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Geriatric Neurologic Emergencies Alan Lucerna, DO Emergency Department Kennedy University Hospitals - Stratford.

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1 Geriatric Neurologic Emergencies Alan Lucerna, DO Emergency Department Kennedy University Hospitals - Stratford

2 Geriatric Neurologic Emergencies This Care of the Aging Medical Patient in the Emergency Room (CAMP ER ) presentation is offered by the Department of Emergency Medicine in coordination with the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

3 Which of these tests is not part of the stroke evaluation in the ED? A.CT with contrast B.Accucheck C.ECG D.Cardiac enzymes E.Coagulation panel

4 When evaluating for potential thrombolysis, which of these criteria is an absolute contraindication to rtPA administration in a patient who is in the 3 hour window? A.Age less than 80 B.Platelet < 100, 000 C.Glucose of 200 D.INR 1.2 E.SBP 179

5 According to the recent published trials on the use of rtPA in patients presenting in the hour window, age above 80 is a contraindication. A.True B.False

6 Geriatric Neurologic Emergencies Objective: To discuss the diagnosis, treatment, and unique features of common neurological emergencies as it pertains to the geriatric population This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

7 CVA SDH Trauma SAH Dizziness Meningitis/Epidural Abscess

8 Geriatric Trauma

9 Trauma Epidemiology Overall incidence of TBI in ER is 444 cases/100,000 persons in the US Incidence increases in the elderly and peaks at 1,026/100,000 in patients older than 85 Females> males ( younger patients 1.6 times likely to be male SDH far more common: 46% of TBI vs 28% in young cohort Epidural hematoma less common Elderly have more pedestrian accidents and falls

10 Falls Older than 65, annual incidence of 30% Rate increased to 50% in octogenarians Multifactorial: - Normal aging: changes with vision, joints, propioception - Superimposed diseases (DM/ autonomic dysfunction) - Meds

11 “But, Doc, she fell from a standing position. It can’t be that bad….”

12 68 year old female; fall from standing; on coumadin, ASA, Plavix Image Source: Kennedy Health Systems

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14 81 year old SAH posterior sylvian fissure S/P fall Image Source: Kennedy Health Systems

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16 Falls When compared to younger patients, falls in the elderly are: -7 times more to be the predominant etiology of injury (48% vs 7%) -7 times more to be the cause of death (55% vs 7.5%)

17 Falls Same level falls resulted in 30% injuries in the elderly compared with 4% of a younger cohort Head and neck (47% vs 22%) Mortality of these “low falls” approaches 15%

18 The elderly have a different predominant mechanism and patterns of injury Increased upper cervical spine injury, particularly the odontoid Typically C4-7 most flexible and most likely to be injured in the young Senile DJD alter spine mechanics making upper cervical spine more mobile Spinal Injuries Photo: Microsoft Office Images #MP (http://office.microsoft.com/en-us/images/)

19 Lomoschitz and colleagues: 149 patients older than age 65, C2 injuries account for 40% of fx In lower cervical spine: C5/C6, 12% each Four in 10 had multilevel trauma: C1/2 or C5/6 Patients > 75 yrs more likely to have upper cervical spine injuries regardless of mechanism Risk factors: DJD, osteopenia Spinal Injuries

20 Cervical plain films lack obvious prevertebral soft tissue swelling in 17% of upper cervical spine 40% of lower cervical spine Some experts advocate bypassing plain films However, 3 out of 4 elderly who have cervical spine injury have normal neurologic exam Therefore, low threshold for immobilization and imaging Spinal Injuries

21 Pedestrian Injuries SAH- 26% SDH - 29% Mortality % Those transferred to trauma centers have enormous survival benefit ( 56% vs 8% in acute care hospital) However, elderly is less likely to be transported to trauma centers compared to younger patients ( 60% vs 82%) Image Source: Microsoft Clip Art

22 Traumatic Brain Injury Overall, in-hospital mortality for isolated TBI was two fold higher, 30% vs 14% Age remained an independent risk factor for death even when pre-existing medical conditions and complications were removed Geriatric TBI patients who survive to discharge have poor cognitive and functional outcomes

