Transcript Dementia
GERIATRIC EMERGENCIES AGS Joel Gernsheimer, MD, FACEP Attending Physician SUNY Downstate THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. 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. Slide 2 INTRODUCTION: WHY? • The Graying of America • The Elderly Are Special • Need for Education Slide 3 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 Slide 4 ED RESOURCE USE BY 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 Slide 5 ED RESOURCE USE BY 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 Slide 6 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 Slide 7 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. Slide 8 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 Slide 9 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 Slide 10 PATHOPHYSIOLOGY (2 of 3) • Renal • Hepatic • Immunologic • Pulmonary • Cardiovascular • CNS and sensory • Musculoskeletal • Body habitus Slide 11 PATHOPHYSIOLOGY (3 of 3) • More diseases • More complicated • Less ability to cope • Greater severity • More adverse drug reactions (ADRs) Slide 12 DR. GERNSHEIMER’S ABC’s FOR THE ELDERLY A — Attentive & Aggressive B — Be Nice & Be Patient C — Careful & Compassionate S — Suspicious & Supportive Slide 13 BE NICE! “When I was young I appreciated cleverness but when I became old I appreciated kindness much more” —Margaret Mead Slide 14 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 Slide 15 PRINCIPLES OF GERIATRIC EMERGENCY MEDICINE (2 of 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! Slide 16 GERIATRIC COMPETENCIES FOR 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 Slide 17 CLINICAL SITUATIONS WITH ATYPICAL PRESENTATIONS IN THE ELDERLY • Acute myocardial infarction • Pulmonary embolism • Pneumonia • Acute abdomen • Hyperthyroidism • Hypothyroidism • Alcoholism • Depression • Drug therapy • Sepsis • Physical abuse Slide 18 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 Slide 19 ETIOLOGIES: RAPID FUNCTIONAL DECLINE • Neurologic: CVA, SDH • Infections: UTI, pneumonia • Cardiovascular: atrial fibrillation, CHF, MI • ADR • Metabolic: dehydration, elect., HHNK • Abdominal events: perforation, bleeding • Psychiatric: depression, abuse Slide 20 MEDICATIONS IN ELDERLY PEOPLE • Average 4.5 prescription drugs, 2.1 over-thecounter drugs • Adverse reactions twice as likely • Half of hospital admissions for ADRs involve elderly people Slide 21 ALTERED PHARMACOKINETICS & PHARMACODYNAMICS • Decreased functional reserve • Changes in volume of distribution • Drug clearance impaired • Paradoxical reactions occur Slide 22 DRUGS TO CONSIDER AVOIDING IN ELDERLY PERSONS • Drugs with: Long half-life Prominent anticholinergic side effects Low therapeutic-to-toxicity ratio • Muscle relaxants • Certain NSAIDs Slide 23 DRUGS IMPLICATED IN DELIRIUM • Digitalis • Sedatives • Antidepressants • Steroids • Alcohol • Barbiturates • Anticonvulsants • Neuroleptics • Antihistamines • Diuretics • Antihypertensives Slide 24 ATYPICAL PRESENTATIONS OF 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 Slide 25 INFECTIONS IN ELDERLY NURSING HOME PATIENTS • Pneumonia • UTI • Skin infection • Intra-abdominal infection • Meningitis • Endocarditis Slide 26 INCREASED MORTALITY FROM INFECTIONS IN ELDERLY PATIENTS Pneumonia Upper UTI Sepsis Appendicitis Cholecystitis Tuberculosis Endocarditis Meningitis 300% 750% 300% 1750% 500% 1000% 250% 300% Slide 27 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% Slide 28 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” Slide 29 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 Slide 30 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 Slide 31 THANK YOU FOR YOUR TIME! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatricssociety Slide 32