GERIATRIC EMERGENCIES Joel Gernsheimer, MD, FACEP Attending Physician SUNY Downstate THE AMERICAN GERIATRICS SOCIETY Geriatrics 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 2 Emergency 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 USE BY 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 USE BY 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 SPECIAL They 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: Ann Emerg Med. 1992;21:

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’S ABC’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 COMPETENCIES FOR 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 AVOIDING IN 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 PRESENTATIONS OF 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 ELDERLY NURSING HOME PATIENTS Pneumonia UTI Skin infection Intra-abdominal infection Meningitis Endocarditis Slide 26

INCREASED MORTALITY FROM INFECTIONS 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

SUMMARY To 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

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