Geriatric Emergencies

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Geriatric Emergencies

• Nadim Lalani MD

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Trivia

• What style of fencing is this?

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Foil

• From 17th C
• Lightest weapon
• valid target restricted to torso
• Strict rules as to priority of hits and thus
  scoring
• Must connect with point
• 4.9 N x 15msec

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Epee

• From 19thC
• Heavier to simulate more real combat
• valid target area entire body
• double touches are allowed.
• Contact with end
• 7.5 N x 1msec

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Sabre

• From 19th C
• can cut and thrust
• valid target area everything above the waist
• (except back of the head hands)
• Priority rules like Foil

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Objectives

• Background
• Geriatric Trauma
• 2 Common Presentations
• ALOC
• Infections
• Elderly Abuse
• No syncope. No weakness
• Feel free to share Q/A fun and engaging

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Background

• Elderly 15-20 of ED visits and increasing
• Have longer ED length of stay and consume more
  resources
• More likely to arrive via ambulance and be
  admitted 40 ED admissions
• More likely to have medical rather than surgical
  admit
• Atypical presentations are the norm esp gt85yo
  oldest old
• Most common causes
• Cardiac ? Ischemic HD, dysrhythmia CHF
• Syncope
• CVA
• Pneumonia
• Abdominal disorders
• Dehydration
• UTI

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Adverse Outcomes

• Elderly pts that are sent home have signif risk
  of AOs
• Risk factors for adverse outcomes
• Decline in Baseline function
• Recent admit
• Lives alone
• No social Support
• Polypharmacy gt 3 meds
• Certain diseases CV, DM, dementia, depression
• Mortality 10 ? 3 mo after ED visit
• 25 ED bounce-back and 25 post-D/C admit rate
• Incumbent on EPs to identify and manage this
  risk

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List meds assoc with Adverse outcomes

• 12 ? 30 elders admitted in whole/part due to
  drug reactions or interactions.
• Altered pharmacokinetics pharmacodynamics
• Worst offenders
• cardiovascular meds ? diuretics ? NSAID ?
  hypoglycemics ? anticoagulants.
• Speaks to the fact that we shouldnt be fiddling
  if we can help it.

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CASE

• 70 yo trying to put up Christmas lights.
• Fall off roof.
• EMS ? can we go to PLC?
• List 3 physiologic considerations in caring for
  the elderly trauma patient and how they change
  you management.

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Physiology

• Generally more severe response to any given
  mechanism
• Airway
• Edentulous ? cant bag.
• Reduced oral diameter and neck extension.
• Breathing
• Reduced FRC, compliance and chest wall expansion
  ? Desat QUICK
• Circulation
• Limited capability to increase CO
• Might not vasoconstrict Due to cardiac meds
• Result is that these pts cannot tolerate shock
• Disability Exposure
• Dura attached to inner table ? less EDH but MORE
  SDH
• Spinal stenosis
• Osteoporotic ? trivial trauma ? fracture

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Other physiology
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Other physiology
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Other physiology
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Geriatric Trauma

• Injury significant cause of death due to
• Physiologic differences
• Injury patterns
• gt 80 trauma 4 fold mortality cf younger
  trauma pts
• Falls 40 ? MVC auto vs ped ? other assault
• Gimme 3 risk factors for falls
• RFs
• Meds narcotics, cardiac meds
• Hx CVA
• Cognition
• Visual and hearing impairment

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Falls and MVCs

• Falls
• ¼ due to underlying medical condition
• Most common injury is s occurring in 5
• Even with minor mechanism, absence of clinical
  findings does not rule out injury.
• Low threshold for radiography
• MVCs
• NB Single-vehicle Accidents ? need to r/o medical
  cause
• Mortality as high as 20
• Am Coll Surg recommendations anyone gt 55 goes to
  trauma centre.

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Back to Case

• 70 yo Male in collar on spine board.
• VS 80, 110/45, 30, 90, 370, c/s 5.0, GCS E3,
  V4, M6
• AMPLE ? on BB/warf for AF. HCTZ for HTN has RA
• C/o numb fingers, L chest wall pain.
• O/e Tender L CW, Abdo non-specific tender but
  soft. Cannot do pelvis because RT is doing a
  fem-poke
• Doctor?

