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Title: Issues in Geriatric Medicine


1
Issues in Geriatric Medicine
  • Juliette Sacks
  • November 9, 2006

2
Outline
  • Aging changes
  • Polypharmacy
  • Chest pain
  • Abdominal pain
  • Not included Falls, Head injury, Trauma, altered
    LOC

3
Elderly
  • Fastest growing subset of population especially
    gt85 yrs of age
  • More likely to have emergency diagnosis than
    younger demographic
  • More likely to manifest atypical symptoms

4
McNamara et al.
  • 45 or more of emergency physicians have
    difficulty in the management of older
    patientsThey take more time and resources than
    younger patients
  • Practicing emergency physicians are
    uncomfortable with elderly patients, and this may
    reflect the inadequacies of training, research,
    and continuing medical education in geriatric
    emergency medicine.

5
Physiology of Aging
  • CVS
  • Increased BP
  • Decreased HR, CO, vessel elasticity, cardiac
    myocyte size and number, B-adrenergic
    responsiveness
  • Endocrine
  • Increased NE, PTH, insulin, vasopressin
  • Decreased thyroid and adrenal corticosteroid
    secretion
  • Gastrointestinal
  • Increased intestinal villous atrophy
  • Decreased esophageal peristalsis, gastric acid
    secretion, liver mass, hepatic blood flow,
    calcium and iron absorption
  • Integumentary
  • Atrophy of sebaceous and seat glands
  • Decreased dermal and epidermal thickness, dermal
    vascularity, melanocytes, collagen synthesis

6
Physiology contd
  • Reproductive
  • Decreased androgen, estrogen, sperm count,
    vaginal secretion
  • Decreased ovary, uterus, vagina, breast size
  • Respiratory
  • Increased tracheal cartilage calcification,
    mucous gland hypertrophy
  • Decreased elastic recoil, mucociliary clearance,
    pulmonary function reserve
  • Renal and urologic
  • Increased proteinuria, urinary frequency,
  • Decreased renal mass, creatinine clearance, urine
    acidification, hydroxylation of vitamin D,
    bladder capacity
  • Special senses
  • Decreased lacrimal gland secretion, lens
    transparency, dark adaptation, sense of smell and
    taste
  • Increased presbyopia

7
Physiology contd
  • MSK
  • Increased calcium loss from bone
  • Decreased muscle mass, cartilage
  • Neurologic
  • Increased wakefulness
  • Decreased brain mass, cerebral blood flow

8
Causes of morbidity and mortality in seniors
Morbidity
Arthritis
Hypertension
Allergies
Back problems
Heart disease
Cataracts
Diabetes
Mortality
Heart/vascular disease (41)
GI disease (35)
Cancer (25)
Respiratory disease (11)
9
Geriatric PharmacologyAge associated
pharmacokinetics
Parameter Age Effect Implications
Distribution total body fat, lean body mass, total body water and albumin Lipophilic drugs have larger volume of dist increased binding of basic drugs
Elimination renal blood flow, GFR, tubular secretion and renal mass For every x reduction in clearance, decrease the dose by x and increase the interval by x
10
Absorption in gastric pH splanchnic blood flow, GI absorptive surface, dermal vascularity delayed gastric emptying Dug-drug and drug-food interactions more likely to affect absorption.
Metabolism in hepatic mass and hepatic blood flow impaired oxidative reactions Lower doses may be therapeutic.

11
Pharmacodynamics
  • Less predictable
  • Altered drug response at usual or lower
    concentrations
  • Increased sensitivity to sedative hypnotics,
    anticholinergics, analgesics, warfarin
  • Decreased sensitivity to B blockers

12
Polypharmacy
  • Definition
  • Prescription, administration or use of more
    medications than are clinically indicated
  • Epidemiology
  • Over 25 of elderly women and 20 of elderly men
    reported using gt3 medications
  • Average elderly person takes 4.5 prescription
    drugs and 2.1 OTC meds daily (Rosens)
  • Hospitalized elderly are given an average of 10
    meds over admission
  • LTC residents take an average of 7.2 meds daily

