Geriatric EmergenciesGeriatric Emergencies

March 20, 2008

Mark Scott

March 20, 2008

Mark Scott

ObjectivesObjectives

Physiological changes of aging Polypharmacy Approach Atypical Presentations

Chest pain Abdominal pain

Geriatric Trauma

Physiological changes of aging Polypharmacy Approach Atypical Presentations

Chest pain Abdominal pain

Geriatric Trauma

Geriatric Patients are Challenging (McNamara et Al, Annals Emerg Med 1992)

Geriatric Patients are Challenging (McNamara et Al, Annals Emerg Med 1992)

Survey of 485 Emergency physicians 45% had difficulty diagnosing and treating elderly pts. Difficult presentations included: chest pain,

dizziness/vertigo, fever without focus, headache, trauma, altered LOC, and abdominal pain)

Majority believed lack of research and CME, and time spent during residency were inadequate.

Survey of 485 Emergency physicians 45% had difficulty diagnosing and treating elderly pts. Difficult presentations included: chest pain,

dizziness/vertigo, fever without focus, headache, trauma, altered LOC, and abdominal pain)

Majority believed lack of research and CME, and time spent during residency were inadequate.

GeriatricsGeriatrics Rapidly expanding subset of the population

>65 incr from 12% to 20% of population >85 will grow by 500%

Utilize more medical resources We use 90% of healthcare resurces in last 10 yrs of life Spend more time in ED More likely to receive ancillary tests Higher admission rate Higher use of ambulance

Rapidly expanding subset of the population >65 incr from 12% to 20% of population >85 will grow by 500%

Utilize more medical resources We use 90% of healthcare resurces in last 10 yrs of life Spend more time in ED More likely to receive ancillary tests Higher admission rate Higher use of ambulance

GeriatricsGeriatrics Have higher morbidity

From cardiac ds. Abdominal emergencies ICH Sepsis Trauma

More likely to present atypically

Have higher morbidity From cardiac ds. Abdominal emergencies ICH Sepsis Trauma

More likely to present atypically

Physiological Changes of AgingPhysiological Changes of Aging

Cardiac Elevated BP Decreased HR Decreased CO

Respiratory Reduced compliance and func reserve Decreased mucociliary clearance

MSK Increased calcium loss from bone Decreased muscle mass, cartilage

Neurologic: Increased wakefulness Decreased brain mass, cerebral blood flow Impaired balance

Cardiac Elevated BP Decreased HR Decreased CO

Respiratory Reduced compliance and func reserve Decreased mucociliary clearance

MSK Increased calcium loss from bone Decreased muscle mass, cartilage

Neurologic: Increased wakefulness Decreased brain mass, cerebral blood flow Impaired balance

Physiological Changes of AgingPhysiological Changes of Aging

Other Endo - Blunted B-adrenergeic response

- Increased NE, PTH, Insulin GI - prolonged transit time

- decreased splanchnic blood flow- Decreased Ca, Fe absorption

Eyes - presbyopia, cataracts, IOP Renal Skin

Other Endo - Blunted B-adrenergeic response

- Increased NE, PTH, Insulin GI - prolonged transit time

- decreased splanchnic blood flow- Decreased Ca, Fe absorption

Eyes - presbyopia, cataracts, IOP Renal Skin

Case 1Case 1

86 M “weak and dizzy”HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained

ground level fall with no LOC.PMHX: MI, OA, BPH, afib Meds: ASA 81mg po od

Ramipril 5mg po odAtorvastatin 20mg po odAcetaminophen 500mg po q6hlorazepam 1mg po hswarfarin 4mg po oddimehydrinate 25mg po q6h

86 M “weak and dizzy”HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained

ground level fall with no LOC.PMHX: MI, OA, BPH, afib Meds: ASA 81mg po od

Ramipril 5mg po odAtorvastatin 20mg po odAcetaminophen 500mg po q6hlorazepam 1mg po hswarfarin 4mg po oddimehydrinate 25mg po q6h

Could a medication be the cause this presentation?Could a medication be the cause this presentation?

Beer’s Criteria (Fick et Al, Arch Int Med, 2003)Beer’s Criteria (Fick et Al, Arch Int Med, 2003)

Guidelines for inappropriate, in-effective, and dangerous medication for age >65yrs.

Development based on extensive evidence and expert opinions

Revised over past 10 yrs Identified 48 medication/classes to avoid, and 20 medications contra-indicated for specific conditions

Guidelines for inappropriate, in-effective, and dangerous medication for age >65yrs.

