Issues in Geriatric Medicine

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Issues in Geriatric Medicine

• Juliette Sacks
• November 9, 2006

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Outline

• Aging changes
• Polypharmacy
• Chest pain
• Abdominal pain
• Not included Falls, Head injury, Trauma, altered
  LOC

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Elderly

• Fastest growing subset of population especially
  gt85 yrs of age
• More likely to have emergency diagnosis than
  younger demographic
• More likely to manifest atypical symptoms

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McNamara et al.

• 45 or more of emergency physicians have
  difficulty in the management of older
  patientsThey take more time and resources than
  younger patients
• Practicing emergency physicians are
  uncomfortable with elderly patients, and this may
  reflect the inadequacies of training, research,
  and continuing medical education in geriatric
  emergency medicine.

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Physiology of Aging

• CVS
• Increased BP
• Decreased HR, CO, vessel elasticity, cardiac
  myocyte size and number, B-adrenergic
  responsiveness
• Endocrine
• Increased NE, PTH, insulin, vasopressin
• Decreased thyroid and adrenal corticosteroid
  secretion
• Gastrointestinal
• Increased intestinal villous atrophy
• Decreased esophageal peristalsis, gastric acid
  secretion, liver mass, hepatic blood flow,
  calcium and iron absorption
• Integumentary
• Atrophy of sebaceous and seat glands
• Decreased dermal and epidermal thickness, dermal
  vascularity, melanocytes, collagen synthesis

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Physiology contd

• Reproductive
• Decreased androgen, estrogen, sperm count,
  vaginal secretion
• Decreased ovary, uterus, vagina, breast size
• Respiratory
• Increased tracheal cartilage calcification,
  mucous gland hypertrophy
• Decreased elastic recoil, mucociliary clearance,
  pulmonary function reserve
• Renal and urologic
• Increased proteinuria, urinary frequency,
• Decreased renal mass, creatinine clearance, urine
  acidification, hydroxylation of vitamin D,
  bladder capacity
• Special senses
• Decreased lacrimal gland secretion, lens
  transparency, dark adaptation, sense of smell and
  taste
• Increased presbyopia

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Physiology contd

• MSK
• Increased calcium loss from bone
• Decreased muscle mass, cartilage
• Neurologic
• Increased wakefulness
• Decreased brain mass, cerebral blood flow

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Causes of morbidity and mortality in seniors
Morbidity
Arthritis
Hypertension
Allergies
Back problems
Heart disease
Cataracts
Diabetes
Mortality
Heart/vascular disease (41)
GI disease (35)
Cancer (25)
Respiratory disease (11)
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Geriatric PharmacologyAge associated
pharmacokinetics
Parameter Age Effect Implications
Distribution total body fat, lean body mass, total body water and albumin Lipophilic drugs have larger volume of dist increased binding of basic drugs
Elimination renal blood flow, GFR, tubular secretion and renal mass For every x reduction in clearance, decrease the dose by x and increase the interval by x
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Absorption in gastric pH splanchnic blood flow, GI absorptive surface, dermal vascularity delayed gastric emptying Dug-drug and drug-food interactions more likely to affect absorption.
Metabolism in hepatic mass and hepatic blood flow impaired oxidative reactions Lower doses may be therapeutic.

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Pharmacodynamics

• Less predictable
• Altered drug response at usual or lower
  concentrations
• Increased sensitivity to sedative hypnotics,
  anticholinergics, analgesics, warfarin
• Decreased sensitivity to B blockers

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Polypharmacy

• Definition
• Prescription, administration or use of more
  medications than are clinically indicated
• Epidemiology
• Over 25 of elderly women and 20 of elderly men
  reported using gt3 medications
• Average elderly person takes 4.5 prescription
  drugs and 2.1 OTC meds daily (Rosens)
• Hospitalized elderly are given an average of 10
  meds over admission
• LTC residents take an average of 7.2 meds daily

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Adverse Drug Reactions (ADRs)

• Any noxious or unintended response to a drug that
  occurs at doses used for prophylaxis or therapy
• Risk factors in the elderly
• Intrinsic co-morbidities, age related
  pharmacokinetic changes, pharmacodynamics
• Extrinsic of meds multiple prescribers
  unreliable drug history
• 90 are from ASA, analgesics, anticoagulants,
  antimicrobials, antineoplastics, digoxin,
  diuretics, hypoglycemics, steroids
• 12 30 of admitted elderly pts have ADRs as
  primary cause of presentation to ED

