Geriatric Emergencies

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Geriatric Emergencies

• March 20, 2008
• Mark Scott

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Objectives

• Physiological changes of aging
• Polypharmacy
• Approach Atypical Presentations
• Chest pain
• Abdominal pain
• Geriatric Trauma

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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.

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Geriatrics

• Rapidly expanding subset of the population
• gt65 incr from 12 to 20 of population
• gt85 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

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Geriatrics

• Have higher morbidity
• From cardiac ds.
• Abdominal emergencies
• ICH
• Sepsis
• Trauma
• More likely to present atypically

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Physiological 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

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Physiological 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

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Case 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 od
• Atorvastatin 20mg po od
• Acetaminophen 500mg po q6h
• lorazepam 1mg po hs
• warfarin 4mg po od
• dimehydrinate 25mg po q6h

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Could a medication be the cause this presentation?

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Beers Criteria (Fick et Al, Arch Int Med, 2003)

• Guidelines for inappropriate, in-effective, and
  dangerous medication for age gt65yrs.
• 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

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Beers 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)

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PolyPharmacy

• 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.

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PolyPharmacy (Hohl et al, Ann Emerg Med 2001)

• Chart review of 283 .gt65 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.

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Back 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 od
• Atrovastatin 20mg po od
• Acetaminophen 500mg po q6h
• lorazepam 1mg po hs
• warfarin 4mg po od
• dimehydrinate 25mg po q6h

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Case 2

• 76 M Epigastric pain and fatigue x 12hrs
• HPI mild orthopnea, no assod sx
• PMHXDM, blind
• ?RF no HTN, 40pack year hx smoke, N lipids, no
  FMhx
• ROS N bowels, no RFs for PUD or colon CA, no
  surgical hx.
• Meds none
• PE T 36.8, HR 92reg, RR20, BP 145/87, 96RA
• Abdo soft, non-tender, no organomegaly

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Case 2 - ECG
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Myocardial 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

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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.

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MI in the Elderly (canto et Al. JAMA 2000)
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Suspect MI in patients presenting with

• Atypical chest pain arm, jaw, abdominal pain
  (/- nausea)
• Acute functional decline
• Dyspnea
• Syncope
• Confusion
• Vomiting
• Weakness
• CHF
• Fatigue

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Case 3

• 81 M Severe generalized Abdo pain
• HPI sudden onset 2hrs ago, 9/10 periumbilical,
  non-radiating. Emesis x1, no bowel or bladder
  symptoms
• ROS no melena/hematochezia
• PMHXHTN, OA, smoker, appy 70yrs ago
• Meds HCTZ, ibuprofen
• PE T 37.4, HR 105reg, RR20, BP 106/75, 98RA
• Abdo soft, diffusely tender, no peritoneal signs,
  no organomegaly, FOBT

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Abdominal 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.

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Abdominal 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)

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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

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Hustey 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

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CT Results of elderly pts. presenting with acute
Abdo pain (n71)
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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Appendicitis in the Elderly

• Atypical presentations are common
• Storm-Dickerson et al. (Am J Surg 2003) Case
  series of 113 patients 60 or older
• 30 had no RLQ AP
• 67 afebrile
• 26 no ?WBC and 56 had no left shift
• 54 of time admitting diagnosis was wrong (21
  dx diverticulitis and 16 bowel obstruction)
• Require high index of suspicion and lower
  threshold for CT

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Ischemic Colitis
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Mesenteric 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

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Mesenteric 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 gt3mm, or pneumatosis
  intestinalis)
• May have WBC or FOBT, metabolic acidosis
• Angiogram is imaging of choice (Sn 88-98, Sp
  95)
• If considering - perform early, even with only
  moderate pain.

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Mesenteric Ischemia
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Mesenteric Ischemia
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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
• gt90 Sn and gt95 Sp

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Mesenteric Ischemia
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Mesenteric Ischemia

• 4 types cont
• 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

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Possible Approach to Imaging (RL)

• Low to Moderate Risk
• Screen with CT scan and confirm indeterminates
  with Angiography
• High Risk
• Emergent angiography

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Mesenteric 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

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Mesenteric Ischemia

• Overall mortality gt60
• More lethal than MI or CVA
• Mesenteric artery thrombosis gt mesenteric artery
  embolism gt mesenteric venous thrombosis

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Case 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, 94RA, c/s 5.2
• PMHX HTN, OA, hyperlipidemia
• Meds Ramipril, Metoprolol, lipitor, ibuprofen

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Geriatric Trauma

• Only 12 of total trauma is gt65yrs 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 (gt65) is
  53

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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

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• 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.

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Summary

• 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.

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References

1. McNamara et Al. Annals of Emerg Med. Volume 21,
   Issue 7, July 1992, Pages 796-801
2. Tintinelli
3. Amal Mattu. EM Rap Abdominal Emergency in the
   Elderly. May 2006

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