Common Causes for Emergency Geriatric Treatment

Common Causes for speck Geriatric TreatmentIntroductionchronological age of 65 years or above is accepted as the defining criteria for Geriatric diligents in most developed countries 1 .This extended heterogeneous group is further classified into three sub existences parkly referred as Young-Old 65-74 Years, Old 75-84 Years and Old-Old 85 years and quondam(a). Worldwide, the number of Elderly persons is expected to much than fork-like from 841 million people in 2013 to more than 2 billion in 2050 2.In United States, patients over the age of 64 years account for 15-18% of ED visits 3 .Of these, about 35% requires admission as inpatient and a signifi peckt proportion of this gets admitted to Intensive cautiousness units 3.. The common gerontological syndromes in the Emergency division include altered mental stance, usable line of descent, fall, trauma, lancinating abdomen, infections, lancinate coronary syndromes, cerbrovascular accidents and exacerbations of chronic resp iratory disorders.There argon unusual characteristics and special needs which have to be kept in opinion while addressing aged patients in the emergency incision. The clinical presentation of geriatric patients is ordinarily complex with more of atypical manifestations confounding effects of co-morbid diseases, superior added cognitive dysfunction, polypharmacy and associated adverse drug reactions, psychosocial issues and lack of adequate social nurse etc 4. Assessment of these issues usually demands a comprehensive turn up with detailed clinical and liberal laboratory and visualise evaluations. This is justified in the context that a brief focused evaluation mountain overlook many grave conditions in these patient group. More over the attending physician should withal try to understand the instaurationline functional military position of the patient front to the presentation as it has got definitive prognostic implications. Thus it requires great skill, companio nship and patience from the part of the attending physician and the health cargon team as such(prenominal) to effectively and safely manage this vulnerable patient population.Approach to Unstable Elderly patient in Emergency DepartmentIn general, the principles of resuscitation in elderly patients be same as the pattern guidelines followed for adult patients. But it is desirable for the emergency physician to speak to the prompt relatives or to the patient himself if possible to see whether there is any hit directive or patients wishes for end of life care decisions. If present, it has to be respected before taking treatment decisions.The special characteristics in elderly while assessing Airway, Breathing and Circulation are summarized in emblem 1.Nasal air duct or Nasogastric tube has to be inserted gently with care as the os nasale mucosa is very friable and has a tendency to bleed in elderly patients. Always examine the oral cavity in unconscious patients for loose adapt ation dentures or partly chewed food as they can cause potential air lane obstruction and if present, has to be removed. Edentulous airway can result in ineffective bag-mask ventilation. Hence tumesce fitting dentures can be kept insitu while bag mask ventilation but always has to be removed before attempts of intubation. Difficulty in extending neck or in escapeding mouth has to be anticipate while attempting intubation repayable to degenerative diseases of spine and temperomandibular joints. Arterial telephone line gases are an definitive adjunct to the clinician as the clinical response to hypoxia, hypercapnea and acidosis can be blunted in elderly.Arterial hypotension (systolic BP 5. Serial assessment of roue pressures and Arterial Blood gas enquiry to see trends in lactate, base excess and acidosis can identify such potential high assay of exposure candidates early 6. Fluid resuscitation should follow in the type fashion with fluids or blood in an elderly patient wh o is hemodynamically touch-and-go in the Emergency department. But it should be careful with constant monitoring to avoid pulmonic edema. Early blood transfusion should be considered in elderly unstable trauma patient.Common Geriatric syndromes in Emergency department alter Mental statusAt least 25% of elderly patients in the ED have altered mental status 7, 8. Delirium is an cutting confusional state and dementia is a chronic confusional state. Etiology of delirium is oftentimes mutltifactorial but often represents an underlying medical checkup emergency. Diagnosis of delirium is clinical and is base on assessment of the level of consciousness and cognition. The confusion assessment method (CAM) is a useful tool for diagnosing delirium at ED 9.The important attention steps in the Emergency department are illustrated in Figure 2.The first priority is to address predisposing and precipitate factors like hypovolemia, hypotension, hypoxia, hypoglycemia, hyponatremia, Acidosis et c. Often inpatient admission is needed for the management of the underlying illness. Drugs like haloperidol or lorazepam may be used in cases of extreme agitation but with caution and at titrating doses.Decline in Functional statusFunctional status reflects how well a person is able to meet his or her own periodic needs-like feeding oneself, dressing up, getting out of bed, bathing, toileting etc. The attending physician should not misinterpret a lineage in functional status as a part of normal ageing process. Functional status of an elderly patient can be formally assessed with use of standard scales for basic activities of daily living. Activity of Daily living ADL is one such tool and is shown in figure 4. New onset Functional decline is often precipitated by medical, psychological or social reasons. Patients with unexplained functional decline need admission for evaluation and management. Functional decline is an