Development based on extensive evidence and expert opinions

Revised over past 10 yrs Identified 48 medication/classes to avoid, and 20 medications contra-indicated for specific conditions

Beer’s Criteria (Fick et Al, Arch Int Med, 2003)Beer’s Criteria (Fick et Al, Arch Int Med, 2003)

List includes: Indomethacin (CNS effects) Ketorolac (GI bleeds) Muscle relaxants (sedation) Amitriptyline (anticholinergic Sfx, Fall risk) Diphenhydramine (anticholinergic SEs) Long acting Benzos (sedation and falls) Meperidine (CNS toxicity)

List includes: Indomethacin (CNS effects) Ketorolac (GI bleeds) Muscle relaxants (sedation) Amitriptyline (anticholinergic Sfx, Fall risk) Diphenhydramine (anticholinergic SEs) Long acting Benzos (sedation and falls) Meperidine (CNS toxicity)

PolyPharmacyPolyPharmacy

Persons over the age of 65 are taking an average of 4.2 Rx meds and 2.1 OTCs.

Over 30% will develop an adverse drug-related event.

Persons over the age of 65 are taking an average of 4.2 Rx meds and 2.1 OTCs.

Over 30% will develop an adverse drug-related event.

PolyPharmacy (Hohl et al, Ann Emerg Med 2001)PolyPharmacy (Hohl et al, Ann Emerg Med 2001)

Chart review of 283 .>65 pts presenting to the ED ADRE occurred in 10.6% 31% had at least 1 PADI Most common culprit meds: NSAIDs, Abx, anticoagulants, diuretics,

hypoglycemics, B-blockers, Ca-channel blockers, chem Tx agents. ADRE are under-diagnosed and can lead to serious morbidity.

Chart review of 283 .>65 pts presenting to the ED ADRE occurred in 10.6% 31% had at least 1 PADI Most common culprit meds: NSAIDs, Abx, anticoagulants, diuretics,

hypoglycemics, B-blockers, Ca-channel blockers, chem Tx agents. ADRE are under-diagnosed and can lead to serious morbidity.

Back to Case 1Back to Case 1

86 M “weak and dizzy”HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained

grouud level fall with no LOC.PMHX: MI, OA, BPH, afib Meds: ASA 81mg po od

Ramipril 5mg po odAtrovastatin 20mg po odAcetaminophen 500mg po q6hlorazepam 1mg po hswarfarin 4mg po oddimehydrinate 25mg po q6h

86 M “weak and dizzy”HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained

grouud level fall with no LOC.PMHX: MI, OA, BPH, afib Meds: ASA 81mg po od

Ramipril 5mg po odAtrovastatin 20mg po odAcetaminophen 500mg po q6hlorazepam 1mg po hswarfarin 4mg po oddimehydrinate 25mg po q6h

Case 2Case 2

76 M Epigastric pain and fatigue x 12hrsHPI: mild orthopnea, no asso’d sxPMHX:DM, blindRF: no HTN, 40pack year hx smoke, N lipids, no

FMhxROS: N bowels, no RFs for PUD or colon CA, no

surgical hx.Meds: nonePE: T 36.8, HR 92reg, RR20, BP 145/87, 96%RAAbdo soft, non-tender, no organomegaly

76 M Epigastric pain and fatigue x 12hrsHPI: mild orthopnea, no asso’d sxPMHX:DM, blindRF: no HTN, 40pack year hx smoke, N lipids, no

FMhxROS: N bowels, no RFs for PUD or colon CA, no

surgical hx.Meds: nonePE: T 36.8, HR 92reg, RR20, BP 145/87, 96%RAAbdo soft, non-tender, no organomegaly

Case 2 - ECGCase 2 - ECG

Myocardial Infarction in the ElderlyMyocardial Infarction in the Elderly

Elderly are more likely to have silent or atypical presentations of MI

Mortality from MI is higher in the geriatric population

Elderly are more likely to have silent or atypical presentations of MI

Mortality from MI is higher in the geriatric population

MI in the Elderly (canto et Al. JAMA 2000)MI in the Elderly (canto et Al. JAMA 2000)

Prospective observational study of 434877 pts from 1674 hospitals

33% did not have CP, more in the elderly subset Pts without CP had longer delay to hospital presentation,

in hospital mortality, less likely to receive thrombolysis of PCI, and less likely to received medical therapy.

Prospective observational study of 434877 pts from 1674 hospitals

33% did not have CP, more in the elderly subset Pts without CP had longer delay to hospital presentation,

in hospital mortality, less likely to receive thrombolysis of PCI, and less likely to received medical therapy.