13
Adverse Drug Reactions (ADRs)
  • Any noxious or unintended response to a drug that
    occurs at doses used for prophylaxis or therapy
  • Risk factors in the elderly
  • Intrinsic co-morbidities, age related
    pharmacokinetic changes, pharmacodynamics
  • Extrinsic of meds multiple prescribers
    unreliable drug history
  • 90 are from ASA, analgesics, anticoagulants,
    antimicrobials, antineoplastics, digoxin,
    diuretics, hypoglycemics, steroids
  • 12 30 of admitted elderly pts have ADRs as
    primary cause of presentation to ED

14
Preventing Polypharmacy
  • Consider the drug safer side effect profiles
    convenient dosing schedules convenient route,
    efficacy
  • Consider the patient other meds clinical
    indications co-morbidities
  • Consider patient-drug interaction risk factors
    for ADRs
  • Review drug list to eliminate meds with no
    clinical indication or with evidence of toxicity
  • Avoid treating ADRs with another medication

15
Inappropriate Prescribing
  • Beers Criteria (1997)
  • Explicit criteria to identify inappropriate
    medications for people gt65 yrs of age
  • Examples include long acting BDZ, strong
    anticholinergics, high dose sedatives
  • Elderly are often under treated (ACEI, ASA, BB,
    thrombolytics, coumadin)

16
Updating the Beers Criteria
  • Updating the Beers Criteria for Potentially
    Inappropriate Medication Use in Older Adults
    Results of a US Consensus Panel of Experts
  • Donna M. Fick, PhD, RN James W. Cooper, PhD,
    RPh William E. Wade, PharmD, FASHP, FCCP
    Jennifer L. Waller, PhD J. Ross Maclean, MD
    Mark H. Beers, MD
  • Arch Intern Med. 20031632716-2724.

17
Updating Beers
  • 30 of hospital admissions in elderly patients
    may be linked to ADRs that lead to depression,
    constipation, falls, immobility, confusion and
    hip fractures.
  • Medication related problems would be 5th leading
    cause of death in US.
  • Beers is based on expert consensus from
    literature review with bibliography and
    questionnaire evaluation by experts in geriatric
    care, pharmacology, psychopharmacology.

18
Beers Criteria
  • Applies to those over the age of 65 years
  • Three main aims
  • 1) reevaluate the 1997 criteria to include new
    products and incorporate new information from
    scientific literature
  • 2) assign or reevaluate a relative rating of
    severity for each medication
  • 3) identify any new conditions or considerations
    since 1997.

19
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20
Beers Criteria
  • 48 individual/classes of meds to avoid
  • 20 diseases/conditions, individual/classes meds
    to avoid
  • Including
  • Indomethicin
  • Keterolac
  • Muscle relaxants
  • Amytriptyline
  • Diphenhydramine
  • Long acting BDZ
  • Meperidine

21
Polypharmacy in the ED
  • Polypharmacy, adverse drug-related events, and
    potential adverse drug interactions in elderly
    patients presenting to an emergency department
  • Corinne Michèle Hohl MD, Jerrald Dankoff MD,
    Antoinette Colacone BSc, CCRA and Marc Afilalo
    MD, FRCPCFrom the McGill University Royal
    College Emergency Medicine Residency Training
    Program, and the Department of Emergency
    Medicine, Sir Mortimer B. Davis-Jewish General
    Hospital, McGill University, Montreal, Quebec,
    Canada.
  • Annals of Emergency Medicine Volume 38, Issue 6
    , December 2001, Pages 666-671

22
Hohl et al.
  • Retrospective chart review of 300 randomly
    selected ED visits by patients 65 years of age
    and older between Jan. Dec. 1998
  • ADRs defined according to a standardized
    algorithm
  • 257/283 (90.8) pts were taking gt1 med
  • Average number of meds 4.2/pt (0-17)
  • ADRs 10.6 of all ED visits

23
Hohl et al.
  • Medications most frequently involved
  • NSAIDs
  • Antibiotics
  • Anticoagulants
  • Diuretics
  • Hypoglycemics
  • Bblockers
  • CCB
  • Chemotherapeutic drugs
  • Consistent with Beers criteria
  • ADRs underestimated but important source of
    morbidity in elderly