23 Stroke is a Medical Emergency Image Source: Image Source: Used by permission.http://www.nhs.uk/actfast/Pages/stroke.aspx

24 Does the FACE look uneven? Ask the person to smile. Does one ARM drift down? Ask the person to raise both arms. Does the person’s SPEECH sound strange? Ask the person to repeat a simple phrase, for example, “The sky is blue.” If you observe any of these signs, then it’s TIME to call 911. Image Source: Used by permission.http://www.nhs.uk/actfast/Pages/stroke.aspx

25 Epidemiology: USA 700,000 to 795,000 people suffer a new or recurrent stroke in the US each year Of these 625, 000 are ischemic By 2025, annual number of strokes will reach 1 million In 2003, nearly 200, 000 died from stroke It is the 3rd leading cause of death after heart disease and cancer

26 Kammersgaard LP, Jørgensen HS, Reith J, et al. Age and Ageing 2004;33:

27 Copenhagen Study Very old (>85) was found to be associated with severe strokes, as was: Being female Having atrial fibrillation Pre-existing disability

28 Kammersgaard LP, Jørgensen HS, Reith J, et al. Age and Ageing 2004;33: ©Image used by permission.

29 Epidemiology: World 3rd leading cause of death in industrialized Europe and leading cause of adult disability WHO estimates 15 million suffer a stroke worldwide per year This results in 5.7 million deaths and 5 million with disability. † Global incidence will only increase since people over 65 will be 10% of the world population by †http://www.medscape.org/viewarticle/719320

30 Feigin FL, Lawes CMM, Bennett DA, Anderson CS. Lancet Neurol 2003;2(1): ©Image used by permission.

31 Pathophysiology The brain: 2% of the body's mass Requires 15-20% of the total resting cardiac output to provide the necessary glucose and oxygen for its metabolism Stroke: sudden disruption of blood flow to the brain with subsequent neurologic deficit

32 Pathophysiology: The Ischemic Cascade Seconds to minutes of the loss of glucose and oxygen delivery to neurons, the cellular ischemic cascade begins Cessation of the normal cell electrophysiologic function Cytokine cascade = edema = cell death

33 Pathophysiology: Ischemic Penumbra Zones of decreased or marginal perfusion The core: regions of the brain without significant flow; these cells are presumed to die within minutes of stroke onset Tissue in the penumbra can remain viable for several hours because of marginal tissue perfusion Currently studied pharmacologic interventions for preservation of neuronal tissue target this penumbra

34 Mechanisms of Stroke 80% Ischemic -Embolic: may either be of cardiac or arterial origin; sudden onset, several previous infarcts in neuroimaging -Thrombotic: large-vessel strokes and small-vessel or lacunar strokes; situ occlusions on atherosclerotic lesions in the carotid, vertebrobasilar, and cerebral arteries, typically proximal to major branches -Lacunar: 20% of all ischemic strokes, great majority are related to hypertension -Watershed: border zone infarcts, develop from relative hypoperfusion in the most distal arterial territories

35 Intrinsic to the blood vessels of the brain Embolus from the heart or extracranial vessel Decreased perfusion pressure or increase blood viscosity Image Source: Microsoft Images by Fotolia Image Source: PhotoDisc  Health & Medicine Volume 18. Used by permission. Rupture of the vessel in Subarachnoid space or intracerebral space Image Source: Microsoft Images by Fotolia

36 Mortality/Morbidity Stroke is the leading cause of disability in the United States 26% of stroke survivors need assistance with daily living 30% need some type of assistance for walking 26% require admission to a long-term care facility. at least one third of stroke survivors have depression as well as many of their care providers

37 What is the cost? The direct costs (ie, treatment) and indirect costs (ie, lost productivity) of stroke in the United States are approximately $68.9 billion/year in 2009

