Free UKMLA medicine of older adults questions with explanations

E. Identify and treat the underlying cause

Postoperative delirium in an elderly patient with a hip fracture requires identification and treatment of precipitating causes as the immediate priority. Common triggers include infection, pain, constipation, urinary retention, dehydration, electrolyte disturbance, hypoxia, and offending medications; addressing these alongside non-pharmacological measures (reorientation, familiar staff, adequate lighting) is the cornerstone of management.

A. J waves (Osborn waves)

J (Osborn) waves are positive deflections at the J point (the junction of the QRS complex and ST segment) and are the classical ECG finding in moderate to severe hypothermia, typically appearing once core temperature falls below 32°C and becoming more prominent with deeper cooling. This patient's core temperature of 29.8°C and environmental exposure make hypothermia the diagnosis; associated features include bradycardia, prolonged PR/QRS/QT intervals and a predisposition to atrial fibrillation.

A. Giant cell arteritis

Central retinal artery occlusion in a patient over 50 with jaw claudication, scalp/temporal tenderness and markedly raised inflammatory markers is giant cell arteritis until proven otherwise, and high-dose glucocorticoids must be started immediately to protect the fellow eye without waiting for temporal artery biopsy. IV methylprednisolone 500 mg–1 g daily for 3 days followed by oral prednisolone 60 mg daily can be considered when there is visual involvement.

E. Structured sick-day rules education with carer involvement

HHS recurrence in elderly patients is driven by intercurrent illness, dehydration and inappropriate continuation or adjustment of oral hypoglycaemics; structured sick-day rules education delivered with carer involvement addresses all three modifiable factors and is recommended. In patients with cognitive impairment, carer involvement is essential because the patient may not reliably recognise early warning signs or maintain fluid intake.

B. Persistent vertigo with associated focal neurological signs

Central vertigo is suggested by persistent (rather than brief positional) symptoms accompanied by focal neurological deficits such as dysarthria, diplopia, limb ataxia or new sensorimotor signs. The HINTS examination (head impulse, nystagmus, test-of-skew) further differentiates central from peripheral causes in acute vestibular syndrome, with a normal head impulse, direction-changing nystagmus or skew deviation raising concern for stroke.

D. Phacoemulsification with intraocular lens implantation

Gradual painless visual loss with glare, faded colour vision and a diminished red reflex in an elderly patient indicates lens opacification, and phacoemulsification with intraocular lens implantation is the standard definitive treatment as it removes the cataractous lens and replaces it with a clear prosthetic IOL. No pharmacological agent reverses lens protein cross-linking, so surgery is offered when the cataract impairs daily function.

B. Crusted (Norwegian) scabies

Crusted (Norwegian) scabies is the diagnosis, characterised by hyperkeratotic scaly plaques with a huge mite burden but paradoxically minimal pruritus due to a blunted cell-mediated immune response; it typically occurs in immunosuppressed, elderly or institutionalised patients, as here with long-term corticosteroid use. Combined topical permethrin and oral ivermectin with isolation is advised given high transmissibility.

D. Respect her refusal, keep engaging and, with her knowledge, involve adult social care

A person with capacity is entitled to make an unwise decision, and the Mental Capacity Act does not allow treatment or care to be imposed on her. That does not mean walking away: self-neglect with capacity is still a safeguarding matter under the Care Act, and the expected response is persistent, respectful engagement, building trust, offering the least restrictive support, regular review, and sharing information and raising a safeguarding concern with her knowledge (and normally her agreement) so that a multi-agency plan can be made. Neither the Mental Health Act nor DoLS applies: there is no mental disorder warranting detention, and DoLS can only authorise deprivation of liberty for someone who lacks capacity. Document the capacity assessment, her reasons and the offers made.

E. Raise a safeguarding concern with the local authority

A pressure ulcer down to bone, dehydration and unexplained weight loss in a dependent resident suggest neglect, and a cluster of similar admissions from one home points to organisational neglect, meaning poor care arising from the practices of an institution. Under the Care Act 2014 the local authority has the statutory duty to make enquiries when an adult with care and support needs is experiencing or at risk of abuse or neglect and cannot protect themselves, so the correct route is a safeguarding concern to the local authority safeguarding team, raised with the hospital safeguarding lead, which coordinates the response and brings in the Care Quality Commission, commissioners and where appropriate the police. Telling the manager or filing an internal incident report can be done in addition, but neither triggers the statutory enquiry. The patient's own views and, if she lacks capacity, her best interests remain central.

C. Raise a safeguarding concern with the local authority in his best interests, despite her objection

"Next of kin" has no legal authority in England and Wales: only a registered lasting power of attorney for health and welfare, a court-appointed deputy, or a best-interests decision by the responsible clinician under the Mental Capacity Act can act for a person who lacks capacity, and even an attorney cannot veto safeguarding when they are the suspected abuser. For an adult who lacks capacity and may be being abused, sharing information with the local authority safeguarding team is in his best interests and is expected under the Care Act; the daughter's objection is recorded but cannot block it, and as the alleged perpetrator she is not an appropriate person to consult about his best interests. The local authority instructs an independent mental capacity advocate where there is no one independent to support him. He must not be discharged back to the setting where the abuse occurred until a protection plan is in place.