419 if the slough is allowed to separate the help of wet dressings. In more with spontaneously recent lesions than those described, the separation of similar small sloughs after burns has been greatly facilitated by initially wrapping the area in ordinary plastic kitchen cling film for 3 to 5 days at a time. Extravasated cytotoxic infusions are likely to cause more extensive damage to the tissues, and debridement followed by more extensive repair procedures may be required. Although a skin slough is a small price to pay for successful resuscitation from a life-threatening illness, it has in most of these cases delayed the patient’s final recovery. The prompt use of elevation, warmth, and the local injection of procaine or hyaluronidase as recommended by Lee and Atkinson4might prevent an actual slough when one of these substances is extravasated dur-
tions
are
less
likely
Geriatrics is Medicine
HOW TO INVESTIGATE AN OLD PERSON W. B. WRIGHT
Royal Devon and Exeter Hospital, Heavitree, Exeter EXI 2ED
GERIATRIC medicine is still regarded by some as a of caretaking rather than cure. Geriatric physicians who resist this suggestion emphasise the rehabilitative aspect of their work and the turnover of their department. This lays them open to the alternative charge of "flogging a dead horse". Widespread attitudes always have a grain of truth, or are at least understandable. We are, after all, accustomed to the convention that emergency resuscitation is not normally given to hospital patients over 70, and accounts of pointless attempts to secure the survival of very old people are distressing. Geriatric physicians, however, are almost never responsible for such incidents. They arise incasualty departments and other reception wards, usually because the patient’s great age has not been noticed. No-one wishes to torment old people with unnecessary investigamatter
on the other hand, no-one wishes them to end their days in chronic invalidism for the want of timely medical intervention. We should, therefore, have some simple guidelines for the investigation of old people which would yield the maximum benefit for the least dis, turbance. Some suggestions, based on observations in a geriatric department, may be helpful. A fairly typical example is a person over 75 who has taken to his bed and in whom initial physical examination has not revealed any specific diagnosis to account for his weakness. It is almost impossible to examine any elderly person in these circumstances without finding some abnormality, but the diagnosis which you are after should be adequate to explain the patient’s debility. In deciding what steps to take, the patient’s mental state is a prime consideration. Severe debility in the presence of
tions :
normal brain signifies some serious, though possibly reversible, condition. On the other hand, the patient who has been mentally feeble for some time is much a
ing treatment; however, initial recognition of possible damage is not easy. The accompanying figure shows the progression from mild blistering to an extensive ulcer after extravasation of sodium bicarbonate. The knowledge that this is likely to occur with certain infusions may help to limit subsequent damage. I thank Mr M. Shaw, Mr D. Eastwood, Mr T. L. Barclay, and Mr D. J. Crockett for permission to record cases under their care, the Departments of Photography at Leeds and Bradford Hospitals, and Miss E. Drury for secretarial help. REFERENCES
P., Ekland, D., Shaw, R. C., Parsons, R. W. Ann. Surg. 1975, 182, 553. 2. Lawrence, D. R.-Clinical Pharmacology. p. 370. Edinburgh, 1966. 3. Riyami, A. Irish med. J. 1968, 61, 23. 4. Lee, J. A., Atkinson, R. S. A Synopsis of Anæsthesia. p. 286. Bristol, 1968. 1. Yosowitz,
be severely debilitated by a minor illness, infection of the upper respiratory tract. In any case, it is important to think about minor epidemic infections, because they are so difficult to diagnose in old people, who do not show the same febrile response as the young. Geriatric and psychogeriatric departments have a considerable increase in applications for admission during the peak influenza periods of winter and early spring, and the seasonal death-rate in long-stay institutions has probably a similar connection, though this may not be obvious from the death certificates. Broadly speaking, infections of the respiratory or urinary tract are the most likely. They probably account for many cases of symptomless debility in the elderly which im-
more
likely
such
as an
to
prove strikingly on
a course
of ampicillin.
