Geriatric Emergencies

1. Geriatric Emergencies Dr Jack Bond Teaching Fellow Oct 25th 2011

2. Objectives • How to assess the older adult • Know how to investigate and initially manage falls • Know how to investigate and initially manage acute delirium

3. Brought in by ambulance Left weakness GCS 14 What is the diagnosis

4. How do we get here?

5. Obtain a collateral history • Who? • Partner • Family/next of Kin • Care agency workers • Nursing home staff • GP • Community pharmacist • Neighbours • In hospital nursing staff

6. Illness in older people • Present atypically and non-specifically • Greater morbidity and mortality • Rapid progression • Health, social and financial implications • Co-pathology common • Lack of reserve to cope

7. “Normal” functional state • All 85 year olds are not equal • The patient's functional state when well has big implications on:- • diagnosis and management • Mobility, cognition, continence, living situation • PMH and DH are crucial

8. Why is it happening now? Acute stress event Internal External Severity Co-pathology Less physiological reserve

9. Assessing geriatric emergencies • Establish the background • Determine the acute event that has precipitated the admission • “Acopia” “Off legs” are not diagnoses • They are the visiblesymptom of a change in a older persons situation

10. Falls • Why do we not fall over?

11. Causes of falls Internal • Medical • Cardiac • Neurally mediated • Motor, sensory, vagal, autonomic • Orthostatic hypotension • Drug related • Gait/balance External • Environment • Clutter, footwear, pets, lack of grab rails

12. Most neurally mediated causes are usually benign • Although the effect of a fall may not be • Aim to differentiate cardiac vs neurally generated causes

13. Cardiac exercise induced Chest pain, SOB Palpitations Symptoms when lying down Immediate recovery Neurogenic Pain, fear, warm environment Light headed, dizziness, blurred vision, abdo pain Symptoms on prolonged standing, or change in posture Post event nausea Pallor, sweating – vagal “blue” – seizure Amnesia, confusion Cardiac vs neurogenic symptoms

14. Examination in syncope • Cardiac • Pulse • Heart sounds • Postural BP and HR • Neuro • Motor weakness • Sensory impairment • coordination

15. Investigation of syncope T/F • Most patients with syncope require echocardiogram T/F 2. 12 lead ECG and postural BP measurement provides a diagnosis for syncope in 2/3rd of all falls T/F 3. Postural hypotension is defined as 20/10 drop in systolic/diastolic BP T/F 4. 24 hour ECG provides a diagnosis in remaining 1/3rd of all falls T/F 5. Limb jerking is consistent with diagnosis of epilepsy T/F

16. Investigations • 12 lead ECG + postural BP (together) • Provides diagnosis in 2/3rd cases • Echocardiogram • If murmur and clinically suspect relevant • 24 hour ECG • Very low yield (<1%) • Specifically best in people with daily symptoms, even then <30%

17. Management after a fall • Examine for injury - #NOF • History/exam - neuro/cardiac • Establish reason • Investigations • Review medications • Assess long term risk

18. Drugs in falls • >4 meds = more falls • Specific drug classes include • Antihypertensives (ACEi, diuretic, ca2 etc) • Sedatives (benzos) • antidepressants

19. Falls prevention • Screening – controversial evidence • Timed up and go test <12 secs • Prevention • Home assessment • Vitamin D • Exercise • Medication rationalisation • Visual • Combined interventions

20. Acute delirium • Objectives • Understand range of presentations • Suggest initial work up and provide differential diagnosis • Management of aggressive patients

21. Case 1 A 78 year old woman is found by her neighbours confused and wandering in the street at night wearing her night clothes. In the emergency room she appears unkempt and dishevelled. She is alert, but disoriented in time and place and cannot recall her home address. She engages well with questions, but tends to shift the conversation to stories about her husband and children. She is admitted to hospital and wanders around the ward appearing lost and, when asked, says that she is looking for a bus stop to go home

22. Case 1 • What differentials? • Acute or chronic? • Delirium or dementia? • Collateral history is key

23. Dementia vs delirium • Continuum • Collateral helps identify a precipitant • Vulnerability to delirium • Different thresholds young/old/pre-existing dementia

24. Case 3 A 85 year old gentleman is admitted from a nursing home with confusion. The staff tell you that he normally walks with a stick but in the last few days he has been very aggressive, shouting and threatening people. He has generally been fine apart from some arthritis for which his GP saw him a few days ago. A urine dip in A+E shows 1+ protein, trace blood. He takes furosemide 40mg OD. What is most likely to have changed his behaviour? A. UTI B. TIA C. Ibuprofen 400mg TDS D. hyponatremia E. co-codamol 8/500mg TDS

25. Delirium - causes • Often multi-factorial but consider the following: • Infection • Drugs • Electrolyte imbalances • Alcohol/drug withdrawal • Organ dysfunction/failure • Endocrine • Epilepsy • Pain • Accentuated on admission by unfamiliar hospital environment

26. UTI diagnosis • No reliable test • Dipsticks – most helpful when nitrites/leucocytes +ve • false negative absence of nitrite occur with atypical organisms common in elderly patients • Bacteruria on MSU • Can be asymptomatic – interpret in context

27. History Previous intellectual function Episodes of acute of chronic confusion Onset and course Symptoms suggestive of underlying cause e.g. infection Full drug history (prescribed/non prescribed) Alcohol history Sensory deficits Examination Conscious level (also if hypo or hyperactive) Cognitive function (standardised test e.g. MMSE/or AMT) Attention (e.g. serial 7’s or months of year backwards) Neurological examination (including assessment of speech) Evidence of alcohol abuse or withdrawal e.g. tremors Pyrexia or other evidence of an infective process Nutrition status Focus

28. Urine analysis FBC – WCC U+Es Low Na+ Bone profile High Calcium TFTs B12/Folate Obs and MEWS hypoxia hydration nutrition early sepsis Investigating delirium

29. Imaging in delirium

30. CT head in delirium • new focal neurologic deficit • new seizure • low platelet count or coagulopathy • head trauma • fall

31. Case 4 78 woman with dementia is admitted with delirium due to pneumonia. She is pulling at her IV cannula and taking oxygen mask off. How would you manage the patient? True/False • Haloperidol 0.5mcg IM • Lorazepam 2mg IM • Risperidone 250mcg PO • Physical restraint to minimise risk of dislodging cannula • Maintain orientation with clocks, lighting • Discourage family visitors as it may distress them further

32. Managing delirium • Environment - lighting • Maintain orientation • Encourage family • Minimise shift changes (familiarity) • Bowels/bladder addressed • Pain addressed • Avoid restraints – causes more chance of injury

33. Sedation in delirium • Sedation • When above has failed • Comes with risks • Resp depression • Increased falls (hangover) • 1st line haloperidol (0.5 – 1mcg) • Risperidone also • Lorazepam 2nd line • See guidelines on intranet

34. Take home messages • Establish the background • Determine the acute event that has precipitated the admission • Collateral history • “Acopia” “Off legs” are not diagnoses • They are the visiblesymptom of a change in a older persons situation