38 Stroke Evaluation

39 EMS Systems “must provide education/training to minimize delays to dispatch, assessment,and transport of potential stroke victims” AHA.ASA EMS needs to -Provide high priority dispatch -Support cardiopulmonary function -Perform rapid stroke assessment -Define “time last seen normal” -Notify receiving hospital of “stroke alert” -Transport to Stroke Center if possible and prudent EMS Evaluation and Transport

40 Cincinnati Prehospital Stroke Scale -Facial droop -Arm weakness -Speech abnormalities Los Angeles Prehospital Stroke Scale -Age >45 -History of seizures or epilepsy absent -Symptoms duration, 24 hours -At baseline not wheelchair bound or bedridden -Blood glucose Obvious asymmetry of one following: facial smile/grimace, hand grip, or arm strength EMS Stroke Assessment

41 Better one year survivals, functional outcomes and quality of life in patients treated in Dedicated Stroke Center- studies done outside US, many randomized trials and meta analysis. “ When a dedicated stroke center is available within a reasonable transport interval stroke patients who require hospitalization should be admitted there” -Class 1 evidence AHA Should all “Stroke” patients be transported to Primary Stroke Center ?

42 Case 77 yo female presents to the ER for an evaluation of right sided weakness and dysarthria. The patient states she was doing laundry when she noticed that she could not lift her right arm up. She arrived in the ER with VS 160/95, 89, 20, 98.6, 99% on RA. Her NIHSS is 16.

43 Single most important piece of historical information… Image Source: Microsoft Images

44 What is the time of onset? Image Source: Microsoft Images

45 TIME IS BRAIN Every 60 seconds of ischemia leads to irreversible damage of 1.9 million neurons. Neurons LostSynapses Lost Myelinated Fibers Lost Accelerated Aging Per Stroke1.2 billion8.3 trillion7140 km/4470 miles36 years Per Hour120 million830 billion714 km/447 miles3.6 years Per Minute1.9 million14 billion12 km/7.5 miles3.1 weeks Per Second million200 meters/218 yards8.7 hours Quantitative estimates of the pace of neural circuitry loss in human ischemic stroke emphasize the time urgency of stroke care. The typical patient loses 1.9 million neurons each minute in which stroke is untreated. From: Saver JL. Stroke 2006;37(1): Estimated Pace of Neural Circuitry Loss in Typical Large Vessel, Supratentorial Acute Ischemic Stroke

46 TIME IS BRAIN If stroke ran a full course: 10 hours, look at what is lost: -1.2 billion neurons -8.3 trillions synapses -4,470 miles of myelinated fibers

47 Stroke Evaluation Sudden weakness of face, arm, leg; sudden confusion; sudden difficulty speaking or understanding speech; visual disturbances; trouble walking; dizziness; sudden severe headache History -Time of onset? Single most important piece of information -Sx’s now resolved, worse, or getting better -Similar episodes before ? -Family history of CVA, cerebral aneurysm?

48 Acute Stroke Syndromes Motor and/or sensory deficit ( Foot > face, arm). Grasp, sucking reflex. Abulia, paratonic rigidity, gait apraxia. Embolic > atherothrombotic. Dominant hemisphere: aphasia, motor and sensory deficit (face, arm > leg > foot). Internal capsule: hemiplegia. Homonymous hemianopsia. Non-dominant hemisphere: neglect, anosognosia, motor and sensory deficit (face, arm > leg > foot). Homonymous hemianopsia. Homonymous hemianopsia; alexia without apraxia. Visual hallucinations, visual perseverations. Choreoathetosis, spontaneous pain (thalamus). CN III palsy, vertical eye movement paresis. Motor deficit ( cerebral peduncle, midbrain). Image Source:

49 Acute Stroke Syndromes Penetrating Blood Vessels Pure motor hemiparesis ( classic Lacunar) Pure sensory Pure sensory-motor Hemiparesis, homolateral ataxia Dysarthria/clumsy hand Vertebro-basilar: Cranial nerve palsy Crossed sensory deficits Diplopia. Dizziness, N/V, dysarthria Dysphagia, hiccup Limp, gait ataxia Motor deficit, coma B/L signs suggests basilar artery disease Internal Carotid: Progressive or stuttering onset of MCA syndrome, Occasionally ACA syndrome as well if inadequate Collateral flow Image Source:

