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
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