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TAEM11: Geriatric Emergency

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  • 1. Background In 2000, there were 600 million people aged 60 and over; there will be 1.2 billion by 20251 The rate of ED visits increased and was greater for elder patients. ED visits made by elder patients, the numbers of admissions and ambulance transports have grown at a rate faster than that for ED patients as a whole.2 1. www.who.int/ageing/en/ 2. Acad Emerg Med. 1998;5:1157-1162.
  • 2. ED utilization by elderly patients
  • 3. 14.8% 42.8% p (organic disease) Sanders AB, In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. New York: McGraw- Hill,2004:1896-900.
  • 25. Functional decline Instrumental Activities of Daily Living (IADL) scale acute medical condition (myocardial infarction) (sepsis) (subdural hematoma) Sanders AB, In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. New York: McGraw- Hill,2004:1896-900.
  • 26. Algorithm for the evaluation and management of functional decline in elderly patients Lachs MS, in Sanders AB (ed): Emergency Care of the Elder Person. St. Louis,Beverly Cracom publications, 1996
  • 27. - Laboratory tests : (CBC, glucose, Na, K, BUN, creatinin), UA and CXR. - After initial medical evaluation in the ED a diagnosis considered as acute because it required treatment without delay, was established in 129 of the 253 patients (51%)
  • 28. Pitfalls Reasons for undertriage were 1. absence of vital signs measurement (n = 16) 2. poor recognition of neurological symptoms (n = 9) 3. atypical clinical presentation (n = 8)
  • 29. Acute chest pain in the elderly patients Must first consider potential life-threatening causes. Acute myocardial infarction (AMI) Aortic dissection Pulmonary embolism Pneumothorax Esophageal rupture Pericarditis with cardiac tamponade
  • 30. Acute coronary syndrome 0.4% - 10% of patients who have AMI are incorrectly discharged from the emergency department Clinician fail to consider the possibility of ACS and, therefore, fail to initiate the appropriate diagnostic workup.1 Specific subgroups that are at greater risk for misdiagnosis.2 Very young Very old Women Diabetics 1. Emerg Med Clin North Am 2005;23:93757. 2. ED Legal Letter 2003;14(10):10920.
  • 31. Acute coronary syndrome Women Older than men who have ACS. There are more comorbid diseases, such as DM or HT, and a family history of premature coronary heart disease. More likely to present with neck and shoulder pain, nausea, fatigue, and dyspnea. Douglas PS, Ginsburg GS. N Engl J Med 1996;334(20):13115.
  • 32. Acute coronary syndrome Diabetic patients Silent ACS Late presentations are common More likely : exertional dyspnea, severe fatigue, or lightheadedness Cooper S, Caldwell JH. Clin Diabetes 1999;17:5872.
  • 33. Acute coronary syndrome Elderly patients Chest pain accompanies AMI much less frequently. In patients aged 85 years or older, dyspnea, not chest pain, is the single most common presenting symptom of angina1. More frequently : fatigue, lightheadedness, worsening congestive heart failure, altered mental status, and syncope2 1. Konotos MC. Cardiol Rev 2001;9(5):26675. 2. Haro LH, et al. Cardiol Clin 2006;24(1):117.
  • 34. Acute coronary syndrome Diagnostic evaluation ECG, CXR. Serum cardiac biomarkers : CK-MB, Troponin T or I Tend to rise 3 to 4 hours after the onset of an AMI. Serial sampling over a 12- to 24-hour period will detect the majority of AMIs. Further evaluation with provocative stress testing must be performed when UA is a possibility.
  • 35. Aortic dissection (AD) Unrecognized AD carries a 1% to 2% mortality per hour for the first 48 hours. The mortality reaches 90% at 1 year. Physicians correctly suspect in 15-43% of patients at the time of presentation. When AD is misdiagnosed as ACS, the consequences of giving thrombolytics can be disastrous.
