Health care emergencies among the geriatric or elderly populations

1. Age Does Matter: Critical Issues in the
ED Evaluation of Geriatric Patients
Marc Evans M. Abat, MD, FPCP, FPCGM
Section of Adult Medicine, Department of Medicine, PGH
Head, Center for Healthy Aging, The Medical City

2. Case
• 92/F
• CC: increased sleeping
• (+)hypertension
• (+)type 2 diabetes on 4 oral hypoglycemic
agents
• (+) dyslipidemia

3. • Came from Samar due to fever and
headaches
• Seen at another tertiary hospital in Manila
– Dx: viral upper respiratory tract infection
– DM medications adjusted due to high CBGs
• Increased sleeping started 2 days before
current consultation

4. • ROS: (+)memory lapses notable since 2
months prior to admission
• Physical examination at the ER
– BP 100/60 HR 84 RR 20 T 36.7°C
– Patient drowsy to stuporous, minimal eye
opening on name calling and tapping, groans
only with no distinct verbal output
– E/N findings for other organ systems including
neuro

5. What is your initial
impression?
A. Hypoglycemia
B. Infection
C. Electrolyte Imbalance
D. Stroke
E. Dehydration

6. Outline
• Critical Role of the Emergency Medicine
Physician
• Clinical Vignettes in the Care of the Older
Patient at the Emergency Department
• Common Presenting Complaints

7. Critical Role of the
Emergency Medicine
Physician

8. BMC Geriatrics 2013, 13:83

9. BMC Geriatrics 2013, 13:83

10. Compared to ages 18-60, those > 60 years
• Adjusted OR for admission
– 1.7 (1.6-1.8, p<0.001)
• Adjusted OR for mortality
– 2.3 (2.0-2.5, p<0.001)
BMC Geriatrics 2013, 13:83

11. Critical Care 2006, 10:R82 (doi:10.1186/cc4926)

12. Critical Care 2006, 10:R82 (doi:10.1186/cc4926)

13. Clinical Vignettes in the
Care of the Older Patient at
the Emergency Department

14. Geriatric syndromes
• refer to multifactorial health conditions that
occur when the accumulated effects of
impairments in multiple systems render an
older person vulnerable to situational
challenges
• Emphasizes multiple causation of a unified
manifestation

15. Syndromes in the young
population
Geriatric syndromes
a group of symptoms that do not
need to be highly prevalent
highly prevalent, mostly single
symptom states
a single pathogenetic pathway,
known or unknown, causes the
symptoms.
the leading symptom is linked to
a number of aetiological factors
or diseases in other organs.
separate entities, and there is no
overlap between aetiological
factors of different syndromes
large overlap between the
aetiological factors of different
geriatric syndromes.
in younger patients, one usually
finds a single syndrome in one
patient
A geriatric patient often suffers
from more than one geriatric
syndrome

17. • Use of the terminology leads to special
considerations
– multiple risk factors and multiple organ systems are
often involved
– diagnostic strategies to identify the underlying causes
can sometimes be ineffective, burdensome,
dangerous, and costly
– therapeutic management of the clinical manifestations
can be helpful even in the absence of a firm diagnosis
or clarification of the underlying causes

19. • Education Committee Writing Group
(ECWG) of the American Geriatrics
Society recommends that undergraduate
students should be trained profoundly in
the 13 most common geriatric syndromes
dementia inappropriate
prescribing of
medications
osteoporosis
depression incontinence sensory alterations
including hearing
and visual impairment
delirium iatrogenic problems immobility and
gait disturbances
falls failure to thrive
pressure ulcers sleep disorders

20. Paradigm shifts
• Diseases often present atypically
– Reflects organ system most restricted in homeostasis
– Confusion, increased somnolence, incontinence are
common manifestations of infection, hip fracture
• Aggressive medical attention is necessary to
prevent domino effect of illness
– Endpoint: multiple organ failure
• Law of parsimony does not hold
– Symptoms in elderly often due to multiple causes

21. Common Presenting
Complaints

22. Acute Myocardial
Infarction
• “Silent” MI more
common
• Dyspnea only
• May present with
signs, symptoms of
acute abdomen--
including
tenderness, rigidity

23. Acute Myocardial
Infarction
• Possibly just vague symptoms
– Weakness
– Fatigue
– Syncope
– Incontinence
– Confusion
– TIA/CVA

24. Congestive Heart Failure
• Nocturnal confusion
• Bed-ridden patients may have
fluid over sacral areas rather
than feet, legs
• Without orthopnea or
paroxysmal nocturnal dyspnea
in earlier stages
• “Visceral” or pulmonary
congestion without peripheral
edema

25. Acute Arterial Occlusion
• May be painless and
easily missed
• May manifest only with
a cyanotic, pulseless
and cold extremity
• Unpredictable and may
follow any acute
disease

26. Pulmonary Edema
• May be tricky to differentiate
from other causes of
crackles
– Pneumonia
– Bronchiectasis
• Need to use other modalities
– Hepatojugular reflux
– labs (e.g. BNP)

27. Pulmonary Embolism
• Suspect in any patient with sudden onset
of dyspnea when cause cannot be quickly
identified
– D-dimer??
– DVT screening??
– Venous duplex scanning??