50 Data from Gorelick PB, et al. Neurology 1986;36(11):

51 Image courtesy of UpToDate. Used by permission.

52 Baseline NIH ScorePercent of Favorable Outcome < 60 YO > YO > YO >200 > 75 YO >200 Uptodate.com (NIHSS: National Institutes of Health Stroke Scale Adapted from NINDS t-PA Stroke Study Group, Stroke 1997; 28:2119)

53 Ensuring Medical stability ( ABC’s, IV, O2, monitor) Reversing any conditions that may contribute to the problem Moving towards uncovering the basis the neurologic symptom ( history, CT scan) Screening for contraindication to thrombolysis is acute ischemic stroke Emergency Room Assessment Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.www.uptodate.com

54 Assess VS, O 2, monitor Fingerstick Glucose ECG NIH CBC/BMP/CE/Coags 2 IV’s (# 18) Head CT w/o Contrast Contact Neurologists Contraindications to tPA Stroke Alert Algorithm LFT UDS Etoh LP EEG UA, Blood Cx Type and Screen Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.www.uptodate.com

55 Identify signs of Possible Stroke Critical EMS Assessments and Actions Immediate General Assessment and Stabilization Immediate Neurologic Assessment by Stroke Team or Designee Hemorrhage on CT Scan? Patient Remains Candidate For Fibrinolytic Therapy? Begin Stroke Pathway… Probable Acute Ischemic Stroke; Consider Fibrinolytic Therapy No Hemorrhage Consult Neurologist Or Neurosurgeon; consider transfer if not available Hemorrhage Review Risks/Benefits with Patient And Family… Candidate Administer Aspirin Not Candidate Identify Signs of Possible Stroke Critical EMS Assessments and Actions Support ABC; give oxygen if needed Perform prehospital stroke assesment Establish time when patient last known normal (Note: therapies may be available beyond 3 hrs. from onset) Transport: Consider bringing a witness, family member or caregiver Alert hospital Check glucose if possible Immediate General Assessment and Stabilization Assess ABCs, vital signs provide oxygen if hypoxemic Obtain IV access and blood samples Check glucose; treat if indicated Perform neurologic screening assessment Activate stroke team order emergent CT scan of brain Obtain 12-lead ECG Immediate Neurologic Assessment by Stroke Team or Designee Review patient history Establish symptom onset Perform neurologic examination (NIH Stroke Scale or Canadian Neurologic Scale) Any Hemorrhage on CT Scan? NO Hemorrhage: Probable Acute Ischemic Stroke; Consider Fibrinolytic Therapy Check for fibrinolytic exclusions Repeat neurologic exam: are deficits rapidly improving to normal? Patient Remains Candidate For Fibrinolytic Therapy? Candidate for Fibrinolytic Therapy: NOT Candidate for Fibrinolytic Therapy: Review Risks/Benefits with Patient and Family: If acceptable – Give tPa No anticoagulants or antiplatelet treatment for 24 hours Administer Aspirin Hemorrhage: Consult Neurologist Or Neurosurgeon; consider transfer if not available Hemorrhage OR No Hemorrhage: Begin Stroke Pathway Admit to stroke unit if available Monitor BP; treat if indicated Monitor neurologic status; emergent CT if deterioration Monitor blood glucose; treat if needed Initiate supportive therapy; treat co-morbidities

56 Hypoattenuation involving one- third or more of the middle cerebral artery (MCA) territory Obscuration of the lentiform nucleus [blue arrow] Cortical sulcal effacement Focal parenchymal hypoattenuation Loss of the insular ribbon or obscuration of the Sylvian fissure Early Signs of Stroke on CT Image Source: the Radiology Assistant (www.radiologyassistant.nl)www.radiologyassistant.nl Tomura N, et al. Radiology 1988;40(10): Hyperattenuation of large vessel (e.g., “hyperdense MCA sign”) Loss of gray-white matter differentiation in the basal ganglia

