taem10: common pitfalls in geriatric emergency
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พ.ญ.วราลักษณ์ ศรีนนท์ประเสริฐTRANSCRIPT
Common pitfalls in
Geriatric Emergencies
Varalak Srinonprasert, MD.
Division of Geriatric Medicine
Siriraj Hospital
Older adults in EDFrom a systematic review, compared to younger persons; older adults
utilize ED at a higher rate
visit with greater level of urgency
longer stays in ED
more likely to be admitted or have
repeat ED visits
experience higher rates of adverse
health outcomes after discharge
Aminzadeh F, Ann Emer Med, 2002 : 39 : 238-47
Older adults in ED
Older people are referred to the ED
for medical reasons rather than injuries
Take longer to triage
Spend more time in the ED
Consume more resources which does not
always correspond to better diagnostic
accuracy (on the contrary, missed or
incorrect diagnoses are frequent)
Salvi F, Intern Emerg Med 2007:2;292–301
Older adults in ED
More frequently admitted
(30–50% vs. 10–20% of young/adults)
Undergo adverse health outcomes
after their discharge from the ED
Repeated ED visits (24% at 3 mo, 44% at 6 mo)
Hospitalization (24%)
functional decline (10–45% at 3 mo)
institutionalization and death (10% at 3 mo).
Salvi F, Intern Emerg Med 2007 2:292–301
After ED visits…Risk factors for negative outcomes :
Age
Functional impairment
Recent hospitalization or ED use
Living alone
Lack of social support
Aminzadeh F, Ann Emer Med, 2002 : 39 : 238-47
What are the challenges for those older clients??
Atypical presentations
Multiple co-morbidities
Impaired cognition/difficulty with
communication
Polypharmacy
Those make our life (works) more challenging!!
Atypical presentation
Exhibit less symptoms and signs than
younger persons
Present with „Geriatric Giants‟
Immobility
Inappetite
Iatrogenesis
Incontinence
Intellectual impairment
Instability
Atypical presentation
Exhibit less symptoms&signs
20-30% of elderly with severe infection
show no fever & leukocytosis
15-30% of elderly have no fever at ED
despite of having bacteremia
50% of older person with unstable
angina experience no chest pain
Atypical presentation
Present with „Geriatric Giants‟
Pt. present to ED without specific
complaint ( mainly declined function)
Had „ standard evaluation‟
Clinical history and complete physical exam,
laboratory tests (blood cell numeration,
glucose, Na, K, BUN,Cr),U/A and CXR
Rutschmanna, H. Swiss Med Wkly 2005 : 135;145-50
Atypical presentation
Acute medical conditions were
identified in 51%
infections, cardiovascular problems,
neurological, delirium, fractures
Considering final diagnosis : 26 %
was „undertriage‟
Rutschmanna, H. Swiss Med Wkly 2005 : 135;145-50
Atypical presentation
All would not be missed if
Triaging performed according to
guideline
Taking vital sign for all elderly
All was not missed because
Physicians follow guidance performing
„ Standard evaluation „
Rutschmanna, H. Swiss Med Wkly 2005 : 135;145-50
Common diagnoses in older patients in ED: USA
Cardiovascular diseases 8.2%
Chest pain : 18.5%
Respiratory disorders 10.5%
dyspnea : 3.5%
GI disorders 6.1%
Nervous system disorders 3.0%
Ciccone A, Amer J Emer Med : 16;143-8
Common diagnoses in older patients in ED: Asia
Chest infection/pneumonia 8.2%
Non-fracture head injury 7.2%
Heart failure 6.6%
Ischemic heart disease 6.2%
COPD 6.2%
Soft tissue injuries 6.0%
Fractures 6.0%
Lim H, Singapore Med J 1999; Vol 40(12): 742-44
Common symptoms in older patients visiting ED
Abnormalities of breathing 10.6%
Falls 9.6%
Musculoskeletal pain 8.2%
Cough 6.9%
Dizziness/Guidiness 5.6%
Lim H, Singapore Med J 1999; Vol 40(12):742-44
How about other ‘common problems’???
„No specific complaint‟ up to 20%
Delirium/acute confusion 10-30%
Adverse drug reactions 10-16%
Abnormalities of breathing 10.6%
Falls 9.6%
Musculoskeletal pain 8.2%
How about other ‘common problems’???
„No specific complaint‟ up to 20%
Delirium/acute confusion 10-30%
Adverse drug reactions 10-16%
Abnormalities of breathing 10.6%
Falls 9.6%
Musculoskeletal pain 8.2%
Delirium and cognitive impairment
Delirium : an acute decline in
attention and cognition
Prevalence : 10-30% at ED
Higher rate of mortality
Increased health care costs
Up to 2/3 unrecognized
Delirium and cognitive impairment
Approximately 25% of older patients
presented to ED having „ cognitive
impairment‟ ( delirium or dementia)
Creating difficulties communication
and management
Cognitive Impairment in Older Patients Presented to ED
Gerson Naughton „95 Naughton „97
Impaired consciousness
NA 8.5% 4.8%
Delirium NA 9.6% 17%
Cog impaired without delirium
NA 22% 38%
Cognitivelyintact
40% 60% 40%
Moderate Cogimpaired
34% NA NA
Mild Cog impaired
26% NA NA
Unrecognized delirium
Impact on both short term and long
term outcomes
Mortality at 3 mo
31 % for unrecognized
12 % if physician noticed delirium
12 % for non-delirious older patients
Kakuma R, J Am Geriatr Soc 2003;51:443-50
Delirium (DSM-IV)
• Disturbance of consciousness with inattention
• Change in cognition or perceptual
disturbance
• Acute onset and fluctuating course
• Resulted from medical conditions
Delirium : other features
• Disorientation
• Cognitive deficits
• Psychomotor agitation or retardation
• Perceptual disturbances
• Emotional lability
• Sleep-wake cycle reversal
Confusion Assessment Method ( CAM)
A. Acute onset and fluctuating course
B. Inattention
C. Disorganized thinking
D. Altered level of consciousness : hypoalert or hyperalert
Diagnosis of delirium :
A+B and C or D
Inouye SK, Ann Intern Med 113: 941,1990
Precipitating causes for delirium
D rugs
E nvironment
L ow oxygen
I nfections
R etention
I schemia
M etabolic
S ubdural hematoma
Salvi F, Intern Emerg Med 2007 2:292–301
Precipitating causes for delirium
History taking : particularly drugs
Thorough physical examination,
particularly neurological
Investigations
Approach to older delirious patients
Recommended
CBC, BUN, Cr, BS,
electrolyte
U/A
Optional
LFT
CXR
ABG, EKG
How about CT brain ?
