1 Geriatric Emergency UpdateWho’s Old? Elderly Falls - HIPS Elderly Abuse Infectious Diseases That Kill Burn Trauma Abdominal Emergencies

2 The 65 and over group will increase from 32 to 52 million by 2020

3 Who’s Old? Geriatric: Age 64 until death People are living longerBy year 2000, more than 75% of elderly will be over age 75! By mid yrs. and older group will have grown 5x in size!

4 Who’s Old? Today, over age 65 is 12% of population“Old-old” represents age 75 and older 36% of EMS calls 9% of burn victims are elderly Polypharmacy is a factor in 15% of ED admissions Successful aging...

5 Who’s Old? Aging is : Discovery of the real self… (Cicero)Metamorphosis of the soul with aging that allow for the emergence of precursors of wisdom and the discovery of new values and meanings not possible by younger generations…(Plato)

6 Who’s Old? Myths About AgingMajority of persons are senile or demented Majority of older persons feel miserable most of the time. Most older people cannot work as effectively as younger persons. Most old persons are unhealthy and need assistance with daily activities. Majority of older persons are socially isolated and lonely. Less than 20% have measurable memory impairment Happiness and life satisfaction studies show that the majority of the elderly are just as happy as when they were younger. Older workers are more consistent, have fewer accidents, and less absenteeism than younger workers. Less than 20% are unable to perform activities of daily living, less than 5% are institutionalized for debilitating health problems. Although loneliness is a severe problem in one third of elderly, most elderly have close relatives, friends, organizations, and church activities that are considered significant.

7 When abnormalities in function are found!Don’t Blame Old Age... When abnormalities in function are found!

8 Pitfalls in Geriatric Assessment & DiagnosisInfluenza & pneumonia are leading killers ASHD is NOT associated with aging alone Sudden or rapid altered mental status NEVER caused by dementia or OBS Classic signs of abdominal pain may be masked. The older the patient the higher the risk for painless MI. Falling is often a marker of disease. Dizziness is NOT normal in elderly, but sway is.

9 Elderly Falls - Mobility is Precious!1/3 of adults will reach 80 - and 1/3 who do will have a severe fall. Fast walkers fall forward - wrist fx Slow walkers fall sideways - hip fx

10 Elderly Falls 28% of elderly fall / yr.Twice as many women as men Frailty triples falls Those on more than 4 medications fall Poor quad muscle strength = fall risk Watch out! When elderly pt. falls, who is fit, think arrhythmia or MI! If quad muscle strength is 100% - then its 62% in nursing home patients and 37% in nursing home fallers. Leg muscles can always be strengthened! Most falls are neither random, unpredictable or inevitable! Exercise will prevent falls! Medical reasons for poor balance: After trauma 9head injury, whiplash) Anemia, stroke / TIA, heart disease, visual problems, CNS disorder, degenerative changes (Parkinson’s, Meniere’s Disease); Skeletal changes, psychogenic problems, physician-caused (iatrogenic). DIZZINESS IS NOT NORMAL in elderly, but sway is. Episodes of vertigo (dizziness) less than one hour suggest blood vessel trouble. If more than one hour, but less than 24 hours, may suggest Meniere’s disease (deafness, ear ringing, imbalance).

11 Fractures in Elderly Occurrence per 10,000 population:74 for hip 39 for wrist 92 upper arm 850,000 fx / yr.. And cost Medicare $10 billion (3% total costs) Culprit: many due to osteoporosis

12 Costs of managing fractures will increase by $1.4 billion by 2020...

13 69% of these increased costs will be due to preventable hip fractures...

14 Serious falls occur primarily in women over age 50

15 Each year about 10% of persons age 75 or older experience a serious fall resulting in $13 billion in cost

16 3/4 of serious falls occur in the home between the hours of 8AM and 8PM.