57 2 hours after symptoms Image Source: Kennedy Health Systems

58 S/P tPA, 16 hours after initial symptoms Image Source: Kennedy Health Systems

59 21 hours Image Source: Kennedy Health Systems

60 Day 5 Image Source: Kennedy Health Systems

61 Hypoattenuation involving one-third or more of the middle cerebral artery (MCA) territory Obscuration of the lentiform nucleus Cortical sulcal effacement Focal parenchymal hypoattenuation Loss of the insular ribbon or obscuration of the Sylvian fissure Hyperattenuation of large vessel (e.g., "hyperdense MCA sign") Loss of gray-white matter differentiation in the basal ganglia Early Signs of Stroke on CT Early CT signs of infarction implies a worse prognosis The presence of these signs was associated with an increased risk of poor functional outcome Analysis from the NINDS trial found that early CT signs of infarction were not independently associated with increased risk of adverse outcome after IV alteplase treatment Patients treated with alteplase did better whether or not they had early CT signs Albers GW, et al. Chest 2008;133(6_suppl):630S-669S. Oliveira-Filho J, Koroshetz WJ. Accessed 9/20/2010.www.uptodate.com

62 TPA in Acute Ischemic Stroke is Level 1 Care!!! The Decision may no longer be yours!!! Medical Therapy of Stroke American Heart Association

63 Patient Selection -Must present within 4.5 hours of sx’s -CT excludes ICH -Review History for contraindications -Treatment of patients with minor neuro deficits or rapidly improving deficits is not recommended TPA For Acute Ischemic Stroke

64 Contraindications: -Evidence of ICH -Suspicion of Subarachnoid hemorrhage pretreatment -Recent (within 3 months) intracranial,or intraspinal surgery -Any history of intracranial hemorrhage in past -Uncontrolled Hypertension -Seizure at the onset of stroke TPA For Acute Ischemic Stroke

65 Contraindications: -Active internal bleeding -Brain tumor, AVM, or aneurysm -Known bleeding diathesis -Current warfarin use; INR> 1.7, or PT >15 seconds -Heparin within 48 hours -Elevated PTT -Platelets < 100,000 TPA For Acute Ischemic Stroke

66 Image courtesy of UpToDate. Used by permission.

67 Warnings -Patients with severe neurologic deficits at presentation( NIHSS>22) are high risk for ICH -Patients with major early infarct signs on Pretreatment CT with cerebral edema, mass effect, or midline shift TPA For Acute Ischemic Stroke

68 rtPA Expansion To 4.5 Hours European Cooperative Acute Stroke Study (ECASS)-3 28% given tPA at hours of symptom onset had modest improvement at 6 months Eligibility criteria is the same as the 3 hour time period However, there are exclusions: 1. patients. older than 80 yrs old 2. Taking anticoagulants with INR  Baseline NIHSS >25 del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Stroke 2009;40(8):

69 Protocol -Monitor bp q 15 min. Bp, 185/110 qualifies, -BP> 185/110 not remaining below this threshold with treatment- no TPA -Dosing: 0.9 mg/kg maximum 90 mg -10% of total dose given as IV bolus over one minute -Remaining 90% infused over one hour TPA For Acute Ischemic Stroke

70 Protocol -Monitor closely vital signs and neurologic status -Maintain Bp < 185/110 -No anticoagulant or antiplatelet therapy for 24 hours -Avoid hypotension -Mental status change, new neuro deficits during treatment, suspect ICH -Discontinue therapy and do emergent CT brain TPA For Acute Ischemic Stroke

71 rtPA and Stroke Mimics Image Source: Photo by Mydriatic. Used by permission.http://commons.wikimedia.org/wiki/File:Phyllocrania_paradoxa_Morphology.jpg