The duration of mental disturbance is an important factor. The patient who has been dementing for some time is unlikely to be improved as a result of investigations which include, for example, extensive radiology, whatever the findings. On the other hand, if the patient has led a normal full life until recently and is valued by his relatives, then his age and mental state are almost immaterial, provided that whatever investigations are done could lead to effective treatment. Effective treatment should mean for the elderly a significant improvement in the quality of life, not merely its prolongation. If the patient is a demented cripple whose dependence cannot be altered, then one’s objectives should be limited to the relief of pain and discomfort-investigation is quite inappropriate. For some demented patients an increase of physical ability would represent an enormous added burden to the relatives in terms of wandering and safety in the home, and in such cases intervention is best
avoided. be seen to be dying, or at first inspection, even if the illness, diagnosis is not obvious. Continuous heavy breathing is always a bad sign in the elderly and indicates impending dissolution more surely even than Cheyne-Stokes breathing. In other cases it is very difficult to decide the prognosis, and some investigations may be necessary so that appropriate plans can be made for the patient’s Some
elderly patients
least in their last
can
on
care.
When is
one
indicated,
has made up one’s mind that investigation it is worth remembering that obscure but
420
remediable illnesses are uncommon in the elderly and that only these justify extensive procedures. Many curable conditions are iatrogenic and one’s first thought should be a reappraisal of the drugs the patient has been taking. Examination of blood and urine can be done at home and can lead to the diagnosis of nutritional anaemias, diabetes, myxoedema, gout, osteomalacia, and
electrolyte depletion. A very high erythrocyte-sedimentation rate is always significant and can confirm that the patient has had a severe infection or lead to a diagnosis of temporal arteritis or polymyalgia rheumatica. Enzyme studies may reveal a silent coronary thrombosis or bone carcinomatosis. A stool smear can be taken for occult blood (indicating peptic ulceration) and fat globules (indicating malabsorption syndrome).
Further investigation requires hospital referral, but this may not mean hospital admission. Very old people do badly in outpatient departments, but most geriatric physicians now run day hospitals. These normally cater for invalids who require physiotherapy, occupational therapy, and a break from their own homes; but they can also be used like surgical day-care units, where the old person is an inpatient for a day, has his meals, and has none of the strain of a waiting-room. The patient can have the various required investigations at convenient times during his day in the day hospital. More extensive stool investigation can be done here (and enema treatment if this proves necessary). Electrocardiography is easy and radiology is usually available. Painful bones should be X-rayed to distinguish osteomalacia, Paget’s disease, secondary deposits, and unsuspected fractures.
Day hospitals are suitable only for patients who are failing but still able to travel without too much distress. Some old people more feeble than this still merit further investigation, and these must be admitted for inpatient care. This is particularly important where dehydration is obvious and difficult to treat at home, so that a short of intravenous fluids will be required. Some patients might have to be admitted to hospital so that severe pressure-sores can be prevented. Others have to be admitted because they are isolated or lack family support. Investigation is much easier in hospital and can be pursued more vigorously along conventional lines with a view to re-establishing the patient at home. course
,
debility develops quickly and is associated history of acute illness or injury, phlebothrombosis with pulmonary embolus must be a first thought. How very common this complication is among the elderly is only now being realised. The patient with
If with
severe
a recent
heart-failure
or a
to
the
fractured neck of femur which has not correct treatment will be found more responded often than not to have a positive lung scan. Where there is no specific contraindication, treatment is indicated and often prevents recurrence. In conclusion, it should be said that a rewarding investigation is to go back and take another look at the patient
to
see whether, for instance, her bearing and
man-
those of endogenous depression or early Parkinson’s disease; whether she is not after all debilitated because she has been starving herself from false economy; and whether her bedroom is not so cold that she is hypothermic. ner are not
In
Now
England
DIRECT Current has never presented any problem: I mastered it by the time I was seven. The stuff flowed along one wire from the red positive terminal of my battery, like water from an upstairs cistern, did something useful on its way, and came back home along another wire to the blue negative terminal. When the red cistern-thing ran dry there was no more flow. It was good honest two-wire there-and-back stuff. Then Science taught me that it wasn’t a fluid but a column of jostling little chaps (called "ions") and, what’s more, that they travelled from negative to positive, which seemed as incredible as water flowing uphill; but, since it made no difference to the final outcome, I learned to live with it. I never took to Alternating Current, where it seems that the little chaps are made to charge to and fro, like defaulters doing pack-drill on the barrack square, never getting anywhere, and with no prospect of getting home and putting their feet up: in fact, there didn’t seem to be a home, either positive or nega-
tive,
to
go
to.
