UMEM Educational Pearls - Geriatrics

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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Elderly patients are high risk for missed MI because of atypical presentations. Though this seems to be relatively common knowledge, it is not always remembered. So here's a reminder....

• Elderly patients present with chest pain during their MI only ~ 50% of the time
• Dyspnea is the most common anginal equivalent (alternative complaint). Other common anginal equivalents are syncope, nausea, vomiting, or diaphoresis
• The ECG in elderly patients with AMI is more frequently non-diagnostic. Only 40% of the time do they present with a STEMI, and when they do have ST elevation it may be less elevation than with younger patients. Furthermore, baseline abnormalities such as BBB, pacers, and prior MIs may make the ECG more difficult to interpret.

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The most common sources of bacteremia and serious bacterial infections in the elderly are the GU tract, the respiratory tract, and #3-the abdomen.

This third source is a bit of a surprise to many clinicians but worth remembering. Always consider the abdomen as the source of dangerous infections in the elderly when the source is not clearly the lungs or urine!

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Here are a few important points to keep in mind when evaluating elderly patients in the ED or when prescribing a new drug:

• Adverse drug effects lead to 11% of ED visits in patients > 65
• Older patients in the ED generally take > 4 medications per day, with 13% taking > 8 medications
• 11% of elderly patients in the ED receive at least 1 inappropriate medication
• 3 medication classes account for 48% of all ED visits for adverse drug effects in the elderly: oral anticoagulants or antiplatelet meds, antidiabetic medications, and agents with a narrow therapeutic index (e.g. digoxin, phenytoin)

Pay special attention to medication lists and new prescriptions in the elderly....much more attention than with younger patients!

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We already know that polypharmacy is a big issue in the elderly, but here are a few key points to keep in mind:
1. Adverse drug effects are responsible for 11% of ED visits in the elderly.
2. Almost 50% of all adverse drug effects in the elderly are accounted for by only 3 drug classes:
     a. oral anticoagulant or antiplatelet agents
     b. antidiabetic agents
     c. agents with narrow therapeutic index (e.g. digoxin and phenytoin)
3. 1/3 of all adverse-effect-induced ED visits are accounted for by warfarin, insulin, and digoxin.
4. Up to 20% of new prescriptions given to elderly ED patients represents a potential drug interaction.

The bottom line here is very simple--scrutinize that medication list and any new prescriptions in the elderly patient!

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Rib fractures are associated with significant morbidity and mortality in the elderly, and the risk increases dramatically with each successive rib fractured. An elderly patient with 3 rib fractures has a mortality of 20% and risk of pneumonia is 31%. As a general rule, you should really think twice about discharging home any elderly patients with rib fractures.

[credit to Dr. Joe Martinez for bringing forth this information]

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Elderly patients are prone to hypovolemia for the following two major reasons:
1. They have a decreased thirst response.
2. They have decreased renal vasopressin response to hypovolemia.

The result is that elderly patients have an impaired ability to compensate for a decreased cardiac output, which causes them to develop shock earlier and more easily with stressor.

Takeaway point: Always assume that most elderly patients are hypovolemic, and when they are stressed, give them fluids early!
 

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Adverse drug effects are a major issue in geriatrics.
Elderly patients take, on average, 5 prescription medications + 2 over-the-counter medications.
Adverse drug effects account for approximately 5% of all hospital admissions.
Nearly 20% of patients brought to the ED for psychiatric complaints have symptoms that are primarily caused by medication effects.

Be very wary whenever prescribing ANY new medications for even a short time to elderly patients.

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There is a correction factor for erythrocyte sedimentation rate in the elderly. The top normal ESR in the elderly is (age + 10)/2. For example, an 80 yo patients would have a top normal ESR of (80+10)/2 = 45. Most laboratories do not, however, report this correction factor, but simply list < 20 (or thereabouts) as normal.

Be certain to take this correction factor into account when using ESRs for workups for temporal arteritis or other similar conditions.
 

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Elderly patients are at higher risk for skin infections for numerous reasons:
1. Blunted immune system response of skin to infections.
2. Slower wound repair after 3rd decade.
3. More frequent exposure to infections, especially drug resistant infections, especially if the patient is frequently hospitalized or in nursing homes.
4. Frequent portals of entry for skin infections: indwelling tubes and lines, leg ulcers, fissures and maceration on feet and between toes.

A key takeaway point is to always check the skin thoroughly of your elderly patients when searching for infections, especially the feet and toes!

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The majority of "classic" symptoms and signs in elderly patients with pneumonia (fever, cough, sputum production, leukocytosis,chest pain) are unreliably present. However, tachypnea is one of the most reliable early findings in elderly patients with pneumonia, and in fact the same can be said about other serious bacterial illnesses in the elderly. The takeaway point here is simple: always count the respiratory rate in elderly patients (and don't trust those triage respiratory rates)!

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The WBC count is not an accurate predictor of bacteremia in the elderly. 20-45% of elderly patients with proven bacteremia have a normal WBC on presentation.

[from Caterino JM, et al. Bacteremic elder emergency department patients: procalcitonin and white count. Acad Emerg Med 2004;11:393-396.]

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The nitrite test on urine dipstick is commonly used for diagnosis of UTI. However, the test is only reliable in those bacteria that convert nitrates to nitrites, which primarily includes enterobaceriaceae. However, elderly patients often develop UTIs with Staph saprophyticus, pseudomonas, and enterococcus, none of which produce positive nitrites on dipstick testing. The takeaway point here is very simply....don't assume you've excluded UTI (esp. in elderly populations) just because the nitrite test is negative.

reference: Anderson RS, Liang SY. Infections in the elderly. Critical Decisions in Emergency Medicine, April 2010.

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Up to 25% of elderly patients with appendicitis are initially sent home from the ED, an indication of the high misdiagnosis rate for appendicitis in the elderly population. Why are elderly patients so often misdiagnosed when they have appendicitis? The answer is simple....they present very atypically.

• The classic migratory pattern (periumbilical pain that migrates to the RLQ) is absent in > 50%
• Nasea, vomiting, and anorexia are each absent in > 50%
• Fever is absent in up to 50%
• Guarding and rebound are absent in 50%
• The WBC is normal in up to 45%
• Up to 15% have pyuria or bacteriuria, leading to misdiagnoses of UTI

Expect the atypical in elderly patients!
 

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