Geriatric Emergencies

Educational Objectives

The goal of this program is to recognize and improve the management of altered mental states in the elderly and the unique risks that elderly patients present in the emergency department (ED). After hearing and assimilating this pro­gram, the clinician will be better able to:

1.   Distinguish between delirium and dementia.

2.   Discuss the pathophysiology of delirium.

3.   Recognize the importance of obtaining a careful drug history in the elderly.

4.   Review the physiologic changes of aging.

5.   Practice extra caution in the management of the elderly in the ED.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee 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 and plan­ning committee reported nothing to disclose.

Acknowledgements

Dr. Schneider was recorded at Managing Medical Emergencies, held May 11, 2009, in Lebanon, NH, and sponsored by the Dartmouth Medical School and Darthmouth-Hitchcock Medical Center. Dr. Nipomnick was recorded at 20th Annual High-Risk Emergency Medicine, held May 27-28, 2009, in Las Vegas, NV, and sponsored by the Center for Emergency Medicine Education. The Audio-Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

Altered Mental Status in the Elderly

Sandra Schneider, MD, Professor, Department of Emergency Medicine, University of Rochester Medical Cen­ter, Rochester, NY

Normal mental status: requires intact mid pons, midbrain, thalamus, and bilateral cerebral cortex

Delirium: sudden and reversible confusion, while dementia slow in onset and permanent; transient (days to weeks); tends to improve; global impairment; patient unable to focus; some degree of delirium seen in £50% of older pa­tients admitted to hospital; marker for longer length of stay and need for long-term care; also marker for death

Pathophysiology of delirium 

Theories:  cholinergic system  —  abnormal in elderly, so giving anticholinergic drug in therapeutic dose results in central nervous system (CNS) toxicity (similar to overdose); neurotransmitter problems  —  present in elderly, and use of drugs (eg, sedative hypnotics, antipsychotics) disturbs neurotransmitter system even more; inflammation  —  theory that physical stress (eg, surgery, stroke) induces cerebral cytokines and alters neurotrans­mitter system in brain, causing confusion; caveat  —  important  that physicians treating patients avoid worsening delirium by giving drugs

Risk factors for delirium: cognitive impairment (eg, dementia); sleep deprivation; immobility; visual impairment; hearing impairment; dehydration

Dementia: degeneration of neurons (irreversible); structural lesion in brain; exacerbated or triggered by metabolic diseases and neuropsychiatric diseases; slow onset; short- and long-term memory problems and personality changes seen; highly susceptible to delirium

Pure delirium: most likely due to medications, followed by infection and other causes, eg, electrolyte abnormalities

Drugs: obtain careful drug history, particularly over-the-counter (OTC) medication; focus on anticholinergics, sed­ative-hypnotics, and aspirin; anticholinergics  —  several available OTC; anticholinergic side effects seen with me­peridine, cimetidine, tricyclic antidepressants, most antipsychotics, most anti-Parkinson drugs, and ranitidine; sedative hypnotics  —  most widely abused drugs of elderly; aspirin  —  builds up in brain, particularly if taken long-term and ingested in large quantities; even though levels in brain high, serum levels sometimes normal

Infection: urinary tract infection (UTI)  —  bacteriuria present in large portion of elderly population, particularly those with indwelling catheters; also those with benign prostatic hyperplasia, cystocele (in women), and Foley catheter; pneumonia  —  studies show that £15% of initial chest x-rays taken in emergency department (ED) nor­mal; obtain serial chest x-rays and have high index of suspicion for diagnosis; majority of deaths due to pneumo­nia occur in elderly; sepsis  —  sources include UTI, pneumonia, skin infection, and cholecystitis; in many cases, source not found; »90% of cases of delirium due to drugs and infection

Other causes: electrolyte abnormalities; pulmonary embolism or other condition causing oxygenation problem; acute myocardial infarction; hypotension; stroke; seizure; also consider toxins and CO (interfere with O₂ and neurotransmission); psychiatric disease rarely cause of delirium (except depression)