My first
real bafflement came with thermionic valves, which had at least three, sometimes four, and even five wires going into or coming out of them. How could the little chaps know which was the shortest way home, given these multiple choices? Trial and error, I suppose. One path seemed to involve a desperate leap across a chasm. I hope this turned out to be the right one, and not just a dirty trick. Talking of dirty tricks, I have just been studying the circuit diagram that came with my cassette recorder. It is, mercifully, Direct Current, but it is the most diabolically contrived maze. I have been trying to trace the path they have to take travelling from the battery’s negative pole to its positive one. No sooner have they proceeded along a wire than they are confronted with a T-junction (unsignposted). Those who take the left turn have to struggle through a beastly resistance, only to run smack into the blank wall of a capacitor. No thoroughfare; so they have to scramble back through the resistance, and join those who turned right. More T-junctions will send many on similar wild-goose chases down other blind alleys. In the heart of the network are some half-dozen shirt-buttons, three-wire of course; one wire of which admittedly has an arrow showing direction, but the ambiguity remains. I give up. Presumably there must be some justification for all this sadistic boobytrappery, but to me it is un-British. And, in fact, the trade-mark, I find, shows it to be Oriental. THE people in New York City are all in such a desperate hurry that I was determined to avoid the "stranger here myself’ syndrome. I was outside Macy’s ("The Largest Store in the World") and wanted to board a certain bus, but had no idea where it stopped. So I waited, in order to choose my man carefully. As soon as I saw him, I felt sure I was on to a winner. Venerable, soberly dressed, just slightly shambling. But obviously benevolent. "Am I a local, did you ask? Friend, I am a direct descendant of Amerigo Vespucci, no less. And I am not joking! So I can tell you anything you want to know." He told me his life story. Charming old boy. Had led quite a life of it. Nevertheless he gave me the wrong directions. *
*
*
SYNOPSIS OF GASTROENTEROLOGY
Therapy (a) Any symptoms: new bran pill with cimetidine coat. (b) No symptoms: laparotomy. Diet
(a) Too thin: gluten-free diet. (b) Too fat: glutton-free diet. Research
(a) Use of fibrescopes. (b) Scope of fibre uses.
tions
are
less
likely
Geriatrics is Medicine
HOW TO INVESTIGATE AN OLD PERSON W. B. WRIGHT
Royal Devon and Exeter Hospital, Heavitree, Exeter EXI 2ED
GERIATRIC medicine is still regarded by some as a of caretaking rather than cure. Geriatric physicians who resist this suggestion emphasise the rehabilitative aspect of their work and the turnover of their department. This lays them open to the alternative charge of "flogging a dead horse". Widespread attitudes always have a grain of truth, or are at least understandable. We are, after all, accustomed to the convention that emergency resuscitation is not normally given to hospital patients over 70, and accounts of pointless attempts to secure the survival of very old people are distressing. Geriatric physicians, however, are almost never responsible for such incidents. They arise incasualty departments and other reception wards, usually because the patient’s great age has not been noticed. No-one wishes to torment old people with unnecessary investigamatter
on the other hand, no-one wishes them to end their days in chronic invalidism for the want of timely medical intervention. We should, therefore, have some simple guidelines for the investigation of old people which would yield the maximum benefit for the least dis, turbance. Some suggestions, based on observations in a geriatric department, may be helpful. A fairly typical example is a person over 75 who has taken to his bed and in whom initial physical examination has not revealed any specific diagnosis to account for his weakness. It is almost impossible to examine any elderly person in these circumstances without finding some abnormality, but the diagnosis which you are after should be adequate to explain the patient’s debility. In deciding what steps to take, the patient’s mental state is a prime consideration. Severe debility in the presence of
tions :
normal brain signifies some serious, though possibly reversible, condition. On the other hand, the patient who has been mentally feeble for some time is much a
