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GERIATRIC EMERGENCIES Joel Gernsheimer, MD, FACEP Attending Physician SUNY Downstate

GERIATRIC EMERGENCIES Joel Gernsheimer, MD, FACEP Attending Physician SUNY Downstate. AGS. THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. GERIATRIC EMERGENCIES. Introduction: Why? Pathophysiology

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GERIATRIC EMERGENCIES Joel Gernsheimer, MD, FACEP Attending Physician SUNY Downstate

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  1. GERIATRICEMERGENCIESJoel Gernsheimer, MD, FACEPAttending PhysicianSUNY Downstate AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

  2. GERIATRIC EMERGENCIES • Introduction: Why? • Pathophysiology • Principles of Geriatric Emergency Medicine • Geriatric Competencies for EM Residents • Specific Important Acute Geriatric Illness • Conclusions and Summary Emergency Medicine Clinics of North America, May 2006.

  3. INTRODUCTION: WHY? • The Graying of America • The Elderly Are Special • Need for Education

  4. The Graying of America • The elderly (>65) are 12% of the population • By 2050 they will be 21% • The very elderly (>85) are the fastest-growing age group • They use 50% of the federal health care budget • They spend the most on drugs

  5. ED RESOURCE USEBY THE ELDERLY (1 of 2) • More than 15% of all ED patients • 40% of all EMS arrivals • More emergent and urgent • More comorbidities • More complicated work-ups • More labs and x-rays

  6. ED RESOURCE USEBY THE ELDERLY (2 of 2) • Greater rate of admissions • 50% of ICU admissions • Stay longer in the ED • Higher rate of mortality and morbidity • More misdiagnoses • More ED bouncebacks

  7. THE ELDERLY ARE SPECIAL They are not just old adults! • Own physiology • Own presentations • Own diseases: AAA, temporal arteritis, mesenteric ischemia, dementia, etc. • Own special management

  8. Need for Education • Lack of educational materials • 69% of emergency physicians — insufficient CME • 53% — lack of training in residency • 40% of residency directors — training inadequate Ann Emerg Med. 1992;21:796-801. Ann Emerg Med. 1992;21:825-829.

  9. SAEM Geriatric Emergency Medicine Task Force • Director of GEM Subdivision —Dr. Gernsheimer • Chairman of GEM Task Force —Dr. Rinnert • Director of GEM Research —Dr. Baron • Director of GEM Grants —Dr. Stetz • Director of GEM Simulations —Dr. Gillett • Liaison for GEM Resident Education —Dr. Doty • Director of GEM Disaster Planning —Dr. Arquilla SAEM = Society for Academic Emergency Medicine

  10. PATHOPHYSIOLOGY (1 of 3) • Decline in physiologic systems • Loss of reserves • Decreased ability to exert homeostatic control • Accumulation of life’s stresses • Diseases • Environmental hazards — toxins • Drugs

  11. PATHOPHYSIOLOGY (2 of 3) • Renal • Hepatic • Immunologic • Pulmonary • Cardiovascular • CNS and sensory • Musculoskeletal • Body habitus

  12. PATHOPHYSIOLOGY (3 of 3) • More diseases • More complicated • Less ability to cope • Greater severity • More adverse drug reactions (ADRs)

  13. Dr. Gernsheimer’sABC’sfor the Elderly A —Attentive & Aggressive B —Be Nice & Be Patient C —Careful & Compassionate S —Suspicious & Supportive

  14. BE NICE! “When I was young I appreciated cleverness but when I became old I appreciated kindness much more” —Margaret Mead

  15. Principles of Geriatric Emergency Medicine (1 of 2) • The patient’s presentation is complex • Diseases present atypically, making diagnosis more difficult • Comorbidities and impairments have confounding effects • Polypharmacy is common and often causes problems • The risk of ADRs is increased

  16. Principles of Geriatric Emergency Medicine (2of 2) • The elderly may decompensate rapidly • It is important to recognize cognitive impairment • Expect decreased functional reserve • Functional status is important • Social issues are extremely important • The ED visit is an opportunity!

