Geriatric Emergencies

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Geriatric Emergencies
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Demographic Imperative

• People gt65 y.o. are fastest growing segment of
  U.S. population
• By 2030 elderly will make up 22 of population

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Factors Complicating Assessment

• Variability
• More variety in health status at any given age
  than younger people

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Factors Complicating Assessment

• Response to Illness
• Seek assistance for only small part of symptoms
• May perceive important symptoms as just getting
  old
• May delay seeking treatment
• May trivialize chief complaints

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Factors Complicating Assessment

• Presence of multiple pathology
• 85 have one chronic disease
• 30 have gt3 chronic diseases
• Acute illness in one system may stress reserve
  capacity of another
• Symptoms of one disease may mask another
• Treatment of one disease may mask another

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Factors Complicating Assessment

• Altered presentations
• Pain diminished, absent
• Temperature regulation depressed
• Thirst mechanisms depressed
• Increased susceptibility to confusion,
  restlessness, hallucinations
• Increased susceptibility to generalized
  deterioration
• Vague, poorly defined complaints

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• The Organs of the Aged Do NOT Cry!

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Factors Complicating Assessment

• Communication Problems
• Diminished sight
• Diminished hearing
• Diminished mental faculties
• Depression
• Poor cooperation, limited mobility

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Factors Complicating Assessment

• Polypharmacy
• 30 of geriatric hospitalizations are drug
  induced!!!

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History Taking

• Probe for significant symptoms
• Chief complaint may be trivial, non-specific
• Patient may not volunteer information

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History Taking

• Talk to patient first
• If possible, talk to patient alone
• Formal, respectful approach
• Face patient near center of visual field
• Reduce background noise
• Speak slowly and enunciate
• Do NOT shout!

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History Taking

• Thorough medication history
• More than one MD
• More than one pharmacy
• Multiple medications
• Old vs. current medications
• Shared medications
• Over-the-counter medications

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Physical Exam

• Examine in warm area
• May fatigue easily
• May have difficulty with positioning for exam
• Consider modesty
• Decreased pain sense requires thorough exam
• If they say something hurts, evaluate carefully

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Physical Exam

• Findings may be misleading
• Inelastic skin mimics decreased turgor
• Mouth breathing gives impression of dehydration
  (dry oral mucosa)
• Pedal edema may result from inactivity, dependent
  positioning of feet
• Peripheral pulses may be difficult to feel

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Specific Problems
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Trauma

• Head Injury
• More common, even with minor trauma
• Signs of increased ICP develop slowly
• Patient may have forgotten injury

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Trauma

• Cervical Spine Injury
• Osteoporosis Increased risk of injury with
  trivial accidents
• Arthritic changes Narrow spinal canal,
  increased injury risk
• Sudden neck movement may cause cord injury
  without fracture
• Decreased pain sensation may mask fx

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Trauma

• Cardiovascular System/Shock
• Decreased ability to compensate
• Move to irreversible shock very rapidly
• Tolerate shock poorly, even for short periods
• Hypoperfusion may lead to CVA, MI, bowel
  infarcts, renal failure, adult respiratory
  distress syndrome

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Trauma

• Cardiovascular System/Shock
• May be hypoperfused at normal pressures
• Chronic beta blocker therapy may mask signs of
  shock

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Cardiovascular Disease

• Acute Myocardial Infarction
• Silent MI much more common
• May present as dyspnea 2o to CHF
• May present with signs, symptoms of acute
  abdomen, including tenderness/rigidity

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Cardiovascular Disease

• Acute Myocardial Infarction
• Vague symptoms
• Weakness
• Fatigue
• Syncope
• Incontinence
• TIA/CVA
• Confusion

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Cardiovascular Disease

• Congestive Heart Failure
• May present with episodes of nocturnal confusion
• May present with large blisters on legs,
  especially if patient sleeps sitting up
• Bed-ridden patients may have fluid accumulation
  over sacrum rather than in feet, legs

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Environmental Emergencies

• Tolerate exposure to temperature extremes poorly
• Be suspicious of altered mental status or vague
  presentations in hot or cool environments

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Neuropsychiatric Problems

• Dementia or confusion
• Distinguish between acute and chronic onset
• Never assume acute dementia is due to senility
• Possible causes

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Neuropsychiatric Problems

• Depression
• Common in elderly
• May account for symptoms attributed to senility
• Persons gt65 y.o. account for 25 of all suicides
• Consider depression to be immediate life-threat

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Geriatric Abuse/Neglect

• Physical or psychological injury to older person
  by their children or other care providers
• Knows no socioeconomic bounds

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Geriatric Abuse/Neglect

• Contributing factors
• Older patients Average age is mid-80s
• Multiple chronic diseases
• Unable to be totally independent
• Often has sleep pattern disruption leading to
  nocturnal wandering or shouting
• Family often has difficulty upholding commitment
  to care

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Geriatric Abuse/Neglect

• Primary findings
• Trauma inconsistent with history
• History that changes with multiple tellings