AKT – Older persons’ health (Geriatrics)

Robert Jenkins, aged 83, presents to your clinic after a fall at home. He was getting up at night to urinate when he lost balance and fell backward. He did not lose consciousness and denies chest pain or palpitations. His only injury is a minor occipital scalp abrasion. He reports getting up 2–3 times most nights to void.

Medications: Perindopril 5mg daily, Tamsulosin 400mcg daily. PMH: Hypertension, BPH. No prior falls. Lives alone. No recent changes in vision, footwear, or environment.

On examination: HR 72 regular, BP 132/78 lying, 104/66 standing. Gait is slow but steady. MMSE is 29/30.

What is the MOST appropriate next step in managing Robert’s falls risk?

Margaret Yeo, aged 75, presents with progressive forgetfulness over the past 12 months. She repeats questions, misplaces items, and recently got lost walking to a nearby shop. Her daughter is concerned about her safety and ability to manage finances.

Medications: Atorvastatin, Metformin. PMH: Type 2 diabetes, dyslipidaemia. No alcohol. Lives with her daughter.

On examination: MMSE 24/30. Gait normal. No focal neurology. Recent HbA1c 7.2%, B12 and TSH normal.

What is the MOST appropriate next step?

George Malcolm, aged 79, is brought in by his wife due to concerns about new urinary incontinence over the past 3 weeks. He has had increasing urgency and occasional dribbling. No dysuria or haematuria. He denies nocturia. Appetite and weight stable.

Medications: Amlodipine, Aspirin, Tamsulosin (started 2 months ago). PMH: Hypertension, BPH. No prior prostate surgery.

On examination: Abdomen soft, no palpable bladder. DRE: smooth enlarged prostate, non-tender. Urinalysis: Negative. Bladder scan: PVR 220mL.

What is the MOST appropriate management?

Elaine Brooks, aged 86, is seen in the clinic by her son’s request. She has become more withdrawn over the last two months and has lost interest in gardening and TV. Appetite reduced. No suicidal ideation. No complaints of pain. No acute stressors.

Medications: Ramipril, Amlodipine, Calcium + vitamin D. PMH: Hypertension, osteoporosis. Lives in aged care facility. No history of depression.

On examination: Flat affect, minimal spontaneous speech. Weight has decreased by 4kg in 2 months. Cognition: MMSE 27/30.

What is the MOST appropriate initial management?

Thomas Delaney, aged 91, presents with increasing drowsiness and confusion over the past 2 days. He lives in residential care and has a background of moderate Alzheimer’s disease. No recent illness. He is now sleeping through most of the day and eating very little.

Medications: Donepezil, Furosemide, Paracetamol PRN. PMH: CHF, dementia, CKD stage 3. Last bloods 4 months ago.

On examination: Drowsy but rousable, BP 100/66, HR 88, afebrile, chest clear. No focal neurology. Urinalysis shows leukocytes and nitrites.

What is the MOST appropriate next step?

Barbara Lacey, aged 82, is brought in by her daughter who reports she has become more forgetful and sometimes seems confused about the time of day. She recently left the stove on unattended. Her daughter is concerned about her driving. Barbara insists she drives only short distances and is ‘very careful’.

PMH: Mild cognitive impairment, osteoarthritis, hyperlipidaemia. Medications: Rosuvastatin, Paracetamol PRN.

On MMSE today: 25/30. MOCA: 21/30. No recent accidents or tickets. Visual and auditory exams are normal.

What is the MOST appropriate next step regarding her fitness to drive?

Frank Keating, aged 88, is seen in a residential aged care facility after staff report he has become more agitated and aggressive towards other residents. He has advanced dementia and is largely non-verbal. He is not on psychotropic medications. His sleep has been poor and he’s had occasional nocturnal wandering.

Medications: Donepezil, Aspirin, Lactulose. PMH: Alzheimer’s disease, chronic constipation, IHD.

On examination: He appears distressed, clenches jaw intermittently. Abdomen soft but moderately distended. PR: hard stool palpable.

What is the MOST likely cause of Frank’s agitation?

Joyce Dutton, aged 72, presents for a routine check-up. She has no specific complaints but mentions occasional stiffness in the morning and some difficulty opening jars. She remains independent and mobile. She does not take any regular medications.

On examination: Mild Heberden’s nodes bilaterally. Normal gait and no joint swelling. Hand grip slightly reduced. BP 136/82, HR 76.

