As the global geriatric population continues to grow, an increasing proportion of people reporting to emergency departments are elderly. The work-up of these patients uses more time and resources than that of younger patients, and is complicated by the fact that acute disease often presents more subtly, without the outward manifestations typically seen in younger patients. This volume focuses on the unique pathophysiology of the elderly, presenting guidelines for resuscitation, evaluation and management. The first section discusses general principles including demographics, pharmacology and pain management. The following sections cover high-risk chief presenting complaints and review geriatric emergencies. Finally, topics of particular relevance in the geriatric population are discussed, including functional assessment, end-of-life care, financial considerations and abuse. This book provides a comprehensive, practical framework for community and academic emergency medicine practitioners, as well as emergency department administrators striving to improve delivery of care to this vulnerable, growing population.
Each chapter includes pearls and pitfalls, providing a rapid review of the key components of the chapter
Dedicated chapters discuss topics that are of particular relevance in the geriatric population such as falls, elder abuse and end-of-life considerations
Practical guidelines help readers to apply theory in a clinically relevant manner
Author(s): Joseph H. Kahn, Brendan G. Magauran, Jr, Jonathan S. Olshaker
Edition: 1
Publisher: Cambridge University Press
Year: 2014
Language: English
Tags: Geriatrics; Emergency Medicine
Cover
Geriatric Emergency Medicine
Title
Copyright
Contents
Contributors
Preface
Section 1 General principles
1 Overview of geriatric emergency medicine
Geriatric emergency medicine
Population aging
Health system aim
Clinical challenge
Complex patients
Expensive care
Chaotic environment
Families
Special challenges
Palliative care in the ED
Interfacing with PCPs and care facilities
Geriatric emergency medicine education
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
2 The geriatric emergency department
Introduction
Where are we today?
Barriers
Defining the goal
Considering a geriatric emergency department
The geriatric emergency department
Physical plant
Quality initiatives
Falls and fall assessment
Medications
Staff education
Operations
Advancing emergency severity index criteria for elderly
Two-step geriatric program
Coordination of hospital resources
Coordination of community resources
Staffing enhancements
Patient satisfaction
Observation and extended home observation
Geriatric palliative care
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
3 General approach to the geriatric patient
Introduction
Principles of geriatric emergency medicine
Healthy aging
Physiologic changes with age
Body composition
Vital signs
Skin/mucosa
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Neurologic
Psychological
Endocrine
Immunologic
Hematologic
Polypharmacy and elders
Diagnostic testing and age
Atypical disease presentation
Infections
Acute coronary syndrome
Acute abdomen
Appendicitis
Geriatric emergency care model
Approach
Pre-hospital care
ED assessment
Triage
History
Physical exam
Preventive care
Disposition
Patient satisfaction
Pearls and pitfalls
Summary
References
4 Resuscitation of the elderly
Introduction
Epidemiology and outcomes
Pathophysiology
Management of resuscitation
Ethics of resuscitation and end-of-life care
Advance directives
Medical futility
Family-witnessed resuscitation
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
5 Pharmacology in the elderly
Introduction
Epidemiology
Definitions
Pharmacokinetics
Outcomes of adverse drug reactions
Risk factors for adverse drug reactions
Poisoning in the elderly
Inappropriate medications in the elderly
Preventability
Conclusion
Pearls and pitfalls
