🩺 Clinical Decision Support Tools

Evidence-based tools for geriatric care decisions

🧠 Delirium Risk Stratification

Age > 80 years Cognitive impairment Severe illness (APACHE > 16) Visual impairment Dehydration (BUN/Cr > 18) Infection present

💊 Polypharmacy Risk Assessment

Number of medications:

High-risk medications (Beers) Renal impairment Cognitive impairment Fall in past year

🏥 Admission vs Discharge Decision

Unstable vital signs O2 sat < 92% on room air New confusion/AMS Unable to ambulate baseline No caregiver at home Failed oral intake

💬 Code Status Discussion Guide

1. Assess understanding:
"What is your understanding of your current medical condition?"

2. Explore values:
"What's most important to you in your life?"

3. Discuss prognosis:
"Would you like to know what to expect?"

4. Present options:
"Let me explain what different levels of care mean..."

5. Make recommendation:
"Based on what you've told me, I recommend..."

🧩 Capacity Assessment Tool

Four Elements:

Understands relevant information Appreciates situation & consequences Can reason through options Can express a choice clearly

🦠 UTI Treatment Decision

Loeb Criteria — required for treatment

Acute dysuria (sufficient alone) Fever ≥38°C CVA tenderness (if fever present) New/increased frequency (if fever) New urgency (if fever) Suprapubic pain (if fever)

Indwelling catheter (CAUTI) ⚠️ Confusion/delirium only (no urogenital sx) Cognitive change from baseline

🦶 Falls Risk Assessment

Age > 80 Fall in past 12 months >4 medications Visual impairment Gait/balance problem Cognitive impairment Orthostatic hypotension Psychoactive medications

🏥 FRAIL Scale (Quick Frailty Screen)

Fatigue — Are you fatigued? Resistance — Can't climb 1 flight of stairs? Ambulation — Can't walk 1 block? Illness — >5 comorbidities? Loss of weight — >5% in past year?

🩹 Pressure Injury Risk (Braden)

Sensory Perception:

Moisture:

Activity:

Mobility:

Nutrition:

Friction/Shear:

⚡ Quick Reference Protocols

Hyponatremia Workup

1. Check volume status (orthostatics, JVP, edema)
2. Order: Serum osm, urine osm, urine Na
3. If euvolemic + urine osm >100: Consider SIADH
4. Fluid restrict if SIADH (500-1000ml/day)
5. Correct slowly: Max 8-10 mEq/L in 24h

Acute Confusion Protocol

1. ABCs, glucose, O2 sat
2. Review meds (anticholinergics, benzos, opioids)
3. Check: CBC, BMP, LFTs, TSH, UA, CXR
4. CAM assessment for delirium
5. Non-pharm: Orient, mobilize, sleep hygiene

Fall Assessment

1. Check for injury (head, hip, spine)
2. Orthostatic vitals
3. Review medications (>4 = high risk)
4. Gait assessment (TUG test)
5. Vision/hearing check

Constipation Management

1. R/O obstruction (KUB if concern)
2. Start: PEG 17g daily
3. Add: Senna 2 tabs QHS
4. If no BM x3 days: Bisacodyl supp
5. Severe: Consider lactulose or enema

Pain Management in Elderly

1. Assess: pain scale, location, timing
2. First line: Paracetamol 1g QID (max 3g if liver disease)
3. Topical NSAIDs for MSK (safer than oral)
4. Avoid oral NSAIDs if possible (GI, renal, cardiac)
5. Weak opioids: Tramadol 25mg (serotonin risk)
6. Strong opioids: start low, go slow (morphine 2.5mg)

Insomnia in Elderly

1. Sleep hygiene education (first line)
2. CBT-I (cognitive behavioral therapy)
3. Avoid: benzodiazepines, Z-drugs (Beers criteria)
4. Consider: low-dose trazodone 25-50mg
5. Melatonin 0.5-3mg (limited evidence)
6. Address: pain, nocturia, depression, medications

AKI in Elderly

1. Assess volume status (prerenal most common)
2. Stop nephrotoxins: NSAIDs, ACEi/ARB, aminoglycosides
3. Urinary catheter if obstruction suspected
4. IV fluids if prerenal (cautious in HF)
5. Renal ultrasound if no clear cause
6. Nephrology if: K+ >6, acidosis, oliguria, Cr rising

DVT Prophylaxis in Hospital

1. Assess VTE risk: Padua score ≥4 = high risk
2. Assess bleeding risk before anticoagulation
3. Mechanical: SCDs for all immobile patients
4. Pharmacological: enoxaparin 40mg SC daily
5. Reduce dose if CrCl <30: enoxaparin 20mg SC daily
6. Early mobilization is key prevention