24
Myocardial Infarction
  • Presentation is frequently atypical
  • Atypical presentation is not more benign
  • High index of suspicion is required
  • Up to 30 of patients with ACS may experience no
    chest pain at all (Umachandran et al, 1991)

25
Suspect MI in patients with
  • No chest pain
  • Atypical chest pain arm, jaw, abdominal pain
    (/- nausea)
  • Acute functional decline
  • Dyspnea
  • Syncope
  • Confusion
  • Vomiting
  • Weakness
  • CHF
  • Fatigue

26
Coronado et al.
  • Clinical features, triage, and outcome of
    patients presenting to the ED with suspected
    acute coronary syndromes but without pain A
    multicenter study. 
  • The American Journal of Emergency
    Medicine, Volume 22, Issue 7, Pages 568-574
  • B. Coronado, J. Pope, J. Griffith, J. Beshansky,
    H. Selker

27
Coronado et al
  • Prospective clinical trial of all adults gt30 y.o.
    who presented to ED with symptoms suggestive of
    ACS to EDs of 10 US hospitals
  • Including chest pain, chest pressure, left arm
    pain, jaw pain, upper abdominal pain, dizziness,
    nausea, vomiting, dyspnea
  • Painless presentation included complaints of SOB,
    extreme fatigue, nausea or fainting

28
Coronado et al
  • 10783 subjects
  • ACS diagnosed in 24 of which 35 had AMI and 65
    had UA
  • Pain was absent in 6.2 of patients with acute
    ischemia and 9.8 with AMI
  • Those without pain tended to be
  • Older
  • Women
  • Had cardiac and related diseases

29
Characteristics of Patients with Cardiac Ischemia
by Clinical Presentation (n2541)
30
Other findings
  • AMI without pain
  • Fewer patients admitted to CCU
  • Increased hospital mortality
  • Higher incidence of heart failure
  • Under treatment of these patients
  • Increased incidence of diabetes, prior
    infarctions
  • Slower time to assessment from triage

31
Abdominal Pain
  • Difficult but common complaint in the elderly
  • 75 will get a diagnosis in the ED
  • 63 will be admitted
  • 20 will go to the OR
  • 60 of causes of abdominal pain in elderly are
    surgical
  • 10x the mortality compared with younger pts

32
DDx of Abdominal Pain in Elderly Patients
Disorder Incidence
Cholecystitis/ Biliary Colic 12-41
Nonspecific abdo pain 9.6-23
Appendicitis 2.5-15.2
Obstruction 7.3-14
Hernia 4.0-9.6
Perforation 2.3-7.0
Pancreatitis 2.0-7.3
Diverticular Disease 3.4-7.0
33
Why worry?
  • May present with few or no symptoms
  • May have vague symptoms with serious illness
  • Complication rates are higher with serious
    consequences
  • May need lab tests and imaging to supplement
    equivocal physical exam
  • Admission and observation often necessary

34
Imaging in abdominal pain in the elderly
  • The American Journal of Emergency Medicine Volume
    23, Issue 3 , May 2005, Pages 259-265 The use
    of abdominal computed tomography in older ED
    patients with acute abdominal pain
  • Fredric M. Hustey MD, Stephen W. Meldon MD,
    Gerald A. Banet RN, MPH, Lowell W. Gerson PhD,
    Michelle Blanda MD and Lawrence M. Lewis MD

35
background
  • Abdominal pain accounts for 3-4 of all ED visits
    in gt65 yrs of age
  • Associated with morbidity and mortality
  • Seniors have 2x rate of surgery
  • 6-8x increase in mortality
  • Evaluation requires more time, resources and
    interventions

36
Hustey et al
  • Prospective, multicenter study regarding the
    etiology and clinical course of older ED patients
    with acute nontraumatic abdominal pain
  • 3 objectives
  • Prevalence of use of CT in this population
  • Describe most common diagnostic findings
  • Determine proportion of CT scans in this
    population

37
Demographics
  • 337 enrolled
  • Gender
  • Women 222/337 66
  • Men 115/337 34
  • Age
  • 60-69 135/337 40
  • 70-79 117/337 35
  • gt80 85/337 25

