UMEM Educational Pearls - Geriatrics

The top-normal value for ESR (sed rate) increases with age, such that the top-normal ESR value = (age +10)/2. For example, if you were checking the ESR for evaluation of temporal iritis in an 80yo patient, the top normal value of his ESR is 45.

Elderly patients are at higher risk of barotrauma with positive pressure ventilation (e.g. CPAP, BiPAP, and especially after intubation) because of decreased vital capacity and lung compliance. Watch those plateau pressures closely!

If an elderly patient develops hypotension within minutes of endotracheal intubation, always consider tension PTX (and don't forget about hypovolemia, as we've discussed before).

The most common cause of delirium in the elderly is infection, and the most common type of infection is just a simple UTI. The second most common cause of delirium is medication effects. ALWAYS look carefully for signs of infection and look carefully at medication lists whenever evaluating an elderly patient with a change in mental status.

When caring for elderly patients that are having dysrhythmias, especially ventricular dysrhythmias, or in cardiac arrest, give strong consideration to empiric use of magnesium. Elderly patients are more likely to be hypomagnesemic because of diuretic use, poor GI absorption, poor daily intake, and diabetes.

[Narang AT, Sikka R. Resuscitation of the elderly. Emerg Med Clin N Am 2006;24:261-272.]

Be wary of the limitations of correlating a temperature with infection in the elderly:
1. The elderly are 3-4x more likely to develop hypothermia in response to serious infections. Never rule out a serious infection simply based on a low or normal body temperature.
2. The elderly take longer to mount a fever than younger patients.
3. The elderly have a slightly lower body temperature at baseline, possibly 1 degree lower. As a result, "fever" in the elderly is sometimes defined as 99.5 degrees rather than the traditional 100 or 100.4 used in younger patients.

Hypovolemia is very common in the ederly for two reasons:

1. The elderly have a decreased thirst response...in other words, it takes longer for them to develop thirst in the setting of dehydration.

2. The elderly have a decreased renal vasopressin response to hypovolemia.

From a treatment standpoint, one should always assume an elderly patient is hypovolemic. Hydration is incredibly important during resuscitation of the elderly patient.

The elderly are at tremendous risk of death after MI, in no small part because we tend to undertreat them. The 30-day mortality rate after MI in patients < 65 is 3%.

In patients 65-74, the 30-day mortality is 10%.

In patients 75-84, the 30-day mortality is 20%.

In patients > 85, the 30-day mortality is 30%.

Be vigilant and be aggressive with elderly patients. Their early management has a tremendous bearing on their later outcomes.

Whereas only 6% of young patients with PE present with syncope, 15-20% of elderly patients with PE present with syncope. The simple takeaway point is that whenever an elderly patient presents with syncope, always strongly consider the possibility of PE, even though they may lack classic pleuritic chest pain.
Count that respiratory rate for an inexpensive clue!