Delirium on dementia: resident of nursing home  —  more likely to have infection because more likely to have in­dwelling catheter; also, often on multiple medications long term; sedation  —  if elderly patient in ED requires seda­tion, hospitalize in anticipation of adverse effects on mental function; haloperidol and droperidol used; antipsychotic drugs useful in elderly include quetiapine (Seroquel) and ziprasidone (Geodon); restraints  —  not ac­ceptable most of time; used temporarily until effect of drug seen; use sparingly; explain reasons for use; document use and monitor patient

Other drugs: consider substance abuse when patient does not fall into any category; also consider steroid psychosis; alcoholism  —  may start in later years due to loneliness; elderly more likely to become intoxicated due to decrease in volume of distribution from reduced gastric antidiuretic hormone (ADH); increased falls correlate with alcohol use; only »20% of problem drinkers in elderly population identified by ED physicians; gastrointestinal (GI) prob­lems more common

Delirium in ED: detection  —  only small percentage of patients identified (<20%; 0% in those with mild symptoms); in those with altered mental status, only 22% had mention of impairment in chart; assessment  —  tools include mini mental status (MMS) examination, quick confusion scale, and confusion assessment method (CAM); who to screen  —  elderly discharged to home (particularly those living alone); history of repeated falls; neurologic symp­toms; pulmonary symptoms; work-up  —  vital signs and pulse oximetry, to ascertain whether patient hypotensive or hypoxemic; serum glucose; consider naloxone (Narcan); patient safety; screen for delirium; complete blood count and differential; serum electrolytes; urinalysis; chest x-ray; electrocardiography (ECG); also consider arterial blood gases and computed tomography (CT), particularly for patients on antiplatelet medications or warfarin (Couma­din); lumbar puncture questionable (low yield); serum calcium, phosphorus, magnesium, and thyroid function tests also low yield; blood culture; obtain history of medications (particularly OTC); consider head injury and infection risk; reassess patient; criteria for discharge  —  known cause; treatable as outpatient; safe discharge destination; ad­equate home support; few elderly patients meet criteria

New Risks in the Elderly Population

Elliott S. Nipomnick, MD, Regional Medical Director, Emergency Physicians Medical Group, and Staff Physi­cian, Chinese Hospital, San Francisco, CA

Managing elderly in ED  —  falls number one cause of death due to trauma in elderly; must sort out complex symp­toms; complaints often not expressed clearly; long work-up; pressure to move patients through ED quickly; chal­lenging communications; Medicare payment restrictions (InterQual admission criteria)

Case 1: woman, 72 yr of age, presented to ED with worsening left hip pain (especially with weight bearing); history of stumble (not fall); numbness in left thigh and buttock; no abdominal or chest pain; history of hypertension, ar­thritis, and irregular heart rate; nondiabetic, nonsmoker, and does not drink alcoholic beverages; medications left at home; polypharmacy significant issue in geriatric patients; vital signs normal; physical examination (PE) showed irregular heart rate; full range of motion of both hips, with pain on flexion and internal and external rotation of right hip; x-ray of hip and pelvis showed no fracture with possible degenerative joint disease; patient sent home with di­agnosis of arthritis of left hip; prescription for ibuprofen and hydrocodone and acetaminophen (Vicodin) given; ad­vised to limit weight bearing, perform stretching exercises, follow up with private physician in 1 wk, and return if condition worsens; returned by ambulance 3 days later unable to walk, with bilateral lower extremity weakness and worsening pain; head CT showed age-related changes, but otherwise normal; international normalized ratio (INR) tested; patient on warfarin; CT of abdomen and pelvis showed large retroperitoneal hematoma; patient survived but with partial paraplegia, left foot drop, chronic paresthesias, and urinary incontinence; patient formerly independent and living alone; lawsuit filed, with allegations of incompetence, preventable loss of function, and elder abuse; al­though patient complained of paresthesias of buttocks and pain, functional examination satisfactory; however, no directed examination or history performed on those issues; lessons learned  —  in elderly, irregular heart rate due to atrial fibrillation until proven otherwise; always consider possibility that elderly patients on warfarin; if patient on warfarin, check levels; nonsteroidal anti-inflammatory drugs (NSAIDs) high risk in elderly, even if not on warfarin; never give NSAID to patients on warfarin or those with decreased creatinine clearance; follow-up in 2 to 3 days, not 1 wk

