Reasoning GP · Algorithm · 1-page summary
Acutely unwell older adult ("off legs")
For: older adults at home or in care homes who are "off legs", more confused or "not themselves". Not for: known dying patients with a plan (see Care of the dying); isolated falls (see the falls algorithm).
Core rule: new confusion or a fall in function is a red flag in older people — do full observations including respiratory rate and glucose, a 4AT, and a medicines review; never diagnose UTI on a dipstick at 65+.
0Stop — call 999 now (unless a ReSPECT plan or agreed decision says otherwise)
- Sepsis: new confusion, systolic ≤90 (or >40 below normal), HR >130, RR ≥25, SpO₂ <92%, mottled skin, no urine in 18 hours → 999. Fever may be absent.
- Stroke (FAST), suspected ACS (breathless, sweaty, collapse without chest pain), hip fracture or long lie, GI bleed → 999
- Hypoglycaemia not responding or unable to swallow; hyponatraemia with seizure → 999
1Triage — what changed, and how fast?
| Time course | Think |
|---|---|
| Hours | Stroke, sepsis, ACS, drug, hypoglycaemia |
| Days | Infection, AKI, sodium, retention, constipation |
| Weeks | Subdural, cancer, heart failure, depression |
Get the carer's account of baseline. Score the Clinical Frailty Scale on function 2 weeks ago; 4AT ≥4 suggests delirium.
2Screen — serious causes
- AKI stage 2–3 or K⁺ ≥6.0 with AKI → Same-day hospital.
- Sodium <125 with symptoms → Same-day hospital.
- Head injury on an anticoagulant → Same-day CT via the emergency department.
- Retention (palpable bladder) → catheterise; Same-day if not possible in the community.
- Delirium with no cause or unsafe at home → Same-day hospital.
- Safeguarding — unexplained injury, neglect → Same-day referral if at risk.
3Assess
☐ Full obs incl. RR, SpO₂, glucose, lying/standing BP ☐ 4AT ☐ Chest, abdomen, bladder, hips, skin, neurology ☐ ECG ☐ FBC, U&E, CRP, calcium, LFTs, CK if long lie ☐ MSU before antibiotics if urinary symptoms
No urine dipstick for UTI at 65+ (UKHSA). Do not delay transfer for tests.
4Classify — often more than one cause
- Infection — pneumonia (commonest serious), true UTI, cellulitis, pressure sore.
- Medicines — anticholinergics, opioids, sedatives, hypotensives, hypoglycaemics.
- Metabolic — dehydration/AKI, sodium, calcium, glucose.
- Bladder/bowel — retention, constipation, impaction.
- Injury — fracture, rhabdomyolysis, subdural.
- Uncertain — treat what you find, same-day review, reassess within 24 hours.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Wishes first: find or start ReSPECT/advance care plan; capacity, LPA, best interests.
- Medicines: stop sedatives and anticholinergics; sick-day holds if dehydrated; reduce sulfonylurea/insulin if not eating; never stop Parkinson's drugs abruptly.
- Delirium: treat the cause; hydration, glasses, hearing aids, familiar faces; avoid sedatives.
- Dying recognised: anticipatory medicines, DNACPR, preferred place.
6Where to care and review
- Urgent community response (within 2 hours) — falls without serious injury, mild infection, carer crisis.
- Hospital at home / virtual ward — needs daily review or IV therapy at home.
- Later: falls service (NG249), memory service after delirium, medication review.
7Never reassure by
- A normal temperature — older people may be afebrile or hypothermic.
- A positive urine dipstick — it is not a UTI diagnosis at 65+.
- "It's just their dementia" — new confusion is delirium until proven otherwise.
- No chest pain — ACS is often silent.
- A quiet, sleepy patient — hypoactive delirium.
- Missing the respiratory rate.
8Safety-net — say it to the carer, then document it
999 “Very drowsy or hard to wake, breathing fast, blotchy or blue skin, no urine all day, weakness of the face or arm, or chest pain — call 999.” Same-day “More confused, not drinking, or can't get up — call us or 111 the same day.”
Review within 24 hours if at home; share the escalation plan with OOH and ambulance. Remote consultation with any 999 feature → convert to a 999 call.
✓Safe to stay at home only if — all five, documented
No block 0–2 feature (or plan agreed)
Full obs, glucose and 4AT recorded
Medicines reviewed; cause treated
Carer coping; ReSPECT discussed
24-hour review booked; safety-net given
Summary of the full Reasoning GP unwell older adult algorithm, which holds the history, differential, investigations, recovery and evidence. Sources: NICE NG253 (sepsis, 2025), CG103 (delirium), NG249 (falls), NG232 (head injury), CG124, NG148; UKHSA UTI quick reference; NEWS2; Clinical Frailty Scale; ReSPECT; NHS England urgent community response. Clinical reference — follow local urgent care pathways and check doses: NICE/SPC, BNF.