Pearls
Pitfalls
References
6 Generalized weakness in the elderly
Introduction
Generalized weakness and fatigue
Failure to thrive
Sarcopenia
Geriatric syndromes
Falls
Frailty
Functional decline
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
7 Management of trauma in the elderly
Background
Epidemiology
Mechanisms of injury
Falls
Motor vehicle collisions
Pedestrians struck by automobiles
Burns
Elder abuse and neglect
Physiology of aging and trauma
Cardiovascular
Pulmonary
Gastrointestinal
Renal
Central nervous system
Musculoskeletal
Skin
Endocrine
Pre-existing medications
Anticoagulants and antiplatelet agents
Pre-hospital considerations
Evaluation and management
Initial evaluation
Central nervous system
Spine
Thorax
Abdomen
Musculoskeletal
Prognosis
Disposition
Pearls and pitfalls
Pearls
Pitfalls
References
8 Pain management in the elderly
Pitfalls
Undertreatment
Drug sensitivity and clearance in older adults
Adverse drug events
Beers Criteria and analgesic risks
Analgesic options
Non-opioids
Acetaminophen
NSAIDs
Opioids
Regional anesthesia
Geriatric ED pain care quality indicators
Goals of pain care management
Pain assessment
Pain scores
Patient goals of pain care
Summary
Pearls
References
Section 2 Common high-risk presentations in the elderly
9 Chest pain in the elderly
Introduction
Cardiac causes of chest pain
Acute coronary syndrome
ST elevation myocardial infarction
NSTEMI
Demand ischemia
Post-MI complications
Pericarditis
Pulmonary causes of chest pain
Pneumonia
Pulmonary embolism
Pneumothorax
Vascular causes
Aortic dissection
Aortic aneurysm
Chest wall pathology
Costochondritis
Malignancy
Chest trauma
Herpes zoster
Gastrointestinal causes of chest pain
Esophageal rupture
Abdominal etiologies
Pearls and pitfalls
References
10 Dyspnea in the elderly
Introduction
Respiratory system structural mechanics
Effects on lung function
Cardiovascular changes in the elderly
Structural changes
Physiological changes
Vascular system changes
Conditions causing dyspnea
Congestive heart failure
Pulmonary embolism
Acute coronary syndrome
COPD
Asthma exacerbation
Pneumonia
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
11 Abdominal pain in the elderly
Background
History
Physical examination
Diagnostic tests
Imaging studies
Plain radiographs
Ultrasound
Computed tomography
Angiography
Differential diagnoses
Vascular catastrophes
Ruptured abdominal aortic aneurysm
Acute mesenteric ischemia
Bowel obstructions
Small bowel obstruction
Large bowel obstruction
Peptic ulcer disease
Biliary tract disease
Pancreatitis
Appendicitis
Diverticular disease
Extra-abdominal causes
Disposition
Pearls and pitfalls
Pearls
Pitfalls
References
12 Altered mental status in the elderly
Introduction
Acute disturbances in consciousness
Coma and stupor
Delirium
Subtypes
Epidemiology and outcomes
Risk factors
Chronic disturbances in cognition
Dementia
Assessment
History
Physical examination
Assessing level of consciousness
Assessing cognition
Neurologic examination
General physical examination
Assessment of delirium
Diagnostic testing
Treatment
Non-pharmacological treatment of delirium and agitation
Pharmacological treatment of delirium
Assessment of decision-making capacity
Disposition
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
13 Syncope in the elderly
Introduction
Aging
Epidemiology
Causes
Neurally mediated
Vasovagal
Situational
CSH
Cardiac
Dysrhythmia
Structural heart disease
Vascular steal syndromes
Orthostatic hypotension
Unlikely causes of syncope
History
Sequence of events
Specific data points
Symptoms distinguishing seizure from syncope
Symptoms suggestive of cardiac etiology
Factors associated with autonomic failure
Physical exam
Ancillary studies
Cardiovascular testing
ECG
Telemetry monitoring
Echocardiography
Autonomic nervous system testing
Electrophysiologic testing
Cardiac catheterization
Ambulatory blood pressure recording
