Geriatric Emergencies

1. Geriatric Emergencies March 20, 2008 Mark Scott

2. Objectives • Physiological changes of aging • Polypharmacy • Approach Atypical Presentations • Chest pain • Abdominal pain • Geriatric Trauma

4. Geriatric Patients are Challenging(McNamara et Al, Annals Emerg Med 1992) • Survey of 485 Emergency physicians • 45% had difficulty diagnosing and treating elderly pts. • Difficult presentations included: chest pain, dizziness/vertigo, fever without focus, headache, trauma, altered LOC, and abdominal pain) • Majority believed lack of research and CME, and time spent during residency were inadequate.

6. Geriatrics • Rapidly expanding subset of the population • >65 incr from 12% to 20% of population • >85 will grow by 500% • Utilize more medical resources • We use 90% of healthcare resurces in last 10 yrs of life • Spend more time in ED • More likely to receive ancillary tests • Higher admission rate • Higher use of ambulance

7. Geriatrics • Have higher morbidity • From cardiac ds. • Abdominal emergencies • ICH • Sepsis • Trauma • More likely to present atypically

9. Physiological Changes of Aging • Cardiac • Elevated BP • Decreased HR • Decreased CO • Respiratory • Reduced compliance and func reserve • Decreased mucociliary clearance • MSK • Increased calcium loss from bone • Decreased muscle mass, cartilage • Neurologic: • Increased wakefulness • Decreased brain mass, cerebral blood flow • Impaired balance

10. Physiological Changes of Aging • Other • Endo - Blunted B-adrenergeic response - Increased NE, PTH, Insulin • GI - prolonged transit time • decreased splanchnic blood flow • Decreased Ca, Fe absorption • Eyes - presbyopia, cataracts, IOP • Renal • Skin

12. Case 1 86 M “weak and dizzy” HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained ground level fall with no LOC. PMHX: MI, OA, BPH, afib Meds: ASA 81mg po od Ramipril 5mg po od Atorvastatin 20mg po od Acetaminophen 500mg po q6h lorazepam 1mg po hs warfarin 4mg po od dimehydrinate 25mg po q6h

13. Could a medication be the cause this presentation?

14. Beer’s Criteria(Fick et Al, Arch Int Med, 2003) • Guidelines for inappropriate, in-effective, and dangerous medication for age >65yrs. • Development based on extensive evidence and expert opinions • Revised over past 10 yrs • Identified 48 medication/classes to avoid, and • 20 medications contra-indicated for specific conditions

15. Beer’s Criteria(Fick et Al, Arch Int Med, 2003) • List includes: • Indomethacin (CNS effects) • Ketorolac (GI bleeds) • Muscle relaxants (sedation) • Amitriptyline (anticholinergic Sfx, Fall risk) • Diphenhydramine (anticholinergic SEs) • Long acting Benzos (sedation and falls) • Meperidine (CNS toxicity)

16. PolyPharmacy • Persons over the age of 65 are taking an average of 4.2 Rx meds and 2.1 OTCs. • Over 30% will develop an adverse drug-related event.

17. PolyPharmacy (Hohl et al, Ann Emerg Med 2001) • Chart review of 283 .>65 pts presenting to the ED • ADRE occurred in 10.6% • 31% had at least 1 PADI • Most common culprit meds: NSAIDs, Abx, anticoagulants, diuretics, hypoglycemics, B-blockers, Ca-channel blockers, chem Tx agents. • ADRE are under-diagnosed and can lead to serious morbidity.

18. Back to Case 1 86 M “weak and dizzy” HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained grouud level fall with no LOC. PMHX: MI, OA, BPH, afib Meds: ASA 81mg po od Ramipril 5mg po od Atrovastatin 20mg po od Acetaminophen 500mg po q6h lorazepam 1mg po hs warfarin 4mg po od dimehydrinate 25mg po q6h

20. Case 2 76 M Epigastric pain and fatigue x 12hrs HPI: mild orthopnea, no asso’d sx PMHX:DM, blind RF: no HTN, 40pack year hx smoke, N lipids, no FMhx ROS: N bowels, no RFs for PUD or colon CA, no surgical hx. Meds: none PE: T 36.8, HR 92reg, RR20, BP 145/87, 96%RA Abdo soft, non-tender, no organomegaly

21. Case 2 - ECG

22. Myocardial Infarction in the Elderly • Elderly are more likely to have silent or atypical presentations of MI • Mortality from MI is higher in the geriatric population

23. MI in the Elderly(canto et Al. JAMA 2000) • Prospective observational study of 434877 pts from 1674 hospitals • 33% did not have CP, more in the elderly subset • Pts without CP had longer delay to hospital presentation, in hospital mortality, less likely to receive thrombolysis of PCI, and less likely to received medical therapy.

