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IM25.1-22 | Geriatrics — PBL Case

CLINICAL SETTING

It is a Monday morning in the General Medicine ward of a government teaching hospital in Hyderabad. Dr Ananya, the second-year resident, is presenting to the geriatric consult team. The patient is Mr Subramaniam Iyer, a 79-year-old retired schoolteacher who was brought in by his neighbour after being found on the floor of his flat at 8 am. He lives alone; his only daughter lives in Bengaluru and manages his affairs remotely. His neighbour says Mr Subramaniam has been unwell for about a week — she had noticed he was not collecting his newspaper, something he did every morning without fail. On arrival at the emergency department, he was conscious but very confused, could not say what day it was, and kept asking for his wife, who, Dr Ananya later learns, passed away three years ago. His clothes were soiled with urine. He has a right wrist deformity (X-ray confirms a Colles fracture). His medications brought by the neighbour include: glibenclamide 5 mg twice daily, amlodipine 5 mg, losartan 50 mg, aspirin 75 mg, atorvastatin 40 mg, alprazolam 0.5 mg at night, and diclofenac 50 mg as needed. He has no patient-held medical records.

Trigger 1: The First Assessment: What Brought Him Down?

Dr Ananya examines Mr Subramaniam. He is unkempt, with poor skin turgor and dry mucous membranes. GCS 14/15 (confused). Vital signs: temperature 38.1°C, BP 100/60 mmHg lying and unobtainable standing (too painful due to wrist), pulse 110 bpm regular, RR 20/min. Blood glucose on glucometer: 2.6 mmol/L. SpO2 96% on room air. He has a right wrist Colles fracture (X-ray confirmed). His abdomen is soft but he flinches on right-sided palpation. Urinalysis shows pyuria and nitrites. Blood results are pending. Dr Ananya turns to the students and asks: 'What are the active medical problems right now, and which one needs to be managed in the next 10 minutes?'

DISCUSSION POINTS

  • List all the active clinical problems you can identify in the first assessment. Which problem requires immediate intervention and why?
  • Blood glucose of 2.6 mmol/L in a patient on glibenclamide: what is the mechanism? Why is hypoglycaemia particularly dangerous in an elderly patient on a long-acting sulfonylurea? What is the correct management and what monitoring is needed for the next 24 hours?
  • Mr Subramaniam is confused, febrile, and hypotensive. How do you differentiate between delirium (acute confusional state) and a pre-existing dementia as the cause of his confusion at this early stage? What clinical and collateral history features would you seek?
Click to reveal Trigger 2: Blood Results and a More Complete Picture (discuss previous trigger first!)

Trigger 2: Blood Results and a More Complete Picture

An hour later, blood results are back: Hb 9.8 g/dL (normocytic), WBC 14,200 cells/mm3, Na 129 mEq/L, K 3.2 mEq/L, urea 62 mg/dL, creatinine 1.6 mg/dL (eGFR 38 mL/min/1.73m2), albumin 23 g/L, random blood glucose now 5.8 mmol/L after IV dextrose, CRP 86 mg/L. ECG: sinus tachycardia, no ischaemia. Urine culture sent. Dr Ananya calls Mr Subramaniam's daughter in Bengaluru. The daughter says: 'Papa has been getting more forgetful over the past year — sometimes he calls me three times asking the same question, and recently he mistook the neighbour for my mother. He had a fall two months ago but we thought it was a carpet. He has been eating poorly for a month. I offered to get him a maid but he refused, saying he can manage.' She pauses and adds: 'I'm worried that someone may be stealing his pension — he mentioned money going missing from his account. He gets confused about his tablets and I think he has been missing them and doubling up.'

DISCUSSION POINTS

  • Interpret the blood results systematically. What is the likely cause of hyponatraemia in this patient, and how does it interact with his confusion and fall risk? How would you correct it safely?
  • The daughter's history reveals a year of progressive memory loss, functional decline in IADL (medication management, finances), and repeated falls. How does this change your diagnostic thinking? Apply the CAM (Confusion Assessment Method) — does he meet criteria for delirium? Is pre-existing dementia likely?
  • Mr Subramaniam's renal function shows eGFR 38 mL/min. Review his medication list with this in mind. Which medications are now potentially harmful given his renal function, and which Beers Criteria or STOPP criteria violations are present? Prioritise by urgency of harm.
Click to reveal Trigger 3: The Fall Is Not the Diagnosis (discuss previous trigger first!)

Trigger 3: The Fall Is Not the Diagnosis

Mr Subramaniam stabilises over the next 48 hours — the UTI responds to IV co-amoxiclav, glucose normalises, and he is more oriented (he now knows his name and the city but not the date). His confusion has improved but not resolved. MMSE is 20/30. Dr Ananya performs a formal Comprehensive Geriatric Assessment. TUG test (done cautiously with wrist supported) takes 22 seconds with marked unsteadiness. The physiotherapist notes he has significant bilateral proximal muscle weakness, likely sarcopaenia. Lying-to-standing BP shows a 28 mmHg systolic drop. GDS-15 is 10/15. DEXA from his last admission 18 months ago shows T-score -3.1 at the hip. The Colles fracture has been managed in a splint by the orthopaedic team, who ask for 'medical clearance before discharge.' Dr Ananya is asked by the consultant: 'What has this man's fall taught us about his overall functional trajectory? What is the risk that he will fall again, and what will happen if he does?'

