THE GERIATRIC PATIENT
| MEDICAL ISSUES IN THE ELDERLY —Jorge A. Diaz, MD, Assistant Clinical Professor of Medicine, David Geffen
School of Medicine at the University of California, Los Angeles, and Attending Physician, Department of Emergency Medicine,
Olive View-UCLA Medical Center
|
| Issues in geriatric care: multiple morbidities, drug effects, and symptoms; presentation of medical and surgical illnesses
different from that of younger people; diminished physiologic reserves (at age 20 yr, organs have reserves 4 to 10 times
that needed for homeostasis; geriatric illness associated with “domino effect,” in which failure of one organ system leads
to failure of others); polypharmacy; symptoms may be subtle, atypical, vague, and easily dismissed as part of old age; patients
often postpone physician visits for fear they may never return home if hospitalized; high risk for adverse drug
events (ADEs); history may be difficult to obtain due to dementia, stroke, or (usually) poor hearing (ask patients if they
can hear you; check ears for wax); bottom line—with elderly patients, treat and admit
|
| Aging and cardiovascular system: cardiac output decreases 1% annually after age 30 yr; ventricular stiffness increases,
often due to hypertension; elderly more susceptible to diastolic heart failure (need to preload); patients less able to tolerate
tachycardia or atrial fibrillation, and decompensate quickly; decreased reserves for responding to shock (autonomic
nervous system cannot respond as well to endogenous or exogenous catecholamines); systolic blood pressure increases
with age; general rule—elderly person’s systolic blood pressure (BP) should be 100 + age (“normal” pressure for young
person abnormal in someone older; suspect shock, sepsis, bleeding, or other pathologic process)
|
| Aging skin and musculoskeletal system: all skin layers atrophy; risk for skin tearing increases (placing sterile tape on either
side of laceration facilitates suturing); bone mass decreases, making patients prone to fractures; kyphosis may develop, with
consequent loss of height; fat proportion increases
|
| Aging and body temperature regulation: ability to tolerate hypothermia and hyperthermia decreases (patient may be septic
without fever); check rectal temperature, as many patients breathe through mouth; consider oral temperatures of 99°F
to 100o F fever in elderly patients; almost always signals serious infection
|
| Immune system: most elderly patients immunocompromised and tolerate infections poorly; increases risk for cancer; consider
admitting older patients with pneumonia
|
| Nervous system: one of first systems to decompensate in illness; elderly patients with fever, urosepsis, or myocardial infarction
(MI) may appear confused; impaired balance and coordination increases risk of falling; hearing, vision, and memory
all diminish (consult primary care physician, caretaker, or family when taking history)
|
| Renal system: renal mass and vascular bed decrease with aging; older people depend on prostaglandins for renal perfusion;
therefore, nonsteroidal anti-inflammatory drugs (NSAIDs) may cause renal failure, hyperkalemia, or congestive heart failure
(CHF) due to fluid retention; elderly also at high risk for gastrointestinal bleeding from NSAIDs; decreased renal reserves
increase susceptibility to nephropathy from contrast dye and other drug effects; serum creatinine may underestimate degree
of renal impairment (use creatinine clearance instead)
|
| Age-related alterations in pharmacokinetics and pharmacodynamics: make patients more prone to ADEs; may see paradoxic
reaction to drugs such as lorazepam; polypharmacy—average elderly patient takes ≤5 prescription medications,
plus over-the-counter drugs and herbal products; ADEs responsible for 5% to 10% of hospital admissions
|
| Sample case 1: man 77 yr of age admitted feeling weak, dizzy, and short of breath; history of coronary artery disease, hypertension,
atrial fibrillation (AF), and CHF; recent hospitalization and cardioversion for AF; on admission, patient
awake and alert but pale and ashen; lungs clear on auscultation; severe bradycardia (confirmed by electrocardiography);
medications included warfarin, digoxin, amiodarone, atenolol, lisinopril, lovastatin, lasix, allopurinol; patient
also fond of green tea; laboratory findings—serum urea nitrogen 78 mg/dL, creatinine 3.6 mg/dL, potassium 7.2
mmol/L, international normalized ratio (INR) 3.11; patient placed on atropine, digoxin immune Fab (Digibind), calcium,
glucagon, sodium bicarbonate, insulin, 50% protein (D50), sodium polystyrene sulfonate (Kayexalate), and