MI in the Elderly (canto et Al. JAMA 2000)MI in the Elderly (canto et Al. JAMA 2000)

Suspect MI in patients presenting with:Suspect MI in patients presenting with:

Atypical chest pain: arm, jaw, abdominal pain (+/- nausea)

Acute functional decline Dyspnea Syncope Confusion Vomiting Weakness CHF Fatigue

Atypical chest pain: arm, jaw, abdominal pain (+/- nausea)

Acute functional decline Dyspnea Syncope Confusion Vomiting Weakness CHF Fatigue

Case 3Case 3

81 M Severe generalized Abdo painHPI: sudden onset 2hrs ago, 9/10 periumbilical, non-

radiating. Emesis x1, no bowel or bladder symptomsROS: no melena/hematocheziaPMHX:HTN, OA, smoker, appy 70yrs agoMeds: HCTZ, ibuprofenPE: T 37.4, HR 105reg, RR20, BP 106/75, 98%RAAbdo soft, diffusely tender, no peritoneal signs, no

organomegaly, +FOBT

81 M Severe generalized Abdo painHPI: sudden onset 2hrs ago, 9/10 periumbilical, non-

radiating. Emesis x1, no bowel or bladder symptomsROS: no melena/hematocheziaPMHX:HTN, OA, smoker, appy 70yrs agoMeds: HCTZ, ibuprofenPE: T 37.4, HR 105reg, RR20, BP 106/75, 98%RAAbdo soft, diffusely tender, no peritoneal signs, no

organomegaly, +FOBT

Abdominal Pain in the ElderlyAbdominal Pain in the Elderly

ED physicians rate abdo pain in elderly as one of most challenging presentations.(McNamara et al, 1992)

Symptoms often vague or atypical Wide ddx Abdo pain associated with much higher morbidity

and mortality in elderly.

ED physicians rate abdo pain in elderly as one of most challenging presentations.(McNamara et al, 1992)

Symptoms often vague or atypical Wide ddx Abdo pain associated with much higher morbidity

and mortality in elderly.

Abdominal Pain in the ElderlyAbdominal Pain in the Elderly

75% will get a diagnosis in the ED 63% will be admitted 20% will go to the OR 60% of causes of abdominal pain in elderly are

surgical 6-8x the mortality compared with younger pts (brewer

et Al 1976)

75% will get a diagnosis in the ED 63% will be admitted 20% will go to the OR 60% of causes of abdominal pain in elderly are

surgical 6-8x the mortality compared with younger pts (brewer

et Al 1976)

Use of CT in Older Patients with acute abdominal Pain

Use of CT in Older Patients with acute abdominal Pain

Prospective Obs study of 337 pts over the age of 60 with abdo pain Objectives:

Prevalence of use of CT in this population Describe most common diagnostic findings Determine proportion of CT scans in this population

Prospective Obs study of 337 pts over the age of 60 with abdo pain Objectives:

Prevalence of use of CT in this population Describe most common diagnostic findings Determine proportion of CT scans in this population

Hustey et al 2005Hustey et al 2005

CT ordered for 37% 57% of results were diagnostic 31% non-diagnostic 12% normal scans

75% of pts with diagnostic scans had medical or surgical interventions

5.6% of pts had medical intervention with normal CT 0% of pts with normal CT had surgical intervention

CT ordered for 37% 57% of results were diagnostic 31% non-diagnostic 12% normal scans

75% of pts with diagnostic scans had medical or surgical interventions

5.6% of pts had medical intervention with normal CT 0% of pts with normal CT had surgical intervention

CT Results of elderly pts. presenting with acute Abdo pain (n=71)

CT Results of elderly pts. presenting with acute Abdo pain (n=71)

Findings # of abdo CT scans, n (%, 95%CI)

SBO or ileus 13 (18%, 10-29%)

Diverticulitis 13 (18%, 10-29%)

Urolithiasis 7 (10%, 4-19%)

Cholelithiasis/systitis 7 (10%, 4-19%)

Abdo mass 6 (8%, 3-18%)

Pyelonephritis 5 (7%, 2-16%)

Pancreatitis 4 (6%, 2-14%)

Appendicitis in the ElderlyAppendicitis in the Elderly

• Atypical presentations are commonAtypical presentations are common• Storm-Dickerson Storm-Dickerson et al. et al. (Am J Surg 2003) Case (Am J Surg 2003) Case series of 113 patients 60 or olderseries of 113 patients 60 or older