72 Hypoglycemia Seizures with post-ictal Todd’s paralysis CNS infections Systemic Infections Toxic metabolic diseases ( Renal failure/TTP, hyponatremia, hepatic disease, drugs) Intracranial mass lesions (chronic SDH, tumors) Head trauma Complex migraines Functional deficit ( conversion disorder) Stroke Mimics

73 Studies showed no hemorrhagic complications in these patients -Chernyshev OY, Martin-Schild S, Albright KC, et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010;74(17): Winkler DT, Fluri F, Fuhr P, et al. Thrombolysis in stroke mimics: Frequency, clinical characteristics, and outcome. Stroke 2009;40(4): Scott PA, Silbergleit R. Misdiagnosis of stroke in tissue plasminogen activator-treated patients: Characteristics and outcomes. Ann Emerg Med 2003;42(5): Stroke Mimics

74 Discontinue TPA Repeat CT Repeat CBC, PT,PTT, fibrinogen, D-dimer Consider -FFP -Cryoprecipitate -Platelet infusion Stat Neurosurgical consult ICH During Therapy With TPA

75 Oxygenation and Airway control Fever control Blood Sugars Seizure control Hypertension control Anti coagulant therapy ? Rapidly progressing strokes( Brainstem) -Class 1 evidence AHA Medical Therapy of Stroke Considerations

76 Oxygen and Airway control -Give supplemental oxygen to hypoxic patients -No clear evidence for oxygen for non-hypoxic patients -Insufficient data on hyperbaric oxygen Medical Therapy of Stroke

77 Temperature control -Treat fever with antipyretics -Induced hypothermia unproven Sugar control -Treat hypoglycemia promptly -Hyperglycemia treatment recommended  ASA/AHA recommends treatment of of bld sugar >140 to 185 mg/dL  ESI recommends treatment for glycose above 180 mg/dL  Treat with fluids and insulin  Avoid Dextrose containing fluids  Monitor closely: don’t over treat Medical Therapy of Stroke

78 Hypertension control Treatment cautiously advised for sustained BP greater/equal to 185/110 BP> 220/120 = Not lytic candidate. Search for end-organ damage: Aortic Dissection, MI, CHF, Renal Failure, Encephalopathy -Treat as hypertensive emergency, Labetelol, Nicardipine, Nitroprusside BP >185/110- Candidate for lytic therapy -Treat with Labetolol IV mg -Nitropaste 1-2 inches -Nicardipine 5mg/hr IV increase 2.5 mg/hr q 5 mins to max 15 mg/hr Monitor closely: don’t over treat Medical Therapy of Stroke

79 Seizure Control No prophylactic anticonvulsants recommended -Treat seizures with Benzodiazopines -Prevent further seizures -Witnessed seizure at stroke onset is Contraindication to Thrombolytic therapy Medical Therapy of Stroke

80 Anti- Coagulant Therapy –Never the decision of ED physician –May be indicated for A. Fib, Prosthetic heart valves, CHF, Brain stem stroke with progression –Never used at time zero with TPA –Call Neurologist at Stroke Center early !!! Medical Therapy of Stroke

81 Head position: Flat vs 30 degrees -Neurology 2005; 64: Wojner-Alexander and colleagues used transcranial Doppler on MCA blood flow on 20 patients with AIS -Lowering HOB from 30 to 0 degrees increased blood flow velocities, on average 20% from 30 to 15 degrees -3 patients showed improved neurologic function Medical Therapy of Stroke Wojner-Alexander,AW, et al. Neurology 2005; 64(8):

82 Head position: 30 degrees and neutral Elevated intracranial pressure (e.g., with large ischemic stroke, intracerebral hemorrhage, space- occupying lesion, or other cause of elevated intracranial pressure) Aspiration (e.g., those with dysphagia and/or diminished consciousness) Cardiopulmonary decompensation or low pox Medical Therapy of Stroke Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.www.uptodate.com