  • 36. Demographics and History of Patients with Acute Aortic Dissection
  • 37. Anteriorposterior chest radiograph demonstrating a widened mediastinum in a 67-year-old woman with chest pain and acute aortic dissection.
  • 38. Aortic dissection (AD) Diagnostic evaluation CXR CT : MDCT-sensitivity 99% MRI Echocardiography : transthoracic or transesophageal Aortography Lab : D-dimer sensitivity 100% but poor specificity Lab : smooth muscle myosin heavy chains, and soluble elastin fragments highly sensitive and specific for AD (not available)
  • 39. Aortic dissection (AD) Patients must be asked to describe the quality of the pain intensity at the onset the pain radiates A retrospective review of confirmed thoracic AD patients only 42% of conscious patients were asked these three simple questions. Rosman HS, et al. Chest 1998;114:7935.
  • 40. Helical CT of the pulmonary arteries with intraluminal filling defects in the lobar artery of the left lower lobe (solid arrow) and the main artery of the right lung (open arrow) in a patient with a chest deformity.
  • 41. Am J Med. 2007; 120(10): 871879
  • 42. Pulmonary embolism Signs, Symptoms and Combinations According to Age Most symptoms and all signs occurred with similar frequencies in patients 70 years old and younger patients. In patients with pulmonary embolism, dyspnea or tachypnea occurred less frequently in elderly patients than in younger patients. Am J Med. 2007; 120(10): 871879
  • 43. Symptoms in Patients with PE and No Pre-Existing Cardiac or Pulmonary Disease According to Age Am J Med. 2007; 120(10): 871879
  • 44. Am J Med. 2007; 120(10): 871879
  • 45. Am J Med. 2007; 120(10): 871879
  • 46. Rate of Onset of Dyspnea Am J Med. 2007; 120(10): 871879
  • 47. Clinical probability of pulmonary embolism clinical probability category Total points High >8 Intermediate 5-8 Low 0-4 Wells PS, et al. Thromb Haemost 2000;83:416-20. Wicki J, et al. Arch Intern Med. 2001;161:92-97
  • 48. The prevalence of pulmonary embolism* Low Moderate High Pretest Pretest Pretest Score Probability Probability Probability Wells 1-3% 16-28% 38-78% Geneva 7% 34-35% 77-85% - The study that compared both prediction rules reported similar results. - The area under the ROC curve for the Wells pulmonary embolism prediction rule ranged 0.52- 0.88 and the area for the Geneva pulmonary embolism prediction rule ranged 0.69-0.84.** * **
  • 49. Acute Abdominal Pain in the elderly patients Acute abdominal pain in the elderly was the problem required most time-consumed diagnosis.1 Previous studies have demonstrated a diagnostic accuracy of only 40% to 65% in geriatric patients with abdominal pain.2-4 1. J Am Geriatr Soc.1987; 35: 398404. 2. Arch Surg. 1978; 113:1149-52. 3. Br Med J. 1972; 3:393-8. 4. Emerg Med Clin North Am. 1996; 14:615-27.