dopamine drip
|
 | Case analysis: lisinopril last drug added to patient’s regimen; standard of care to perform chemistry-7 panel within 1 wk
of placing patient on angiotensin-converting enzyme (ACE) inhibitor because these drugs can precipitate acute renal
failure or life-threatening hyperkalemia; amiodarone decreases digoxin clearance; additive toxicity between amiodarone
and metoprolol; side effects of amiodarone include bradycardia, hypo- and hyperthyroidism, and pulmonary
disease (high doses); green tea contains vitamin K, and in large quantities may interact with warfarin; allopurinol contraindicated
when creatinine >1.5 mg/dL (may precipitate renal failure)
|
| Pearls: sedative hypnotics and muscle relaxants increase risk for syncope, hypotension, and falls in elderly; NSAIDs
poorly tolerated by elderly; anticholinergic drugs associated with delirium, urinary retention, and constipation; warfarin
interacts with many drugs, and may cause bleeding; calcium channel blockers may cause syncope
|
| Avoiding ADEs: obtain list of current medications when patient enters emergency department (ED); calculate creatinine
clearance; avoid NSAIDs whenever possible; avoid high-risk drugs, eg, ACE inhibitors unless close follow-up possible;
add stool softeners when prescribing narcotics; start with half of usual adult dose, especially when using conscious
sedation; always consider drug-drug interactions; educate patient about possible side effects
|
| Sample case 2: 80-yr-old man, status, post-nephrectomy (discharged 1 wk ago); enters ED agitated, disoriented, hallucinating,
and incoherent; no focal neurologic findings; normal vital signs
|
| Characteristics of delirium: reversible; alternates with lucid intervals; sleep-wake cycle reversed; most common causes
general anesthesia, medications, infection, MI
|
| Geriatric trauma: take patient to trauma center whenever significant motor vehicle trauma involved (severity of injuries
easily underestimated)
|
| Sample case 3: 72-yr-old woman whose car hit telephone pole and sustained moderate frontal damage; restrained driver;
unconscious initially and woke up confused; BP 120/70 mm Hg; pulse 90 bpm; respiratory rate 28/min; Glasgow
Coma Scale (GCS) score 12; 1-in laceration on forehead; ecchymoses over left chest; patient has seizure while undergoing
head computed tomography (CT); blood glucose 26 mg/dL; analysis — patient diabetic, had hypoglycemic episode
while driving, passed out and hit pole; when evaluating acute mental status, always check blood glucose first;
respiratory rate also “great clue for things going awry in an elderly person”
|
| Falls: main cause of geriatric trauma death; broken hip, arm, or ankle can precipitate irreversible functional decline; 50%
of elderly patients who undergo hip replacement unable to walk without help thereafter
|
| Abuse: always suspect in geriatric trauma cases
|
| Acute coronary syndromes: main cause of death in elderly; usually present as painless MI; anginal equivalent symptoms
include shortness of breath, diapheresis, nausea, vomiting, fatigue, syncope, delirium, indigestion, upper abdominal pain;
mortality rate 2 to 3 times that of younger patient
|
| Pneumonia: sixth leading cause of death in elderly; patients often have no fever and may or may not have leukocytosis; no
cough 50% of time; delirium may be only presenting symptom; most consistent finding tachypnea; admit patient
|
| Abdominal pain: 50% of patients need admission; 30% to 40% require surgery; always consider appendicitis; do not stint
on tests and imaging studies
|
| Hypothyroidism: common in elderly; constipation may be only presenting symptom; push suppository in base-first
|
| GERIATRIC TRAUMA —James T. Brown, MD, Clinical Professor of Surgery and Emergency Medicine, University of Illinois
College of Medicine at Peoria, and Attending Physician, Department of Emergency Medicine, OSF Saint Francis
Medical Center, Peoria, IL
|
| Definitions: “young old”—65 to 80 yr of age; “old old”—>80 yr of age; chronologic age means much less than physiologic
age
|
| Falls: leading cause of geriatric trauma, and trauma fifth to seventh leading cause of death among elderly; responsible for
80% of trauma admissions among people >65 yr of age; underlying cause of death for >9500 patients/yr; 30% of patients
who fall live independently; 50% will fall again; examination of social systems warranted to reduce risk for future
falls; only 20% of falls need attention; 5% of patients sustain serious injuries; lacerations occur in 5% to 10%;
numbers doubled among women >75 yr of age
|