Carotid sinus massage
Laboratory testing
Neurologic testing
Head CT
Electroencephalogram
Systems of evaluation
Determining risk
Prognosis/risk stratification
Driving and syncope
Summary and recommendations
Pearls and pitfalls
Pearls
Pitfalls
References
14 Dizziness in the elderly
Introduction and epidemiology
Vestibular physiology
Medication issues
Falls
Overarching diagnostic strategy
Differential diagnosis
History
Physical examination
Diagnostic tests
Treatment
Disposition
Conclusions
Pearls and pitfalls
References
15 Headache in the elderly
Background
High-risk headache features
Secondary headache disorders
Cerebrovascular emergencies
Subarachnoid hemorrhage
Ischemic stroke and intracerebral hemorrhage
Subdural hemorrhage
Brain tumor
CNS infection
GCA
Acute glaucoma
Non-emergent secondary headache
Primary headache disorders
Conclusion
Pearls and pitfalls
References
16 Back pain in the elderly
Background
History
Physical exam
Diagnostic tests
Laboratory testing
Plain spinal radiographs
CT
MRI
Differential diagnosis
Mechanical causes
Degenerative disk disease/unstable lumbar spine
Lumbar spinal stenosis
Disk displacement causing sciatica
Osteoporotic causes
Vertebral compression fractures
Osteoporotic sacral fractures
Systemic causes
Primary or metastatic cancer
Spinal infections
Visceral diseases unrelated to the spine
Abdominal aortic aneurysm or aortic dissection
Other visceral causes
Treatment
Disposition
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
Section 3 Systems
17 Eye, ear, nose, and throat emergencies in the elderly
Introduction
Eye
Acute angle closure glaucoma
Vitreous hemorrhage
Retinal detachment
Uveitis
Conjunctivitis
Central retinal artery occlusion
Branch retinal artery occlusion
Central retinal vein occlusion
Branch retinal vein occlusion
GCA
Ears
Otitis externa
Malignant otitis externa
Nose
Epistaxis
Throat
Dental abscess
Ludwig’s angina
Peritonsillar abscess
Epiglottitis
Retropharyngeal abscess
Angioedema due to angiotensin-converting enzyme inhibitors
Summary
Pearls and pitfalls
References
18 Neurological emergencies in the elderly
Introduction
Ischemic stroke
Acute ischemic stroke
Transient ischemic attack
Non-traumatic intracranial hemorrhage
Intracerebral hemorrhage
Aneurysmal subarachnoid hemorrhage
Traumatic brain injury
CNS infections
Community-acquired bacterial meningitis
Spinal epidural abscess
Seizures
New seizures
Status epilepticus
Conclusion
Pearls and pitfalls
Pearls
Pitfalls
References
19 Pulmonary emergencies in the elderly
Introduction
Pathophysiology
History
Physical
Diagnostic tests
Asthma/COPD
Bronchiectasis
Pneumonia
Pulmonary embolism
Pneumothorax
Tuberculosis
Pulmonary hypertension
Restrictive lung disease
Lung cancer
Pearls and pitfalls
Pearls
Pitfalls
References
20 Cardiovascular emergencies in the elderly
Introduction
Acute coronary syndrome
Identification
Treatment
Dysrhythmias
Identification
Management
Acute HF syndromes
Identification
Management
Syncope
Identification
Management
Acute thoracic aortic syndromes
Identification
Management
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
21 Gastrointestinal emergencies in the elderly
Background
History
Physical examination
Special considerations
Diagnostic tests
Laboratory studies
Imaging studies
Differential diagnosis
Appendicitis
Pancreatitis
Diverticulitis
Inflammatory and infectious colitis
Gallbladder disease
Peptic ulcer disease
Esophageal obstruction and perforation
Upper gastrointestinal bleed
Lower gastrointestinal bleed
Constipation
Small bowel obstruction
Large bowel obstruction
Acute colonic pseudo-obstruction
Mesenteric ischemia
Ischemic colitis
Disposition
Pearls and pitfalls
Summary
References
22 Genitourinary and gynecologic emergencies in the elderly
Age-related changes in the renal system
Age-related changes in the genital system
History
Physical exam
Genitourinary and gynecologic issues in the elderly