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Preventing Polypharmacy

• Consider the drug safer side effect profiles
  convenient dosing schedules convenient route,
  efficacy
• Consider the patient other meds clinical
  indications co-morbidities
• Consider patient-drug interaction risk factors
  for ADRs
• Review drug list to eliminate meds with no
  clinical indication or with evidence of toxicity
• Avoid treating ADRs with another medication

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Inappropriate Prescribing

• Beers Criteria (1997)
• Explicit criteria to identify inappropriate
  medications for people gt65 yrs of age
• Examples include long acting BDZ, strong
  anticholinergics, high dose sedatives
• Elderly are often under treated (ACEI, ASA, BB,
  thrombolytics, coumadin)

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Updating the Beers Criteria

• Updating the Beers Criteria for Potentially
  Inappropriate Medication Use in Older Adults
  Results of a US Consensus Panel of Experts
• Donna M. Fick, PhD, RN James W. Cooper, PhD,
  RPh William E. Wade, PharmD, FASHP, FCCP
  Jennifer L. Waller, PhD J. Ross Maclean, MD
  Mark H. Beers, MD
• Arch Intern Med. 20031632716-2724.

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Updating Beers

• 30 of hospital admissions in elderly patients
  may be linked to ADRs that lead to depression,
  constipation, falls, immobility, confusion and
  hip fractures.
• Medication related problems would be 5th leading
  cause of death in US.
• Beers is based on expert consensus from
  literature review with bibliography and
  questionnaire evaluation by experts in geriatric
  care, pharmacology, psychopharmacology.

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Beers Criteria

• Applies to those over the age of 65 years
• Three main aims
• 1) reevaluate the 1997 criteria to include new
  products and incorporate new information from
  scientific literature
• 2) assign or reevaluate a relative rating of
  severity for each medication
• 3) identify any new conditions or considerations
  since 1997.

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Beers Criteria

• 48 individual/classes of meds to avoid
• 20 diseases/conditions, individual/classes meds
  to avoid
• Including
• Indomethicin
• Keterolac
• Muscle relaxants
• Amytriptyline
• Diphenhydramine
• Long acting BDZ
• Meperidine

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Polypharmacy in the ED

• Polypharmacy, adverse drug-related events, and
  potential adverse drug interactions in elderly
  patients presenting to an emergency department
• Corinne Michèle Hohl MD, Jerrald Dankoff MD,
  Antoinette Colacone BSc, CCRA and Marc Afilalo
  MD, FRCPCFrom the McGill University Royal
  College Emergency Medicine Residency Training
  Program, and the Department of Emergency
  Medicine, Sir Mortimer B. Davis-Jewish General
  Hospital, McGill University, Montreal, Quebec,
  Canada.
• Annals of Emergency Medicine Volume 38, Issue 6
  , December 2001, Pages 666-671

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Hohl et al.

• Retrospective chart review of 300 randomly
  selected ED visits by patients 65 years of age
  and older between Jan. Dec. 1998
• ADRs defined according to a standardized
  algorithm
• 257/283 (90.8) pts were taking gt1 med
• Average number of meds 4.2/pt (0-17)
• ADRs 10.6 of all ED visits

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Hohl et al.

• Medications most frequently involved
• NSAIDs
• Antibiotics
• Anticoagulants
• Diuretics
• Hypoglycemics
• Bblockers
• CCB
• Chemotherapeutic drugs
• Consistent with Beers criteria
• ADRs underestimated but important source of
  morbidity in elderly

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Myocardial Infarction

• Presentation is frequently atypical
• Atypical presentation is not more benign
• High index of suspicion is required
• Up to 30 of patients with ACS may experience no
  chest pain at all (Umachandran et al, 1991)

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Suspect MI in patients with

• No chest pain
• Atypical chest pain arm, jaw, abdominal pain
  (/- nausea)
• Acute functional decline
• Dyspnea
• Syncope
• Confusion
• Vomiting
• Weakness
• CHF
• Fatigue

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Coronado et al.

• Clinical features, triage, and outcome of
  patients presenting to the ED with suspected
  acute coronary syndromes but without pain A
  multicenter study. 
• The American Journal of Emergency
  Medicine, Volume 22, Issue 7, Pages 568-574
• B. Coronado, J. Pope, J. Griffith, J. Beshansky,
  H. Selker

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Coronado et al

• Prospective clinical trial of all adults gt30 y.o.
  who presented to ED with symptoms suggestive of
  ACS to EDs of 10 US hospitals
• Including chest pain, chest pressure, left arm
  pain, jaw pain, upper abdominal pain, dizziness,
  nausea, vomiting, dyspnea
• Painless presentation included complaints of SOB,
  extreme fatigue, nausea or fainting