What is the MOST appropriate initial management?

Walter Skinner, aged 87, presents with ongoing fatigue and unintentional weight loss of 6kg over the past 4 months. He denies gastrointestinal or urinary symptoms. No fevers or night sweats. Appetite is modest. Lives alone but receives meals on wheels. No cognitive concerns.

PMH: Hypertension, CKD stage 3. Medications: Perindopril, Atenolol.

On examination: Mild pallor, BMI 20, no lymphadenopathy. Abdominal exam NAD. No focal neurology. FOBT pending. Bloods: Hb 98g/L, MCV 75fL, ferritin 12, CRP normal.

What is the MOST appropriate next step?

Helen O’Grady, aged 79, presents with difficulty sleeping for the past 3 months. She describes waking frequently and struggling to return to sleep. She denies low mood, snoring, restless legs or alcohol use. She enjoys gardening and volunteers weekly at a local op shop.

PMH: GERD, hyperlipidaemia. Medications: Esomeprazole, Atorvastatin.

On examination: Vitals stable, BMI 24. No signs of mood disorder. Reports taking naps during the day. Reports using her phone in bed for reading.

What is the MOST appropriate management strategy?

Alfred Nguyen, aged 76, presents for a review of his osteoporosis. He was diagnosed two years ago after a low-trauma wrist fracture. He has been taking alendronate weekly since then. Recent DEXA shows no significant change in BMD. He has had no new fractures and reports good adherence.

PMH: Hypertension, osteoarthritis. Medications: Alendronate, Perindopril. Lifestyle: Ex-smoker, drinks 1–2 beers daily, walks daily.

What is the MOST appropriate management regarding his osteoporosis?

Rita Collis, aged 81, has been brought in by her niece after experiencing several near-misses while cooking. She recently left the gas stove on without lighting it and burned a pan of food. She lives alone, is fiercely independent and denies any issues. MMSE is 27/30, with deficits in recall and executive function.

PMH: Mild cognitive impairment, GERD. Medications: Esomeprazole.

What is the MOST appropriate next step in management?

Trevor Wallace, aged 85, presents with worsening leg swelling and dyspnoea over the past week. He has a background of congestive cardiac failure and chronic kidney disease. He has been feeling more tired and his weight has increased by 3kg.

Medications: Frusemide, Bisoprolol, Perindopril, Atorvastatin. On exam: Bibasal crackles, pitting oedema to knees, JVP raised.

Recent bloods: Creatinine 172 (baseline 145), eGFR 32, K+ 4.8.

What is the MOST appropriate next step?

Dorothy Svenson, aged 84, presents with worsening vision over the past year. She reports difficulty recognising faces and trouble reading despite new glasses. No eye pain or photophobia. PMH: Hypertension, osteoarthritis. Medications: Perindopril, Paracetamol.

On exam: Visual acuity 6/36 both eyes. Fundoscopy shows drusen at the macula, no haemorrhage.

What is the MOST likely diagnosis?

James Faulkner, aged 80, presents for review of chronic low back pain. He describes stiffness and dull ache in the mornings, improved by movement. He uses paracetamol regularly. He has no red flag features. He has seen a physiotherapist but is seeking more pain relief.

PMH: Osteoarthritis, hypertension. Medications: Perindopril, Paracetamol.

What is the MOST appropriate next step in management?

Norma Farrow, aged 90, is brought in by her daughter who is concerned about recent weight loss and reduced appetite. Norma is in a nursing home and has dementia. She has refused several meals and only takes sips of fluids. She is not distressed and appears peaceful.

PMH: Advanced Alzheimer’s disease, hypertension. Medications: Perindopril, Paracetamol.

On exam: Thin, frail, BP 102/64, HR 68, afebrile. No acute findings.

What is the MOST appropriate approach?

Stanley O’Mara, aged 74, presents with a 3-month history of a tremor in his right hand. It is worse at rest and improves with movement. He has also noticed reduced arm swing on walking. He denies any cognitive symptoms or falls. No family history of neurological disease.

On examination: Resting tremor in right hand, cogwheel rigidity, bradykinesia, normal gait with reduced right arm swing.

What is the MOST likely diagnosis?

Patricia Leong, aged 77, presents to discuss her recent hospital discharge after a hip fracture. She had a left-sided neck of femur fracture and underwent hemiarthroplasty. She is now home with support and mobilising with a frame.

She asks what can be done to prevent another fracture. She was not previously diagnosed with osteoporosis.