Acute kidney injury
Geriatric gynecological emergency presentations
Vaginal discharge
Vaginal bleeding
Uterine prolapse
Urinary retention/stricture
Balanitis
Male genital infections: prostatitis, epididymitis, orchitis
Orchitis
Epididymitis
Prostatitis
Antibiotic therapy in male genital system infections in the elderly
Hematuria
Phimosis/paraphimosis
Fournier’s gangrene
UTIs
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
23 Rheumatologic and orthopedic emergencies in the elderly
Rheumatologic emergencies in the elderly
Septic arthritis
History
Physical
Diagnostic tests
Differential
Treatment
Disposition
Pearls and pitfalls
Gout
History
Physical
Diagnostic tests
Differential
Treatment
Disposition
Pearls and pitfalls
Pseudogout
History
Physical
Diagnostic tests
Treatment
Differential
Disposition
Pearls and pitfalls
Rheumatoid arthritis
History
Physical
Diagnostic tests
Treatment
Differential
Disposition
Pearls and pitfalls
Osteoarthritis
History
Physical
Diagnostic tests
Differential
Treatment
Disposition
Pearls and pitfalls
Polymyalgia rheumatica and giant cell arteritis
History
Physical
Diagnostic findings
Treatment
Disposition
Pearls and pitfalls
Back pain and spinal stenosis
History
Physical
Diagnostic tests
Differential
Treatment
Pearls and pitfalls
Orthopedic injuries in the geriatric population
Hip fractures
History
Physical
Diagnostic findings
Treatment
Differential
Disposition
Pearls and pitfalls
Hip dislocations
History
Physical
Diagnostic findings
Treatment
Disposition
Differential
Pearls and pitfalls
Pelvic fractures
History
Physical
Diagnostic findings
Treatment
Differential
Disposition
Pearls and pitfalls
Vertebral fractures
History
Physical
Diagnostic findings
Treatment
Differential
Disposition
Pearls and pitfalls
Proximal humeral fractures
History
Physical
Diagnostic tests
Treatment
Differential
Disposition
Pearls and pitfalls
Shoulder dislocations
History
Physical
Diagnostic findings
Treatment
Disposition
Pearls and pitfalls
Distal radius fractures
History
Physical
Diagnostic findings
Differential
Treatment
Disposition
Pearls and pitfalls
References
24 Infectious diseases in the elderly
Introduction
Age-related impairment of defenses
An onslaught of risks
Altered clinical markers
Approach to the elderly ED patient with suspected infection
History
Physical examination
Differential diagnosis of fever in the elderly
Pneumonia
Urinary tract infection
Community-dwelling elders
Elders presenting to the ED from LTCF
Elders presenting to the ED with indwelling catheters
Abdominal infections
Appendicitis
Diverticulitis
Acute cholecystitis
Clostridium difficile-related diarrhea
Central nervous system infections
Skin and soft tissue infections
Human immunodeficiency virus
Infectious diseases in special geriatric populations
Antibiotics and the elderly patient
Conclusion
Pearls and pitfalls
References
25 Hematologic and oncologic emergencies in the elderly
Introduction
Overview of hematologic diseases
Overview of oncologic diseases
Specific disease conditions
Fever and leukopenia
Tumor lysis syndrome
Hypercalcemia
Superior vena cava syndrome
Hyperviscosity syndrome
Coagulopathy
Anemia
Thrombocytopenia
Transfusion of blood components
Administration of vitamin K
Summary
Pearls and pitfalls
References
26 Psychiatric emergencies in the elderly
Introduction
Suicide
Background and epidemiology
Risk factors
Evaluation
Treatment
Prevention
Depression
Background and epidemiology
Risk factors
Evaluation
DSM IV-TR criteria for major depressive episode
Treatment
Substance abuse
Background and epidemiology
DSM IV-TR criteria for alcohol abuse
DSM IV-TR criteria for alcohol dependence
Risk factors
Evaluation
Treatment
Geriatric psychoses
Background and epidemiology
Risk factors
Evaluation
Treatment
Pearls and pitfalls
Pitfalls
Pearls
References
27 Metabolic and endocrine emergencies in the elderly
Diabetic ketoacidosis and hyperosmolar hyperglycemic state
