Table 2.

Clinical case scenario presenting a rather common case in everyday practice according to the standard management without a “geriatric medicine insight” vs the geriatric medicine approach.

The Scenario	Standard Vision and Critical Management Points	The Geriatric Medicine’s Point of View
A male 82-year-old patient, living with his wife and autonomous regarding the basic daily activities of daily living, is admitted to a non-geriatric hospital ward with an altered level of consciousness and breathlessness. His wife, going back home from the usual visit to the grocery shop, called for help after finding him lying on the ground, conscious but unable to get up. His glasses are broken. He usually walks with a walking stick. His wife reports a moderate loss of appetite during the past few days, a generalized fatigue and weakness, slightly incoherent sayings and a breathlessness in effort. In the last 3 months he has had another two falls but managed to get up immediately.	There is probably an acute medical problem that explains this alteration in the physical state of this gentleman. It is not rare for an old person to stumble and fall for random reasons.	The patient already presents an initial status of possible frailty, at least at a physical level and maybe some signs of reduced autonomy: he uses a walking aid, is autonomous for the basic activities of daily living but it is his wife that does the shopping, he falls repeatedly. Frailty on the cognitive level may also be suspected by the acute cognitive decompensation due to the acute illness. Frailty renders him more prone to short- and long-term adverse outcomes in case of acute illness. The recent fall is a serious event, especially if unable to get up on his own. Questions rise about his nutritional and hydration state these last days.
His medical history includes arterial hypertension, dyslipidemia, chronic obstructive pulmonary disease (COPD), stage IIIa chronic kidney disease, chronic lumbar and knee aches, and an anxiety-depressive syndrome. His usual weight is 78 kilos for a height of 1.67 m (Body Mass Index, BMI 28kg/m2). His usual medical treatment includes a combination of inhaled corticosteroids and long-acting-beta-agonist, simvastatin, perindopril, amlodipine, alopurinol, aspirin, pantoprazole, escitalopram, paracetamol in case of pain, and oral corticoids in case of acute exacerbation of his COPD. His COVID-19, influenza, and pneumococcal vaccination are up to date.	The patient represents a rather common case of an older patient treated for multiple comorbidities. Since his BMI is >25kg/m2, he is considered being overweight. He is treated with medications for all of his comorbidities.	There is no clear indication for the use of alopurinol, aspirin, and pantoprazole. Escitalopram may raise the risk of falls, similarly to antihypertensive drugs in case of hypotension. Could pain have contributed to this risk of fall? Could he be suffering from sarcopenia (due to reduced physical activity, inadequate protein intake, corticosteroid treatment, statin muscle waste…)? Regardless of his BMI, what is his nutritional status?
On admission, the patient presents: confusion with time and space disorientation, diffuse wheezing and crackles at right base, symmetrically swollen ankles, moderate desaturation on air, and a temperature of 38.1 degrees. Blood pressure 105/60 mmHg, pulses 95/min. No serious traumatic injury following his fall, nor focal neurological deficit are observed. The laboratory analysis is characterized by an inflammatory syndrome. Tests for viral pulmonary infections are negative. His electrocardiogram is normal and his brain imaging without significant abnormality for the age.	No acute heart pathology or stroke are found. No traumatic consequence from the fall. Fall-related work up is checked completed. Diagnosis: probable pulmonary infection, acute COPD exacerbation, and possibly heart decompensation.	An acute condition, fever with respiratory tract infection, has decompensated a previous frail status and requires treatment. A rehabilitation plan needs to be elaborated from the beginning and in parallel with his acute condition treatment. A full fall work up needs to be performed as soon as possible. Multiple falls always need further investigation and corrective actions.