PMH: Hypertension, dyslipidaemia. Medications: Atorvastatin, Perindopril.

What is the MOST appropriate management now?

Malcolm Reid, aged 78, is brought in by his daughter who is concerned about his driving. He was recently involved in a minor car accident where he reversed into a post. He has mild cognitive impairment but remains physically independent. He insists he is safe to drive.

On cognitive testing: MMSE 26/30. No focal neurological deficits. Visual acuity and reaction times normal.

What is the MOST appropriate next step?

Irene Boon, aged 85, is seen for follow-up after a hospitalisation for acute delirium secondary to a UTI. She is now back at her residential care home and medically stable. Her daughter notes Irene is still ‘not quite herself’, more forgetful and less interactive than before.

PMH: Mild dementia, hypertension, OA. Medications: Perindopril, Paracetamol.

What is the MOST likely explanation for her current cognitive state?

Geoffrey Wallace, aged 86, presents for review of his antihypertensive medication. His home BP readings have been averaging 105/64, with occasional light-headedness on standing. He takes multiple medications and lives independently. No falls reported.

Medications: Perindopril, Amlodipine, Hydrochlorothiazide, Atorvastatin, Metformin.

On exam: BP 104/66 lying, 92/60 standing. HR 72. ECG: normal sinus rhythm.

What is the MOST appropriate next step?

Florence Mikhail, aged 92, presents with new-onset constipation and abdominal bloating over the past week. She has no nausea or vomiting. Bowels normally regular. Appetite reduced. No fever or weight loss. No recent travel or dietary change.

PMH: Dementia, osteoarthritis, hypothyroidism. Medications: Paracetamol, Codeine, Thyroxine.

On exam: Abdomen mildly distended but soft, bowel sounds present. PR: hard stool in rectum. No peritonism.

What is the MOST appropriate management?

Leonard Chan, aged 80, presents with a persistent dry cough and fatigue over the last 3 months. He is a non-smoker. No chest pain or haemoptysis. Appetite normal. No recent travel. He had a COVID-19 infection 5 months ago, managed at home.

PMH: Hypertension, Type 2 diabetes. Medications: Perindopril, Metformin.

On exam: Chest clear. CXR: unremarkable. HbA1c 7.1%. No peripheral oedema. O2 sat 97% RA.

What is the MOST likely cause of his symptoms?

Hazel D’Souza, aged 89, is seen for follow-up after a recent hospitalisation for pneumonia. She has now returned to her residential aged care facility. Staff report she is more deconditioned, has poor oral intake, and becomes breathless with minimal activity.

PMH: COPD, IHD, dementia. Medications: Salbutamol, Aspirin, Donepezil.

On exam: HR 96, RR 22, SpO2 91% on room air, BMI 18.5. She is alert but easily fatigued. No signs of acute infection.

What is the MOST appropriate next step in her care?

Douglas Frey, aged 88, presents with a painful left knee. He has a history of severe osteoarthritis and is now struggling with mobility. He has previously trialled paracetamol and topical NSAIDs with limited benefit. He has declined surgery in the past. He is keen to try an injection.

PMH: Osteoarthritis, hypertension. Medications: Perindopril, Paracetamol.

On exam: Left knee swollen, crepitus, reduced ROM. No redness or warmth.

What is the MOST appropriate next step?

Maureen Styles, aged 84, presents with frequent urinary tract infections. She has had four confirmed UTIs over the past six months, treated with short courses of antibiotics. She lives independently and is sexually inactive. She uses incontinence pads and drinks 1L water daily.

PMH: Hypertension, osteoarthritis. Medications: Perindopril, Paracetamol.

What is the MOST appropriate next step in management?

Ian Rutherford, aged 87, presents after a fall in the garden. He tripped on a hose and fell forward, sustaining minor abrasions. No loss of consciousness. He walks daily, lives alone, and is independent with ADLs. His daughter is concerned about his safety.

PMH: Hypertension, mild cognitive impairment. Medications: Perindopril, Aspirin.

What is the MOST appropriate next step?

Nancy Berg, aged 79, presents with recent drowsiness and unsteadiness. She was started on amitriptyline 25mg nocte for neuropathic pain two weeks ago. Her husband reports she is more lethargic and has had two near-falls.

PMH: Diabetic neuropathy, hypertension, glaucoma. Medications: Metformin, Perindopril, Amitriptyline.

On exam: BP 118/68, HR 68, normal gait. No focal signs. MMSE 28/30.

