Transcript 2006_11_09-Sacks-Geriatrics

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
More likely to have emergency
diagnosis than younger demographic
More likely to manifest atypical
symptoms
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.”
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
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
Physiology cont’d
MSK:
Increased calcium loss from bone
Decreased muscle mass, cartilage
Neurologic:
Increased wakefulness
Decreased brain mass, cerebral blood
flow
Causes of morbidity and mortality in
seniors
Mortality
Morbidity
Arthritis
Heart/vascular disease
(41%)
GI disease (35%)
Hypertension
Allergies
Cancer (25%)
Back
problems
Heart disease
Respiratory disease
(11%)
Cataracts
Diabetes
Geriatric Pharmacology:
Age associated pharmacokinetics
Parameter
Age Effect
Implications
Distribution
↓ total body fat, lean body
mass, total body water and
albumin
Lipophilic drugs
have larger
volume of dist;
increased
binding of basic
drugs
Elimination
↓ renal blood flow, GFR,
tubular secretion and renal
mass
For every x%
reduction in
clearance,
decrease the
dose by x% and
increase the
interval by x%
Absorption
↑ in gastric pH;
↓ splanchnic blood
flow, GI absorptive
surface, dermal
vascularity; delayed
gastric emptying
Dug-drug and
drug-food
interactions more
likely to affect
absorption.
Metabolism
↓ in hepatic mass
and hepatic blood
flow; impaired
oxidative reactions
Lower doses may
be therapeutic.
Pharmacodynamics
Less predictable
Altered drug response at usual or
lower concentrations
Increased sensitivity to sedative
hypnotics, anticholinergics,
analgesics, warfarin
Decreased sensitivity to B blockers
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
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
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
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)
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.
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.
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.
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
Polypharmacy in the ED
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, FRCPC
From 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 666671
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
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
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)
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
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 568574
B. Coronado, J. Pope, J. Griffith, J.
Beshansky, H. Selker
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
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
Characteristics of Patients with Cardiac Ischemia
by Clinical Presentation (n=2541)
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
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
DDx of Abdominal Pain in Elderly
Patients
Disorder
Cholecystitis/ Biliary
Colic
Nonspecific abdo pain
Appendicitis
Obstruction
Hernia
Perforation
Pancreatitis
Diverticular Disease
Incidence %
12-41
9.6-23
2.5-15.2
7.3-14
4.0-9.6
2.3-7.0
2.0-7.3
3.4-7.0
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
Imaging in abdominal pain in the
elderly
The American Journal of Emergency
Medicine Volume 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
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
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
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%
Most common diagnostic CT findings in older ED
patients with acute abdominal pain (n = 71)
Findings
SBO or ileus
# of abdo CT scans,
n (%, 95%CI)
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%)
Most common diagnostic CT findings in older ED
pts receiving acute medical intervention (n=36)
Findings
Diverticulitis
# of abdo CT
scans, n (%,
95%CI)
11 (31%, 16-48%)
SBO
9 (25%, 12-42%)
Pancreatitis
3 (8%, 2-23%)
Urolithiasis
3 (8%, 2-23%)
Abdo mass/neoplasm
3 (8%, 2-23%)
Pyelonephritis
2 (6%, 0-19%)
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
Mesenteric Ischemia
Mesenteric ischemia
Venous disease
(mesenteric venous thrombosis)
Arterial disease
Occlusive
(Superior mesenteric artery obstruction)
Non-occlusive
(low flow state)
thrombotic
embolic
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
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
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
Risk Factors
Advanced age
Atherosclerosis
Low cardiac output states
Severe valvular heart disease
Recent MI
Intra-abdominal malignancy
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 (1525%):
PVD, atherosclerotic disease, abdominal
trauma, infections
Mesenteric Venous Thrombosis (10%):
Hypercoagulable state, portal hypertension,
abdominal infections, trauma, pancreatitis,
splenectomy
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
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
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
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
4 types cont’d:
MVT:
Occurs in younger patients
Amenable to diagnosis with noninvasive
CT
Lower mortality
Treated with immediate anticoagulation
Papaverine infusion with
arteriography:
Treatment of splanchnic vasoconstriction
Lab Tests
Metabolic acidosis
May have increased WBC
May have + FOB
May have elevated serum lactate
Diagnostic Tests
Diagnosis
Test
Small bowel
ischemia
Sensitivity
Specificity
LR+
LR-
Angiography 88%
(62-98%)
95%
(93-100%)
18
0.1
Small bowel
ischemia
CT and CT
angio
77%
(57-92%)
85%
(71-100%)
5
0.3
Small bowel
ischemia
Gadolinium
enhanced
MRI
83%
(78-100%)
89%
(71-99%)
8
0.2
Small bowel
ischemia
Serum
lactate
90%
(66-100%)
62%
(42-77%)
2
0.2
Imaging
Radiography:
Plain films: r/o free air, ileus, intussusception, volvulus
Pneumatosis intestinalis: >30% of patients
Portal venous gas (rare)
CT:
will show wall thickening >3mm
Large vessel disease is diffuse (SMA, SMV, IMA, IMV)
Small vessel disease is focal
Arterial occlusive disease: segment will not enhance
Venous occlusive disease: segment will enhance due to
retarded flow
False positive: ulcerative colitis
False negative: lymphoma, adenocarcinoma
Angiography
Gold standard
Invasive
Early intervention reduces mortality
Shows attenuation, vasoconstriction,
occlusion of vessel
Less sensitive for veno-occlusive
disease
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
Mortality
Mortality rate can be >60%
25% if due to arterial emboli
29% if due to venous thrombosis
60% if due to arterial thrombosis
In conclusion:
Polypharmacy is an important cause
of morbidity in the elderly
ADRs are often underestimated
Think AMI in patients without chest
pain who are female, elderly, present
with CHF, DM
Abdominal pain in old folks is often
surgical, presents atypically and has
high mortality associated with it.
References
Hustey FM et al. The use of abdominal computed tomography in older
ED patients with acute abdominal pain. Am J Emerg Med (2005)
23;259-265.
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. Am J Emerg Med (2004) 22:568-574.
Fick DM et al. Updating the Beers Criteria for potentially inappropriate
medication use in older adults. Arch Int Med (2003) 163;2716-2724.
Hohl CM et al. Polypharmacy, adverse drug-related events, and
potential drug interactions in elderly patient presenting to an
emergency department. Ann Emerg Med (2001) 38;666-671.
Birnbaumer DM. Chapter 176: The Elder Patient. Rosen’s Emergency
Medicine Concepts and Clinical Practice. Section III.2485-2491.
Reuben DB et al. Geriatrics. 2006-2007: 8th edition. American Geriatric
Society.
Tintinalli JE et al. Emergency Medicine: A comprehensive study guide.
McGraw Hill. 2004.
McNamara RM et al. Geriatric Emergency Medicine: A Survey of
Practicing Emergency Physicians. Ann Emerg Med (1992) 21;796-801.