Acutely Unwell Older Adult Algorithm

Safety

Red flags — the emergencies that present as 'off legs'

Done

Sepsis Suspected infection with any high-risk feature — new confusion or drowsiness, systolic BP ≤90 mmHg (or >40 below their normal), heart rate >130, respiratory rate ≥25, SpO₂ <92% on air (or a new oxygen need), mottled or ashen skin, non-blanching rash, no urine in 18 hours → 999 (NICE NG253). Older adults may have no fever, or may be hypothermic.

Stroke Sudden face, arm or leg weakness, speech or visual disturbance, new unsteadiness → 999 (FAST). Do not attribute sudden weakness to "general frailty".

Silent acute coronary syndrome New breathlessness, collapse, sweating, nausea, epigastric discomfort or sudden fatigue without chest pain — common in older people and diabetes → ECG; suspected ACS → 999.

Hip fracture or long lie Fall with inability to weight-bear, shortened externally rotated leg, or on the floor for more than an hour → 999 (pressure damage, rhabdomyolysis, AKI, hypothermia). Head injury on an anticoagulant → same-day CT head via the emergency department (NICE NG232).

Hypoglycaemia On insulin or a sulfonylurea and drowsy, sweaty or confused → capillary glucose now; <4 mmol/L → treat; unable to swallow or not recovering → 999.

Other emergencies GI bleed (melaena, haematemesis), acute abdomen (ischaemic bowel, perforation — pain may be mild), bowel obstruction, hypothermia, hyponatraemia with sodium <125 mmol/L and symptoms, AKI stage 2–3 or potassium ≥6.0 mmol/L with AKI → same-day hospital; 999 if unstable, or if hyponatraemia causes a seizure or reduced consciousness.

"Off legs", "gone off", "more confused" and "not themselves" are the commonest ways serious illness presents in frail older people. The physiology is blunted — fever and tachycardia may be absent, and pain from a myocardial infarction or perforated viscus may be minimal — so new confusion and a fall in function carry the weight that fever and pain carry in younger adults. NICE NG253 (2025), which replaced NG51 for people aged 16 or over, lists new altered mental state among the high-risk features of sepsis. A good escalation decision starts from the patient's wishes (see step 7), but a reversible emergency should never be missed for want of looking.

Diagnose

History — from the patient, the carer and the records

Done

What has changed, and when

Ask the carer or family: usual function (mobility, continence, cognition, eating), what is different now, and over what time — hours (vascular, sepsis, drugs), days (infection, metabolic, retention, constipation) or weeks (cancer, depression, subdural, heart failure). Collateral history is essential.

Delirium screen

Acute onset, fluctuating attention, drowsiness or agitation, new hallucinations — use the 4AT (score ≥4 suggests delirium). Hypoactive delirium (quiet, sleepy, not eating) is the commonest and the most missed. Pre-existing dementia raises the risk.

Infection

Cough, breathlessness, new incontinence or urinary symptoms (dysuria, frequency, suprapubic pain — not just smelly or cloudy urine), skin wounds, cellulitis, pressure sores, diarrhoea, recent hospital stay.

Falls

Any falls or near-falls, time on the floor, head injury, anticoagulant, pain on weight-bearing. See the falls algorithm.

Medicines — new, changed, stopped

Opioids, benzodiazepines, Z-drugs, anticholinergics (oxybutynin, amitriptyline, chlorphenamine, older antihistamines), antipsychotics, antihypertensives and diuretics (postural hypotension, AKI, hyponatraemia), SSRIs (hyponatraemia), insulin or sulfonylureas, digoxin, lithium, antibiotics, steroids; missed Parkinson's medicines; alcohol or benzodiazepine withdrawal. Check what is actually being taken (blister pack, dosette).

Bowel and bladder

Constipation, overflow, urinary retention (anticholinergics, opioids, prostate), new incontinence.

Intake

Eating and drinking, vomiting, diarrhoea, weight loss, swallowing problems.

Context and wishes

Living situation, carers, care home, frailty, existing advance care plan or ReSPECT form, lasting power of attorney for health, DNACPR, preferred place of care.

