In this episode Dr. Don Melady, Canada’s leading educator in Geriatric Emergency Medicine (Geri-EM) & Dr. Jaques Lee, one of Canada’s leading researchers in Geri-EM, discuss the common yet challenging Geriatric Emergencies: a practical approach to geriatric Delirium, best practice for managing agitation and pain in the older patient, management of recurrent falls, pearls in the assessment of the ‘Weak & Dizzy’ geriatric patient, atypical presentations of common life threatening emergencies including ACS and surgical abdomen, key drug interactions in the geriatric patient and more..
Written Summary and blog post by Claire Heslop, edited by Anton Helman July, 2013
DELIRIUM IN THE GERIATRIC PATIENT
The acute and fluctuating onset of in-attention, with disorganized thinking, and/or altered level of awareness. Unlike dementia (which progresses slowly) delirium happens acutely. In the elderly, 70% of delirium is initially “hypoactive,” which can delay its detection in the ED.
Delirium is a very serious presentation, which always has an underlying medical cause. Length of stay in hospital, and in-hospital mortality increase x2 in patients diagnosed with delirium, and delirium is not always reversible. Always assess the baseline functional status of elderly patients, and be suspicious of any acute decline.
Risk factors for Delirium
- Physical restraints and/or unable to mobilize from their ED bed
- Prolonged stay in the ED -Inouye, SK et al. N Engl J Med. 1999;340:669, Inouye, SK. N Engl J Med. 2006;354:1157
- Under-treated pain
- Dehydration and malnutrition
Avoid restraints, mobilize patients, manage pain adequately, and keep patients fed and hydrated. This can reduce delirium rates by up to 50% -Inouye, SK et al. N Engl J Med. 1999;340:669.
Recognition is key: Patients sent home with unrecognized delirium had mortality rates 3–7x higher than pts without delirium Kakuma, R et al. J Am Geriatr Soc. 2003;51:443.
Recognition of the cause for the delirium is essential to a safe discharge. The cause must be treatable, and close observation and good follow up must be ensured.
Major Causes of Delirium in the Elderly
Drugs and drug withdrawal – largest category in older patients! Be very diligent at reviewing Rx and OTC meds.
Infection – the three most common are PUS: Pneumonia, UTI and Skin
Metabolic – order and review BW carefully for metabolic causes
Environmental – too hot/ too cold
Structural – CNS events (spontaneous or traumatic subdural bleeding, stroke, etc.) Consider imaging when indicated (see below).
**Don’t forget urinary retention and constipation/fecal impaction as a cause of delirium in the elderly.**
Treatment of Delirium
When non-pharmacological treatments are inadequate for managing agitation, chemical sedation may help.
Avoid benzodidiazepines (unless treating a patient in alcohol or benzo withdrawal) as they worsen confusion, ataxia, and disinhibition in older patients. Start with low-dose haloperidol (0.5-1.0 mg po or IV if necessary, q30 minutes prn, and reassess after 3 doses). Add risperidone if haloperidol alone is not effective. Note: Avoid antipsychotic medications in patients at risk for prolonged QTc or extrapyramidal side effects (using other antipsychotic medications, or past history of EPS, Parkinson’s)
Indications for head CT for patients with delirium
Consider a head CT if any of the following:
- History of head trauma
- Substantially impaired consciousness
- New focal neurologic findings
- No explanation from basic workup
Update April 2014: New American College of Emergency Physicians Geriatric EM Guidelines Free Full Text
FALLS IN GERIATRIC EMERGENCY MEDICINE
Falls are a common presentation for geriatric patients, and injurious falls are associated with significant morbidity and risk of death.
Risk Factors for Multiple Falls
- A history of previous falls (especially falls leading to injuries)
- Psychoactive medications
- Impaired hearing and eyesight
- Poor proprioception
- Loss of mobility due to inactivity
How to Manage the ED Patient who has Fallen
Step 1: assess the cause of the fall
- Evaluate risk factors, especially medication changes
- Take a careful fall history, including causes and collateral information, to differentiate a fall from syncope
- In a patient with new onset of falls, look for underlying medical causes (cardiac disease, infection, GI bleed)
Step 2: assess injuries from the fall
Step 3: estimate risk of future falls and formulate a safe discharge plan
Step 4: begin a plan for prevention, which can begin after discharge
i.e. activities or classes that promote balance, and mobility (i.e. Tai-chi)
Before Sending Home a Patient who has Fallen
Do a basic “road test” of mobility and balance, which can predict future falls. A timed “up and go” test (the time to rise from a chair and take 6 steps) predicts future falls, with risk increased if the time is >15 seconds.
Enlist team members (geriatric nurse, physio, pharmacy), family, and community services to optimize the patient for their discharge.
Instigate an Osteoporosis work-up After a Low Impact Fracture in the Geriatric Patient
Outpatient management for osteoporosis should be prompted from the primary care physician for all elderly patients who have suffered a fracture from their low impact fall.
For more FOAMed learning on Geriatric EM visit BoringEM post on Functional Assessment
THE WEAK AND DIZZY GERIATRIC PATIENT
Patients presenting as weak and dizzy should be carefully investigated for life-threatening diagnoses.
