Age Does Matter: Critical Issues in the

ED Evaluation of Geriatric Patients

Marc Evans M. Abat, MD, FPCP, FPCGM

Section of Adult Medicine, Department of Medicine, PGH

Head, Center for Healthy Aging, The Medical City

Case

• 92/F

• CC: increased sleeping

• (+)hypertension

• (+)type 2 diabetes on 4 oral hypoglycemic

agents

• (+) dyslipidemia

• Came from Samar due to fever and

headaches

• Seen at another tertiary hospital in Manila

– Dx: viral upper respiratory tract infection

– DM medications adjusted due to high CBGs

• Increased sleeping started 2 days before

current consultation

• ROS: (+)memory lapses notable since 2

months prior to admission

• Physical examination at the ER

– BP 100/60 HR 84 RR 20 T 36.7°C

– Patient drowsy to stuporous, minimal eye

opening on name calling and tapping, groans

only with no distinct verbal output

– E/N findings for other organ systems including

neuro

What is your initial

impression?

A. Hypoglycemia

B. Infection

C. Electrolyte Imbalance

D. Stroke

E. Dehydration

Outline

• Critical Role of the Emergency Medicine

Physician

• Clinical Vignettes in the Care of the Older

Patient at the Emergency Department

• Common Presenting Complaints

Critical Role of the

Emergency Medicine

Physician

BMC Geriatrics 2013, 13:83

BMC Geriatrics 2013, 13:83

Compared to ages 18-60, those > 60 years

• Adjusted OR for admission

– 1.7 (1.6-1.8, p<0.001)

• Adjusted OR for mortality

– 2.3 (2.0-2.5, p<0.001)

BMC Geriatrics 2013, 13:83

Critical Care 2006, 10:R82 (doi:10.1186/cc4926)

Critical Care 2006, 10:R82 (doi:10.1186/cc4926)

Clinical Vignettes in the

Care of the Older Patient at

the Emergency Department

Geriatric syndromes

• refer to multifactorial health conditions that

occur when the accumulated effects of

impairments in multiple systems render an

older person vulnerable to situational

challenges

• Emphasizes multiple causation of a unified

manifestation

Syndromes in the young population

Geriatric syndromes

a group of symptoms that do not need to be highly prevalent

highly prevalent, mostly single symptom states

a single pathogenetic pathway, known or unknown, causes the symptoms.

the leading symptom is linked to a number of aetiological factors or diseases in other organs.

separate entities, and there is no overlap between aetiological factors of different syndromes

large overlap between the aetiological factors of different geriatric syndromes.

in younger patients, one usually finds a single syndrome in one patient

A geriatric patient often suffers from more than one geriatric syndrome

• Use of the terminology leads to special

considerations

– multiple risk factors and multiple organ systems are

often involved

– diagnostic strategies to identify the underlying causes

can sometimes be ineffective, burdensome,

dangerous, and costly

– therapeutic management of the clinical manifestations

can be helpful even in the absence of a firm diagnosis

or clarification of the underlying causes

• Education Committee Writing Group

(ECWG) of the American Geriatrics

Society recommends that undergraduate

students should be trained profoundly in

the 13 most common geriatric syndromes

dementia inappropriate prescribing of medications

osteoporosis

depression incontinence sensory alterations including hearing

and visual impairment

delirium iatrogenic problems immobility and

gait disturbances

falls failure to thrive

pressure ulcers sleep disorders

• Diseases often present atypically – Reflects organ system most restricted in homeostasis

– Confusion, increased somnolence, incontinence are common manifestations of infection, hip fracture

• Aggressive medical attention is necessary to prevent domino effect of illness– Endpoint: multiple organ failure

• Law of parsimony does not hold– Symptoms in elderly often due to multiple causes

Paradigm shifts

Common Presenting

Complaints

Acute Myocardial

Infarction

• “Silent” MI more common

• Dyspnea only

• May present with signs, symptoms of acute abdomen--including tenderness, rigidity

Acute Myocardial

Infarction

• Possibly just vague symptoms

– Weakness

– Fatigue

– Syncope

– Incontinence

– Confusion

– TIA/CVA

Congestive Heart Failure

• Nocturnal confusion

• Bed-ridden patients may have fluid over sacral areas rather than feet, legs

• Without orthopnea or paroxysmal nocturnal dyspneain earlier stages

• “Visceral” or pulmonary congestion without peripheral edema

Acute Arterial Occlusion

• May be painless and

easily missed

• May manifest only with

a cyanotic, pulseless

and cold extremity

• Unpredictable and may

follow any acute

disease

Pulmonary Edema

• May be tricky to differentiate

from other causes of

crackles

– Pneumonia

– Bronchiectasis

• Need to use other modalities

– Hepatojugular reflux

– labs (e.g. BNP)

Pulmonary Embolism

• Suspect in any patient with sudden onset

of dyspnea when cause cannot be quickly

identified

– D-dimer??

– DVT screening??

– Venous duplex scanning??

