House call for seniors in Berlin — what matters?

What we focus on during a senior house call

For older patients the house call is doubly worthwhile. First, because the trip to a practice with rollator, mobility aids or with dementia is a real burden. Second, because the home gives us information invisible in the consulting room: how far is it to the toilet? Trip hazards on the way? What does the medicine drawer look like? Who is reachable during the day? Is there enough fluid in the fridge? These context cues are often therapeutically more valuable than another lab result. We examine in classic fashion (lungs, heart, abdomen, neuro-status), check blood pressure lying and standing (orthostasis), pulse oximetry, blood glucose, urine dipstick if infection is suspected, and we take time for conversation.

Three pictures belong to senior acute medicine and are often missed at home: first, delirium — the acute disturbance of consciousness with confusion, agitation or unusual drowsiness — in older patients a pneumonia, a urinary infection, dehydration or a drug effect can present almost exclusively as delirium, without classical symptoms. Second, silent pneumonia, which runs without fever and with only subtle respiratory symptoms but is clear on auscultation. Third, the missed hip fracture or head injury after a fall — especially under anticoagulation a time-critical picture. Whoever asks and examines finds these pictures; whoever just deals with the chief complaint regularly misses them.

An important part of the senior house call is the goals-of-care conversation — with the patient if possible, otherwise with family or legal guardians. Not every suspicion has to go to hospital. For a very old person with advanced dementia, in whom hospital stays repeatedly trigger delirium, careful outpatient care with symptomatic therapy and close observation may be the better path. This conversation needs time, empathy and honest prognostic talk — things that rarely fit into a 7-minute practice contact.

Example: 82-year-old with sudden confusion

An 82-year-old patient in Zehlendorf has been unusually confused, agitated and not recognising her daughter since the morning. No fever, no cough, no fall. We come in the afternoon; history and exam show slightly raised respiratory rate, fine crackles right basally, oxygen saturation 92 %. Urine dipstick clear. Diagnosis: strong suspicion of silent pneumonia with delirium. With the daughter we arrange a hospital admission to the geriatric unit at Charité — with saturation below 93 % and delirium, outpatient care is no longer responsible. Ambulance transport organised, hand-over letter included. Three days later discharged on oral antibiotics, follow-up house call after discharge arranged.

Focus points of a senior house call

• Complete medication list (including OTC) — polypharmacy is the most common source of avoidable symptoms.
• Orthostatic test: blood pressure and pulse lying and at 1 / 3 minutes standing — falls-risk indicator.
• Pulse oximetry, blood glucose, temperature, urine dipstick if needed.
• Hydration status: skin turgor, mucous membranes, fluid intake over recent days.
• Cognitive orientation: date, place, simple tasks — distinguish delirium from stable dementia.
• Fall history: trip hazards, footwear, glasses, recent falls — under anticoagulation, low threshold for head CT.
• Goals-of-care conversation with patient or proxy — what is wished, what is to be avoided.
• Communication with care service or GP: a brief letter or note in the care folder.