  17. Geriatric Competenciesfor EM Residents • Atypical presentation of disease • Trauma, including falls • Medication management • Effect of comorbid conditions • Cognitive and behavioral disorders • Palliative care and end-of-life issues • Emergent intervention modifications • Transitions of care

  18. Acute myocardial infarction Pulmonary embolism Pneumonia Acute abdomen Hyperthyroidism Hypothyroidism Alcoholism Depression Drug therapy Sepsis Physical abuse CLINICAL SITUATIONS WITH ATYPICAL PRESENTATIONSIN THE ELDERLY

  19. Altered Mental Status • AMS may be subtle and missed • Differential diagnosis of AMS is broad • Dementia may mask acute AMS • Delirium: acute and fluctuating mental status • Cause of delirium can be life-threatening • Causes: Sepsis, ADR, cardiovascular, neurologic

  20. Neurologic: CVA, SDH Infections: UTI, pneumonia Cardiovascular: atrial fibrillation, CHF, MI ADR Metabolic: dehydration, elect., HHNK Abdominal events: perforation, bleeding Psychiatric: depression, abuse ETIOLOGIES:RAPID FUNCTIONAL DECLINE

  21. Medications in Elderly PEOPLE • Average 4.5 prescription drugs, 2.1 over-the-counter drugs • Adverse reactions twice as likely • Half of hospital admissions for ADRs involve elderly people

  22. Altered Pharmacokinetics & Pharmacodynamics • Decreased functional reserve • Changes in volume of distribution • Drug clearance impaired • Paradoxical reactions occur

  23. Drugs to Consider Avoidingin Elderly Persons • Drugs with: • Long half-life • Prominent anticholinergic side effects • Low therapeutic-to-toxicity ratio • Muscle relaxants • Certain NSAIDs

  24. Digitalis Sedatives Antidepressants Steroids Alcohol Barbiturates Anticonvulsants Neuroleptics Antihistamines Diuretics Antihypertensives DRUGS IMPLICATED IN DELIRIUM

  25. Atypical Presentationsof Infections • Vague symptoms, altered mental status, functional decline • Serious infection without fever • Pneumonia without cough • UTI without flank pain or dysuria • Intra-abdominal infection “without pain” • Invasive cellulitis without pain

  26. Infections in ElderlyNursing Home Patients • Pneumonia • UTI • Skin infection • Intra-abdominal infection • Meningitis • Endocarditis

  27. Increased Mortality fromInfections in Elderly Patients Pneumonia 300% Upper UTI 750% Sepsis 300% Appendicitis 1750% Cholecystitis 500% Tuberculosis 1000% Endocarditis 250% Meningitis 300%

  28. Abdominal Pain (1 of 2) Very dangerous but easy to miss! • >50% require admission • 33%42% require surgery • Mortality 9 that of younger patients • Overall mortality 10%14%

  29. Abdominal Pain (2 of 2) • Diagnosis of abdominal pain in the elderly is difficult • High rate of admission and surgery • Red flags: upper abdominal pain (MI?), ill appearance, and abnormal vital signs • Syncope or hypotension — think AAA • Severe pain — think mesenteric ischemia • Symptoms and signs are subtle! • Be very careful — “over-test”

  30. ACUTE CORONARY SYNDROME • AMI is the leading cause of death in the elderly • The elderly commonly present without classic pain • AMI should be suspected with atypical pain, CHF, syncope, SOB, acute confusion, or functional decline • History alone is sufficient to admit a patient • Normal ECG and labs do not rule out ACS in the ED • The elderly may tolerate medications poorly • Decisions should be based on patient’s physiologic age, functional status, and wishes, not on age in years

  31. Summary To optimize care, need a comprehensive model that considers: • Complexity of chief complaint • Atypical disease presentation • Comorbidities • Polypharmacy ― ADRs • Cognitive impairment • Decreased functional reserve • Assessment of functional status • Need for social and psychological support

  32. Thank you for your time! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society

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