83 If it’s good for acne…. Hayakawa K, Mishima K, Hazekawa M, et al. Stroke 2008;39(3):

84 Incidence: cases per 100, 000 Associated with advancing age: chronic HTN, amyloid angiopathy One month mortality 35% to 52% Treatment: ABCD, BP and ICP monitoring, reversal of coagulopathy, seizure prophylaxis Mannitol/hyperventilation for IICP Spontaneous ICH Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.www.uptodate.com

85 Intraparenchymal bleed Image Source: Kennedy Health Systems

86 A Few Words on SDH

87 Frequently misdiagnosed Male predominance 7 cases per 100, 000 among patients older than 70 yrs of age Contributing factors: prone to falls, antiplatelets, anticoagulants, structural brain lesions CSF Shunting : 8% of patients with shunts due to NPH Chronic SDH

88 Presentation less likely to be classical (HA, visual changes, vomiting) Seizures Focal signs Subtle cognitive deficits ( confusion, personality changes, memory loss, impaired judgment EP must consider this when evaluating an elderly person who has mental status change or sudden progression of neurologic or psychiatric disease Chronic SDH

89 Image Source: Kennedy Health Systems

90 78 per 100, 000 among aged Average age at presentation is 50 yo Advanced age is an independent risk factor for death and severe disability Good outcome in 3 months is 25% in >70 yo ( 73% in <40 yo) Rebleeding rates are also higher 16.4 ( older than 70) More likely to develop intraventircular hemorrhage, hydrocephalus, vasospasm Aneurysmal SAH

91 Age & Aneurysmal SAH Data from: Kulchycki LK, Edlow JA. Emerg Med Clin N Am 2006;24(2): Poor outcomes in patients who have aneurysmal SAH are related to advanced age, as the Glasgow Outcome Scale (GOS) ratings show here.

92 Of course, ABCD BP control: MAP 130 or less or SBP 140 or less Nicardipine or Labetalol No nitroprusside: dilates cerebral vasculature, increase ICP, impairs auto regulation, excesive hypotension patients may require multiple CT’s to evaluate changes is mental status EP’s role: detection by CT/LP and expedited disposition. Involve the neurosurgeon early International Subarachnoid Aneurysm Trial (ISAT): coiling superior to clipping Aneurysmal SAH

93 Dizziness

94 One of the most common presenting complaints in adults older than 75 YO Words to describe: fatigue, near syncope, disequilibrium, vertigo Vertigo, or illusory sense of motion Peripheral: acute onset, severe, assoc with n/v, tinnitus, hearing loss Dizziness

95 Vertigo is concerning in the elderly H&P is not infallible in distinguishing central vs peripheral Vestibular nuclei infarction from basilar artery occlusion can be indistinguishable from vestibular neuritis by exam Norrving conducted a small study: –24 patients 50 to 75 yo with isolated acute vertigo –25% were discovered to have cerebellar ischemia –Some of these events are cardio embolic Unless the cause is clearly benign, maintain a low threshold for imaging and neurologic consultation Dizziness Norrving B, et al. Acta Neurologica Scandinavica 1995;91(1):43-48.

96 Peripheral Vertigo Causes: –Motion Sickness –BPPV –Otitis Media –Vestibular Neuritis –Ménière's disease –Toxiclabyrinthitis/ Ototoxic Meds Dizziness

97 Central Vertigo Causes: –Etoh –Temporal lobe seizures –Migraine –Head trauma –VBI –Posterior fossa mass Dizziness

98 Central Vertigo needs emergent treatment Vascular risk factors and abrupt onset headache increase likelihood of stroke Assess S/S posterior circulatory involvement: diplopia, dysarthria, ataxia, long tract problems REMEMBER: peripheral vertigo: have difficulty walking Cerebellar stroke: CANNOT WALK AT ALL GAIT testing is MANDATORY Dizziness

99 Vertigo Treatment: –Steroids may improve outcome in patients with vestibular neuritis –Modified Epley Maneuver –Meclizine –Benzo’s –Anti-emetic Dizziness

100 Epley Maneuver

101 CNS Infection

102 Immunosenescence: decline of immune cells assoc with normal aging Malnutrition Presenting complaints are often nonspecific: confusion and falls, blunted fever response, at times even hypothermic Factors Affecting Geriatric Immunity