17 40% falls - walking 25% - standing 16% bed to upright 4% - stepping 7% - stepping down 5% - act of sitting 2% - act of lying down

18 Falls occurred after a change of center of gravity - 21% slipping - 10% tripping - 12% loss of consciousness - 8%

19 The preventable fracture that will change your patient’s life forever...

20 Preventing Hip Fractures with “HIPS”270,000 elderly / year suffer from it, Costs exceed $3 billion / year, 10th most common reason for hospital admission.

21 63% of hip fx occur in the home 13% out-of-doors 11% in nursing homes 5% psych hospitals 3% acute care hospitals

22 After age 79 about 35% die after a hip fractureAfter age 79 about 35% die after a hip fracture. Five year survival after a hip fracture can be as low as 20%

23 Prevention is Imperative!

24 Life after a hip fracture: You will spend an average of two weeks in the hospital & 4 weeks in a rehab nursing home provided you survive. Once home, readjusting to home life is very difficult. Shopping and previously enjoyed leisure activities can almost be impossible!

25 HIPS Program

26 Elderly Abuse Alien to the American ideal, but is occurring in 1 out of 10 families! In 4% of cases it is moderate to severe!

27 Elder Abuse What causes it? What defines “abuse”Needs of elderly exceed the ability of the caregiver to meet them. What defines “abuse” Any act that jeopardizes safety and well-being of the elderly...

28 Battering, rough handling,verbal abuse, denial of rights, neglect of care needs, sexual abuse, infantilization, abandonment, misuse of resources.

29 Victims are impaired or intermittently impaired or they are independent elders who are threatened with violence. The average abused is over age 80 and has multiple medical problems.

30 Caregiver abuses alcohol or drugs.

31 Caregiver stressors include giving up financial and emotional goals, social relationships, entertainment or even work to meet the demands of a disabled parent.

32 Emotions include rage, guilt, frustration, helplessness and enormous fatigue.

33 Occurs most often in dysfunctional families

34 85% of abusers are relatives

35 Underpaid, uneducated, HCP who work in poor conditions can be abusers

36 Occurs in all racial, cultural and socioeconomic backgrounds.

37 Why does it continue? Denial Parental guilt“I can’t press charges, he’s my son!” No other resources No support system other than the abuser

38 First, you must believe it can happen...What can you do? First, you must believe it can happen...

39 Assessment & ScreeningLook for unusual injuries, various stages of bruising Unexplained falls Restraint by medications Fear Untreated sores or wounds Evidence of neglect

40 Prehospital InterventionsDon’t confront caregiver or suspected abuser Discretely search for clues in the home. Nursing homes are not exempt! Relate objective findings to PD, MD & RN Document all objective findings Complete Social Service Referral form Insist on transport - enlist PDs help PRN

41 Influenza, Pneumonia and SepsisInfectious diseases that kill...

42 Influenza What causes it? Signs & Symptoms: Influenza type AVirus that changes slightly from year to year, but is predictable. Nov - April. Spread person to person, air droplets. Can fight it with vaccination and anti-viral medications. World-wide outbreaks every years. Signs & Symptoms: 48 hours after exposure Rapid onset chills, fever, muscle aches, headaches. Later, throat, lungs, nose and eyes are affected. Severe cough colored sputum. Lasts 2-3 days

43 Pneumonia Pneumococcal (lobar) - 17% die. Gram positive. PCN sensitive. Origin throat. Nosocomial - 70% die. Gram negative. Not responsive to PCN. Difficult to treat. Origin often colon. Elderly 10x more likely to have complications. Death rate 17x higher than in young. Signs & Symptoms Often misdiagnosed initially. High fever, shaking chills, cough, pleuritic chest pain are young patient’s symptoms! Confused, increased RR high index of suspicion. Only 1/6th have above symptoms.

44 Pneumovax will prevent about 75% of pneumococcal caused pneumonias!

45 Sepsis Septicemia: acute invasion of the bloodstream by microorganisms producing fever, chills, tachycardia, tachypnea, and altered mentation. Septic Shock: Distributive vasodilatory shock that creates a relative hypovolemia. Vasodilation occurs due to endotoxins released from bacteria.

