1 Functional impairment

Impaired function, as determined by inability to perform basic

activities of daily living (ADLs) and instrumental ADLs
(IADLs), is a sign of deterioration in many health conditions
in older patients. ADLs include the basic functions of bathing,
dressing, getting to the bathroom, transferring out of bed or
chair, remaining continent and feeding oneself. IADLs include
more advanced functions that enable a person to live independently:
preparing meals, shopping, taking medications,
managing finances, using a telephone, driving or using public
transportation.
Action: Search for an underlying disease that may be contributing,
such as a stroke, heart failure, pulmonary disease,
dementing illness or infection.
2 Heart failure
Instead of dyspnoea, dry cough may be the presenting complaint
of heart failure in older patients. Because of sedentary
lifestyles, many older patients with heart failure do not
experience progressive exertional dyspnoea. Furthermore,
orthopnoea and paroxysmal nocturnal dyspnoea may not
occur because of compensatory pulmonary vasculature changes
and the common practice of older persons to sleep in a chair or
recliner, rather than supine. Fatigue is also common. Diuretics
may relieve symptoms.
Action: Examine for ankle swelling and listen for added heart
sounds and chest crackles. Arrange echocardiogram, and refer

to specialist services.
3 Cardiovascular syncope
While most falls in older people do not cause serious injury,
1020% of them do, and falls often reflect an important acute or
chronic systemic problem that needs to be elucidated. Unwitnessed
falls, not due to trips or slips, in older persons who are