30% had no RLQ AP 30% had no RLQ AP 67% afebrile67% afebrile 26% no 26% no WBC and 56% had no left shiftWBC and 56% had no left shift 54% of time admitting diagnosis was wrong 54% of time admitting diagnosis was wrong (21% dx = diverticulitis and 16% bowel (21% dx = diverticulitis and 16% bowel obstruction)obstruction)

• Require high index of suspicion and lower threshold Require high index of suspicion and lower threshold for CTfor CT

Ischemic ColitisIschemic Colitis

Mesenteric ischemia

Arterial diseaseVenous disease

(mesenteric venous thrombosis)

Occlusive(Superior mesenteric artery obstruction)

Non-occlusive(low flow state)

thrombotic

embolic

Mesenteric IschemiaMesenteric Ischemia

4 types:• Superior Mesenteric Artery occlusion most common

• Acute emergency (bowel infarcts in 2-3hrs)• Pain out of proportion, pain prior to emesis• Peritoneal findings are a late, ominous sign• Thrombotic (15%): RFs for vascular disease, trauma, infection• Embolic (50): RFs for embolic CVA (Valvular HD, recent MI,

arrhythmias)• May also occlude vessels of colon

• Lower abdo pain, hematochezia

4 types:• Superior Mesenteric Artery occlusion most common

• Acute emergency (bowel infarcts in 2-3hrs)• Pain out of proportion, pain prior to emesis• Peritoneal findings are a late, ominous sign• Thrombotic (15%): RFs for vascular disease, trauma, infection• Embolic (50): RFs for embolic CVA (Valvular HD, recent MI,

arrhythmias)• May also occlude vessels of colon

• Lower abdo pain, hematochezia

Mesenteric IschemiaMesenteric Ischemia

Investigations:

• Serum lactate 90% Sn (even better if serial lactate). SP ~67%.

• CT scan 85-92% Sp, but only 71-77% Sn• May see wall thickening >3mm, or pneumatosis intestinalis)

• May have +WBC or +FOBT, metabolic acidosis

• Angiogram is imaging of choice (Sn 88-98%, Sp 95%)Angiogram is imaging of choice (Sn 88-98%, Sp 95%)• If considering - perform early, even with only moderate pain.If considering - perform early, even with only moderate pain.

Investigations:

• Serum lactate 90% Sn (even better if serial lactate). SP ~67%.

• CT scan 85-92% Sp, but only 71-77% Sn• May see wall thickening >3mm, or pneumatosis intestinalis)

• May have +WBC or +FOBT, metabolic acidosis

• Angiogram is imaging of choice (Sn 88-98%, Sp 95%)Angiogram is imaging of choice (Sn 88-98%, Sp 95%)• If considering - perform early, even with only moderate pain.If considering - perform early, even with only moderate pain.

Mesenteric IschemiaMesenteric Ischemia

Mesenteric IschemiaMesenteric Ischemia

Acute Mesenteric Ischemia - Angiography

Acute Mesenteric Ischemia - Angiography

Considered the gold standard Invasive and time consuming Early and aggressive angiography has been shown to

decrease mortality from acute mesenteric ischemia (Boley et al. Surgery 1997)

Must be willing to accept many negatives to implement >90% Sn and >95% Sp

Considered the gold standard Invasive and time consuming Early and aggressive angiography has been shown to

decrease mortality from acute mesenteric ischemia (Boley et al. Surgery 1997)

Must be willing to accept many negatives to implement >90% Sn and >95% Sp

Mesenteric IschemiaMesenteric Ischemia

Mesenteric IschemiaMesenteric Ischemia

4 types con’t:• Mesenteric Venous Thrombosis (think Abdo DVT)

10% Occurs in younger patients Amenable to diagnosis with noninvasive CT Lower mortality Treated with immediate anticoagulation

Non-occlusive Mesenteric Ischemia (think abdo shock)

25% Associated with low flow states (e.g. CHF) which improves with improvement of

CO

4 types con’t:• Mesenteric Venous Thrombosis (think Abdo DVT)

10% Occurs in younger patients Amenable to diagnosis with noninvasive CT Lower mortality Treated with immediate anticoagulation

Non-occlusive Mesenteric Ischemia (think abdo shock)

25% Associated with low flow states (e.g. CHF) which improves with improvement of

CO

Possible Approach to Imaging (RL)Possible Approach to Imaging (RL)