2) metabolic derangements
5) medication side effects or toxicity.
Digoxin toxicity in the geriatric patient
One particular drug toxicity that is often missed in elderly is Digoxin toxicity.
Digoxin has a narrow therapeutic window and toxicity can occur at “pseudonormal” levels in the elderly. The true effective dig level may be elevated by co-existing hypokalemia, and hypomagnesemia (eg: on diuretics).
Remember to calculate and adjust for creatinine clearance when managing any medications that are renally cleared (mdcalc.com).
DRUG INTERACTIONS AND EFFECTS IN GERIATRIC EMERGENCY MEDICINE
Drugs with High-Risk and Low Benefit
- Benzodiazepines – can cause severe agitation and disinhibition, and side effects last a long time in elderly
- Codeine – a weak analgesic with strong opioid side effects
- NSAIDS – may trigger acute renal failure, exacerbate hypertension, and cause severe gastritis in the elderly
- Anticholinergics – side effects, such as delirium, are common in elderly
Drugs with High-Risk but also High-Benefit
- Anti-coagulants – approx. 2/3 of all drugs interact with warfarin, especially antibiotics, high doses of tylenol, amiodarone, PPIs, SSRIs, and anticonvulsants. When making any medication changes, arrange close follow up for INR surveillance, and inform them of bleeding risk & signs.
- Hypo-glycemics – all hypoglycemics may precipitate low glucose, and falls!
- Opioids – CNS effects of opioids are higher, so start at lower doses.
Acute Coronoary Syndrome in Geriatric Emergency Medicine
The elderly have a higher mortality rate in the 72 hours after a heart attack than younger patients, and have more to gain from rapid interventions. Dx is often delayed as elderly patients with MI often present later, with atypical symptoms and less definitive ECG findings.
Older patients are more likely to have a “painless heart attack,” and if they do have pain, 20% will describe it as “burning” or as “indigestion.” Patients >85 years old are more likely to present with SOB than with CP and ECG is non-diagnostic in 43% (compared to only 23% of patients under age 65). The elderly are also more likely to have pre-existing ECG abnormalities that make new ischemic changes harder to identify.
Abdominal Pain in Geriatric Emergency Medicine
About 30% of elderly patients who present with a chief complain of abdominal pain will require surgery, and their mortality rate is much higher (up to 7x higher than younger patients).
Vital sign abnormalities (tachycardia, fever, hypotension) are less likely present in older patients, even with severe intra-abdominal infections. A “normal” blood pressure may actually represent relative hypotension in the older patient whose BP is typically much higher. Older patients are less likely to mount a fever, and medications (such as B-blockers) blunt tachycardic response to anemia, fever or sepsis. Peritoneal signs are often absent, rebound less specific, and visceral pain is more challenging to localize in older patients.
The 3 most common surgical causes of abdominal pain in the elderly are:
- Cholecystitis—consider this when working up sepsis in older patients, who may present without localized tenderness, nausea, fever, vomiting, or elevated WBC but have high mortality (Parker, LJ et al. Acad Emerg Med. 1997;4:51).
- Bowel obstruction—femoral hernia is a commonly missed cause of bowel obstruction in the elderly
- Appendicitis—presents atypically in the elderly with higher rates of perforation and mortality (Gurleyik, G et al. Eur J Emerg Med. 2003;10:200).
Mesenteric ischemia—ask about “abdominal angina” and have a low threshold for ordering a serum lactate especially if they have “pain out of proportion” with CVD risk factors or Afib. If you’re thinking gastro in older pt, consider mesenteric ischemia
Remember non-abdominal causes of abdominal pain in the elderly. (MI, pneumonia, PE, DKA/ AKA, zoster, hypercalcemia, and medication toxicity)
Have a low threshold for CT imaging, which has a higher yield for decision making in older patients (Esses, D et al. Am J Emerg Med. 2004;22:270).
For pain control: Our experts recommend hydromorphone for pain control, as it is not renally excreted.
Managing constipation in the elderly is important!
Under-treatment of constipation can lead to premature death. Outpatient meds for constipation in the geriatric patient: our experts recommend a combination of lactulose or PEG plus a sennoside or bisacodyl. See this full pdf recent review for further tips (Gandell, D et al. CMAJ. 2013;185:663).
Dr. Helman, Dr. Melady and Dr. Lee have no conflicts of interest to declare.
For more on geriatric emergency medicine on EM Cases:
Best Case Ever 17: Geriatric Emergency Medicine
Inouye, SK et al. N Engl J Med. 1999;340:669. www.ncbi.nlm.nih.gov/pubmed/?term=Inouye%2C+SK+e…
Inouye, SK. N Engl J Med. 2006;354:1157. www.ncbi.nlm.nih.gov/pubmed/16540616
Kakuma, R et al. J Am Geriatr Soc. 2003;51:443. www.ncbi.nlm.nih.gov/pubmed/?term=Kakuma%2C+R+et…
Raja Rao, MP et al. J Emerg Med. 2013;S0736.
Morrison, RS et al. J Gerontol A Biol Sci Med Sci. 2003; 58:76.
For more of Don Melady’s great work visit his fantastic Geri-EM website of educational modules on Geriatric Emergencies.
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