GERIATRICEMERGENCIES
Joel Gernsheimer, MD, FACEPAttending PhysicianSUNY Downstate
THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.
Leading change. Improving care for older adults.
AGS
GERIATRIC EMERGENCIES• Introduction: Why?
• Pathophysiology
• Principles of Geriatric Emergency Medicine
• Geriatric Competencies for EM Residents
• Specific Important Acute Geriatric Illness
• Conclusions and Summary
Slide 2Emergency Medicine Clinics of North America, May 2006.
INTRODUCTION: WHY?• The Graying of America
• The Elderly Are Special
• Need for Education
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THE GRAYING OF AMERICA• The elderly (>65) are 12% of the population
• By 2050 they will be 21%
• The very elderly (>85) are the fastest-growing age group
• They use 50% of the federal health care budget
• They spend the most on drugs
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ED RESOURCE USEBY THE ELDERLY (1 of 2)
• More than 15% of all ED patients
• 40% of all EMS arrivals
• More emergent and urgent
• More comorbidities
• More complicated work-ups
• More labs and x-rays
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ED RESOURCE USEBY THE ELDERLY (2 of 2)
• Greater rate of admissions
• 50% of ICU admissions
• Stay longer in the ED
• Higher rate of mortality and morbidity
• More misdiagnoses
• More ED bouncebacks
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THE ELDERLY ARE SPECIALThey are not just old adults!
• Own physiology
• Own presentations
• Own diseases: AAA, temporal arteritis, mesenteric ischemia, dementia, etc.
• Own special management
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NEED FOR EDUCATION• Lack of educational materials
• 69% of emergency physicians — insufficient CME
• 53% — lack of training in residency
• 40% of residency directors — training inadequate
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Ann Emerg Med. 1992;21:796-801.Ann Emerg Med. 1992;21:825-829.
SAEM GERIATRIC EMERGENCY MEDICINE TASK FORCE
• Director of GEM Subdivision — Dr. Gernsheimer
• Chairman of GEM Task Force — Dr. Rinnert
• Director of GEM Research — Dr. Baron
• Director of GEM Grants — Dr. Stetz
• Director of GEM Simulations — Dr. Gillett
• Liaison for GEM Resident Education — Dr. Doty
• Director of GEM Disaster Planning — Dr. Arquilla
SAEM = Society for Academic Emergency Medicine
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PATHOPHYSIOLOGY (1 of 3)
• Decline in physiologic systems Loss of reserves Decreased ability to exert homeostatic control
• Accumulation of life’s stresses Diseases Environmental hazards — toxins Drugs
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PATHOPHYSIOLOGY (2 of 3)
• Renal• Hepatic• Immunologic• Pulmonary• Cardiovascular• CNS and sensory• Musculoskeletal• Body habitus
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PATHOPHYSIOLOGY (3 of 3)
• More diseases
• More complicated
• Less ability to cope
• Greater severity
• More adverse drug reactions (ADRs)
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DR. GERNSHEIMER’SABC’s FOR THE ELDERLY
A — Attentive & Aggressive
B — Be Nice & Be Patient
C — Careful & Compassionate
S — Suspicious & Supportive
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BE NICE!
“When I was young I appreciated cleverness but when I became old I appreciated kindness much more”
—Margaret Mead
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PRINCIPLES OF GERIATRIC EMERGENCY MEDICINE (1 of 2)
• The patient’s presentation is complex
• Diseases present atypically, making diagnosis more difficult
• Comorbidities and impairments have confounding effects
• Polypharmacy is common and often causes problems
• The risk of ADRs is increased
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PRINCIPLES OF GERIATRIC EMERGENCY MEDICINE (2 of 2)
• The elderly may decompensate rapidly
• It is important to recognize cognitive impairment
• Expect decreased functional reserve
• Functional status is important
• Social issues are extremely important
• The ED visit is an opportunity!