ing treatment; however, initial recognition of possible damage is not easy. The accompanying figure shows the progression from mild blistering to an extensive ulcer after extravasation of sodium bicarbonate. The knowledge that this is likely to occur with certain infusions may help to limit subsequent damage. I thank Mr M. Shaw, Mr D. Eastwood, Mr T. L. Barclay, and Mr D. J. Crockett for permission to record cases under their care, the Departments of Photography at Leeds and Bradford Hospitals, and Miss E. Drury for secretarial help. REFERENCES
P., Ekland, D., Shaw, R. C., Parsons, R. W. Ann. Surg. 1975, 182, 553. 2. Lawrence, D. R.-Clinical Pharmacology. p. 370. Edinburgh, 1966. 3. Riyami, A. Irish med. J. 1968, 61, 23. 4. Lee, J. A., Atkinson, R. S. A Synopsis of Anæsthesia. p. 286. Bristol, 1968. 1. Yosowitz,
be severely debilitated by a minor illness, infection of the upper respiratory tract. In any case, it is important to think about minor epidemic infections, because they are so difficult to diagnose in old people, who do not show the same febrile response as the young. Geriatric and psychogeriatric departments have a considerable increase in applications for admission during the peak influenza periods of winter and early spring, and the seasonal death-rate in long-stay institutions has probably a similar connection, though this may not be obvious from the death certificates. Broadly speaking, infections of the respiratory or urinary tract are the most likely. They probably account for many cases of symptomless debility in the elderly which im-
more
likely
such
as an
to
prove strikingly on
a course
of ampicillin.
The duration of mental disturbance is an important factor. The patient who has been dementing for some time is unlikely to be improved as a result of investigations which include, for example, extensive radiology, whatever the findings. On the other hand, if the patient has led a normal full life until recently and is valued by his relatives, then his age and mental state are almost immaterial, provided that whatever investigations are done could lead to effective treatment. Effective treatment should mean for the elderly a significant improvement in the quality of life, not merely its prolongation. If the patient is a demented cripple whose dependence cannot be altered, then one’s objectives should be limited to the relief of pain and discomfort-investigation is quite inappropriate. For some demented patients an increase of physical ability would represent an enormous added burden to the relatives in terms of wandering and safety in the home, and in such cases intervention is best
avoided. be seen to be dying, or at first inspection, even if the illness, diagnosis is not obvious. Continuous heavy breathing is always a bad sign in the elderly and indicates impending dissolution more surely even than Cheyne-Stokes breathing. In other cases it is very difficult to decide the prognosis, and some investigations may be necessary so that appropriate plans can be made for the patient’s Some
elderly patients
least in their last
can
on
care.
When is
one
indicated,
has made up one’s mind that investigation it is worth remembering that obscure but
420
remediable illnesses are uncommon in the elderly and that only these justify extensive procedures. Many curable conditions are iatrogenic and one’s first thought should be a reappraisal of the drugs the patient has been taking. Examination of blood and urine can be done at home and can lead to the diagnosis of nutritional anaemias, diabetes, myxoedema, gout, osteomalacia, and
electrolyte depletion. A very high erythrocyte-sedimentation rate is always significant and can confirm that the patient has had a severe infection or lead to a diagnosis of temporal arteritis or polymyalgia rheumatica. Enzyme studies may reveal a silent coronary thrombosis or bone carcinomatosis. A stool smear can be taken for occult blood (indicating peptic ulceration) and fat globules (indicating malabsorption syndrome).
Further investigation requires hospital referral, but this may not mean hospital admission. Very old people do badly in outpatient departments, but most geriatric physicians now run day hospitals. These normally cater for invalids who require physiotherapy, occupational therapy, and a break from their own homes; but they can also be used like surgical day-care units, where the old person is an inpatient for a day, has his meals, and has none of the strain of a waiting-room. The patient can have the various required investigations at convenient times during his day in the day hospital. More extensive stool investigation can be done here (and enema treatment if this proves necessary). Electrocardiography is easy and radiology is usually available. Painful bones should be X-rayed to distinguish osteomalacia, Paget’s disease, secondary deposits, and unsuspected fractures.