DISCUSSION POINTS

  • Apply the four Geriatric Giants (immobility, instability/falls, incontinence, intellectual impairment) to this patient. How are they interrelated in his case? What is the likely cascade of events if he returns home without intervention?
  • Mr Subramaniam has a T-score of -3.1 and has now had a Colles fracture (fragility fracture) at this admission. He is not on any anti-resorptive treatment. Design his osteoporosis management plan. Consider his renal function (eGFR 38) when choosing between alendronate and denosumab.
  • The GDS-15 score is 10/15, placing him in the moderate depression range. In the context of bereavement (wife died 3 years ago), social isolation, and progressive cognitive decline, what is the relationship between depression, dementia, and functional decline in the elderly? How would you approach pharmacological and non-pharmacological treatment of his depression?
Click to reveal Trigger 4: Preparing for Discharge — A Difficult Conversation (discuss previous trigger first!)

Trigger 4: Preparing for Discharge — A Difficult Conversation

On day 5, Mr Subramaniam is medically stable. His daughter has flown in from Bengaluru. She says: 'I want to take Papa home — to my home in Bengaluru. But he is refusing. He says this is his home, his friends are here, and he will not leave Hyderabad. He says he is fine and will manage.' The multidisciplinary team meets. The occupational therapist reports a home safety assessment: no grab rails, cluttered flat, poor lighting, stairs to access the first floor. The social worker notes that the pension account discrepancy the daughter mentioned has not been clarified. The geriatrician says to the students: 'Before we make a plan, I want you to consider whether Mr Subramaniam has the capacity to make this decision, and what our obligations are if he does.'

DISCUSSION POINTS

  • Assess Mr Subramaniam's decision-making capacity for the specific decision of refusing to move to his daughter's home. Apply the four functional criteria of capacity assessment (understand, retain, weigh, communicate). How would his current delirium resolution affect this assessment, and when should it be repeated?
  • If Mr Subramaniam has capacity and refuses to leave, what are the team's ethical obligations? How do you balance his autonomy against his safety? How does the Indian Maintenance and Welfare of Parents and Senior Citizens Act 2007 interact with clinical decision-making in this situation?
  • The pension discrepancy raises a concern for financial elder abuse. What is the appropriate clinical response? What is the role of the treating team versus social services? How should this concern be documented and escalated?

Group Task Assignments

  • Construct a complete Comprehensive Geriatric Assessment summary for Mr Subramaniam across all five domains (medical, functional, cognitive, psychological, social/environmental), using the validated tools appropriate to each domain. Based on the CGA, generate a problem list and a prioritised MDT management plan.
  • Design a multifactorial falls prevention programme for Mr Subramaniam that addresses ALL modifiable fall risk factors identified in this case. Your programme should specify: the intervention, the responsible team member, the timeline, and the measurable outcome.
  • The consultant asks the group to debate: 'This patient has glibenclamide, alprazolam, diclofenac, and losartan on his list, with eGFR 38. Using the STOPP/START framework, develop a revised safe medication list and justify every addition and deletion.' Prepare a STOPP/START medication reconciliation table.
  • Draft a discharge communication to Mr Subramaniam's GP in Hyderabad (assuming he stays in his flat). The letter should: summarise the admission, flag the medications stopped and started, recommend follow-up intervals, specify what community supports are needed, and flag the unresolved elder abuse concern.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [IM25.3] What are the DSM-5 criteria for delirium, and how is the CAM (Confusion Assessment Method) applied to diagnose delirium at the bedside? How is delirium superimposed on dementia identified and managed?
  2. [IM25.6] How is Alzheimer disease distinguished from vascular dementia and Lewy body dementia? What are the indications for cholinesterase inhibitors in dementia, and what monitoring is required?
  3. [IM25.2] What are the five domains of the Comprehensive Geriatric Assessment (CGA), and which validated tool is used for each domain? What specific interventions does a positive finding in each domain trigger?
  4. [IM25.13] What is the multifactorial model of falls in the elderly? How are the Timed Get-Up-and-Go test and orthostatic hypotension measurement used in falls assessment? What does the evidence say about multifactorial falls prevention programmes?
  5. [IM25.8] When is denosumab preferred over bisphosphonates for osteoporosis treatment in elderly patients with CKD? What is the mechanism of action of denosumab, and what is the risk of rebound vertebral fractures if it is discontinued without transition therapy?
  6. [IM25.19] What are the types of elder abuse, and what are the clinical signs that should prompt a physician to screen for it? What is the physician's reporting obligation under the Maintenance and Welfare of Parents and Senior Citizens Act 2007?
  7. [IM25.21] What are the four functional criteria for assessing decision-making capacity? How does delirium interact with capacity assessment, and when should capacity assessment be repeated in a recovering delirious patient?