28. Pneumonia
• Possibly atypical
presentations
– Absence of cough, fever
– Loss of appetite and
difficulty sleeping
– Abdominal rather than
chest pain
– Altered mental status
– Falls

29. Chronic Obstructive Pulmonary
Disease
• Usually causes a progressive
degree of dyspnea and
coughing over a long period of
time, with episodes of acute
exacerbation
• May co-exist with other acute
problems (e.g. MI, pneumonia)

30. Constipation
• May acutely present as
– Delirium
– BP spikes
– Gastric retention

31. Diarrhea and Dehydration
• Dehydration may be
difficult to assess in the
elderly due to preexistent
– Xerostomia
– Loss of subcutaneous
tissues

32. • Manifests as
– Delirium
– Decreasing blood
pressure
– Loss of urine
output
– Tachycardia
– hypotension

33. Acute abdominal pain
• Numerous etiologies
– Pneumonia
– Myocardial infarction
– Gastroenteritis
– Malabsorption
syndromes
– Mesenteric disease
– Acute appendicitis
– Malignancy
• May be accompanied by
abdominal rigidity
despite the absence of
peritonitis

34. GI Bleeding
• Manifest with
progressive pallor and
weakness, loss of
appetite, body malaise
• May also present with
progressive abdominal
enlargement with initial
constipation

35. Urinary Tract Infection
• Patient may not complain of painful
urination or frequency or urgency
• May manifest with acute incontinence,
delirium or loss of appetite
• In cases of pyelonephritis, there may be
absence of costovertebral tenderness and
fever

36. Uremia
• Symptoms related to the inability of the
kidney to remove toxins
• May present with delirium, persistent
nausea and vomiting, tachypnea
• May present atypically with body malaise,
poor appetite, weakness

37. Hypoglycemia
• Patient may not
complain of hunger,
tremors, sweating
and other signs seen
in the young
• May just present with
loss of
consciousness or
seizures

38. Hyperglycemia
• Symptoms are attributable to the
underlying disorder
– Diabetic ketoacidosis
– Hyperosmolar, hyperglycemic state
• Include delirium, loss of urine output,
tachypnea, diarrhea, coma

39. Electrolyte disorders
• Hyponatremia
– Weakness, sleepiness, difficulty walking or
ambulating, delirium
• Hypernatremia
– Delirium, seizures, coma
• Hyperkalemia
– Sudden cardiac death
• Hypokalemia
– Muscle weakness, sudden cardiac death

40. Dementia vs. Delirium
• Stable and progressive vs waxing and waning
• chronic onset vs acute onset
• The former has more prominent cognitive
impairment, the latter has sensorium as
dominant impairment
• Never assume acute dementia or altered mental
status is due to “senility”
• Ask relatives, other caregivers what the patient’s
baseline mental status is

41. Possible Causes of Delirium
• Head injury with
subdural hematoma
• Alcohol, drug
intoxication, withdrawal
• Tumor
• CNS Infections
• Electrolyte imbalances
• Cardiac failure
• Hypoglycemia
• Hypoxia
• Drug interactions

42. Cerebrovascular Accident
• signs often subtle—dizziness,
behavioral change, altered
affect
• Headache, especially if
localized, is significant
• Stroke-like symptoms may be
delayed effect of head trauma

43. Seizures
• All first time seizures in elderly are
dangerous
• Possible causes
CVA
Arrhythmias
Infection
Alcohol, drug
withdrawal
Tumors
Head trauma
Hypoglycemia
Electrolyte
imbalance

44. Syncope
• Morbidity, mortality higher
• Consider
– Cardiogenic causes (MI, arrhythmias)
– Transient ischemic attack
– Drug effects (beta blockers, vasodilators)
– Volume depletion

45. Depression
• Common problem
• May account for symptoms of “senility”
• Persons >65 account for 25% of all
suicides
• Treat as possibly life threatening

46. Head Injury
• More likely, even with minor trauma
• Signs of increased ICP develop slowly
• Patient may have forgotten injury, delayed
presentation may be mistaken for CVA

47. Cervical Injury
• Osteoporosis, narrow
spinal canal increase
injury risk from trivial
forces
• Sudden neck
movements may cause
cord injury without
fracture
• Decreased pain
sensation may mask
pain of fracture

48. Hypovolemia & Shock
• Decreased ability to compensate
• Progress to irreversible shock rapidly
• Tolerate hypoperfusion poorly, even for
short periods

49. Hypovolemia & Shock
• Hypoperfusion may occur at “normal” pressures
• Medications (beta blockers) may mask signs of
shock

50. Geriatric Abuse & Neglect
• Physical, psychological injury of older
person by their children or care providers
• Knows no socioeconomic bounds

51. Geriatric Abuse & Neglect
• Contributing factors
– Advanced age: average mid-80s
– Multiple chronic diseases
– Patient lacks total dependence
– Sleep pattern disturbances leading to
nocturnal wandering, shouting
– Family has difficulty upholding commitments

52. Geriatric Abuse & Neglect
• Primary findings
– Trauma inconsistent with history
– History that changes with multiple tellings

53. Serious head injuries sometimes
denote geriatric abuse.

54. General Management
Guides
• No enormous change
• “Start Low, Go Slow, But Keep on Going”
• Be wary of Drug Adverse Reactions!

55. Additional
• Geriatric Emergency Department
Guidelines (2014)
– American College of Emergency Physicians
– American Geriatrics Society
– Emergency Nurses Association
– Society for Academic Emergency Medicine

56. • Geriatric Emergency Medicine Fellowships

57. Summary
• The Emergency Physician plays a vital
role in the initial management of the
Geriatric patient
• Symptoms of the Geriatric ED patient are
often multiple, overlapping, and atypical,
complicated by existing diseases,
medications and age-related changes