Drugs that can lead to hospital admission: diuretics (hyponatremia and hypokalemia); warfarin; NSAIDs, chemo­therapy; drugs for diabetes; risk factors  —  polypharmacy; multiple medical problems; previous adverse drug reac­tions; dementia (incorrect use of medications); renal insufficiency; advanced age; multiple prescribers

Case 2: man, 82 yr of age, tripped while going down steps; arrived in wheelchair; complains of pain and swelling of right foot; unable to bear weight; right foot swollen, ecchymotic, and tender; distal neurovascular examination good; x-rays showed no fractures or dislocation; diagnostic impression sprain of right foot; patient advised to ele­vate right foot, apply ice, and use walker; prescribed narcotic and told to follow up with personal physician; over next 4 wk, patient seen by primary care physician twice, but no improvement; referred to orthopedist; sent to for or­thotic fitting to podiatrist who diagnosed Lisfranc injury; tarsometatarsal fusion performed 6 mo later; lawsuit filed against ED physician, radiologist, and orthopedist for failure to diagnose; function improved, and case dropped; lessons learned  —  obtain CT in any patient with osteopenia if fracture suspected

Case 3: woman, 78 yr of age,  complains of right hip pain when walking and low back pain; laceration on right el­bow; lives alone; tripped on rug, but reports no loss of consciousness; denied head or neck injury;  on multiple med­ications, including one which indicated physician aware that patient had early Alzheimer’s disease; PE showed full range of motion of right hip, with pain on weightbearing and movement; x-rays of hip, pelvis, and lumbar spine showed no fractures; laboratory tests normal; patient discharged with cane and documentation that condition stable; family wanted patient admitted, but ED physician refused; patient given prescription for oxycodone and acetamin­ophen (Percocet), stool softener, and told to follow up same week; next day, x-ray read as questionable lucency in femoral neck; telephone call to patient, but no answer; 36 hr later, patient found in bathroom with altered level of consciousness and severe hip pain; 911 called; blood glucose 55 mg/dL; blood pressure 85/50 mm Hg; heart rate 68 beats/min; patient on b-blocker; given fluid bolus and transported; discharge diagnoses  —  altered level of con­sciousness due to hypoglycemia, displaced right femoral neck fracture, dehydration, acute renal failure secondary to rhabdomyolysis, hyperkalemia, and possible sepsis; in hospital for 1 mo, 10 days in intensive care unit (ICU) with dialysis, and in skilled nursing facility 2 mo for weaning off dialysis; presently in assisted care with long-term problems; issues to consider  —  failure to diagnose, missed hip fracture, inappropriate discharge, and loss of inde­pendence and quality of life, pain and suffering; family complained to medical board; lessons learned  —  perform CT in  patient with painful tender hip and negative x-rays; exercise extreme caution when discharging high-risk el­derly patient without closely monitored home care and follow-up (physician responsible for home care environ­ment); if patient sent home, must document reasons (defensive charting)