24. MI in the Elderly(canto et Al. JAMA 2000)

25. Suspect MI in patients presenting with: • Atypical chest pain: arm, jaw, abdominal pain (+/- nausea) • Acute functional decline • Dyspnea • Syncope • Confusion • Vomiting • Weakness • CHF • Fatigue

27. Case 3 81 M Severe generalized Abdo pain HPI: sudden onset 2hrs ago, 9/10 periumbilical, non-radiating. Emesis x1, no bowel or bladder symptoms ROS: no melena/hematochezia PMHX:HTN, OA, smoker, appy 70yrs ago Meds: HCTZ, ibuprofen PE: T 37.4, HR 105reg, RR20, BP 106/75, 98%RA Abdo soft, diffusely tender, no peritoneal signs, no organomegaly, +FOBT

28. Abdominal Pain in the Elderly • ED physicians rate abdo pain in elderly as one of most challenging presentations.(McNamara et al, 1992) • Symptoms often vague or atypical • Wide ddx • Abdo pain associated with much higher morbidity and mortality in elderly.

29. Abdominal Pain 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 • 6-8x the mortality compared with younger pts (brewer et Al 1976)

31. Use of CT in Older Patients with acute abdominal Pain • Prospective Obs study of 337 pts over the age of 60 with abdo pain • Objectives: • Prevalence of use of CT in this population • Describe most common diagnostic findings • Determine proportion of CT scans in this population

32. Hustey et al 2005 • CT ordered for 37% • 57% of results were diagnostic • 31% non-diagnostic • 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

33. CT Results of elderly pts. presenting with acute Abdo pain (n=71)

34. Appendicitis in the Elderly • Atypical presentations are common • Storm-Dickerson et al. (Am J Surg 2003) Case series of 113 patients 60 or older • 30% had no RLQ AP • 67% afebrile • 26% no WBC and 56% had no left shift • 54% of time admitting diagnosis was wrong (21% dx = diverticulitis and 16% bowel obstruction) • Require high index of suspicion and lower threshold for CT

36. Ischemic Colitis

37. Mesenteric Ischemia 4 types: • Superior Mesenteric Artery occlusion most common • Acute emergency (bowel infarcts in 2-3hrs) • Pain out of proportion, pain prior to emesis • Peritoneal findings are a late, ominous sign • Thrombotic (15%): RFs for vascular disease, trauma, infection • Embolic (50): RFs for embolic CVA (Valvular HD, recent MI, arrhythmias) • May also occlude vessels of colon • Lower abdo pain,hematochezia

38. Mesenteric Ischemia Investigations: • Serum lactate 90% Sn (even better if serial lactate). SP ~67%. • CT scan 85-92% Sp, but only 71-77% Sn • May see wall thickening >3mm, or pneumatosis intestinalis) • May have +WBC or +FOBT, metabolic acidosis • Angiogram is imaging of choice (Sn 88-98%, Sp 95%) • If considering - perform early, even with only moderate pain.

39. Mesenteric Ischemia

40. Mesenteric Ischemia

41. Acute Mesenteric Ischemia - Angiography • Considered the gold standard • Invasive and time consuming • Early and aggressive angiography has been shown to decrease mortality from acute mesenteric ischemia (Boley et al. Surgery 1997) • Must be willing to accept many negatives to implement • >90% Sn and >95% Sp

42. Mesenteric Ischemia

43. Mesenteric Ischemia 4 types con’t: • Mesenteric Venous Thrombosis(think Abdo DVT) • 10% • Occurs in younger patients • Amenable to diagnosis with noninvasive CT • Lower mortality • Treated with immediate anticoagulation • Non-occlusive Mesenteric Ischemia (think abdo shock) • 25% • Associated with low flow states (e.g. CHF) which improves with improvement of CO

44. Possible Approach to Imaging(RL) • Low to Moderate Risk • Screen with CT scan and confirm indeterminates with Angiography • High Risk • Emergent angiography

45. Mesenteric Ischemia - 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

46. Mesenteric Ischemia • Overall mortality >60% • More lethal than MI or CVA • Mesenteric artery thrombosis > mesenteric artery embolism > mesenteric venous thrombosis

48. Case 4 74 F unrestrained passenger MVC (car vs. tree) HPI: distracted driver drove into tree at 60kph. Head-on collision, no loc. c/o central chest pain. 10 Survey: seat belt sign to chest,otherwise nil Vitals: HR65, 130/60, 22, 94%RA, c/s 5.2 PMHX: HTN, OA, hyperlipidemia Meds: Ramipril, Metoprolol, lipitor, ibuprofen

49. Geriatric Trauma • Only 12% of total trauma is >65yrs but, • 25% of hospitalization, 36% ambulance transfers, and 25% total trauma costs • Much higher mortality in elderly • 1 yr mortality following traumatic hip # is 50% • Case fatality rate for MVC vs pedestrian (>65) is 53%

50. Geriatric Pts . . . • Have unreliably “Normal” vitals in setting of shock • Take medications to blunt compensatory mechanisms • More prone to development of morbid conditions • ICH • Fracture • Difficult airway • Sepsis, particularly pneumonia • Anemia • Cardiogenic shock