Safeguarding

Unexplained injuries, neglect, self-neglect, carer strain or exhaustion.

In the acutely unwell older adult the carer's account is the history: only they know what "normal" was and how fast it changed. The time course points to cause — sudden change suggests vascular or drug causes, days suggest infection, metabolic disturbance or retention, and weeks suggest a slower process such as a subdural haematoma, malignancy or depression. Medicines are the commonest reversible cause, particularly anticholinergic load and anything new. Hypoactive delirium is easily mistaken for tiredness or depression, so a formal tool such as the 4AT is used rather than impression.

Diagnose

Examination — observations first

Done

Full observations

Temperature, pulse (rate and rhythm), BP lying and standing if safe, respiratory rate, SpO₂, capillary glucose, conscious level (ACVPU). Compare with their usual readings. A NEWS2 score supports communication with hospital teams but does not replace judgement.

Cognition

4AT; attention (months of the year backwards); compare with known baseline.

Hydration

Mucous membranes, skin turgor (unreliable), postural drop, urine output, weight.

Chest and heart

Crackles, bronchial breathing, effusion, new murmur, heart failure signs, irregular pulse.

Abdomen

Palpable bladder (retention), tenderness, distension, bowel sounds, hernias; PR for faecal loading if constipation suspected.

Neurology

Focal weakness, speech, gait, pupils, neck stiffness; Parkinsonism; signs of head injury.

Musculoskeletal and skin

Hips (rotation, weight-bearing), pain on movement, pressure areas, cellulitis, wounds, bruising (falls or abuse), feet.

Frailty

Rate the Clinical Frailty Scale based on function 2 weeks before this illness, not on how they look today.

A full set of observations including respiratory rate, glucose and a postural BP finds most of the emergencies. Respiratory rate is the most sensitive early sign of deterioration and is the observation most often omitted. Examination then hunts systematically for the hidden causes — a full bladder, faecal loading, a fractured hip, a pressure sore or a quiet pneumonia. The Clinical Frailty Scale is scored on the baseline before the acute illness, because that predicts outcome and informs the escalation conversation.

Diagnose

Investigations — what helps today

Done

At the bedside

Capillary glucose; ECG (arrhythmia, ischaemia, hyperkalaemia); bladder scan if available; urine dipstick only if under 65 and not catheterised — do not use urine dipsticks to diagnose UTI in people aged 65 or over (UKHSA), because asymptomatic bacteriuria is common.

Bloods (urgent if staying at home)

FBC, U&E (AKI, sodium, potassium — see the raised creatinine and hyponatraemia algorithms), CRP, LFTs, calcium, glucose/HbA1c, TFTs, CK if long lie (rhabdomyolysis), B12/folate if delirium; drug levels where relevant (digoxin, lithium).

Urine culture

Send an MSU (or catheter sample from a new catheter) before antibiotics if urinary symptoms or new delirium with no other source.

Imaging

Chest X-ray if pneumonia suspected and staying at home (do not delay treatment); hip X-ray via the emergency department if fracture suspected; CT head via hospital if head injury on anticoagulants, new focal signs or suspected subdural.

Do not

Delay transfer for tests when a 999 feature is present; treat a positive dipstick in an older person without symptoms.

Investigations are chosen to answer a decision: can this person be safely managed at home? Glucose, ECG and urgent bloods (sodium, potassium, creatinine, calcium, CRP) find the common metabolic causes. UKHSA advises against urine dipsticks for diagnosing UTI in people aged 65 or over because a third or more of older women and many older men have bacteria in their urine without infection, and "positive dipstick" diagnoses lead to missed pneumonia, unnecessary antibiotics and C. difficile.

Diagnose

Differential — find the cause (often more than one)

Done

Infection

Pneumonia (commonest serious), UTI (only with genuine urinary symptoms or no other source), cellulitis, infected pressure sore, biliary sepsis, COVID-19 or influenza, C. difficile.