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GERIATRIC COMPETENCIESFOR EM RESIDENTS
• Atypical presentation of disease
• Trauma, including falls
• Medication management
• Effect of comorbid conditions
• Cognitive and behavioral disorders
• Palliative care and end-of-life issues
• Emergent intervention modifications
• Transitions of care
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CLINICAL SITUATIONS WITH ATYPICAL PRESENTATIONS
IN THE ELDERLY
• Acute myocardial infarction
• Pulmonary embolism• Pneumonia• Acute abdomen• Hyperthyroidism
• Hypothyroidism• Alcoholism• Depression• Drug therapy• Sepsis• Physical abuse
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ALTERED MENTAL STATUS• AMS may be subtle and missed
• Differential diagnosis of AMS is broad
• Dementia may mask acute AMS
• Delirium: acute and fluctuating mental status
• Cause of delirium can be life-threatening
• Causes: Sepsis, ADR, cardiovascular, neurologic
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ETIOLOGIES:RAPID FUNCTIONAL DECLINE
• Neurologic: CVA, SDH• Infections: UTI, pneumonia • Cardiovascular: atrial fibrillation, CHF, MI• ADR• Metabolic: dehydration, elect., HHNK• Abdominal events: perforation, bleeding• Psychiatric: depression, abuse
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MEDICATIONS IN ELDERLY PEOPLE
• Average 4.5 prescription drugs, 2.1 over-the-counter drugs
• Adverse reactions twice as likely
• Half of hospital admissions for ADRs involve elderly people
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ALTERED PHARMACOKINETICS & PHARMACODYNAMICS
• Decreased functional reserve
• Changes in volume of distribution
• Drug clearance impaired
• Paradoxical reactions occur
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DRUGS TO CONSIDER AVOIDINGIN ELDERLY PERSONS
• Drugs with: Long half-life Prominent anticholinergic side effects Low therapeutic-to-toxicity ratio
• Muscle relaxants
• Certain NSAIDs
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DRUGS IMPLICATED IN DELIRIUM
• Digitalis• Sedatives• Antidepressants• Steroids• Alcohol• Barbiturates
• Anticonvulsants• Neuroleptics• Antihistamines• Diuretics• Antihypertensives
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ATYPICAL PRESENTATIONSOF INFECTIONS
• Vague symptoms, altered mental status, functional decline
• Serious infection without fever
• Pneumonia without cough
• UTI without flank pain or dysuria
• Intra-abdominal infection “without pain”
• Invasive cellulitis without pain
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INFECTIONS IN ELDERLYNURSING HOME PATIENTS
• Pneumonia
• UTI
• Skin infection
• Intra-abdominal infection
• Meningitis
• Endocarditis
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INCREASED MORTALITY FROMINFECTIONS IN ELDERLY PATIENTS
Pneumonia 300%Upper UTI 750%Sepsis 300%Appendicitis 1750%Cholecystitis 500%Tuberculosis 1000%Endocarditis 250%Meningitis 300%
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ABDOMINAL PAIN (1 of 2)Very dangerous but easy to miss!
• >50% require admission
• 33%42% require surgery
• Mortality 9 that of younger patients
• Overall mortality 10%14%
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ABDOMINAL PAIN (2 of 2)• Diagnosis of abdominal pain in the elderly is difficult
• High rate of admission and surgery
• Red flags: upper abdominal pain (MI?), ill appearance, and abnormal vital signs
• Syncope or hypotension — think AAA
• Severe pain — think mesenteric ischemia
• Symptoms and signs are subtle!
• Be very careful — “over-test”
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ACUTE CORONARY SYNDROME• AMI is the leading cause of death in the elderly
• The elderly commonly present without classic pain
• AMI should be suspected with atypical pain, CHF, syncope, SOB, acute confusion, or functional decline
• History alone is sufficient to admit a patient
• Normal ECG and labs do not rule out ACS in the ED
• The elderly may tolerate medications poorly
• Decisions should be based on patient’s physiologic age, functional status, and wishes, not on age in years
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SUMMARYTo optimize care, need a comprehensive model that considers:• Complexity of chief complaint• Atypical disease presentation • Comorbidities • Polypharmacy ― ADRs• Cognitive impairment • Decreased functional reserve• Assessment of functional status• Need for social and psychological support
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