  • 50. Demographic Characteristics of the Study Population Demographic N = 378 Gender (male : female) 175 : 203 Age (median (range)) 71(60-94) Underlying diseases N(%) 269 (71.2) - Hypertension 104 (27.5) - Diabetes mellitus 59 (15.6) - Cardiovascular disease 58 (15.3) - Malignancy 52 (13.8) - Pulmonary disease 38 (10.1) - Miscellaneous 170 (45.0)
  • 51. Miscellaneous group* 16.0 9.2 Myalgia 0.8 1.1 Urinary retention 1.1 1.1 Abdominal aortic aneurysm 0.8 1.1 Peritonitis 0.3 1.6 Acute appendicitis 2.4 2.4 Intestinal obstruction 4.5 4.0 5.3 Constipation 5.6 8.2 Overall Cholecystitis, cholelithiasis and biliary tract disease Urinary tract infection 7.1 7.9 N = 378 7.9 Calculus of urinary system 6.9 9.0 (100%) Acute gastritis, gastroenteritis or diarrhea 10.6 10.8 35.2 Non specific 39.2 0.0 10.0 20.0 30.0 40.0 Overall : Final diagnoses(%) Overall : Initial diagnoses(%)
  • 52. Non specific abdominal pain - What should we aware? 1. Cholecystitis, cholelithiasis or biliary tract disease = 4 2. Intestinal obstruction = 3 Overall 3. Acute pancreatitis = 1 378 Non Operative specific Revisited Procedures 148 & 8 Admitted 23 Non specific 9 Medical conditions 6
  • 53. Miscellaneous group* 8 6 Scrub typhus 0 2 Herpes zoster 0 2 Diverticulitis 2 1 Gastrointestinal ulcer 2 1 Hepatic conditions 0 3 Acute gastritis, gastroenteritis and 3 2 Urinary tract infection 2 3 Calculus of urinary system 1 3 Admitted Patients 5 Acute pancreatitis 3 3 N = 100 Abdominal aortic aneurysm 4 Peritonitis 1 5 (100%) 9 Acute appendicitis 9 Intestinal obstruction 17 15 10 Non specific 23 Cholecystitis, cholelithiasis or biliary 30 25 0 10 20 30 Admitted patients : Final Dx Admitted patients : Initial Dx
  • 54. 1. Cholecystitis, cholelithiasis or 14 biliary tract disease Admitted 2. Acute appendicitis 8 Patients 3. Intestinal obstruction 7 100 4. Gastrointestinal ulcer 2 5. Hepatic conditions 2 Operative Procedures 6. acute pancreatitis 1 38 7. abdominal aortic aneurysm 1 8. Calculus of urinary track 1 9. Hernia 1 10. Tubo-ovarian abscess 1
  • 55. Overall (N= 378) This study Lewis LM, et al* Concordant diagnoses = 83% Concordant diagnoses = 82% Top 5 of Final diagnoses Top 5 of Final diagnoses 1. Non specific 1. Non specific 2. Acute gastritis, gastroenteritis, 2. Urinary tract infection and diarrhea. 3. Intestinal obstruction 3. Calculus of urinary system 4. Acute gastroenteritis 4. Urinary tract infection 5. Gall bladder disease 5. Cholecystitis, cholelithiasis and biliary tract disease *Lewis LM, et al. J Gerontol A Biol Sci Med Sci 2005; 60: 1071-76.
  • 56. Hospitalized patients (N=100) This study Kizer1 Irvin2 Concordantstudy Kizer1 This diagnoses Concordant diagnoses Irvin2 66% 79% Biliary tract disease Non specific Intestinal obstruction 30% 26% 28% Intestinal obstruction Intestinal obstruction Non specific 17% 11% 22.5% Non specific Gastrointesitinal ulcer Cholelithiasis 10% 11% 8.9% 1. Kizer KW. Am J Emerg Med 1998; 16: 357-362. 2. Irvin TT. Br J Surg 1989; 76: 1121-1125.
  • 57. Concordant Discordant p-value diagnoses diagnoses Hospitalization 5.5 8.0 0.016 time (day) * (1.0-42.0) (2.0-136.0) Hospital costs 345.9 647.8 0.022 (USD) * (51.4-6667.4) (60.4-11681.1) *reported in median (range) calculated in hospitalized patients
  • 58. Summary The patient's presentation is frequently complex. Common diseases may present atypically in this age group. A knowledge of baseline functional status is essential for evaluating new complaints. The confounding effects of comorbid diseases must be considered. Polypharmacy is common and may be a factor in presentation, diagnosis, and management. The emergency department encounter is an opportunity to assess important conditions in a patient's personal life.(ie. caregiver needed) Lachs MS, in Sanders AB (ed): Emergency Care of the Elder Person. St. Louis,Beverly Cracom publications, 1996