indicated if focal neurological
deficits present
a retrospective study revealed
15 % „ new changes‟
focal neurological deficits or decreased
level of consciousness
Approach to older delirious patients
Naughton BJ, Acad Emerg Med 1997;4:1107-10.
A missed case
84 yo gentleman presented to ED with paranoidal idea and aggressive behavior, altered sleep-wake pattern
Any ideas ?
A missed case
84 yo gentleman presented to ED with paranoidal idea and aggressive behavior.
onset : over 2 days
Underlying disease : HT, BPH
Medications : Felodipine, Cardura
Recently „ catching a cold „ received „ cold remedies‟ , not eating so well
Lab : essentially normal
CT brain : unremarkable
A missed case
Medication review : Norgesic, Actifed
Complete resolution after ceasing medication and adequate IV replacement
Delirium is an emergency medical
condition
Delirium is a treatable condition
Delirium in elderly represents an
intrinsically multifactorial syndrome
Any patient with acute confusion or
mental deterioration should be consider
to be delirious until another diagnosis is
found
Delirium in older persons
35% of older persons present to Trauma
emergency room
10 % in combined ED
Leading cause of death from accident in
older persons
Cause of falls identified in 94% of older
fallers
Appropriate intervention could reduce
future hospitalization
Falls
Causes of falls identified
Weakness, generalized 31.2%
Environmental hazard 27.3%
Orthostatic hypotension 15.6%
Acute illness 5.2%
Gait or balance disorder 3.9%
Drug effect 3.9%
Weakness, focal 3.9%
Poor vision 2.6%
Drug reaction 1.3%
Unknown 5.2%
Rubenstein LZ.Ann Intern Med 1990;113:308
Evaluate falls-related injuries
Identify potential causes
detail history for the incident
identify intrinsic risk factors : thorough
physical examination including gait
assessment when feasible
appropriate investigations : CBC, BUN,
Cr, electrolyte, BS might be helpful
How to evaluate older fallers
10-16% of ED visits in elderly caused by
ADRs
Patients older than 65 years are prescribed
a mean of 6 medications
Only 42% able to remember all drugs they
are taking
12-16% having problem understanding
prescriptions, especially when new and
multiple
Adverse drug reactions (ADRs)
Salvi F, et al. Intern Emerg Med 2007 ;2: 292-301Rudolph J,et al. Arch Intern Med. 2008;168:508-513
Adverse drug reactions (ADRs)
ADRs increases with age
Another missed caseA 67 yo lady complains of „feeling dizzy‟ in her head,
unsteady, nausea and vomiting for 4 days. She developed
headache without fever for 2 days. Neuro exam :
unremarkable.
Medical BG : DM, HT, Dyslipidemia, Osteoporosis.
She had come to ED 3 visits over the last 3 days. Her blood
sugar has been below 200 mg/dl. Her blood pressure has
been mildly elevated.
She had a CT brain performed at her second visit with
unremarkable result.
Drug use in elderly
A 67 yo lady complains of „feeling dizzy‟ in her head
Medication review was performed :
Another missed case
Plendil 2.5 mg Co-aprovel 150 mg Amaryl 2 mg
ASA 81 mg Metformin 2000mg α-D3 0.25mg
CaCO3 1000 mg Simvastatin 10 mg Lesec 40 mg
Motilium 1*3 Merislon 24 mg Cinrizine 75 mg
Drug use in elderly
A 67 yo lady complains of „feeling dizzy‟ in her head
Medication review was performed :
Felodipine 2.5 mg Irbesartan+HCTZ150 mg/12.5mg
Glimepiride 2 mg
ASA 81 mg Metformin 2000mg α-D3 0.25mg
CaCO3 1000 mg Simvastatin 10 mg Omeprazole 40 mg
Motilium 1*3 Betahistine 24 mg Cinnarizine 75 mg
Another missed case
What next???
Drug use in elderly
Serum electrolyte came back
110 4.1
74 26
NSS infusion was administered and Co-approvel was
ceased. Her serum sodium returned back to normal
with in 3 days with complete resolution of her
symptoms.
Another missed case
10-16% of ED visits in elderly caused by
ADRs
Only half of those received correct
diagnosis
On the contrary, nearly 50% , another new
drug was prescribed without considering
ADRs
No routine drug review was undertaken
Adverse drug reactions (ADRs)
Salvi F, et al. Intern Emerg Med 2007 ;2: 292-301
“It is a good remedy sometimes… ….to take some remedies away..”
“It is a good remedy sometimes to do nothing” - Hippocrates (circa: a long, long time ago)
Give some more time to older persons
presented to ED, most of them do
really unwell when they come to ED
Appropriate history and thorough
physical examination would be
suitable
„ Basic investigations‟ would be quite
helpful
Don‟t forget : medication review
“ Drugs could cause illnesses!!!”
Take home message
Thank you foryour attention
Questions?