Case 4: man, 70 yr of age, involved in motor vehicle accident; wore seatbelt; extracted by fire department; sustained injury to head and extremity; confused and moaning with pain in anterior chest wall, with large contusion on fore­head; CT of head, neck, chest, abdomen, and pelvis, x-ray of right arm, portable chest x-ray, blood tests, intrave­nous (IV) access, and morphine ordered; seen by ED physician 5 min after arrival; chest x-ray taken 45 to 50 min after arrival; diagnosed with fracture of left upper ribs; BP 110/60 mm Hg (hypotensive for geriatric patient); most geriatric patients hypertensive and when stressed, BP usually in range of 160 to 180/90 to 100 mm Hg; pulse 64 beats/min; few hours later, patient became agitated; BP 90/50 mm Hg; emergent transfusion performed; central line attempted (failed); patient died; autopsy found significant trauma (fracture of several ribs on right, left clavicle, 3rd through 7th left ribs, bilateral hemothorax, and 3-cm laceration over lung); cause of death exsanguination due to blunt chest trauma and right lung laceration; complaint of inadequate evaluation and resuscitation and wrongful death; case settled; best defense that patient unlikely to have had good results; lessons learned  —  low physiologic reserves in elderly; study showed that even with 1 or 2 rib fractures, admission recommended; transfer to trauma center or call surgeon early, especially if ED in rural area; should not delay resuscitation for diagnostic procedures; plan ahead in cases of major trauma

Case 5: man, 89 yr of age, brought in by ambulance for sudden onset of substernal chest pain and pressure, with shortness of breath; given nitroglycerin, O₂, and nebulizer en route; symptoms resolved by time patient presented at ED; history of severe chronic obstructive pulmonary disease (COPD), pneumonia, hypertension, and peptic ulcer disease; previously smoked; lives alone; adequate history and PE documented; ECG, chest x-ray, and troponin ob­tained; patient on monitor in ED for 3 hr and received nebulizer treatment; discharged with diagnosis of exacerba­tion of COPD; nurse’s notes indicate episodes of dyspnea; 4 hr later, patient returned with severe shortness of breath and decreased responsiveness; on 100% O₂; ECG unchanged; second troponin negative; patient placed on bi-level positive airway pressure (BiPAP); chest x-ray showed bilateral infiltrates; taken to ICU where code called; family decided on do-not-resuscitate order; death certificate indicated aspiration; lawsuit filed, with verdict favor­able to defense; lessons learned  —  carefully consider before discharging high-risk patient, unless after informed re­fusal, patient and family agree with disposition; document patient and family’s decision in medical record with signed against-medical-advice form

Tools used in ED: CAM and MMS examination  —  study showed that only 40% of patients in ED cognitively intact (<50% in nursing homes); delirium  —  acute fluctuating changes in cognition accompanied by impaired attention and consciousness; usually short-term; present in »10% of ED patients >65 yr of age; if undetected and untreated, 31% mortality in 3 mo (12% mortality if detected and treated); in elderly, due to anything that impairs cognitive function, eg, fever, chemicals

Recommendations: avoid NSAIDs if patient >65 yr of age; determine which medications patient taking; decrease dose and frequency of psychoactive medications; evaluate and document mental status; liberal use of CT for head and neck trauma and suspected fractures; rectal temperatures  (more accurate), particularly in patient with constitu­tional symptoms; obtain fecal occult blood test; liberal admission of elderly; rapid transfer to trauma center or early involvement of surgeon in cases of trauma; admit patient if home environment unsafe; document discharge plans carefully

Suggested Reading

Barnes DE et al: Predicting risk of dementia in older adults. The late-life dementia risk index. Neurology 73:173, 2009; Chang DC et al: Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg 143:776, 2008; Ebell MH: Predicting delirium in hospitalized older patients. Am Fam Physician 76:1527, 2007; Focht A: Differential diagnosis of dementia. Geriatrics 64:20, 2009; Miller MO: Evaluation and management of delirium in hospitalized older patients. Am Fam Physician 78:1265, 2008; Peterson JF et al: Guided prescription of psychotropic medications for geriatric inpatients. Arch In­tern Med 165:802, 2005; Pham CB et al: Minimizing adverse drug events in older patients. Am Fam Physician 76:1837, 2007; Verghese J et al: Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci 64:896, 2009; Voelker R: Common drugs can harm elderly patients. JAMA 302:614, 2009; Yaffe K et al: Predictors of maintaining cognitive function in older adults: the Health ABC study. Neurology 72:2029, 2009; Young J et al: Delirium in older people. BMJ 334:842, 2007.