| Contributing factors: postural instability, poor balance, loss of strength or coordination, deterioration of senses, eg, vision,
hearing; medication effects
|
| Prevention: exercise programs to improve strength and balance; may reduce fall risk by 50%; encourage year-round activity;
calcium and vitamin D supplements may improve strength and reduce fall risk by 50%; monitor prescriptions,
especially psychotropic medications; look for physical disabilities (cataracts, assisted walking, cardiac pacemaker
[associated with syncope]); multifactoral risk-reduction strategy recommended
|
| Motor vehicle accidents (MVAs): second leading cause of geriatric trauma; most common cause of fatal accidents in this
population; accidents involving elderly people usually occur in daylight, good weather, at intersections, and involve >2
cars; contributing factors include declining visual, auditory, motor, and cognitive skills, postural changes, and slower reaction
time; pedestrian MVAs—elderly second only to children as victims (≈22%); fatality rate >50%; contributing factors
similar to those in MVA-only accidents; must walk 4 ft/sec to get through intersection
|
| Burns: elderly comprise 13% to 20% of admissions to burn centers; fatality rate high due to high rate of comorbidities
|
| Violence: morbidity rate higher among elderly than among younger victims; always consider abuse
|
| Injury severity score (ISS): ranks injuries from 1 (minor) to 6 (fatal) in 6 areas of injury (AIs; head and neck, face, chest,
abdomen, extremities, external); combined score ranges from 0 to 75 (dead); calculated by adding and squaring ISS
from 3 most seriously injured areas; AIs of 6 = ISS of 75
|
| Associated mortality: minimal with ISS <25; 50% if ISS=50; almost always fatal when ISS >70
|
| Considerations: when to send patient to trauma center; studies show elderly patients underutilize trauma care; encourage
prehospital care providers to have low threshold for sending older patients to trauma centers; in retrospective review of
8980 trauma patients with ISS scores >15 (5855 young, 3125 elderly), age was negative predictor of admission to
trauma center; take-home message—during triage of older patients in prehospital setting, do not assume (just based on
age) that they do not need to go to trauma center
|
| Vital signs: in study of 15 elderly trauma patients, 8 had stable, (ie “normal”) vital signs, yet cardiac output low (<3.5 L/
min); all responded poorly to volume loading; of 7 with “normal” cardiac output, 5 had inadequate oxygen delivery; on
average, cardiac output and contractility of patient 80 yr of age 50% that of younger patient; elderly patients do not respond
to catecholamines; many already have conduction defects, eg, bundle branch block; consider patients’ other medications
|
| Head injuries: brain size decreases 10% between 30 and 70 yr of age; never assume dementia or senility cause of altered
mental status before excluding every other possibility; epidural hematoma (bleeding between skull and brain layers)
less common in older than in younger patients due to brain atrophy; incidence of subdural hematoma (bleeding adjacent
to brain) high in elderly; symptoms slower to appear due to “dead space” between skull and brain; in retrospective
study of brain-injured patients, mortality highest among elderly, even with mild to moderate injuries; GCS score of 14
to 15 considered mild; outcomes for older patients worse, even with relatively mild GCS score; age and GCS score independent
predictors of poor functional outcomes
|
| Head injuries in elderly patients on anticoagulants: in retrospective study of 32 elderly patients, 24 (75%) discharged
(group 1); remaining 8 (group 2) admitted; group 1—all had GCS score of 15; mean INR 2.45; 3 patients underwent
CT; all did well; Group 2a—4 patients; neurologically intact; all had GCS of 15; 3 lost consciousness; on CT, all had
intracranial hemorrhage; mean INR 2; group 2b—3 had normal GCS scores; 1 lost consciousness; mean INR 2.5; all
4 died; take-home message—25% of total group had intracranial hemorrhage; of those, 50% died; usual means of
evaluation poor predictors of outcome; any elderly patient on anticoagulants with minor head trauma is candidate for
CT
|
| Worfain (coumadin) protocol: in one study, investigators expedited evaluation and care of head-injured elderly patients
on anticoagulants; among 35 patients ≈75 yr of age, falling most common mechanism of injury; time to physician evaluation
19 min (compared to usual time of 31 min); CT performed within 85 to 132 min; no impact on symptom progression,
time to receiving medication, or mortality rate; conclusion—expediting care of little help