Background
History
Physical
Diagnostic testing
Differential diagnoses
Treatment
Disposition
Thyroid disorder emergencies: myxedema coma and thyroid storm
Background
Myxedema coma
History
Physical
Diagnostic testing
Differential diagnoses
Treatment
Thyroid storm
History
Physical exam
Diagnostic testing
Differential diagnoses
Treatment
Disposition
Rhabdomyolysis
Background
History
Physical exam
Diagnostic testing
Management
Disposition
Adrenal crisis
Background
History
Physical exam
Diagnostic tests
Treatment
Differential diagnosis
Disposition
Pituitary apoplexy
Background
History
Physical exam
Diagnostic tests
Differential diagnosis
Treatment
Disposition
Potassium disorders
Background
Hyperkalemia
Background
History and physical exam
Diagnostic tests
Treatment
Disposition
Hypokalemia
Background
History and physical exam
Diagnostic tests
Treatment
Disposition
Sodium disorders
Background
Hyponatremia
Background
History and physical exam
Diagnostic tests
Treatment
Disposition
Hypernatremia
Background
History and physical exam
Diagnostic tests
Treatment
Disposition
Calcium disorders
Background
Hypercalcemia
Background
History and physical exam
Diagnostic tests
Differential diagnosis
Treatment
Disposition
Hypocalcemia
Background
History and physical exam
Diagnostic tests
Differential diagnosis
Treatment
Disposition
Acid–base disorders
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Summary
Pearls and pitfalls
References
Section 4 Special topics
28 Alternative geriatric care and quality metrics
Introduction
Input (reducing ED and hospital use)
Avoiding ED presentation with primary care
“Hospital at Home”
Preventing hospital returns
Telemedicine
Throughput (care of patients within the ED)
Output (safely transitioning patients out of the ED)
“Transitional Care”
Acute Care Elderly Unit/Mobile Acute Care Elderly Unit
Quality indicators of care
Summary
Pearls and pitfalls
References
29 Functional assessment of the elderly
Comprehensive geriatric assessment
Assessment tools for functional status
Performance testing of function
Prediction tools for post-ED functional decline
ISAR
BRIGHT
SIGNET/TRST
HARP
SHERPA
Inouye et al.
Screening for common issues in elderly ED patients
Visual impairment screening
Hearing impairment
Malnutrition
Alcohol abuse
Balance, gait, falls
Summary and recommendations
Pearls and pitfalls
Pearls
Pitfalls
References
30 Palliative and end-of-life care in the emergency department
Introduction
Trajectories of illness and prognosis
Cardiopulmonary resuscitation and prognosis in advanced illness
Pre-hospital
Family presence in resuscitation
Rapid identification and assessment in the ED
SPEED
ABCD
Advance directive
Better symptom control
Capacity
Decision and disposition
Ventilator discontinuation
End of life
The actively dying patient
Hospice patients in the ED
Hospice patients presenting to the ED
Hospice referrals from the ED
Summary
References
31 Social services and case management
Introduction
Issues facing geriatric patients in the ED
Case management
Discharge planning
Effectiveness of case management
Assessing older driver safety
Summary
Pearls and pitfalls
References
32 Falls and fall prevention in the elderly
Epidemiology
Morbidity and mortality
Risk factors (identifying high-risk fallers)
Pearls and pitfalls for fall prevention
Recommendations and future directions
Summary
References
33 Financial issues in geriatric emergency care
Background
Demographics
EMTALA
Medicare
Affordable Care Act
Summary
Pearls and pitfalls
Pearls
Pitfalls
References
34 Elder mistreatment
History
Definitions
Epidemiology
Risk factors for abuse
Suspicious presentations
Physical abuse
Sexual abuse
Neglect
Historical indicators
Physical indicators
Behavioral indicators
Screening for elder abuse
Documentation
Legal/ethical considerations
Preventive services
Conclusion
Pearls and pitfalls
Pearls
Pitfalls
References
Index