Low to Moderate Risk Screen with CT scan and confirm

indeterminates with Angiography

High Risk Emergent angiography

Low to Moderate Risk Screen with CT scan and confirm

indeterminates with Angiography

High Risk Emergent angiography

Mesenteric Ischemia - TreatmentMesenteric Ischemia - Treatment

Resuscitation Empiric antibiotics Superior Mesenteric Artery Embolism

Angiography, intra-arterial thrombolytics, vasodilators Embolectomy, bowel resection

Superior Mesenteric Thrombosis Graft, bypass, bowel resection, +/- thrombolectomy

Mesenteric Venous Thrombosis Anticoagulation with heparin Thrombolectomy, bowel resection

NOMI Papaverine infusion with angiography, +/- resection, +/- ASA

Resuscitation Empiric antibiotics Superior Mesenteric Artery Embolism

Angiography, intra-arterial thrombolytics, vasodilators Embolectomy, bowel resection

Superior Mesenteric Thrombosis Graft, bypass, bowel resection, +/- thrombolectomy

Mesenteric Venous Thrombosis Anticoagulation with heparin Thrombolectomy, bowel resection

NOMI Papaverine infusion with angiography, +/- resection, +/- ASA

Mesenteric IschemiaMesenteric Ischemia

Overall mortality >60% More lethal than MI or CVA Mesenteric artery thrombosis > mesenteric artery

embolism > mesenteric venous thrombosis

Overall mortality >60% More lethal than MI or CVA Mesenteric artery thrombosis > mesenteric artery

embolism > mesenteric venous thrombosis

Case 4Case 4

74 F unrestrained passenger MVC (car vs. tree)

HPI: distracted driver drove into tree at 60kph. Head-on collision, no loc. c/o central chest pain.

10 Survey: seat belt sign to chest, otherwise nil

Vitals: HR65, 130/60, 22, 94%RA, c/s 5.2

PMHX: HTN, OA, hyperlipidemiaMeds: Ramipril, Metoprolol, lipitor,

ibuprofen

74 F unrestrained passenger MVC (car vs. tree)

HPI: distracted driver drove into tree at 60kph. Head-on collision, no loc. c/o central chest pain.

10 Survey: seat belt sign to chest, otherwise nil

Vitals: HR65, 130/60, 22, 94%RA, c/s 5.2

PMHX: HTN, OA, hyperlipidemiaMeds: Ramipril, Metoprolol, lipitor,

ibuprofen

Geriatric TraumaGeriatric Trauma

Only 12% of total trauma is >65yrs but, 25% of hospitalization, 36% ambulance transfers, and

25% total trauma costs Much higher mortality in elderly

1 yr mortality following traumatic hip # is 50% Case fatality rate for MVC vs pedestrian (>65) is 53%

Only 12% of total trauma is >65yrs but, 25% of hospitalization, 36% ambulance transfers, and

25% total trauma costs Much higher mortality in elderly

1 yr mortality following traumatic hip # is 50% Case fatality rate for MVC vs pedestrian (>65) is 53%

Geriatric Pts . . .Geriatric Pts . . .

Have unreliably “Normal” vitals in setting of shock Take medications to blunt compensatory mechanisms More prone to development of morbid conditions

ICH Fracture Difficult airway Sepsis, particularly pneumonia Anemia Cardiogenic shock

Have unreliably “Normal” vitals in setting of shock Take medications to blunt compensatory mechanisms More prone to development of morbid conditions

ICH Fracture Difficult airway Sepsis, particularly pneumonia Anemia Cardiogenic shock

Early invasive monitoring and rapid correction of shock state improves survival

Small study but good design Highlights importance of high index of suspicion

and aggressive management.

Early invasive monitoring and rapid correction of shock state improves survival

Small study but good design Highlights importance of high index of suspicion

and aggressive management.

SummarySummary

Geriatric pts confer much higher morbidity and mortality

Polypharmacy is here to stay! Be aware. Atypical is typical for common presentations

Fever, MI, abdo pain, etc Have lower threshold for invasive investigations

and aggressive management.

Geriatric pts confer much higher morbidity and mortality

Polypharmacy is here to stay! Be aware. Atypical is typical for common presentations

Fever, MI, abdo pain, etc Have lower threshold for invasive investigations

and aggressive management.

ReferencesReferences1. McNamara et Al. Annals of Emerg Med. Volume 21, Issue 7, July 1992,

Pages 796-8012. Tintinelli3. Amal Mattu. EM Rap: Abdominal Emergency in the Elderly. May 2006

1. McNamara et Al. Annals of Emerg Med. Volume 21, Issue 7, July 1992, Pages 796-801

2. Tintinelli3. Amal Mattu. EM Rap: Abdominal Emergency in the Elderly. May 2006