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Head injuries

• Much higher mortality ? 1/5 SDH do not survive
• 75 admit rate
• Indications for warfarin reversal?
• What if he tripped, fell, small abrasion
  forehead. GCS 15. No deficits? Management?
• Minimal mechanism coumadin Normal exam 7-
  15 serious intracranial hemorrhage.
• ULTRA LOW THRESHOLD FOR CT

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Acute/chronic Subdural
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Spinal Injuries

• Most common mech is a fall
• Degen joint dis ? reduced mobility ? brittle
  spinal column
• Most common level of injury is C1-C3
• Most common injury is Type 2 Odontoid
• Overall mortality 15

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Central Cord Syndrome

• Two places where spinal cord is large relative to
  canal
• C5-T1 brachial plexus L2-S3 lumbosacral
  plexus.
• Limited space Hyperextension injury ? cord gets
  pinched by inward bulging of ligamentum flavum ?
  central contusion
• Clinically
• Bilateral motor weakness of upper extremities gtgt
  lower extremities
• distal muscle groups gtgt proximal muscle groups.
• Can have burning dysesthesias in upper
  extremities.
• Variable prognosis ? goes by age
• gt 50yo ? only 30 regain bladder function 50
  regain ambulation.

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Central Cord
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Chest Injuries

• Falls gtgt MVC cause broken ribs
• Increased incidence of solid organ injury
• CANNOT tolerate
• huge risk of respiratory failure and Pneumonia
• BOTTOM LINE Elderly rib fractures ? Low
  threshold for admit.

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Abdominal Injuries

• Seen in 30 older trauma patients.
• Mortality 25
• Even with careful selection, Non-operative
  management only 75 success.
• Unreliable exam Liberal use of CT

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Pelvic Injuries

• Falls ? break pelvis ? also bleed more
• Rami gtgt acetab gtgt ischium
• Aggressive management
• Binder
• Warm Fluids
• Blood
• Consider embolisation
• GLF no on xray cannot walk?
• Needs MRI

myweb.lsbu.ac.uk
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Extremity Injuries

• Low mechanism osteoporosis Fracture!
• Perform really good tertiary survey EVEN FOR
  MEDICAL PATIENTS
• Case of syncope on park bench ? when went to
  check for pedal edema ? ouch! ? had ankle on
  Xray!
• Low threshold for radiography

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Trauma Summary

• Go into elder mode
• Liberal use of radiography
• Think of elder-specific issues central cord
• Elder Airway ? Edentulous, reduced mouth
  open/neck mobility
• Elder Breathing ? rib fractures signif
  morbidity
• Elder Circulation ? meds will hide shock. PELVIS!

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Mental break

• Quiz Which of these are new features on the Wii
  Tiger Woods 2009 All Play game?
• Online play
• All-play mode for beginners
• 11 swing
• Create your own avatar
• Juggle the golf ball on club

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Name the shot
link
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Case 2

• 83 yo F sent in from NH confused
• Hx COPD, Deaf, ? Dementia, OA, Diverticulitis.
• Outline Key aspects of the history
• Outline Key aspects of Exam
• Ddx?

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ALOC in the Elderly

• Prevalent in the ED.
• Associated with adverse outcomes
• Poorly recognised and even more poorly documented
• EPs assume that dementia is being managed ?NOT
• Still high rate of mis-diagnosis of delirium
• Mortality 20

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ALOC in the Elderly
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Evaluation

• Difficult
• Average elderly pt has 3 medical conditions. NH
  patient 10
• Will end up using more tests
• Despite this need to bite the bullet and be
  meticulous and thorough
• H/x should be exhaustive a la Pediatric hx
• P/e should be more meticulous.
• NB they have benign presentations despite
  catastrophic path.

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Elder History
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Elder Exam
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(No Transcript)
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Poor Mans Ddx
IS IT MEATh? I?intracranial Hemorrhage
S?structural AbN /STROKE I?infection
mening,enceph or sepsis T?trauma M?metabolic
hypoGlycemia, hypo/hyper Na,hepatic,,
hypoCa, HypoMg E? endocrine A?anoxia/ischemia
cardiac arrest, severe hypox T?toxins/Drugs AS
A, antiD, w/drawal h?htn encephalopathy
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Delirium? Dementia? Psychosis?
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Know this

• Delirium
• Sudden onset
• Fluctuating course
• Reduced or clouded LOC
• Disordered attention
• Disordered cognition
• Impaired orientation
• Visual hallucinations
• Transient delusions, poorly organized
• Asterixus/tremor

• Dementia
• Insidious onset
• Stable course
• Alert
• Normal attention
• Impaired cognition
• Impaired orientation
• Hallucinations usu absent
• Delusions absent
• No abN movements (usu)

Dr. Kowal 2003
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Delerium vs Psychosis
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Does this patient have delirium?