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Coronado et al

• 10783 subjects
• ACS diagnosed in 24 of which 35 had AMI and 65
  had UA
• Pain was absent in 6.2 of patients with acute
  ischemia and 9.8 with AMI
• Those without pain tended to be
• Older
• Women
• Had cardiac and related diseases

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Characteristics of Patients with Cardiac Ischemia
by Clinical Presentation (n2541)
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Other findings

• AMI without pain
• Fewer patients admitted to CCU
• Increased hospital mortality
• Higher incidence of heart failure
• Under treatment of these patients
• Increased incidence of diabetes, prior
  infarctions
• Slower time to assessment from triage

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Abdominal Pain

• Difficult but common complaint 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
• 10x the mortality compared with younger pts

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DDx of Abdominal Pain in Elderly Patients
Disorder Incidence
Cholecystitis/ Biliary Colic 12-41
Nonspecific abdo pain 9.6-23
Appendicitis 2.5-15.2
Obstruction 7.3-14
Hernia 4.0-9.6
Perforation 2.3-7.0
Pancreatitis 2.0-7.3
Diverticular Disease 3.4-7.0
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Why worry?

• May present with few or no symptoms
• May have vague symptoms with serious illness
• Complication rates are higher with serious
  consequences
• May need lab tests and imaging to supplement
  equivocal physical exam
• Admission and observation often necessary

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Imaging in abdominal pain in the elderly

• The American Journal of Emergency Medicine Volume
  23, Issue 3 , May 2005, Pages 259-265 The use
  of abdominal computed tomography in older ED
  patients with acute abdominal pain
• Fredric M. Hustey MD, Stephen W. Meldon MD,
  Gerald A. Banet RN, MPH, Lowell W. Gerson PhD,
  Michelle Blanda MD and Lawrence M. Lewis MD

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background

• Abdominal pain accounts for 3-4 of all ED visits
  in gt65 yrs of age
• Associated with morbidity and mortality
• Seniors have 2x rate of surgery
• 6-8x increase in mortality
• Evaluation requires more time, resources and
  interventions

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Hustey et al

• Prospective, multicenter study regarding the
  etiology and clinical course of older ED patients
  with acute nontraumatic abdominal pain
• 3 objectives
• Prevalence of use of CT in this population
• Describe most common diagnostic findings
• Determine proportion of CT scans in this
  population

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Demographics

• 337 enrolled
• Gender
• Women 222/337 66
• Men 115/337 34
• Age
• 60-69 135/337 40
• 70-79 117/337 35
• gt80 85/337 25

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Most common diagnostic CT findings in older ED
patients with acute abdominal pain (n 71)
Findings of abdo CT scans, n (, 95CI)
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)
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Most common diagnostic CT findings in older ED
pts receiving acute medical intervention (n36)
Findings of abdo CT scans, n (, 95CI)
Diverticulitis 11 (31, 16-48)
SBO 9 (25, 12-42)
Pancreatitis 3 (8, 2-23)
Urolithiasis 3 (8, 2-23)
Abdo mass/neoplasm 3 (8, 2-23)
Pyelonephritis 2 (6, 0-19)
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CT findings diagnostic of abdominal pain

• 57 diagnostic scans
• 31 nonspecific scans
• 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

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Mesenteric Ischemia
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Mesenteric Ischemia

• Low intestinal blood flow caused by occlusion,
  vasospasm
• Can result in sepsis, bowel infarction, death
• Can be acute or chronic timing is dependent
  upon rapidity and degree to which blood flow is
  compromised

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Acute Mesenteric Ischemia

• Arterial occlusion is caused by emboli,
  thrombosis of mesenteric arteries
• Venous obstruction is caused by thrombosis,
  segmental strangulation
• Non-occlusive disease is caused by primary
  splanchnic vasoconstriction

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Response to ischemia

• If there is insufficient oxygen and nutrients for
  cellular metabolism, ischemic injury occurs
• Bowel can maintain itself up to 12h by increased
  oxygen extraction from collateral circulation
• With progressive vasoconstriction there is
  decompensation of collateral flow and subsequent
  increased vascular pressures leading to a
  reduction in flow with resultant hypoxia and
  reperfusion injury

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Risk Factors

• Advanced age
• Atherosclerosis
• Low cardiac output states
• Severe valvular heart disease
• Recent MI
• Intra-abdominal malignancy

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High Risk Patients for Mesenteric Ischemia

• Superior Mesenteric Artery Embolism (50)
• Valvular heart disease, recent MI, dysrhythmias
• Thrombus from left atrium, left ventricle, valves
• Superior Mesenteric Artery Thrombosis (15-25)
• PVD, atherosclerotic disease, abdominal trauma,
  infections
• Mesenteric Venous Thrombosis (10)
• Hypercoagulable state, portal hypertension,
  abdominal infections, trauma, pancreatitis,
  splenectomy