Day hospitals are suitable only for patients who are failing but still able to travel without too much distress. Some old people more feeble than this still merit further investigation, and these must be admitted for inpatient care. This is particularly important where dehydration is obvious and difficult to treat at home, so that a short of intravenous fluids will be required. Some patients might have to be admitted to hospital so that severe pressure-sores can be prevented. Others have to be admitted because they are isolated or lack family support. Investigation is much easier in hospital and can be pursued more vigorously along conventional lines with a view to re-establishing the patient at home. course
,
debility develops quickly and is associated history of acute illness or injury, phlebothrombosis with pulmonary embolus must be a first thought. How very common this complication is among the elderly is only now being realised. The patient with
If with
severe
a recent
heart-failure
or a
to
the
fractured neck of femur which has not correct treatment will be found more responded often than not to have a positive lung scan. Where there is no specific contraindication, treatment is indicated and often prevents recurrence. In conclusion, it should be said that a rewarding investigation is to go back and take another look at the patient
to
see whether, for instance, her bearing and
man-
those of endogenous depression or early Parkinson’s disease; whether she is not after all debilitated because she has been starving herself from false economy; and whether her bedroom is not so cold that she is hypothermic. ner are not
In
Now
England
DIRECT Current has never presented any problem: I mastered it by the time I was seven. The stuff flowed along one wire from the red positive terminal of my battery, like water from an upstairs cistern, did something useful on its way, and came back home along another wire to the blue negative terminal. When the red cistern-thing ran dry there was no more flow. It was good honest two-wire there-and-back stuff. Then Science taught me that it wasn’t a fluid but a column of jostling little chaps (called "ions") and, what’s more, that they travelled from negative to positive, which seemed as incredible as water flowing uphill; but, since it made no difference to the final outcome, I learned to live with it. I never took to Alternating Current, where it seems that the little chaps are made to charge to and fro, like defaulters doing pack-drill on the barrack square, never getting anywhere, and with no prospect of getting home and putting their feet up: in fact, there didn’t seem to be a home, either positive or nega-
tive,
to
go
to.
My first
real bafflement came with thermionic valves, which had at least three, sometimes four, and even five wires going into or coming out of them. How could the little chaps know which was the shortest way home, given these multiple choices? Trial and error, I suppose. One path seemed to involve a desperate leap across a chasm. I hope this turned out to be the right one, and not just a dirty trick. Talking of dirty tricks, I have just been studying the circuit diagram that came with my cassette recorder. It is, mercifully, Direct Current, but it is the most diabolically contrived maze. I have been trying to trace the path they have to take travelling from the battery’s negative pole to its positive one. No sooner have they proceeded along a wire than they are confronted with a T-junction (unsignposted). Those who take the left turn have to struggle through a beastly resistance, only to run smack into the blank wall of a capacitor. No thoroughfare; so they have to scramble back through the resistance, and join those who turned right. More T-junctions will send many on similar wild-goose chases down other blind alleys. In the heart of the network are some half-dozen shirt-buttons, three-wire of course; one wire of which admittedly has an arrow showing direction, but the ambiguity remains. I give up. Presumably there must be some justification for all this sadistic boobytrappery, but to me it is un-British. And, in fact, the trade-mark, I find, shows it to be Oriental. THE people in New York City are all in such a desperate hurry that I was determined to avoid the "stranger here myself’ syndrome. I was outside Macy’s ("The Largest Store in the World") and wanted to board a certain bus, but had no idea where it stopped. So I waited, in order to choose my man carefully. As soon as I saw him, I felt sure I was on to a winner. Venerable, soberly dressed, just slightly shambling. But obviously benevolent. "Am I a local, did you ask? Friend, I am a direct descendant of Amerigo Vespucci, no less. And I am not joking! So I can tell you anything you want to know." He told me his life story. Charming old boy. Had led quite a life of it. Nevertheless he gave me the wrong directions. *
*
*
SYNOPSIS OF GASTROENTEROLOGY
Therapy (a) Any symptoms: new bran pill with cimetidine coat. (b) No symptoms: laparotomy. Diet
(a) Too thin: gluten-free diet. (b) Too fat: glutton-free diet. Research
(a) Use of fibrescopes. (b) Scope of fibre uses.
