1. Kevin Biese MD, MAT Kristen Barrio MD Nikki Waller, MD Ellen Roberts PhD, MPH Jan Busby-Whitehead, MD Precise Evaluation of the Geriatric Patient Adult in the ED: An interactive case series With Support from The Donald W. Reynolds Foundation, John A. Hartford Foundation & American Geriatrics Society © The University of North Carolina at Chapel Hill, Center for Aging and Health

2. The Overview Overview Geriatric Emergency Medicine (GEM) The Precise Evaluation game Frequent GEM pitfalls – Trauma, delirium, triage, care transition, abdominal pain Wrap up with key GEM take home points Discussion

3. Why Geriatrics: Phenomenal growth

4. Why Geriatrics: Unsustainable costs

5. Kevin Biese MD, MAT Kristen Barrio MD Nikki Waller, MD Ellen Roberts PhD, MPH Jan Busby-Whitehead, MD Center for Aging and Health Precise Evaluation: The game With Support from The Donald W. Reynolds Foundation, John A. Hartford Foundation & American Geriatrics Society © The University of North Carolina at Chapel Hill, Center for Aging and Health

6. Kevin Biese MD, MAT Kristen Barrio MD Nikki Waller, MD Ellen Roberts PhD, MPH Jan Busby-Whitehead, MD Center for Aging and Health Precise Evaluation: The answers With Support from The Donald W. Reynolds Foundation, John A. Hartford Foundation & American Geriatrics Society © The University of North Carolina at Chapel Hill, Center for Aging and Health

7. Acute Abdominal Pain in the Elderly: Significant Mortality and Morbidity ≥65 years old (yo) and come to the ED with acute abdominal pain – 50% admission – 33% surgery – Mortality 10% (similar to ST elevation myocardial infarction) Kizer KW, Am J Emerg Med 1998; 16: 357-62.

8. Geriatric Abdominal Pain: Different Causes Final DiagnosisAge <50Age > 50 Biliary Tract6%21% Nonspecific40%16% Appendicitis32%15% Bowel Obstruction2%12% Pancreatitis2%7% Diverticular<.1%6% Cancer<.1%4% Hernia<.1%3% Vascular<.1%2% Gyn4%<.1% Other13% Tintinalli J, et al. Emergency Medicine: A Comprehensive Study Guide. 6 th ed. New York: McGraw-Hill; 2000.

9. Case 1 Ultrasound

10. Case 1: Cholecystitis #1 abdominal surgical emergency in elderly Incidence increases with age Often only epigastric pain (foregut innervation is visceral) LFTS often not helpful Ultrasound is study of choice

11. Cholecystitis: Are LFTs Helpful? Trowbridge RL. JAMA. 2003; 289(1): 80-86.

12. Case 2 Insert picture of CT scan with mesenteric ischemia

13. Case 2 Insert picture of CT scan with mesenteric ischemia

14. Case 2: Mesenteric Ischemia Classically pain out of proportion to exam Risks include atrial fibrillation, hypercoagulable, low-flow, increasing age Arterial (usually) or venous Embolus or thrombosis Sometimes “intestinal angina” Usually superior mesenteric artery Multi-detector CT scan 77-90% sensitive Elevated lactate is a late finding (check >1 time) Newman TS. AmSurg. 1998; 64: 611-16. Horton KM. Radiographics. 2002: 22; 161. Emedicine 2006

15. Case 3: GI Bleed - Syncope DO A RECTAL EXAM

16. Case 4: Fall/Pain Management Pain related complaints are common among elderly patients – Approximately 7 million US ED visits/year are due to acute pain in patients >65 Persistent pain has been associated with functional decline, falls, death Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, McLean SA. Ann Emerg Med. 2012 Aug;60(2):199- 206.

17. Case 4: Fall/Pain Management Studies have reported that pain is undertreated in elderly patients – One recent analysis showed >1/2 of all patients >75, 1/3 rd with severe pain that presented with a pain related complaint were not given analgesic – Patients >75 approx 19% less likely to receive pain meds than pts aged 35-54 years Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, McLean SA. Ann Emerg Med. 2012 Aug;60(2):199-206.