What is the MOST appropriate next step?

Louisa Tran, aged 76, presents with difficulty swallowing solids and recent unintentional weight loss of 4kg over 3 months. She denies pain but describes a sensation of food ‘getting stuck’. No odynophagia, reflux or nausea. No smoking history.

PMH: Hypertension, osteopenia. Medications: Alendronate, Amlodipine.

On exam: BMI 20, no palpable masses or lymphadenopathy. Oral cavity normal.

What is the MOST appropriate next step?

Ronald Baker, aged 91, is brought in by his wife who reports he has become increasingly sleepy and occasionally confused since starting a new medication. He was recently prescribed oxybutynin for urinary urgency.

PMH: BPH, hypertension, mild dementia. Medications: Perindopril, Aspirin, Oxybutynin.

On exam: Drowsy but rousable, vitals stable. MMSE decreased from previous 25/30 to 20/30.

What is the MOST likely cause of his presentation?

Hilda Francis, aged 94, is brought to the clinic by her carer, who reports increased drowsiness and a dry mouth. Hilda has end-stage COPD and moderate dementia. Her carer thinks she may be nearing the end of life. She is on comfort care only.

Medications: Morphine PRN, Atrovent inhaler, Mirtazapine. Fluids are sips only. Observations: HR 92, RR 10, SpO2 88% RA, BP 88/60.

What is the MOST appropriate next step?

Arthur Gale, aged 75, is concerned about recent hearing loss, mainly in noisy environments. He struggles to follow conversations in group settings. No tinnitus or vertigo. He has no history of noise exposure or ototoxic medications.

PMH: T2DM, hypertension. Medications: Metformin, Ramipril.

On exam: Normal otoscopy. Whispered voice test reduced bilaterally. Rinne positive both sides, Weber central.

What is the MOST likely diagnosis?

Olga Petrova, aged 88, presents with persistent bruising on her arms and legs. She is not on anticoagulants. She denies trauma, alcohol use, or new medications. There is no bleeding from gums or other sites.

PMH: Hypertension, osteoarthritis. Medications: Amlodipine, Paracetamol.

On exam: Multiple ecchymoses, mainly over forearms and shins. No petechiae. BP 140/82. Normal systemic exam. FBE: Hb 118, Plt 210, WCC normal.

What is the MOST likely diagnosis?

Clive Rowe, aged 80, presents with poor sleep, fatigue and difficulty concentrating. His wife died 2 months ago. He reports feeling numb and occasionally tearful but is eating and functioning independently. He denies suicidal thoughts.

PMH: Hypercholesterolaemia. Medications: Atorvastatin.

On exam: Affect is flat. He agrees support from friends has helped but says mornings are hard. GDS score is 4/15.

What is the MOST appropriate next step?

Janet Locke, aged 82, presents with worsening lower leg swelling over several weeks. She denies dyspnoea, chest pain, or recent travel. No new medications. She has visible varicosities and reports the swelling worsens as the day progresses.

PMH: Osteoarthritis. Medications: Paracetamol.

On exam: Bilateral pitting oedema to knees, no tenderness. Pulses intact. No JVP elevation. No proteinuria. D-dimer not indicated.

What is the MOST likely cause of her symptoms?

Betty Holman, aged 86, presents with increased confusion and restlessness over the last 24 hours. She has dementia and lives in a nursing home. She was recently commenced on oxybutynin for urinary urgency. Her fluid intake has been poor due to hot weather.

On examination: Disoriented, dry mucous membranes, HR 106, BP 92/60, temp 37.4°C.

What is the MOST likely cause of her presentation?

Gordon McRae, aged 84, presents with difficulty initiating sleep. He goes to bed at 9pm but often lies awake for hours. He naps for 2 hours in the afternoon and watches TV in bed at night. He denies pain or mood disturbance.

PMH: Hypertension, glaucoma. Medications: Amlodipine, Latanoprost.

What is the MOST appropriate initial management strategy?

June Little, aged 90, presents with worsening balance and several near-falls. She uses a walking stick. She has noticed her legs feel ‘heavier’ and she walks more slowly. No vertigo. No recent illness. She lives in a retirement village independently.

PMH: T2DM, hypertension. Medications: Metformin, Perindopril.

On exam: Wide-based gait, diminished vibration sense in feet, Romberg positive. No cerebellar signs.

What is the MOST likely cause?