Delirium

A syndrome, not a diagnosis — look for its cause; consider dementia, depression and hypoactive delirium. See the confusion algorithm.

Medicines

Anticholinergic burden, opioids, sedatives, hypotensives (postural hypotension), hypoglycaemic agents, drug-induced hyponatraemia, digoxin or lithium toxicity, missed Parkinson's medicines.

Metabolic

Dehydration and AKI, hyponatraemia, hypercalcaemia (cancer, myeloma), hypo- or hyperglycaemia (HHS), hypothyroidism.

Bladder and bowel

Urinary retention, constipation and faecal impaction — both can cause delirium and "off legs".

Falls and injury

Hip or pubic ramus fracture, vertebral fracture, rhabdomyolysis after a long lie, subdural haematoma (weeks after a minor head injury).

Cardiovascular and neurological

Silent MI, arrhythmia (AF), heart failure, stroke or TIA, PE, Parkinson's progression.

Other

New or progressing cancer, depression, alcohol, hypothermia, pain, elder abuse or neglect, carer breakdown.

Approaching end of life

Progressive decline over weeks in advanced frailty, dementia or organ failure, with no reversible cause — recognise dying and plan.

Uncertain

Treat the reversible causes you can find, arrange same-day review (urgent community response or same-day hospital), and reassess within 24 hours.

Frail older people rarely have one problem: a mild chest infection, a new opioid and constipation together can be enough to stop someone walking. The differential is therefore a checklist to complete, not a single answer. A subdural haematoma should be remembered when the decline follows a fall days or weeks earlier, especially on an anticoagulant. Sometimes the honest diagnosis is advancing frailty or dying, and recognising this is as important as finding a treatable cause.

Refer

Where should this person be cared for?

Done

999

Sepsis with high-risk features · stroke · suspected ACS · hip fracture or unable to get up · GI bleed · hypoglycaemia not responding · severe hyponatraemia with seizure or reduced consciousness · any 999 feature in step 1 — unless a ReSPECT plan or agreed decision says otherwise.

Same-day hospital or SDEC

Moderate-to-high-risk sepsis features without a clear plan · AKI stage 2–3 or potassium ≥6.0 · sodium <125 mmol/L with symptoms · urinary retention needing catheter not available in the community · delirium with no identifiable cause or unsafe at home · head injury on an anticoagulant (CT).

Urgent community response (within 2 hours)

Falls without serious injury, deconditioning, mild infection, minor delirium or carer crisis where the person can be safely kept at home with rapid nursing, therapy, equipment and social care (NHS England 2-hour urgent community response).

Hospital at home / virtual ward

Acute frailty or infection needing daily review, IV therapy or monitoring that the person wishes to receive at home.

Same-day social care

Carer breakdown, unsafe home, safeguarding concerns — local authority adult social care; safeguarding referral if abuse or neglect suspected.

Routine follow-up

Falls service (multifactorial assessment, NICE NG249), memory service once delirium has resolved, comprehensive geriatric assessment, medication review.

Where the person is cared for is a shared decision between clinical need, the person's wishes and what the local system can provide. Urgent community response teams, set up nationally to reach people at home within 2 hours, and hospital at home (virtual wards) can avoid admissions that often harm frail people through deconditioning and hospital-acquired delirium. But some problems — sepsis with high-risk features, hip fracture, stroke — need hospital unless the person has chosen otherwise.

Treat

Management at this consultation

Done

Escalation and wishes — first

Check or start a ReSPECT plan

Find existing advance care plan, ReSPECT form, DNACPR or lasting power of attorney. Discuss treatment escalation (hospital, hospital at home, comfort) with the person if they have capacity, or with the attorney/family in their best interests (Mental Capacity Act 2005). Document and share with ambulance and OOH services.

Medicines

Stop or hold the culprits

Stop new sedatives and anticholinergics where possible; hold antihypertensives if postural or hypotensive; apply sick-day rules (ACEi/ARB, diuretics, metformin, SGLT2 inhibitor, NSAIDs) if dehydrated or AKI; reduce sulfonylurea or insulin if eating poorly; do not stop Parkinson's medicines abruptly.