46 Causes (% of cases) Gram Negative bacteria (60 - 70%) E. coli ProteusPseudomonas Serratia Neisseria meningiditis Gram Positive Bacteria ( %) Staphylococci Streptococci, pneumococci Opportunistic Fungi (2-3%) Rarely viruses, protozoans

47 Epidemiology of Sepsis2/3 are already hospitalized. Gram negative sepsis carries 25% death rate. Elderly with urinary dysfunction have very high risk. Underlying diseases predispose: diabetes, cirrhosis, alcoholism, cancer, immunosuppressed.

48 Clinical Manifestations of SepsisTypically sudden onset. Earliest signs can be AMS. May be pyrexic or hypothermic. Rash pustules or vesicles may contain organism. Petechiae - may suggest meningococcus. Nausea, vomiting, diarrhea, ileus may mask sepsis.

49 Treatment Most important - recognize early sepsisOxygen, airway management Isotonic Crystalloid Fluids wide open Vasopressors if unresponsive to fluids Immediate panculturing Antibiotics

50 Elderly Burns Age and burn size are the two most important factors that influence survival...

51 Burns in elders deserve aggressive treatmentBurns in elders deserve aggressive treatment. Survival rates have increased from 9% in 1950 to 30% in 1990! 1.4 – 2.0 million burns / year 54,000 – 100,000 will be hospitalized. Fourth leading cause of death from unintentional injury 6,000 die with 73% from house fires Inhalation of toxic substances is leading cause of death from fire. (CO, phosgene, carbon tetrachloride, hydrogen cyanide gas) plastics, foams, etc. Over 50% of deaths from fire had a elevated BAL. Scald burns are more frequent for those under 5 and over 65. (100 deaths / yr.) Hot water from taps, showers and bath tubs leading cause for <5 yr.. Age 65 and older account for 75% of deaths related to clothing ignition. Contact with electrical current 5th leading cause of death. Fire & flames is 13th cause Lightning accounts for 80 /year

52 A 65 year old 190 lb. Male with a 40% burn will need 16 liters of IV fluid in the first burn day. 8 liters will be infused in the first 8 hours - if the lungs are dry or wet!

53 Abdominal EmergenciesDiagnosis can be difficult since signs and symptoms can be absent, vague or masked!

54 The majority of recent fatalities from appendicitis have occurred in geriatric patients!

55 Common Abdominal Emergencies In 75 - 100 age groupStrangulated hernia - 20% Intestinal obstruction - 25% Gallbladder problems - 10% - 30% Acute Appendicitis - 15% GI bleeds, diverticulitis, perforate an ulcer - 5% - 10% Ruptured abdominal aneurysm or main artery - 2%

56 Rule of Thumb: any elderly patient with abdominal pain and a rapid pulse is in trouble! And, be more suspicious if they are on masking medications

57 Mental deterioration can affect as many as 20% of those over age 80 adding to the risk of missing a surgical abdomen.

58 Altered Mental Status in the Elderly

59 Delirium is an acute confusional state and is typically triggered by an underlying problem.

60 Hallmarks of Delirium Rapid decline in cognitive functionDisturbed intellectual function Disorientation Decreased attention span Poor recent memory Poor immediate recall Poor judgement Restlessness Altered LOC Suspiciousness Hallucinations Delusions

61 Common Causes of DeliriumHypoglycemia Infection Trauma Pneumonia Drug Toxicity Shock Dehydration CVA Tumors Sepsis

62 Common Questions to Determine Illness-Related Causes of AMSHas pt. Been drinking? Does urine smell strong? Urinating frequently? UTI are common causes of agitation / sudden behavioral changes Does the pt. Hold or protect a part of his body? Moaning, yelling or screaming is often not a behavioral problem but a pain problem. Ask about bowel habits, constipation, diarrhea.

63 Common Questions to Determine Illness-Related Causes of AMSEvaluate prescriptions & OTC drug use. 15% of all patients have problems related to drug interactions and / or polypharmacy. Evaluate for other substance use. Never consider delirium a normal change of aging!

64 The graying of America is here!Every old person is someone’s grandparent! We are the old person’s best advocate!