UMEM Educational Pearls - Geriatrics

Is your older patient hard of hearing (HoH)? Instead of shouting, get a stethoscope. Put the ear buds in your patient's ears and talk into the bell. It is a hearing amplifier you carry with you.

Bonus pearl: If you use the disposable stethoscopes, then the patient can keep it in their room and use it whenever anyone wants to talk to them.

Based in part upon Geriatric Emergency Department Guidelines, the American College of Emergency Physicians has initiated a Geriatric Emergency Department Accreditation Program. Emergency departments (EDs) can be accredited at one of three levels- Gold (Level 1), Silver (Level 2) and Bronze (Level 3). There are various aspects upon which and EDs’ level is determined, including nurse and physician staffing and education, appropriate policies and protocols, quality improvement activities, outcome measures, equipment and the physical environment.

Older patients are less likely than their younger counterparts to mount a fever in response to an infection. One explanation is that their basal temperature is lower. Some experts suggest redefining fever in older patients to match this decrease of 0.15C per decade. Therefore, your 80 year old patient would be considered “febrile” if their temperature is above 37.3C, rather than the traditional 38C.

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- Half of elderly patients presenting with pneumonia will manifest signs of delirium

- Tachypnea is the most reliable and earliest vital sign abnormality

- Classic symptoms are not often helpful at predicting severity of illness

- Symptoms are unreliable

- Cough (63-84%)

- Dyspnea (58-74%)

- Fever by history (53-60%)

- Fever at arrival (12-32%)

- Pleuritic chest pain (8-32%)

- Sputum (30-65%)

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25% of U.S. health care spending goes to the 6% of people who die every year. ICUs account for 20% of all health care costs. A new study has shown that patients with POLST (Physician Orders for Life-Sustaining Treatments) forms are less likely to receive unwanted life sustaining treatments when compared to patients with traditional Do-Not-Resuscitate orders (http://www.ohsu.edu/polst/). Using the POLST did not impact the degree of comfort care received for symptom management and helped individuals make more informed choices about the type and level of end-of-life care they wish to receive.

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15% of older adults presenting to ED for dizziness have serious etiologies; 4-6% are stroke-related and sensitivity of CT for identifying stroke or intracranial lesion in dizziness is poor (16%), so if CNS etiology suspected, seek neuro consult or MRI (83% sensitivity)

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A recent study was undertaken to validate the 4A's Test for the assessment of delirium in the elderly, with particular focus on inpatient geriatric patients; it revealed that the tool had high sensitivity in detecting delirium, particularly in those with dementia or language barriers, in whom this diagnosis can often be difficult to make.  Further studies would be useful in a similar demographic of emergency department geriatric patients to confirm that this straightforward test is generalizable to the emergency department geriatric patient population.

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Asymptomatic bacteriuria is common and increases with age, with an incidence of up to 50% in women over the age of 70.  Asymptomatic bacteriuria does not carry an associated high morbidity or mortality if left untreated; it is usually transient and resolves spontaneously.  In order to decrease polypharmacy and possible drug interactions in our elderly patients, they should only be diagnosed with and treated for a UTI if they have laboratory evidence of a UTI (bacteriuria and pyuria) and have two of the following:

·      Fever

·      Worsened urinary urgency or frequency

·      Acute dysuria

·      Suprapubic tenderness

·      Costovertebral angle tenderness

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Providing consistent, quality emergency care to the elderly is critically important. The Geriatric Emergency Department (GED) guidelines, developed collaboratively, provide a standardized set of guidelines to help improve care of the geriatric population in the emergency department.

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20% of unexplained falls in the elderly can be attributed to an arrhythmia.

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When you are working up an elderly patient for trauma  look for patterns such as circumferential bruising on the wrists that have the pattern of fingers the same way you would look at the injuries of a child. Remember that the person who is sitting next to them is frequently the person that is abusing them. Therefore, it is important to interview the patient alone. 

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Older patients with acute coronoary syndrome (ACS) are less likely to present with typical ischemic chest pain (pressure-like quality, substernal location, radiating to jaw, neck, left arm/shoulder and exertional component) compared with younger counterparts.

Typical angina symptoms predictive of acute myocardial infarction (AMI) in younger patients were less helpful in predicting AMI in the elderly population.

Autonomic symptoms such as dyspnea, diaphoresis, nausea and vomiting, pre-syncope or syncope are more common accompaniments to chest discomfort in elderly ACS patients.

Symptoms may also be less likely to be induced by physical exertion; instead, they are often precipitated by hemodynamic stressors such as infection or dehydration

Bottom Line: Keep a high index of suspicion for ACS in older patients as they present atypically.

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·       In the elderly, falling is the most common mechanism of injury
·       Unavoidable Risk factors: age 85 or older, male, Caucasian, history of falls
·       Other factors: alcohol consumption, polypharmacy
·       Mechanisms of fall:  slipping, tripping, stumbling
·       Physical exam to include: gait, balance, proprioception, vision, strength and cognitive function testing
·       Must consider neglect/abuse, affects 10% of seniors per year
·       Evaluate for anticoagulant use due to increased risk of intracranial injury
·       Use advanced imaging to identify occult hip fractures when clinically suspected and plain radiographs are negative

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The Beers' Criteria lists 34 classes of medications that may be potentially inappropriate for geriatric patients due to a high risk of complications including increased risk for falls. When prescribing medications from the emergency department in geriatric patients, try to avoid these categories if other options are available.

http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf

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The WBC count is normal in up to 45% of elderly patients with bacteremia. The most predictive factors for bacteremia in the elderly are delirium, vomiting, bandemia, and tachypnea.

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The 30-day mortality for patients < 65 years of age who are diagnosed with and treated for acute MI is 3%. In contrast, the 30-day mortality for patients > 85 years of age who are diagnosed with and treated for acute MI is 30%! Obviously the mortality is far higher if the patient's diagnosis is delayed or missed; or if the patient is not treated appropriately.

This simple statistic highlights the critical importance of being aggressive with diagnostic and therapeutic planning for elder patients with potential ACS. We cannot afford to be cavalier in their evaluation or treatment.

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Elderly patients in general have a lower baseline body temperature than younger patients. Consequently, it makes sense to redefine the definition of what constitutes a "fever" in the elderly. Rather than using the typical oral temperature cutoff of 38^o C (100.4^o F) for defining a fever, instead consider using 37.2^o C (99^o F). Redefining fever in this way increases the sensitivity for detecting bacterial infections from 40% to 83% while retaining an 89% specificity.

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