38
Most common diagnostic CT findings in older ED
patients with acute abdominal pain (n 71)
Findings of abdo CT scans, n (, 95CI)
SBO or ileus 13 (18, 10-29)
Diverticulitis 13 (18, 10-29)
Urolithiasis 7 (10, 4-19)
Cholelithiasis/systitis 7 (10, 4-19)
Abdo mass 6 (8, 3-18)
Pyelonephritis 5 (7, 2-16)
Pancreatitis 4 (6, 2-14)
39
Most common diagnostic CT findings in older ED
pts receiving acute medical intervention (n36)
Findings of abdo CT scans, n (, 95CI)
Diverticulitis 11 (31, 16-48)
SBO 9 (25, 12-42)
Pancreatitis 3 (8, 2-23)
Urolithiasis 3 (8, 2-23)
Abdo mass/neoplasm 3 (8, 2-23)
Pyelonephritis 2 (6, 0-19)
40
CT findings diagnostic of abdominal pain
  • 57 diagnostic scans
  • 31 nonspecific scans
  • 12 normal scans
  • 75 of pts with diagnostic scans had medical or
    surgical interventions
  • 5.6 of pts had medical intervention with normal
    CT
  • 0 of pts with normal CT had surgical
    intervention

41
Mesenteric Ischemia
42
Mesenteric Ischemia
  • Low intestinal blood flow caused by occlusion,
    vasospasm
  • Can result in sepsis, bowel infarction, death
  • Can be acute or chronic timing is dependent
    upon rapidity and degree to which blood flow is
    compromised

43
Acute Mesenteric Ischemia
  • Arterial occlusion is caused by emboli,
    thrombosis of mesenteric arteries
  • Venous obstruction is caused by thrombosis,
    segmental strangulation
  • Non-occlusive disease is caused by primary
    splanchnic vasoconstriction

44
Response to ischemia
  • If there is insufficient oxygen and nutrients for
    cellular metabolism, ischemic injury occurs
  • Bowel can maintain itself up to 12h by increased
    oxygen extraction from collateral circulation
  • With progressive vasoconstriction there is
    decompensation of collateral flow and subsequent
    increased vascular pressures leading to a
    reduction in flow with resultant hypoxia and
    reperfusion injury

45
Risk Factors
  • Advanced age
  • Atherosclerosis
  • Low cardiac output states
  • Severe valvular heart disease
  • Recent MI
  • Intra-abdominal malignancy

46
High Risk Patients for Mesenteric Ischemia
  • Superior Mesenteric Artery Embolism (50)
  • Valvular heart disease, recent MI, dysrhythmias
  • Thrombus from left atrium, left ventricle, valves
  • Superior Mesenteric Artery Thrombosis (15-25)
  • PVD, atherosclerotic disease, abdominal trauma,
    infections
  • Mesenteric Venous Thrombosis (10)
  • Hypercoagulable state, portal hypertension,
    abdominal infections, trauma, pancreatitis,
    splenectomy

47
NOMI MVT
  • NOMI
  • Caused by mesenteric vasospasm
  • Cardiac and cerebral blood flow is maintained
    preferentially at the expense of splanchnic
    circulation
  • MVT
  • Resistance in mesenteric venous blood flow causes
    wall edema
  • Fluid exudes into lumen causing systematic drop
    in blood pressure
  • Increased blood viscosity with concomitant
    stagnant arterial blood flow
  • Resultant submucosal infarction and hemorrhage

48
Presentation
  • Poorly localized abdominal visceral-type pain
    without tenderness
  • Pain may resolve as mucosa infarcts and then,
    with development of full thickness intestinal
    necrosis, peritoneal findings are manifested
  • pain out of proportion to physical exam
  • /- nausea and vomiting
  • Mental status changes occur in 1/3 of elderly
    patients

49
Is it small bowel or colon?
  • It is colon if there is
  • Lower abdominal pain
  • Hematochezia
  • It is small bowel if there is
  • Severe pain
  • Pain prior to vomiting

50
How to differentiate between types
  • Onset
  • Embolic abrupt
  • MVT slow
  • Arterial thrombosis intermediate timing
  • Non-Occlusive Mesenteric Ischemia
  • Associated with low flow states (e.g. CAD) which
    improves with improvement of CO

