2015 geriatric pharma frontmatter fundamentals of geriatric pharmacotherapy
Geriatric Emergencies “The Essentials” · Geriatric Emergencies “The Essentials ... –...
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Geriatric Emergencies “The Essentials”
Everton A. Prospere, M.D., M.P.H.Chief of Geriatrics
University Hospital of Brooklyn
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NO FINANCIAL DISCLOSURES
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Why do we do what we do?
• WHO– “The state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity
• Impact state of health– Improve quality of life– Promote independent function– Improve life expectance
» Decrease morbidity and mortality
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• What is an emergency?
• What is a geriatric emergency?
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• “ a sudden urgent, usually unexpected occurrence requiring immediate action”
• an acutely debilitating or life threatening condition in the elderly
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• Response time and nature of response determines outcome
• It is better to be alive with a deficit than dead…
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Why is this relevant?
• Medical Ethics» Hippocratic Oath
– Respect patients autonomy– Informed consent– Non-maleficence– Beneficence– Teach
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Why is this relevant?• AGING is Inevitable
• Significant fraction of population is elderly– >300,000 in Brooklyn
• Predisposition for “Physiological Hypo-function”, illness and injury or death?
• Evidenced Based Standard of Care• “Not opinion”• “Not feelings”
• Assessment/Intervention decreases morbidity/mortality
• Improve life expectancy• Quality of life
– ADLs/IADLs
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Guides Assessment
• History• Physical• Serology• Imaging
– What is the indication?• Cost• Risk• Litigation
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Questions…
• What is the next step in the management of this patient?
• What is the next step in the care…?• How much time do I spend examining?• What are the risks/benefits of this
measure?• When or how soon do I follow up?• Who is going to “pay”…?
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• How do patients present?• What signs or symptoms are suggestive of
an underlying problem?• What signs/symptoms are suggestive of
an underlying medical emergency?
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Guides Management
• Goal– Reduce morbidity & mortality
• Improve quality of life– Decreased pain & suffering– Reduce risk of an unfavorable outcome
» Illness, injury, deformity, death – Treat underlying cause
» Remove, Reverse, Restore
• Improve life expectancy– Promote independent function
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How does it differ from standard medical evaluation?
• Focus is on elderly individuals with complex problems
• Stabilize first then consider continuous plan of care
» Response time correlates with favorable outcome
• A good geriatric assessment requires multidisciplinary team approach
• Quality of life and functional status may be emphasized.
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Setting for Assessment
• Ambulatory• Acute Care Setting
– Emergency Room– Hospital
• Home– Skilled Nursing Facility– Assisted Living
» ***Time Constraints***
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Factors impacting functional status
MEDICAL
PHYSICAL
SOCIAL
ECONOMIC PSYCH
DRUGS
SPIIRITUA;L
ENVIRON…
COGNITIVE
FUNCTIONALSTATUS
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Physical Exam
• Observation/Inspection
• Vitals– ABCs– Extremes of Vitals
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Geriatric emergencies• CVA or stroke• Pulmonary Edema/CHF• Pulmonary Embolism• Gastro-intestianl Bleeding• Rhabdomyolysis• Cord compression• Hypercalcemia• Temporal Arteritis
• Hip Fracture• Depression• Tooth Abscess• Septic joint• The eyes• Pneumothorax• Acute Renal Failure• Acute Abdomen
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How do we treat?
• Treat underlying cause…• Primary Prevention…
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• ROS• Common things occur commonly
– Previous episode is predictor of recurrent event
• Did I Ask?– D.I.D.I.A– Drugs, Infection, Dehydration, Impaction
• V.I.T.A.M.I.N.S
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Pulse can tell the story
• Tachycardia– Medications– Infections– Dehydration– Anemia– Hyperthyroidism– Myocardia infarction– Pulmonary Embolism
• Bradycardia– Infection– Hypoglycemia– Sick-sinus syndrome– Hypothermia– Hypothyroidism– ICP– Infection– IWMI
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PULMONARY EMBOLISM
More than ½ million estimated PE yearlyUntreated, 30% dieWith early detection and Rx, mortality still
high [10%]More than 90% from DVT
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RISK FACTORS
Virchow’s Triad: endothelial damage,venous stasis, immobilization
Acquired risks: surgery, trauma, malignancy, previous PTE, advanced age, CHF, high estrogen state, spinal cord injury
Hypercoagulable state: protein C def., ATIII deficiency, lupus anticoagulants, homocystinuria
Hematologic: persistent thrombocythosis, PNHOther: IBD, nephrotic syndrome
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KEY FEATURES IN HISTORY & PHYSICAL
• Dyspnea-sensitive but not specific• Pleuritic chest pain; about 50% sensitive
and specific• Cough: 60-80%specific• Leg swelling: 70-90%specific• Hemoptysis: 90-95% specific• Angina-like chest pain: 90+% specific
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Clinical Signs
• Tachycardia• Tachypnea• Accentuated P2: 87%specific• Cyanosis: 85-98%specific• DVT: 89-92%specific• Fever: >38.5• Homan’s sign, wheezing, pleuritic rub, RV lift
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Diagnostic tools• EKG: tachycardia, non specific ST-T changes
most common finding.S1,Q3,T3 rare
• Chest xray: normal, infiltrate, pl effusion• ABG• V/Q scan mismatch: low,intermediate, high
probability• High resolution CT chest• Pulmonary angiogram• Venous doppler/Phlebogram
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Management
• Oxygen• Anticoagulation with unfractionated
heparin or LMWH followed by warfarin• Treat underlying/predisposing factors
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PULMONARY EDEMA/CHF
MAJOR RISK FACTORSHypertensionHyperlipidemiaSmokingFamily history of atherosclerotic diseasesOther: chemotherapy, RT,illicit drugs,thyroid
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PULMONARY EDEMA/CHF
• KEY ELEMENTS IN HISTORY• Dyspnea• Degree of exertion to cause dyspnea• Orthopnea/PND• Other: nausea, abdominal pain, age at
onset• Fatigue• Mental Status Changes
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Differential Diagnosis
• Pulmonary Embolism• Asthma/COPD Exacerbation• Viral and Other Atypical Pneumonias• Pulmonary Fibrosis• Sarcoidosis
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Diagnostic Studies
• Labs: cardiac enzymes, BNP, BUN/Cr, electrolytes,CBC, ABG
• Chest x-ray• EKG• 2D-Echo
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Management• Diuretics to reduce volume load• Vasodilators: ACEI, hydralazine +nitrates
Increase SV by decreasing vasc resistanceDecrease preload by venodilation
Inotropic Drugs: digoxin, Dobutamine. Anti-arrythmics. Oxygen. Treat underlying disease
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Breathing Clues…
• Cheyne-Stokes breathing: CHF, CNS disease, pneumonia, medications, obesity
• Biot’s breathing: sign of increased intracranial pressure
• Apneustic breathing: Severely ill patients.This pattern is suggestive of pontine lesion
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REFERENCE
• GERIATRIC REVIEW SYLABUS• Dr. Mohamed Nurhussein
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THANK YOU