18. Case 4: Fall/Pain Management Strategies for treating pain – Involve patient and the family in treatment options – Consider non-pharmacologic approaches – Scheduled acetaminophen – Start low and titrate slow with opioids and avoid preparations with acetaminophen – Anticipate side effects ( especially constipation, nausea, tiredness) if going to prescribe opioids – Ensure close follow-up Kapo JM. Persistent Pain. In: Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus. 7 th ed. New York: American Geriatrics Society; 2010

19. Geriatric Trauma: Mechanisms Falls - most common –Balance, strength, vision –Often worse than they seem MVC – most fatal –Judgment, vision, reaction times –Crash fatality rates are much higher Burns- 1/5 of all burn unit admissions –Mortality estimate = age + % burn

20. Geriatric Trauma: Complicating Factors Past medical history – Cardiac and pulmonary disease limit physiological response to stressors – Vital signs are difficult to interpret Medications – Anticoagulant use – Beta blockers Cause of the event – MI, syncope, stroke, hypoglycemia, suicide attempt

21. Geriatric Trauma: Triage Geriatric trauma patients are under-triaged pre-hospital, in violation of paramedic protocols Improved outcomes with lower threshold for trauma activation for geriatric trauma Focus on trauma triage! Ma, J Trauma, 1999 Demetriades, 2002

22. Rib Fractures If >65 with 3 or more rib fractures, admit; if >6 rib fractures, ICU Bergeron, J Trauma 2003

23. Case 4 What would have compelled you to obtain a head CT? Insert picture of CT scan with subdural hematoma

24. Warfarin and Elderly ICH Blunt head trauma on warfarin no symptoms, 7-14% with ICH Beware DASH (Delayed Acute Subdural Hematoma) – consider observation even if negative head CT (especially INR >4) Patients frequently supra-therapeutic INR –11% with INR >5 =Check INR Risk of spontaneous ICH on warfarin 0.3- 5.4% Frequent medication interactions – (>700 interactions including fluoroquinolones) Callaway, Emerg Med 2007

25. Aggressive Warfarin protocol 82 patients/ 19 with ICH Initiation of reversal from 4.3 to 1.9 hours Mortality from 48% to 10% Ivascu, J Trauma 2005

26. Case 5:Delirium 2° ASA Toxicity Delirium: – Acute onset with fluctuating course – Need to know the baseline Call the referring facility – Vital sign of older adults

27. Case 5: CAM http://jajsamos.files.wordpress.com/2011/03/cam-delirium-flow-chart.jpg

28. Mini - Cog Rapid assessment cognitive impairment Less subject to language and education Detects mild impairment www2f.biglobe.ne.jp

29. Benzodiazepines for Acute Agitation Avoid entirely if possible – see Beers Criteria Table 2 – Appropriate if being used to treat alcohol withdrawal May cause a paradoxical reaction in the elderly – Increasing agitation and anxiety – May lead to prescribing cascade (ie. antipsychotic use) Long-acting – Prolonged half-life in older adults (days) Benzodiazepines are lipophilic – Sedation, aspiration, delirium – Increased risk of falls and fractures Beers criteria Table 2: JAGS 2012 Apr;60(4):616-31

30. Case 5: Treating agitation Avoid benzodiazepines unless seizures or withdrawal Cardiac history required with IM ziprasidone Increased risk of QT prolongation with haloperidol given IV Use oral route if possible Use lowest effective dose and repeat if needed (60 min) Benzodiazepines within 1-2 hours of IM olanzapine are contraindicated Consider non-pharmacologic treatment first Rule out delirium Avoid physical restraints Reorientation Modify environment Attend to basic needs Risperidone ≤ 1 mg PO Olanzapine 2.5-5 mg PO/IM (NO BZDs with IM) Quetiapine ≤ 50 mg PO Haloperidol 1-2.5 mg PO/IM Ziprasidone 10-20 mg IM Haloperidol 0.25-1 mg IV Lorazepam 0.5-1 mg (PO, IM, IV) Tintinalli J, et al. Emergency Medicine: A Comprehensive Study Guide. 8 th ed. New York: McGraw-Hill; 2014

31. Case 5: ASA Toxicity Tinnitus, N/V, confusion, pulmonary edema Mixed metabolic acidosis and respiratory alkalosis Chronic toxicity more common in elderly and often missed Possible etiology of delirium

32. Take Home Points GEM is its own subspecialty with unique and evolving knowledge base and skills To avoid pitfalls – Be wary - don’t under triage (particularly trauma and always “blood thinners”) – Acute abdominal pain is often life threatening – Utilize Mini Cog and ICU CAM – Delirium means something is wrong – Treat pain, intelligently – Treat agitation, gently – Prepare for care transitions You can be an excellent physician by taking extra- ordinary care of your older patients