Pneumonia

• Possibly atypical presentations– Absence of cough, fever

– Loss of appetite and difficulty sleeping

– Abdominal rather than chest pain

– Altered mental status

– Falls

Chronic Obstructive Pulmonary

Disease

• Usually causes a progressive

degree of dyspnea and

coughing over a long period of

time, with episodes of acute

exacerbation

• May co-exist with other acute

problems (e.g. MI, pneumonia)

Constipation

• May acutely present as

– Delirium

– BP spikes

– Gastric retention

Diarrhea and Dehydration

• Dehydration may be difficult to assess in the elderly due to preexistent– Xerostomia

– Loss of subcutaneous tissues

• Manifests as

– Delirium

– Decreasing blood

pressure

– Loss of urine

output

– Tachycardia

– hypotension

Acute abdominal pain

• Numerous etiologies– Pneumonia

– Myocardial infarction

– Gastroenteritis

– Malabsorptionsyndromes

– Mesenteric disease

– Acute appendicitis

– Malignancy

• May be accompanied by abdominal rigidity despite the absence of peritonitis

GI Bleeding

• Manifest with

progressive pallor and

weakness, loss of

appetite, body malaise

• May also present with

progressive abdominal

enlargement with initial

constipation

Urinary Tract Infection

• Patient may not complain of painful

urination or frequency or urgency

• May manifest with acute incontinence,

delirium or loss of appetite

• In cases of pyelonephritis, there may be

absence of costovertebral tenderness and

fever

Uremia

• Symptoms related to the inability of the

kidney to remove toxins

• May present with delirium, persistent

nausea and vomiting, tachypnea

• May present atypically with body malaise,

poor appetite, weakness

Hypoglycemia

• Patient may not complain of hunger, tremors, sweating and other signs seen in the young

• May just present with loss of consciousness or seizures

Hyperglycemia

• Symptoms are attributable to the

underlying disorder

– Diabetic ketoacidosis

– Hyperosmolar, hyperglycemic state

• Include delirium, loss of urine output,

tachypnea, diarrhea, coma

Electrolyte disorders

• Hyponatremia

– Weakness, sleepiness, difficulty walking or ambulating, delirium

• Hypernatremia

– Delirium, seizures, coma

• Hyperkalemia

– Sudden cardiac death

• Hypokalemia

– Muscle weakness, sudden cardiac death

Dementia vs. Delirium

• Stable and progressive vs waxing and waning

• chronic onset vs acute onset

• The former has more prominent cognitive

impairment, the latter has sensorium as

dominant impairment

• Never assume acute dementia or altered mental

status is due to “senility”

• Ask relatives, other caregivers what the patient’s

baseline mental status is

• Head injury with

subdural hematoma

• Alcohol, drug

intoxication, withdrawal

• Tumor

• CNS Infections

• Electrolyte imbalances

• Cardiac failure

• Hypoglycemia

• Hypoxia

• Drug interactions

Possible Causes of Delirium

Cerebrovascular Accident

• signs often subtle—dizziness,

behavioral change, altered

affect

• Headache, especially if

localized, is significant

• Stroke-like symptoms may be

delayed effect of head trauma

Seizures

• All first time seizures in elderly are dangerous

• Possible causes

CVA

Arrhythmias

Infection

Alcohol, drug withdrawal

Tumors

Head trauma

Hypoglycemia

Electrolyte imbalance

Syncope

• Morbidity, mortality higher

• Consider

– Cardiogenic causes (MI, arrhythmias)

– Transient ischemic attack

– Drug effects (beta blockers, vasodilators)

– Volume depletion

Depression

• Common problem

• May account for symptoms of “senility”

• Persons >65 account for 25% of all

suicides

• Treat as possibly life threatening

Head Injury

• More likely, even with minor trauma

• Signs of increased ICP develop slowly

• Patient may have forgotten injury, delayed

presentation may be mistaken for CVA

Cervical Injury

• Osteoporosis, narrow spinal canal increase injury risk from trivial forces

• Sudden neck movements may cause cord injury without fracture

• Decreased pain sensation may mask pain of fracture

Hypovolemia & Shock

• Decreased ability to compensate

• Progress to irreversible shock rapidly

• Tolerate hypoperfusion poorly, even for

short periods

Hypovolemia & Shock

• Hypoperfusion may occur at “normal” pressures

• Medications (beta blockers) may mask signs of

shock

Geriatric Abuse & Neglect

• Physical, psychological injury of older

person by their children or care providers

• Knows no socioeconomic bounds

Geriatric Abuse & Neglect

• Contributing factors

– Advanced age: average mid-80s

– Multiple chronic diseases

– Patient lacks total dependence

– Sleep pattern disturbances leading to

nocturnal wandering, shouting

– Family has difficulty upholding commitments

Geriatric Abuse & Neglect

• Primary findings

– Trauma inconsistent with history

– History that changes with multiple tellings

Serious head injuries sometimes

denote geriatric abuse.

General Management

Guides

• No enormous change

• “Start Low, Go Slow, But Keep on Going”

• Be wary of Drug Adverse Reactions!

Additional

• Geriatric Emergency Department

Guidelines (2014)

– American College of Emergency Physicians

– American Geriatrics Society

– Emergency Nurses Association

– Society for Academic Emergency Medicine

• Geriatric Emergency Medicine Fellowships

Summary

• The Emergency Physician plays a vital

role in the initial management of the

Geriatric patient

• Symptoms of the Geriatric ED patient are

often multiple, overlapping, and atypical,

complicated by existing diseases,

medications and age-related changes