, 85 year old female off legs and that's your referral and you're thinking, oh God, what does this mean? So either off legs means difficulty walking or more commonly, it means an acute deterioration in mobility and that's normally what people mean. So, key causes of acute deterioration is immobility are very similar to delirium. So it's always good if you're struggling to think about um the two together. Um and it might prompt you to think of what um some of the causes. So infection is always a culprit. So chest or urine are the two most common but any infection um can cause it dehydration, neurological. So a head injury or if they got a new cord equina or a cord, a compression, um, orthopedics, um, so fractures. So it's really important to remember um, in the elderly that they could have a much lower velocity um, injury and lead to quite a nasty injury. So, um, you know, for example, you know, you've heard about an 85 year old who's only fallen on a carpeted floor from standing and yet she's got a neck femur fracture. Um Just remember that the elderly can be really osteoporotic and, and prone to nasty injuries, metabolic abnormalities. So that's what we've kind of just gone through um, on the slide before, um, and then alcohol, um, drug or medication. So, we've discussed this, um and polypharmacy will talk about and then hypoxia, um I for got a new pneumonia. Um I forgot decompensated heart failure, um to have CO PD. There's lots of reasons why they might be hypoxic and that would stop you from being as mobile as usual and it would be acute. Ok. Difficulty walking. Um So I'm just gonna use this as an opportunity to discuss surgical sieve. So you guys probably, um, have seen this before or you might have a different one that you use. And I, um if you do use a different one, I'd love you to put it in the chat because, um, you know, like I use this at work every day. Um I always love to hear about new ones and it might help other people as well. Um If you don't like this one, you might be able to suggest a different one. So I'd really love it if you do have a different one, just pop it in the chat. So surgical s is a little bit misleading cos it doesn't have to be a surgical presentation. Um and it's basically a way of generating differentials for a condition. So we're gonna do it with difficulty walking today. Um But it could be um chest pain, it could be breathlessness or a headache, abdominal pain. It's really useful um for any kind of presenting complaint. And this is when I would be thinking about using it in an ay um you know, when you get your little thing on the outside and it probably give you a headline. Um you can use this to start generating your differentials that you're then going to rule in or out with your history. Um So vascular um infective traumatic autoimmune metabolic I acts, that's what we do. Um and then idiopathic neoplastic and degenerative, so specifically to difficulty walking, um, vascular eye like to break up into cardiac and neurological or brain. Um So, arrhythmias hypertension have they had a stroke infective and inflammatory so, arthritides, um and that can be in any joint myopathies. Um You can also get like slightly less common um, infections like a discitis or a very common one, like a cellulitis, traumatic. So we've discussed um how the elderly are more at risk of nasty fractures but also soft tissue injuries as well autoimmune. So we could be thinking about MS. Um it's definitely a reason why someone might have trouble walking um metabolic we've already covered really um iatrogenic then. So we're thinking about like toxins and drugs and that might be those that we give or that they consume recreationally and then lots of con loss of confidence as well. So if they've had a previous fall, um they might just really be scared to try immobilize and that will mean they technically have difficulty walking, neoplastic. Um you know, the older someone, the longer someone's been alive, technically, the more likely they are to then go on to develop a cancer. You know, we know that cancers develop um through mutations and when cells like um replicate and lose kind of their um fail safe mechanisms. So it, you know, the older someone gets, the more likely they are to develop a cancer. So it is worth thinking about um is this what's going on and um uh brain metastases, I think especially in the elderly population are far more common than like a brain primary. So, thinking about, is there a chance that that's what's going on and then degenerative? So, um you know, things like motor neuron disease dementias, they can affect the ability to walk. Parkinson's um all of those kind of come under that umbrella. OK. So got another question, I think. Yeah. OK. So question three. So let me just pop that part up for you guys and then I read it out as well. Yeah. Ok. So um a 70 year old male presents to his GP with a three month history of bilateral and swollen ankles. They're not painful, red or warm. He has a past medical history of hypertension type two diabetes and CO PD. He says his friend recently was prescribed water tablets to help with leg swelling and he would like to try them which one of the following drugs is most likely to be causing his symptoms. So I'll let you guys, you guys are on it with this one. You're all um all agreeing with each other. Um and all getting it right. Um So yeah, it is amLODIPine. Um It's a really classic um vinyls question as well, high yield in prescribing safety. Um So it's amLODIPine. Um that is the classic. Um Most talked about side effects of amLODIPine is um peripheral edema or leg swelling. Um the other drugs you wouldn't really see that. So with Losartan and Bisoprolol, you're more likely to see um like partial hypertension, Metformin. Um