Geriatric Emergencies
Nadim Lalani MD
Trivia

What style of fencing is this?
Foil
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From 17th C
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Lightest weapon
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valid target restricted to torso
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Strict rules as to priority of
“hits” [and thus scoring]
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Must connect with point
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4.9 N x 15msec
Epee
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From 19thC
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Heavier to simulate more real
combat
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valid target area = entire body
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double touches are allowed.
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Contact with end
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7.5 N x 1msec
Sabre
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From 19th C
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can cut and thrust
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valid target area = everything
above the waist
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(except back of the head &
hands)
Priority rules like Foil
Objectives
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Background
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Geriatric Trauma
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2 Common Presentations
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ALOC
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Infections
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Elderly Abuse
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No syncope. No weakness
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Feel free to share … Q/A …fun and engaging
Background
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Elderly 15-20% of ED visits and increasing
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Have longer ED length of stay and consume more resources
More likely to arrive via ambulance and be admitted [40% ED admissions]
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More likely to have medical rather than surgical admit
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Atypical presentations are the norm [esp >85yo “oldest old”]
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Most common causes:
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Cardiac  Ischemic HD, dysrhythmia &CHF
Syncope
CVA
Pneumonia
Abdominal disorders
Dehydration
UTI
Adverse Outcomes
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Elderly pts that are sent home have signif risk of AO’s
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Risk factors for adverse outcomes:
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Decline in Baseline function
Recent admit
Lives alone
No social Support
Polypharmacy [> 3 meds]
Certain diseases [CV, DM, dementia, depression]
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Mortality 10%  3 mo after ED visit
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25% ED bounce-back and 25% post-D/C admit rate
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Incumbent on EP’s to identify and manage this risk
List meds assoc with
Adverse outcomes
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12%  30% elders admitted in whole/part due to drug reactions
or interactions.
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Altered pharmacokinetics & pharmacodynamics
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Worst offenders:
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cardiovascular meds  diuretics  NSAID 
hypoglycemics  anticoagulants.
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Speaks to the fact that we shouldn’t be fiddling if we can help it.
CASE
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70 yo trying to put up Christmas lights.
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Fall off roof.
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EMS  can we go to PLC?
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List 3 physiologic considerations in caring for the elderly trauma
patient and how they change you management.
Physiology
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Generally more severe response to any given mechanism
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Airway:
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Breathing:
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Reduced FRC, compliance and chest wall expansion  Desat QUICK
Circulation:
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Edentulous  can’t bag.
Reduced oral diameter and neck extension.
Limited capability to increase CO
Might not vasoconstrict Due to cardiac meds
Result is that these pts cannot tolerate shock
Disability & Exposure:
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Dura attached to inner table  less EDH but MORE SDH
Spinal stenosis
Osteoporotic  trivial trauma  fracture
Other physiology
Other physiology
Other physiology
Geriatric Trauma
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Injury significant cause of death due to:
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Physiologic differences
Injury patterns
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> 80 + trauma = 4 fold mortality cf younger trauma pts
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Falls [40%]  MVC [auto vs ped]  other [assault]
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Gimme 3 risk factors for falls:
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RF’s:
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Meds [narcotics, cardiac meds]
Hx CVA
Cognition
Visual and hearing impairment
Falls and MVC’s
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Falls:
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MVC’s:
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¼ due to underlying medical condition
Most common injury is #’s [ occurring in 5%]
Even with minor mechanism, absence of clinical findings does not
rule out injury.
Low threshold for radiography
NB Single-vehicle Accidents  need to r/o medical cause
Mortality as high as 20%
Am Coll Surg recommendations anyone > 55 goes to trauma
centre.
Back to Case
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70 yo Male in collar on spine board.
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VS: 80, 110/45, 30, 90%, 370, c/s 5.0, GCS E3, V4, M6
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AMPLE  on BB/warf for AF. HCTZ for HTN & has RA
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C/o numb fingers, L chest wall pain.
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O/e: Tender L CW, Abdo non-specific tender but soft. Cannot do
pelvis because RT is doing a “fem-poke”
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Doctor?
Head injuries
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Much higher mortality  1/5 SDH do not survive
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75% admit rate
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Indications for warfarin reversal?
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What if he tripped, fell, small abrasion forehead. GCS 15. No
deficits? Management?
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Minimal mechanism + coumadin + Normal exam = 7- 15% serious
intracranial hemorrhage.