important predictor of further functional decline, repeat ED vi sits, hospitalization, need for base care or institutionalization and death10, 11. The general approach to a patient with decline in functional status is illustrated in figure 5.waterfallFalls account for approximately 10% of emergency visits in Elderly 12, 13.Falls are the most common cause of fatal as well as non fatal injuries in geriatric population. A fall should be hard-boiled as a symptom and the physician should evaluate the causes and consequences of fall. The most common reasons for injurious fall- colligate ED visits among the elderly were fractures (41.0 percent), followed by superficial/contusion injuries (22.6 percent) and open wounds (21.4 percent) 13. Serious injuries associated with fall include hip fracture, rib fracture, subdural hematoma, former(a) serious soft tissue injury or head trauma. It is important to remember that a fall can signal a scout event in an elder persons life triggering a downwards spiral of complicating events, finally leading to death.Acu te abdomen in elderlyAcute abdominal pain in elderly usually poses a challenge to the clinician as the symptoms are often non-specific, abdominal findings are often subtle and the presence of co-morbid conditions which can complicate the definitive working(a) procedures. Common causes of acute abdomen in elderly include acute cholecystitis, acute appendicitis, peptic ulcer perforation, mesenteric ischemia, acute pancreatitis, ruptured abdominal aortal aneurysm, bowel obstruction and diverticular diseases. Elderly usually presents with atypical symptoms, often significantly late in the course of the illness.It is essential to consider serious medical conditions like inferior myocardial infarction, pneumonia, pleurisy, diabetic ketoacidosis and pulmonary intercalation in all cases of pretend acute abdomen. Abdominal tenderness may not be present or poorly localized. Guarding or taunt tenderness might be difficult to appreciate. Serial abdominal examination is important as new sig ns tend to appear with time. High risk features include acute onset of pain, severe pain, pain followed by vomiting, descent or persistent pain, signs of peritonitis, hemoperitoneum and hemodynamic disturbances. Liberal imaging is the usual protocol with right-down x-ray abdomen, abdominal ultrasound and CT abdomen as necessary. Patients with act symptoms but with unremarkable laboratory and imaging studies should be observed and serially evaluated as necessary. An approach to elderly with abdominal pain is illustrated in figure 6.Infections in elderlyElderly are significantly more accustomed to infections and its life morose complications. Presentation of infection can be atypical with lack of fever or localizing features. Sepsis can present with subtle clinical features like lethargy, decline in functional status or confusion. rough-cut site of infections include lung, urinary tract, skin and abdomen. High index of uncertainty is necessary to early identify the patients wit h sepsis. Management of Severe Sepsis and Septic transgress in elderly should follow the standard guidelines used for adults like outside(a) surviving sepsis guidelines 14. Early initiation of antibiotics and other sepsis resuscitation bundles is found to improve mortality and functional recovery 15, 16, 17 .The salient points in the clinical approach to an elderly with suspected sepsis are summarized in figure 7.Medication related problemsAdverse events related to drugs are common in elderly population and is a common cause for ED visits. Elderly are more susceptible to serious and fatal adverse drug effects due to polypharmacy, lack of monitoring , non-adherence, use of multiple medications, use of over the restitution medications, wrong dosage , altered drug metabolism and propensity for drug interactions. The risk factors for serious adverse drug reaction in elderly include old-old patient, lean body mass, more than 6 chronic medical illnesses, 9 or more drugs, more than 12 doses per day and a previous history of adverse drug reaction 18. Most commonly encountered problematic drugs include diuretics, NSAIDs, Warfarin, Digoxin, antidiabetic agents, antiepileptic agents, chemotherapeutic agents, antibiotics and psychotropic drugs 19. elaborated drug history, reviewing prescriptions and direct verification of current medications may prove to be very helpful strategies while evaluating geriatric patients in the ED.Elder convolute and NeglectElder abuse is defined a single or repeated act, or lack of appropriate action, occurring within any consanguinity where there is an expectation of trust which causes harm or distress to an older person 20. It can result either from an act of commission or of omission and may present as physical abuse, psychological abuse, cozy abuse, care giver neglect, self neglect and financial exploitation. It should be suspected in patients who present with unexplained or multiple injuries in sundry(a) stages of evolution.Key pointsThe characteristics and needs of elderly in the Emergency department are quite different than the younger patient.Clinical presentation of life threatening diseases can be atypical, subtle or misleading with absence of authorized symptoms and signs.Presence of multiple co- morbid conditions and cognitive impairment usually complicates the picture.A comprehensive work up-including detailed history, physical examination and liberal investigations and imaging is recommended than a brief goal directed or symptom based work up.Altered mental status, falls, functional decline, acute coronary syndromes, stroke, infections with or without sepsis, acute abdomen and trauma are the common geriatric syndromes in the emergency department.Social and non medical issues are important and need multidisciplinary arousal to ensure safe and effective disposition of these population.