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

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

Slide 5

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 SPECIALThey 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

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

Slide 31

Visit us at:

Facebook.com/AmericanGeriatricsSociety

Twitter.com/AmerGeriatrics

www.americangeriatrics.org

THANK YOU FOR YOUR TIME!

linkedin.com/company/american-geriatrics-society

Slide 32