51
4 types contd
  • MVT
  • Occurs in younger patients
  • Amenable to diagnosis with noninvasive CT
  • Lower mortality
  • Treated with immediate anticoagulation
  • Papaverine infusion with arteriography
  • Treatment of splanchnic vasoconstriction

52
Lab Tests
  • Metabolic acidosis
  • May have increased WBC
  • May have FOB
  • May have elevated serum lactate

53
Diagnostic Tests
Diagnosis Test Sensitivity Specificity LR LR-
Small bowel ischemia Angiography 88 (62-98) 95 (93-100) 18 0.1
Small bowel ischemia CT and CT angio 77 (57-92) 85 (71-100) 5 0.3
Small bowel ischemia Gadolinium enhanced MRI 83 (78-100) 89 (71-99) 8 0.2
Small bowel ischemia Serum lactate 90 (66-100) 62 (42-77) 2 0.2
54
Imaging
  • Radiography
  • Plain films r/o free air, ileus,
    intussusception, volvulus
  • Pneumatosis intestinalis gt30 of patients
  • Portal venous gas (rare)
  • CT
  • will show wall thickening gt3mm
  • Large vessel disease is diffuse (SMA, SMV, IMA,
    IMV)
  • Small vessel disease is focal
  • Arterial occlusive disease segment will not
    enhance
  • Venous occlusive disease segment will enhance
    due to retarded flow
  • False positive ulcerative colitis
  • False negative lymphoma, adenocarcinoma

55
Angiography
  • Gold standard
  • Invasive
  • Early intervention reduces mortality
  • Shows attenuation, vasoconstriction, occlusion of
    vessel
  • Less sensitive for veno-occlusive disease

56
Treatment
  • Resuscitation
  • Empiric antibiotics
  • Superior Mesenteric Artery Embolism
  • Angiography, intra-arterial thrombolytics,
    vasodilators
  • Embolectomy, bowel resection
  • Superior Mesenteric Thrombosis
  • Graft, bypass, bowel resection, /-
    thrombolectomy
  • Mesenteric Venous Thrombosis
  • Anticoagulation with heparin
  • Thrombolectomy, bowel resection
  • NOMI
  • Papaverine infusion with angiography, /-
    resection, /- ASA

57
Mortality
  • Mortality rate can be gt60
  • 25 if due to arterial emboli
  • 29 if due to venous thrombosis
  • 60 if due to arterial thrombosis

58
In conclusion
  • Polypharmacy is an important cause of morbidity
    in the elderly
  • ADRs are often underestimated
  • Think AMI in patients without chest pain who are
    female, elderly, present with CHF, DM
  • Abdominal pain in old folks is often surgical,
    presents atypically and has high mortality
    associated with it.

59
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60
References
  • Hustey FM et al. The use of abdominal computed
    tomography in older ED patients with acute
    abdominal pain. Am J Emerg Med (2005) 23259-265.
  • Coronado et al. Clinical features, triage, and
    outcome of patients presenting to the ED with
    suspected acute coronary syndromes but without
    pain a multicenter study. Am J Emerg Med (2004)
    22568-574.
  • Fick DM et al. Updating the Beers Criteria for
    potentially inappropriate medication use in older
    adults. Arch Int Med (2003) 1632716-2724.
  • Hohl CM et al. Polypharmacy, adverse drug-related
    events, and potential drug interactions in
    elderly patient presenting to an emergency
    department. Ann Emerg Med (2001) 38666-671.
  • Birnbaumer DM. Chapter 176 The Elder Patient.
    Rosens Emergency Medicine Concepts and Clinical
    Practice. Section III.2485-2491.
  • Reuben DB et al. Geriatrics. 2006-2007 8th
    edition. American Geriatric Society.
  • Tintinalli JE et al. Emergency Medicine A
    comprehensive study guide. McGraw Hill. 2004.
  • McNamara RM et al. Geriatric Emergency Medicine
    A Survey of Practicing Emergency Physicians. Ann
    Emerg Med (1992) 21796-801.
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