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?