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ULTRA LOW THRESHOLD FOR CT
Acute/chronic Subdural
Spinal Injuries
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Most common mech is a fall
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Degen joint dis  reduced mobility  brittle spinal column
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Most common level of injury is C1-C3
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Most common injury is Type 2 Odontoid
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Overall mortality 15%
Central Cord Syndrome
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Two places where spinal cord is large relative to canal:
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C5-T1 [brachial plexus] & L2-S3 [lumbosacral plexus].
Limited space + Hyperextension injury  cord gets pinched by
inward bulging of ligamentum flavum  central contusion
Clinically:
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Bilateral motor weakness of upper extremities >> lower extremities
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distal muscle groups >> proximal muscle groups.
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Can have burning dysesthesias in upper extremities.
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Variable prognosis  goes by age
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> 50yo  only 30% regain bladder function & 50% regain ambulation.
Central Cord
Chest Injuries
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Falls >> MVC cause broken ribs
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Increased incidence of solid organ injury
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CANNOT tolerate
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huge risk of respiratory failure and Pneumonia
BOTTOM LINE : Elderly + rib fractures  Low threshold for
admit.
Abdominal Injuries
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Seen in 30% older trauma patients.
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Mortality = 25%
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Even with careful selection, Non-operative management only
75% success.
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Unreliable exam = Liberal use of CT
Pelvic Injuries
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Falls  break pelvis  also bleed more
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Rami >> acetab >> ischium
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Aggressive management:
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Binder
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Warm Fluids
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Blood
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Consider embolisation
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GLF + no # on xray + cannot walk?
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Needs MRI
myweb.lsbu.ac.uk
Extremity Injuries
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Low mechanism + osteoporosis = Fracture!
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Perform really good tertiary survey EVEN FOR MEDICAL
PATIENTS
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Case of syncope on park bench  when went to check for pedal
edema  ouch!  had # ankle on Xray!
Low threshold for radiography
Trauma Summary
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Go into “elder mode”
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Liberal use of radiography
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Think of elder-specific issues [central cord]
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Elder Airway  Edentulous, reduced mouth open/neck mobility
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Elder Breathing  rib fractures = signif morbidity
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Elder Circulation  meds will hide shock. PELVIS!
Mental break
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Quiz Which of these are new
features on the Wii Tiger
Woods 2009 All Play game?
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Online play
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All-play mode [for beginners]
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1:1 swing
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Create your own avatar
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Juggle the golf ball on club
Name the shot
link
Case 2
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83 yo F sent in from NH confused…
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Hx: COPD, Deaf, ? Dementia, OA, Diverticulitis.
1.
Outline Key aspects of the history
2.
Outline Key aspects of Exam
3.
Ddx?
ALOC in the Elderly
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Prevalent in the ED.
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Associated with adverse outcomes
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Poorly recognised and even more poorly documented
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EP’s assume that dementia is being managed NOT
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Still high rate of mis-diagnosis of delirium
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Mortality 20%
ALOC in the Elderly
Evaluation
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Difficult
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Average elderly pt has 3 medical conditions. NH patient = 10
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Will end up using more tests
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Despite this need to bite the bullet and be meticulous and
thorough
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H/x should be exhaustive [a la Pediatric hx]
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P/e should be more meticulous.
NB they have benign presentations despite catastrophic path.
Elder History
Elder Exam
Poor Man’s Ddx
“IS IT MEATh?”
Iintracranial Hemorrhage
Sstructural AbN /STROKE
Iinfection [mening,enceph or sepsis]
Ttrauma
Mmetabolic
[hypoGlycemia, hypo/hyper Na,hepatic,, hypoCa++,
HypoMg++]
E endocrine
Aanoxia/ischemia [cardiac arrest, severe hypox]
Ttoxins/Drugs
[ASA, antiD, w/drawal]
hhtn encephalopathy
Delirium? Dementia?
Psychosis?
Know this
Delirium
Dementia
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Sudden onset
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Insidious onset
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Fluctuating course
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Stable course
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Reduced or clouded LOC
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Alert
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Disordered attention
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Normal attention
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Disordered cognition
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Impaired orientation
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Impaired cognition
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Visual hallucinations
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Impaired orientation
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Transient delusions, poorly
organized
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Hallucinations usu absent
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Delusions absent
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No abN movements (usu)
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Asterixus/tremor
Dr. Kowal 2003
Delerium vs Psychosis
Does this patient have
delirium?
•Validated assessment of
delirium
•Sens 95% spec 95%
•CAM should be documented
on every chart
Back to case
http://www.medvarsity.com
Eldery Infections
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Higher risk due to physiologic changes
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Higher morbidity and mortality cf younger pts
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Can be difficult to sort out due to:
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Vague presentation  ALOC & weakness
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Atypical features and low sensitivity of serum markers
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Co-morbidities
Elderly Fever/bacteremia
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10% of ED visits
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When present almost always bacterial
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Absence of fever not reassuring.