Infection managed at home

Treat the source

Pneumonia or confirmed UTI: antibiotic per local guidance and renal function (e.g. avoid nitrofurantoin if eGFR <45; check trimethoprim interactions and potassium). Send culture first. Avoid treating asymptomatic bacteriuria.

Delirium

Non-drug care first

Treat the cause; hydration, nutrition, glasses and hearing aids, orientation, a familiar person, sleep, avoid moving rooms. Avoid sedatives; seek specialist advice if distress or risk is severe (NICE CG103).

Retention, constipation, dehydration

Fix the simple things

Catheterise retention (community nursing); treat constipation (osmotic ± stimulant laxative, enema if impacted); encourage oral fluid; review in 24 hours.

Dying is recognised

Plan end-of-life care

Agree goals with the family; anticipatory medicines, DNACPR, preferred place of care and death, community nursing and palliative support.

Carers

Check the carer can cope tonight; arrange respite, social care or a care package if not; give a direct number.

Safeguarding

Unexplained injuries, neglect or financial abuse → safeguarding referral to adult social care the same day if the person is at risk.

Next steps: see Care of the dying · Dementia · Acute kidney injury · Sick day rules · Chest infections · Constipation in adults

Management starts with the person's wishes, because the right plan for a fit 80-year-old and for someone with advanced dementia in a care home may be different, and ReSPECT plans exist to make those decisions in advance. Medicines are the commonest reversible cause, so stopping or holding them is often the most effective treatment. Delirium is managed by treating the cause and supportive care rather than sedation. If the person is dying, recognising that and planning end-of-life care is the right treatment.

Lifestyle

Recovery, prevention and support

Done

Keep moving Get up and walk with help as soon as safe — bed rest causes rapid deconditioning; physiotherapy and equipment via the urgent response team.

Fluids and food Regular drinks offered by carers; nutritional supplements if intake poor; check weight (MUST score).

Falls prevention Multifactorial falls assessment, strength and balance exercise, home hazards, footwear, vision.

Medication review Structured review to reduce anticholinergic and sedative load (STOPP/START).

Vaccinations Influenza, pneumococcal, COVID-19, RSV and shingles as eligible.

Carer support Carer's assessment from social care, respite, local carers' organisations.

Plan ahead Encourage advance care planning, lasting power of attorney and a ReSPECT conversation once recovered.

Recovery from an acute illness in frailty depends on early mobilisation, nutrition and carer support. Each episode is also an opportunity to reduce the next one: a structured medication review, falls prevention, vaccination and an advance care planning conversation that will make the next crisis easier for everyone.

Safety

Follow-up and safety-netting

Done

Review

If managed at home, review within 24 hours (call or visit) and arrange repeat bloods within 24–48 hours if abnormal. Hand over to OOH and community teams.

Delirium

Can take weeks to resolve — reassess cognition after recovery; persistent impairment → memory assessment.

Results to chase

Bloods, cultures, ECG, X-ray, bladder scan.

Remote consultations

Telephone, video or online consultation with any 999 feature → convert to a 999 call, not a later appointment; if examination is needed to decide, see the patient the same day.

SCA safety-net wording (to carer)

"If he becomes very drowsy or hard to wake, is breathing fast, his skin looks blotchy, mottled or blue, he hasn't passed urine all day, he has weakness of the face or arm, or chest pain, call 999. If he's more confused, not drinking, or can't get up, call us or 111 the same day. Here's what we've agreed if he gets worse."

Audit checklist

Full observations incl. respiratory rate and glucose · 4AT · medicines reviewed · no dipstick-only UTI diagnosis in 65+ · Clinical Frailty Scale recorded · ReSPECT/escalation discussed · carer coping and safeguarding checked · 24-hour review booked.

Older people deteriorate quickly, so a home-management plan depends on a firm review within 24 hours and a carer who knows exactly which changes mean 999 and which mean a same-day call. Sharing the escalation plan with out-of-hours and ambulance services ensures the patient's wishes are respected if things change overnight.