|
| Cervical spine injuries: in analysis of National Emergency X-Radiography Utilization Study (NEXUS), of 2943 patients
aged >65 yr, cervical spine injuries twice as common as in general population; odontoid fractures much more common
than in younger patients; NEXUS evaluation criteria for x-rays (midline spinal tenderness, distracting injuries, altered
mental status similar for both age groups); conclusion—NEXUS criteria valid for geriatric patients; pay close attention
to odontoid region
|
| Rib fractures: in Canadian study over 7 yr, 61% of elderly patients with rib fractures had comorbidities, compared to 8%
of younger patients; older patients more likely to be injured as result of fall; ISS scores lower among geriatric patients;
GCS scores and revised trauma scores higher in older population; isolated thoracic trauma more common; however, older
patients more likely to sustain multiple rib fractures (32% had >6 ribs injured); length of hospital stay also longer; incidence
of pneumonia 34% among older patients, 10% among nongeriatric patients; mortality risk associated with pneumonia
4 times higher among geriatric patients; take-home message—mortality risk high among geriatric patients with >2
fractured ribs; admission for pain control and treatment recommended
|
| Abdominal trauma: conventional abdominal examination less reliable in older patients, often due to altered pain perception;
consider focused assessment with sonography for trauma (FAST) examination and CT when possible; splenic
injuries—conservative management recommended, but monitor older patients closely for complications
|
| Comorbid illnesses: for each year after age 65 yr, mortality risk from trauma increases by 6.8%; BP and heart rate good
predictors of survival
|
| Functional outcomes: the older the trauma patient, the less likely they are to return home; in study of octogenarians, comorbid
illness associated with poor functional outcomes
|
Suggested Reading
Bergeron E et al: Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 54:478,
2003; Gillis AJ, MacDonald B: Unmasking delirium. Can Nurse 102:18, 2006; Grossman M et al: Functional outcomes
in octogenarian trauma. J Trauma 55:26, 2003; Grossman MD et al: When is an elder old? Effect of preexisting conditions
on mortality in geriatric trauma. J Trauma 52:242, 2002; Inaba K et al: Long-term outcomes after injury in the elderly. J
Trauma 54:486, 2003; Lane P et al: Geriatric trauma patients—are they receiving trauma center care? Acad Emerg Med
10:244, 2003; Mosenthal AC et al: Isolated traumatic brain injury: age is an independent predictor of mortality and early
outcome. J Trauma 52:907, 2002; Mosenthal AC et al: The effect of age on functionl outcome in mild traumatic brain injury:
6-month report of a prospective multicenter trial. J Trauma 56:1042, 2004; Reynolds FD et al: Time to deterioration
of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. J
Trauma 54:492, 2003; Thomas S, Rich MW: Epidemiology, pathophysiology, and prognosis of heart failure in the elderly.
Heart Fail Clin 3:381, 2007; Thompson HJ, Bourbonniere M: Traumatic injury in the older adult from head to toe. Crit
Care Nurs Clin North Am 18:419, 2006; Touger M et al: Validity of a decision rule to reduce cervical spine radiography in
elderly patients with blunt trauma. Ann Emerg Med 40:287, 2002.
Educational Objectives
| The goal of this program is toimprove management of trauma in the geriatric population. After hearing and assimilating this
program, the clinician will be better able to:
|
| 1. Describe the ways in which different organ systems decline with age.
|
| 2. Recognize the symptoms of delirium and distinguish it from dementia.
|
| 3. Name the two leading causes of geriatric trauma.
|
| 4. Decide when to send an elderly trauma patient to a trauma center.
|
| 5. Manage elderly patients with head injuries, cervical spine injuries, rib fractures, and abdominal trauma.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Diaz spoke at the 20th Annual Advances in Emergency Medicine and Primary Care, held April 18-20, 2007, in Las Vegas,
NV, and sponsored by the Olive View-UCLA Department of Emergency Medicine, and the American College of Emergency
Physicians, State Chapter of California, Incorporated. Dr. Brown spoke at the Downstate Emergency Medicine Conference,
held February 15, 2007, in Peoria, IL, and sponsored jointly by the Illinois College of Emergency Physicians and the American
College of Emergency Physicians. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in
the production of this program.
|