103 Largest spike in incidence occur in infants and older than age 60 yrs Geriatric cases 2-9 cases per 100, 000 Diagnostic delays are common Complications and in house mortality are at increased rate Classic triad: fever, nuchal rigidity, altered mental status has 46% sensitivity More than 99% has at least one, absence of all 3 in ruling out the diagnosis Meningitis

104 Nuchal rigidity particularly unhelpful Neck stiffness found in only 57% of elderly with meningitis But also in 35% without CNS infection Rigidity maybe from Parkinson’s, osteoarthritis, cervical spondylosis 12% of healthy elderly display positive Kernig sign 18% have positive Brudzinski 40-58% of the elderly who have meningitis present with concomitant infections Meningitis

105 Causative Bacteria Meningitis in Patients Older than 50 S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli

106 Diagnostic delay occur in up to 75% of patients The elderly often visit the ER for DJD related back pain More than 85% do not have the classic triad: spinal pain, fever, neurologic deficits Lack of fever and leukocytosis does not rule it out MRI is the gold standard along with use of inflammatory markers like ESR as a screening tool for patients who have lower pretest probability Pt suspected of epidural abscess must be transferred to centers capable of neurosurgery Antibiotics prior to transfer Patients with cervical abscess may need intubation Epidural Abscess

107 References 1.Albers GW, Amarenco P, Easton JD, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8 th Edition). Chest 2008;133(6_suppl):630S-669S. 2.Chen R, Balami JS, Esiri MM, et al. Ischemic stroke in the elderly: An overview of evidence. Medscape Education. April 5, Accessed January 3, 2013.http://www.medscape.org/viewarticle/ Chernyshev OY, Martin-Schild S, Albright KC, et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010;74(17): del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the American Heart Association/American Stroke Association. Stroke 2009;40(8): Feigin FL, Lawes CMM, Bennett DA, Anderson CS. Stroke epidemiology: A review of population-based studies of incidence, prevalence, and case-fatality in the late 20 th century. Lancet Neurol 2003;2(1): Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology 1986;36(11):

108 References 7.Hayakawa K, Mishima K, Hazekawa M, et al. Delayed treatment with minocycline ameliorates neurologic impairment through activated microglia expressing a high- mobility group box1-inhibiting mechanism. Stroke 2008;39(3): Jauch EC, Kissela B, Stettler B. Acute management of stroke. Medscape Reference. August 10, Accessed December 12, Kammersgaard LP, Jørgensen HS, Reith J, et al. Short- and long-term prognosis for very old stroke patients: The Copenhagen Stroke Study. Age and Ageing 2004;33: Kulchycki LK, Edlow JA. Geriatric neurologic emergencies. Emerg Med Clin N Am 2006;24(2): Lomoschitz FM, Blackmore CC, Mirza SK, Mann FA. Cervical spine injuries in patients 65 years old and older: Epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. Am J Roentgenol 2002;178(3): Norrving B, Magnusson M, Holtås S. Isolated acute vertigo in the elderly: Vestibular or vascular disease? Acta Neurologica Scandinavica 1995;91(1): Oliveira-Filho J, Koroshetz WJ. Initial assessment and management of acute stroke. Accessed September 20,

109 References 14.Saver JL, Kalafut M. Thrombolytic therapy in stroke. Medscape Reference. March 29, Accessed May 11, Saver JL. Time is brain – quantified. Stroke 2006;37(1):263: Scott PA, Silbergleit R. Misdiagnosis of stroke in tissue plasminogen activator-treated patients: Characteristics and outcomes. Ann Emerg Med 2003;42(5): Winkler DT, Fluri F, Fuhr P, et al. Thrombolysis in stroke mimics: Frequency, clinical characteristics, and outcome. Stroke 2009;40(4): Ruo-Li C, Balami JS, Esiri EM, Chen LK, Buchan AAM,. Ischemic Stroke in the Elderly: An Overview of Evidence. [ online ].


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