• Validated assessment of delirium
• Sens 95 spec 95
• CAM should be documented on every chart

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Back to case
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Eldery Infections

• Higher risk due to physiologic changes
• Higher morbidity and mortality cf younger pts
• Can be difficult to sort out due to
• Vague presentation ? ALOC weakness
• Atypical features and low sensitivity of serum
  markers
• Co-morbidities

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Elderly Fever/bacteremia

• 10 of ED visits
• When present almost always bacterial
• Absence of fever not reassuring.
• Afebrile bacteremia in 20
• NH patients in particular do not seem to mount a
  febrile response.
• Should prompt a thorough search
• CBC, BC, Urine Culture and CXR
• ¾ will end up being admitted

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Elderly fever/Bacteremia

• Most common complaints ? ALOC, Weakness,
  confusion and decreased functional status
• gt 85yo more likely to present atypically
• Urine gtgt resp gtgt unkown gtgt abdo

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Back to case
http//www.medvarsity.com
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Questions

• Should the patient be admitted?
• What is the treatment for elderly CAP?
• What about NHAP?

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Elderly Pneumonia

• Leading cause of death. Particularly prevalent in
  gt85.
• Atypical presentations esp in NH patients ALOC
  more likely
• CAP mortality is 10 overall
• NHAP ? much higher mortality

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Pneumonia
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Pneumonia risk stratification

• Risk Stratification by Pneumonia Severity Index
• Validated score based on 14 clinical and 7 lab
  variables
• Group 1 score lt51 Low risk ? mort only 0.5
  ? outpatient rx
• Group II 51-70 mort 0.9 ? Same ? outpatient rx
• Group III 71-90 mort 1.2 ? intermediate risk
• consider for outpt rx if theyre only in group on
  the basis of age, one comorbidity or one abn
  finding.
• To be safe ? short admit for group III
• Group IV gt91 points 9 mort ? admit
• Group V gt130 points 27 mort ? admit

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Pneumonia Severity Index
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Community Acquired

• CAP
• S pneumo ? 50
• H.Flu Moraxella
• Atypicals mycoplasma ,chlamydia , legionella ?
  15
• Post influenza S aureus
• Management
• Outpatient no co-morbidities? ? usual meds Zpack
  etc
• Comorbidities? ? resp fluoroquinolone GATi,
  GEMI, LEVO, MOX

Sandford 2008
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Nursing Home Pneumonia Hospital Acquired

• Recognition that NHAP bugs are similar to HAP
• S Pneumo
• Gm Negs
• AnO2
• Staph
• Outpatient?
• RespFQ or Clavulin macrolide
• Inpatient? IV Levo or Ceft/Azthro

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Case

• 85yo F brought in by EMS c/o weakness and SOB
• Fell 6/7 agodoing better for 2/7 now
  non-ambulatory
• Pmhx Htn, ? Silent MI, Tremor, OA
• M HCTZ, ASA, Primodine, Tylenol, Zopiclone
• O/e HR 110, BP 90/60, RR 30, SpO2 70 RA, 35.0
• L arm grossly ecchymotic. Swollen L wrist
• R leg short/ext rotated ? deformed crepitus
• Obvious decubitus sores

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Collateral

• Level II ? no heroics
• Lives with sis B in Law whos a retired GP
• States I assessed her and thought she was okay
  didnt want to come to hosp as she doesnt like
  it
• Was ambulating 2 days after fall ? then last 2/7
  in bed not eating/ weak.
• Doctors?

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Elder Abuse Neglect

• Global Health Problem est 200,000/y in Canada
• Mean 78 y, 2/3 are women
• Most victims live with perps ? 2/3 perps are
  family
• Only 1/14 cases actually reported
• Definitions
• Domestic abuse
• Institutional Abuse
• Self-neglect

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Categories of elder abuse

• Victims often subject to gt1 type
• Physical
• Sexual
• Emotional/psychological
• Neglect
• Abandonment
• Financial/material exploitation

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Risk factors for Abuse

• Caregiver rfs
• Alchohol/drugs
• Unemployed
• Stress/burnout
• No caregiving skills
• Elder rfs
• Female
• Financially dependant
• Immobility
• Hx Fam violence

• Environment
• Living together
• Cramped
• Isolated
• Institutional rfs
• Low wages
• Poor work environmt
• Poor training
• Low staff-Patient ratio

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Indicators?
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Screening P/e?

• Physical Abuse
• Contusions bilateral arms grab marks
• Burns
• Imprints of weapons/ligatures
• Multiple fractures
• Sexual Abuse
• Genital tears
• Evidence of STI
• Neglect
• Hygeine lying in feces?
• Bed sores

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Duty to Report

• The Alberta Protection for Persons in Care Act
  1998
• Duty to Report protected from reprisal
• Call SW
• Call Police

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References
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Questions?