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Afebrile bacteremia in 20%
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NH patients in particular do not seem to mount a febrile response.
Should prompt a thorough search
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CBC, BC, Urine Culture and CXR
¾ will end up being admitted
Elderly fever/Bacteremia
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Most common complaints  ALOC, Weakness, confusion and
decreased functional status
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> 85yo more likely to present atypically
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Urine >> resp >> unkown >> abdo
Back to case
http://www.medvarsity.com
Questions:
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Should the patient be admitted?
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What is the treatment for elderly CAP?
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What about NHAP?
Elderly Pneumonia
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Leading cause of death. Particularly prevalent in >85.
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Atypical presentations esp in NH patients [ALOC more likely]
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CAP mortality is 10% overall
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NHAP  much higher mortality
Pneumonia
Pneumonia risk stratification
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Risk Stratification by “Pneumonia Severity Index”
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Validated score based on 14 clinical and 7 lab variables
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Group 1 [score <51] = Low risk  mort only 0.5%  outpatient rx
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Group II [51-70 mort 0.9%]  Same  outpatient rx
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Group III [71-90 mort 1.2%]  intermediate risk
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consider for outpt rx if they’re only in group on the basis of age, one
comorbidity or one abn finding.
To be safe  short admit for group III
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Group IV [>91 points] 9% mort  admit
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Group V [>130 points] 27% mort  admit
Pneumonia Severity Index
Community Acquired
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CAP:
1.
S pneumo  50%
2.
H.Flu & Moraxella
3.
Atypicals [mycoplasma ,chlamydia , legionella]  15%
•
Post influenza = S aureus
Management:
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Outpatient no co-morbidities?  usual meds [Zpack etc]
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Comorbidities?  resp fluoroquinolone [GATi, GEMI, LEVO, MOX]
Sandford 2008
Nursing Home Pneumonia =
Hospital Acquired
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Recognition that NHAP
bugs are similar to HAP:
1.
2.
3.
4.
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Outpatient?
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S Pneumo
Gm Negs
AnO2
Staph
RespFQ or Clavulin +
macrolide
Inpatient? IV Levo or
Ceft/Azthro
Case
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85yo F brought in by EMS c/o weakness and SOB
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Fell 6/7 ago…doing better for 2/7… now non-ambulatory
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Pmhx: Htn, ? Silent MI, Tremor, OA
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M: HCTZ, ASA, Primodine, Tylenol, Zopiclone
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O/e: HR 110, BP 90/60, RR 30, SpO2 70% RA, 35.0
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L arm grossly ecchymotic. Swollen L wrist
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R leg short/ext rotated  deformed + crepitus
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Obvious decubitus sores
Collateral
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Level II  “no heroics”
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Lives with sis & B in Law [who’s a retired GP]
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States “ I assessed her and thought she was okay … didn’t want
to come to hosp as she doesn’t like it”
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Was ambulating 2 days after fall  then last 2/7 in bed not
eating/ weak.
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Doctors?
Elder Abuse & Neglect
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Global Health Problem [est 200,000/y in Canada]
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Mean 78 y, 2/3 are women
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Most victims live with perps  2/3 perps are family
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Only 1/14 cases actually reported
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Definitions:
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Domestic abuse
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Institutional Abuse
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Self-neglect
Categories of elder abuse
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Victims often subject to >1 type
1.
Physical
2.
Sexual
3.
Emotional/psychological
4.
Neglect
5.
Abandonment
6.
Financial/material exploitation
Risk factors for Abuse
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Caregiver rf’s
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Environment
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Alchohol/drugs
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Living together
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Unemployed
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Cramped
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Stress/burnout
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Isolated
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No caregiving skills
Elder rf’s
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Institutional rf’s
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Low wages
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Female
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Poor work environmt
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Financially dependant
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Poor training
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Immobility
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Low staff-Patient ratio
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Hx Fam violence
Indicators?
Screening P/e?
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Physical Abuse:
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Sexual Abuse:
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Contusions bilateral arms [grab marks]
Burns
Imprints of weapons/ligatures
Multiple fractures
Genital tears
Evidence of STI
Neglect:
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Hygeine [lying in feces?]
Bed sores
Duty to Report
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The Alberta Protection for Persons in Care Act 1998
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Duty to Report [protected from reprisal]
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Call SW
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Call Police
References
Questions?