geriatric emergencies joel gernsheimer, md, facep attending physician suny downstate the american...

GERIATRICEMERGENCIES

Joel Gernsheimer, MD, FACEPAttending PhysicianSUNY Downstate

THE AMERICAN GERIATRICS SOCIETY

Geriatrics 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

Slide 3

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

Slide 4

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

Slide 6

THE ELDERLY ARE SPECIAL

They are not just old adults!

• Own physiology

• Own presentations

• Own diseases: AAA, temporal arteritis, mesenteric ischemia, dementia, etc.

• Own special management

Slide 7

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

Slide 8

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

Slide 9

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

Slide 10

PATHOPHYSIOLOGY (2 of 3)

• Renal

• Hepatic

• Immunologic

• Pulmonary

• Cardiovascular

• CNS and sensory

• Musculoskeletal

• Body habitus

Slide 11

PATHOPHYSIOLOGY (3 of 3)

• More diseases

• More complicated

• Less ability to cope

• Greater severity

• More adverse drug reactions (ADRs)

Slide 12

DR. GERNSHEIMER’SABC’s FOR THE ELDERLY

A — Attentive & Aggressive

B — Be Nice & Be Patient

C — Careful & Compassionate

S — Suspicious & Supportive

Slide 13

BE NICE!

“When I was young I appreciated cleverness but when I became old I appreciated kindness much more”

—Margaret Mead

Slide 14

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

Slide 15

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!

Slide 16

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

Slide 17

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

Slide 18

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

Slide 19

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

Slide 20

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

Slide 21

ALTERED PHARMACOKINETICS & PHARMACODYNAMICS

• Decreased functional reserve

• Changes in volume of distribution

• Drug clearance impaired

• Paradoxical reactions occur

Slide 22

DRUGS TO CONSIDER AVOIDINGIN ELDERLY PERSONS

• Drugs with: Long half-life Prominent anticholinergic side effects Low therapeutic-to-toxicity ratio

• Muscle relaxants

• Certain NSAIDs

Slide 23

DRUGS IMPLICATED IN DELIRIUM

• Digitalis• Sedatives• Antidepressants• Steroids• Alcohol• Barbiturates

• Anticonvulsants• Neuroleptics• Antihistamines• Diuretics• Antihypertensives

Slide 24

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

Slide 25

INFECTIONS IN ELDERLYNURSING HOME PATIENTS

• Pneumonia

• UTI

• Skin infection

• Intra-abdominal infection

• Meningitis

• Endocarditis

Slide 26

INCREASED MORTALITY FROMINFECTIONS IN ELDERLY PATIENTS

Pneumonia 300%Upper UTI 750%Sepsis 300%Appendicitis 1750%Cholecystitis 500%Tuberculosis 1000%Endocarditis 250%Meningitis 300%

Slide 27

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%

Slide 28

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”

Slide 29

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

Slide 30

SUMMARY

To 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

Slide 31

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