On the third day of hospitalization under antibiotic and corticosteroid treatment, oxygen therapy, bronchodilators, and diuretics, the patient develops an acute confusional state with agitation, aggressiveness, and opposition to treatment, requiring restraint. Clinical exam reveals no abnormal findings other than some crackles on the right pulmonary basis and signs of urinary retention. Blood testing reveals an improvement of the inflammatory syndrome, normal oxygen and CO2 levels, moderate hyperglycemia, and an elevation of creatinine and sodium levels. A bladder catheter is placed and a treatment with haloperidol IM and alprazolam is initiated. Physical restrain is prescribed on demand in case of significant agitation and opposition to treatments.	Older people frequently present acute psychiatric conditions while hospitalized. Could it be dementia? Physical restraint and pharmacological seduction are judged necessary for the patient’s safety and compliance to treatments.	Delirium is often mistaken for dementia, even though they frequently overlap. Urinary retention, corticosteroid therapy, electrolyte disorders, anticholinergic agents such as bronchodilators, and environmental factors such as transfer in an unfamiliar environment and sensory deficits (visual impairment) may trigger a delirium. Physical restraint often exacerbates agitation, especially when inappropriately administered. The risk of urinary retention would be lower if early mobilization had been achieved. First line treatment of delirium is non-pharmacological approaches and elimination of trigger factors. Currently, there is no good evidence showing whether or not benzodiazepines should be used for the treatment of delirium [139]. Even though the relatively short stay of the patient on the ground during his fall did not lead to significant muscle damage, oxygen therapy, bladder catheter, physical restraint, and a lack of systematic mobilization of the patient result in an excessive bedrest and in a deconditioning state of psychomotor and functional decline.
Progressive rehydration and improvement of the confusional state occurs after almost 5 days. During this time, neuroleptics are continued, and the patient presents a daytime somnolence, due to which he skips meals and visits of the physiotherapist. Physical restraint is applied in the daytime to limit the risk of fall. He feels very weak and with a low appetite. He now weighs 73.5 kilos.	Regarding physical restraint in the daytime, “it’s better being safe than sorry”, since the patient presents now an obvious risk of falling again. Weight lost is considered “beneficial” for the patient’s cardio-metabolic profile and his joint aches.	Nutritional support and mobilization need to be scheduled early and promptly implemented during the process of the acute disease management, along with the evaluation of swallowing problems, risk assessment, and prevention of pressure sores and of delirium. Loss of 4.5 kilos corresponds to more than 5% of the patient’s weight lost in less than a month, which already diagnoses a state of malnutrition in a person > 70 years old. Sedative medication should be discontinued as soon as possible.
The patient’s medical chart and blood tests improve progressively and, after 13 days of hospitalization, he is discharged in a wheelchair with a low salt and sugar diet, tamsulosin, furosemide, and lorazepam added to his prior medication list and advice for the care of a heel pressure sore.	Low salt is recommended as a non-pharmacological measure against hypertension, whereas a low sugar diet is recommended because corticoid-induced hyperglycemia and overweight are considered prodromal signs of diabetes. Three new drugs are added and maintained at discharge: Furosemide due to ankle oedema, tamsulosine under the hypothesis of a prostatic hypertrophy that contributed to the urinary retention and lorazepam because of sleeping problems and circadian rhythm inversion.	Extreme caution should be applied before recommending restrictive diets in frail older people. Risk of malnutrition, sarcopenia, and loss of autonomy usually outweigh anticipated benefits from dietary adaptations that aim at managing cardiovascular risk factors. Restrictive diets bear the risk of inadequate protein intake, which, on the other hand, is essential for recovery and pressure sore healing. It is suggested that older persons with acute and chronic diseases should have an intake of 1.2–1.5 g of protein per kilogram body weight [140]. Long term furosemide treatment is rarely required and the possibility of amlodipine contributing to ankle oedema should be considered. The indication of a tamsulosin treatment is not well documented and may cause hypotensive episodes, especially in association with multiple antihypertensive medication. Sleep hygiene interventions should be used as first line treatment of sleeping disorders. Benzodiazepines increase the risk of falling. Our patient now has several fall risk factors: multiple medication, frailty and probably sarcopenia, prior walking difficulties and fall history, visual deficit, and an aching heel pressure sore. A comprehensive rehabilitation and aid plan should be conducted before going back home, including physiotherapy for gait, balance and muscle strength, nutritional support, and adaptation of the supportive environment.
One month after discharge, the patient is operated under general anesthesia for a hip fracture after a new fall. According to his wife, the last month the patient presented more cognitive difficulties than usual, required aid in toileting and feeding, with occasional swallowing problems, dizziness, gait difficulties, and repeated falls. The patient is discharged from the orthopedics department to a nursing home in a worse state of confusion, bedridden with a bladder catheter and a with major weight loss (66 Kg).	A fall resulting in a hip fracture is an event that can lead to the institutionalization of an older patient	A succession of unfavorable outcomes in a patient presenting an underlying frailty resulted in a downward spiral that ended up in a loss of autonomy. Many of these outcomes were preventable or could have been managed in an earlier and more appropriate way, according to the approach and principles of Geriatric Medicine. Loss of autonomy could have been delayed or prevented.