The classic is um lactic acidosis, but I say it happens a lot less than a textbook would lead you to believe. But for an exam that is what you need to remember. And so salbutamol inhaler, so you'd be looking at like tachycardia um tremor anxiety, that kind of thing. Ok. So I've got another question as well because I we lost a question on the um osk case. So I've added an extra question. So let me set this one up. Here we go. So a 72 year old man presents to his GP after several falls at home, he reports feeling dizzy after he stands up, he experiences no chest pain, palpitations or shortness of breath. His past medical history is hypertension, high cholesterol ischemic heart disease, atrial fibrillation and benign prostatic hyperplasia, which one of the following drugs is most likely to be interacting with Ramipril to cause his symptoms. So we've got tamsulosin, atorvastatin, paracetamol, aspirin, and Apixaban. I'll let you guys have a minute. Yeah. So you guys are on the ball again with this one. So, yeah, it is tamsulosin. Um So this is an alpha blocker. Um So it is also um essentially a va it will cause vasodilation um as ramipril will al bit by a different mechanism. Um So both of those coming together means he's far more likely to experience um postural hypotension, which is what he's describing. Um feeling dizzy after he stands up. So, yeah, um excellent job with those two. So polypharmacy then, um like in my research for this talk, um there wasn't really a consensus of whether it's four or five or more medications in one patient. Um for my finals, I learned four. But um that, you know, other kind of journals will say five. So there's, if you have someone with polypharmacy, there's a much higher risk of drugs interacting with each other. If there's more of them, that makes sense. And there's also a higher risk of adverse drug reactions. So especially in the elderly. Um and we're going to talk about why in the elderly. Um and there's also a risk of a prescribing cascade. So, um an example would be our gentleman in the um case of the question that was taking amLODIPine then got ankle swelling. Um, you know, he could have then been prescribed furosemide um to help with the swelling, um which could have then led to him having like a low potassium. So he needs sound. Ok. Um that would be a cascade. So, um getting a side effect from a drug prescribing another drug for that side effect and so on and so on and we really try and avoid that. Um So just a word then on pharmacokinetics in the elderly and why we mind so much about polypharmacy. So, um you know, the four key um parts of pharmacokinetics are there. So absorption distribution, metabolism and excretion. So um older people don't produce as much stomach acid and they also don't clear it as quickly. Um So not only is their kind of digestion poor but also their gastric emptying is quite slow and they will have a delay in colonic transit. So you can essentially think of it as like a bit of reduced bioavailability distribution. So older people have a higher fat to water ratio. Um So there's a smaller volume of distribution as you get older. Um which means like a the same dose um would have a higher concentration once in the body in someone that's older. Um And so we worry about that as well um metabolism. So, thyroid function just as you get older, it just gets slower, the thyroid. Um you know, you'll see loads of people that are quite old on levothyroxine just because as they get older, their thyroid isn't as good. Um blood flow to the liver um is slower and decreased and the liver itself gets smaller. So metabolism is going to be slower, cos the capacity to do so is less. So then you think about how quickly can these um drugs that you're giving be metabolized and do you need to dose adjust and excretion? So, um you know, much like the thyroid, um generally the kidneys get a little bit less good as you get older and you're gonna see loads of people with chronic kidney disease. So, if you've got poor renal function, um you're going to just take longer to get rid of any drugs that are renally excreted. And a really good example of this is opiates. Um So y you need to really change your dose of opiates because actually, if someone can't get rid of it as quickly as they should, they could end up um having, you know, like a respiratory depression from essentially an overdose because their body just can't get rid of it. So it's hanging around. Um So that's just a quick um just slide about why we care so much about um polypharmacy um in the elderly. So um hopefully on time. Yeah, we're doing quite well for time. So that's um everything that I wanted to cover this evening. Um We've still got like 757 minutes um for questions. So um I'm very happy if you want to put them in the chat, any questions about what we've covered this evening, but also like more general questions about like finals F one. Very happy to take anything. It doesn't have to be specific to care of the elderly. Um I've put the QR code back up. Um So medal just automatically generates your certificate of attendance once you've done the feedback form and I'm very grateful for them because I need it for my portfolio. So thank you very much. Um The next talk is on the 11th, I think that's Monday. Um And that's about urology um for those of you that are joining. Um And if you have any questions that you think of later, which is quite common, um there's just an email address there um for any later questions, but we'll, I'll just hang on to eight. So if you guys um do wanna type any questions in the chat, I'm very happy to answer and yeah, I hope this was useful and um interesting as interesting as it can be. Yeah. Ok, I see. Yes. Ok. Um So thank you all for coming and hope you enjoyed.