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NOMI MVT

• NOMI
• Caused by mesenteric vasospasm
• Cardiac and cerebral blood flow is maintained
  preferentially at the expense of splanchnic
  circulation
• MVT
• Resistance in mesenteric venous blood flow causes
  wall edema
• Fluid exudes into lumen causing systematic drop
  in blood pressure
• Increased blood viscosity with concomitant
  stagnant arterial blood flow
• Resultant submucosal infarction and hemorrhage

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Presentation

• Poorly localized abdominal visceral-type pain
  without tenderness
• Pain may resolve as mucosa infarcts and then,
  with development of full thickness intestinal
  necrosis, peritoneal findings are manifested
• pain out of proportion to physical exam
• /- nausea and vomiting
• Mental status changes occur in 1/3 of elderly
  patients

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Is it small bowel or colon?

• It is colon if there is
• Lower abdominal pain
• Hematochezia
• It is small bowel if there is
• Severe pain
• Pain prior to vomiting

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How to differentiate between types

• Onset
• Embolic abrupt
• MVT slow
• Arterial thrombosis intermediate timing
• Non-Occlusive Mesenteric Ischemia
• Associated with low flow states (e.g. CAD) which
  improves with improvement of CO

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4 types contd

• MVT
• Occurs in younger patients
• Amenable to diagnosis with noninvasive CT
• Lower mortality
• Treated with immediate anticoagulation
• Papaverine infusion with arteriography
• Treatment of splanchnic vasoconstriction

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Lab Tests

• Metabolic acidosis
• May have increased WBC
• May have FOB
• May have elevated serum lactate

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Diagnostic Tests
Diagnosis Test Sensitivity Specificity LR LR-
Small bowel ischemia Angiography 88 (62-98) 95 (93-100) 18 0.1
Small bowel ischemia CT and CT angio 77 (57-92) 85 (71-100) 5 0.3
Small bowel ischemia Gadolinium enhanced MRI 83 (78-100) 89 (71-99) 8 0.2
Small bowel ischemia Serum lactate 90 (66-100) 62 (42-77) 2 0.2
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Imaging

• Radiography
• Plain films r/o free air, ileus,
  intussusception, volvulus
• Pneumatosis intestinalis gt30 of patients
• Portal venous gas (rare)
• CT
• will show wall thickening gt3mm
• Large vessel disease is diffuse (SMA, SMV, IMA,
  IMV)
• Small vessel disease is focal
• Arterial occlusive disease segment will not
  enhance
• Venous occlusive disease segment will enhance
  due to retarded flow
• False positive ulcerative colitis
• False negative lymphoma, adenocarcinoma

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Angiography

• Gold standard
• Invasive
• Early intervention reduces mortality
• Shows attenuation, vasoconstriction, occlusion of
  vessel
• Less sensitive for veno-occlusive disease

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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

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Mortality

• Mortality rate can be gt60
• 25 if due to arterial emboli
• 29 if due to venous thrombosis
• 60 if due to arterial thrombosis

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In conclusion

• Polypharmacy is an important cause of morbidity
  in the elderly
• ADRs are often underestimated
• Think AMI in patients without chest pain who are
  female, elderly, present with CHF, DM
• Abdominal pain in old folks is often surgical,
  presents atypically and has high mortality
  associated with it.

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References

• Hustey FM et al. The use of abdominal computed
  tomography in older ED patients with acute
  abdominal pain. Am J Emerg Med (2005) 23259-265.
• Coronado et al. Clinical features, triage, and
  outcome of patients presenting to the ED with
  suspected acute coronary syndromes but without
  pain a multicenter study. Am J Emerg Med (2004)
  22568-574.
• Fick DM et al. Updating the Beers Criteria for
  potentially inappropriate medication use in older
  adults. Arch Int Med (2003) 1632716-2724.
• Hohl CM et al. Polypharmacy, adverse drug-related
  events, and potential drug interactions in
  elderly patient presenting to an emergency
  department. Ann Emerg Med (2001) 38666-671.
• Birnbaumer DM. Chapter 176 The Elder Patient.
  Rosens Emergency Medicine Concepts and Clinical
  Practice. Section III.2485-2491.
• Reuben DB et al. Geriatrics. 2006-2007 8th
  edition. American Geriatric Society.
• Tintinalli JE et al. Emergency Medicine A
  comprehensive study guide. McGraw Hill. 2004.
• McNamara RM et al. Geriatric Emergency Medicine
  A Survey of Practicing Emergency Physicians. Ann
  Emerg Med (1992) 21796-801.