Stanley Bright, aged 77, presents with difficulty reading and increased glare while driving at night. He has no eye pain or discharge. Vision has gradually worsened over 12 months. No significant PMH. No smoking history.

On examination: Visual acuity 6/18 bilaterally, red reflex reduced, lens opacities visible.

What is the MOST likely diagnosis?

Wilma Greene, aged 88, is seen for her annual review. She reports no acute complaints but has noticed mild forgetfulness and struggles with finding words. She is fully independent in daily activities and manages her own finances.

PMH: Hypertension, osteoarthritis. Medications: Perindopril, Paracetamol.

On examination: MOCA score 24/30. MMSE 28/30. No mood symptoms.

What is the MOST likely diagnosis?

Gloria Tang, aged 79, presents with a 3-month history of progressive low mood, poor sleep, and reduced appetite. She lost her husband 6 months ago. She feels life is now ‘pointless’, and she has little interest in activities. She denies suicidal thoughts but is socially withdrawn.

PMH: Hypertension, hypothyroidism (TSH normal). Medications: Amlodipine, Thyroxine.

On exam: Tearful affect, slow speech, minimal eye contact. GDS score 9/15.

What is the MOST appropriate next step?

Eric Pollard, aged 85, is brought in by his wife due to multiple minor burns on his arms and confusion while cooking. He insists he is fine and enjoys being independent. He has mild cognitive impairment and no formal supports in place. MMSE today is 24/30.

PMH: Osteoarthritis, dyslipidaemia. Medications: Atorvastatin, Paracetamol.

What is the MOST appropriate next step?

Dawn Barrett, aged 90, is seen in residential aged care for ongoing constipation. She has a soft diet and minimal mobility. PR exam reveals hard stool in the rectum. She has previously responded to regular coloxyl with senna but is now more impacted.

PMH: Dementia, IHD. Medications: Aspirin, Donepezil, PRN oxycodone.

What is the MOST appropriate next step?

Trevor Munro, aged 87, presents with tremor and shuffling gait. His daughter reports he is increasingly slow and rigid in movement. He also struggles with buttoning his shirt and rising from chairs. There is no history of stroke or recent medication changes.

On examination: Resting tremor, cogwheel rigidity, and bradykinesia. Gait slow with reduced arm swing. Cognition intact.

What is the MOST appropriate next step?

Milton Zhang, aged 93, is seen during a routine RACF review. He has advanced dementia, is bedbound, and eats very little. Staff ask whether annual influenza vaccination is still required, given his condition.

PMH: Alzheimer’s disease, stroke, T2DM. Medications: Paracetamol, insulin, aspirin.

What is the MOST appropriate response?

Norman Delbridge, aged 78, presents with shortness of breath on exertion and generalised fatigue. He reports waking up at night short of breath. No cough, orthopnoea or chest pain. PMH includes hypertension and T2DM. He is a former smoker.

On exam: HR 84, BP 134/76, bibasal crackles, mild ankle oedema. CXR: cardiomegaly. ECG: sinus rhythm.

What is the MOST likely diagnosis?

Joyce Ng, aged 81, presents with recurrent falls. She recently fell while turning in the hallway. She denies LOC, reports dizziness on standing. No chest pain or palpitations. She takes several regular medications.

Medications: Metoprolol, Perindopril, Sertraline, Tamsulosin.

On exam: BP 130/78 lying, 98/62 standing. HR 72. Cardiac and neuro exams unremarkable.

What is the MOST likely contributor to her falls?

Frederick Lowe, aged 89, is reviewed after a hospital discharge for a lower respiratory tract infection. His mobility has declined, and he now needs help with dressing and toileting. He is at risk of pressure sores and has lost 3kg in hospital.

PMH: COPD, osteoarthritis. Medications: Salbutamol, Paracetamol.

What is the MOST appropriate next step?

Elizabeth Chow, aged 76, presents with weight gain, fatigue, and cold intolerance. She has a history of hypothyroidism but has not had bloods checked in 18 months. She takes thyroxine 50mcg daily.

On exam: Dry skin, bradycardia (HR 56), weight +4kg since last visit, BP 138/76.

What is the MOST appropriate next step?

Harold Yates, aged 84, presents with progressive memory decline. He is still independent in basic ADLs but requires help with finances and managing medications. His MOCA is 20/30. He is aware of his symptoms and appears anxious about the future.

PMH: Hypertension. Medications: Perindopril.

What is the MOST appropriate next step?