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Issues in Geriatric Medicine

Issues in Geriatric Medicine. Juliette Sacks November 9, 2006. Outline. Aging changes Polypharmacy Chest pain Abdominal pain Not included: Falls, Head injury, Trauma, altered LOC. Elderly. Fastest growing subset of population – especially >85 yrs of age

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Issues in Geriatric Medicine

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  1. Issues in Geriatric Medicine Juliette Sacks November 9, 2006

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

  3. Elderly • Fastest growing subset of population – especially >85 yrs of age • More likely to have emergency diagnosis than younger demographic • More likely to manifest atypical symptoms

  4. McNamara et al. • “…45% or more of emergency physicians have difficulty in the management of older patients…[They] 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.”

  5. 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

  6. Physiology cont’d • 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

  7. Physiology cont’d • MSK: • Increased calcium loss from bone • Decreased muscle mass, cartilage • Neurologic: • Increased wakefulness • Decreased brain mass, cerebral blood flow

  8. Causes of morbidity and mortality in seniors

  9. Geriatric Pharmacology:Age associated pharmacokinetics

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

  11. 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 >3 medications • Average elderly person takes 4.5 prescription drugs and 2.1 OTC meds daily (Rosen’s) • Hospitalized elderly are given an average of 10 meds over admission • LTC residents take an average of 7.2 meds daily

  12. 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

  13. 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

  14. Inappropriate Prescribing • Beers Criteria (1997): • Explicit criteria to identify inappropriate medications for people >65 yrs of age • Examples include: long acting BDZ, strong anticholinergics, high dose sedatives • Elderly are often under treated (ACEI, ASA, BB, thrombolytics, coumadin)

  15. 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. 2003;163:2716-2724.

  16. 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.

  17. 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.

  18. 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

  19. 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 Polypharmacy in the ED

  20. 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 >1 med • Average number of meds 4.2/pt (0-17) • ADRs = 10.6% of all ED visits

  21. 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

  22. 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)

  23. 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

  24. 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

  25. Coronado et al • Prospective clinical trial of all adults >30 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

  26. 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

  27. Characteristics of Patients with Cardiac Ischemia by Clinical Presentation (n=2541)

  28. 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

  29. 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

  30. DDx of Abdominal Pain in Elderly Patients

  31. 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

  32. Imaging in abdominal pain in the elderly • The American Journal of Emergency MedicineVolume 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

  33. background • Abdominal pain accounts for 3-4% of all ED visits in >65 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

  34. 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

  35. Demographics • 337 enrolled • Gender: • Women 222/337 66% • Men 115/337 34% • Age: • 60-69: 135/337 40% • 70-79: 117/337 35% • >80: 85/337 25%

  36. Most common diagnostic CT findings in older ED patients with acute abdominal pain (n = 71)

  37. Most common diagnostic CT findings in older ED pts receiving acute medical intervention (n=36)

  38. 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

  39. Mesenteric Ischemia

  40. 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

  41. 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

  42. 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

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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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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