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1-20 of 82 results with category "Geriatrics"
A good reminder to consider careful prescribing to older patients at the time of ED discharge.
From this study: “Nearly 1 in 10 older adults filled a high-risk GEMS-Rx medication within 3?days of ED discharge between 2017 and 2022. Despite a decline in GEMS-Rx medication fills over time, younger cohorts of older adults and females were more likely to fill a high-risk medication upon ED discharge.”
Click for Gems-RX list
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This study looking at older patient contact with the health system within 30 days of ED discharge found an overall lower rate of follow up for those patients with dementia. Perhaps extra care at time of discharge in arranging follow up is warranted for older dementia patients.
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Expert consensus recommends not prescribing these eight classes of medications to older adults mostly due to sedative affect and fall risk. 1. Benzodiazepines 2. Barbiturates 3. Muscle relaxants 4. 1st generation antihistamines 5. Sulfanylureas 6. 1st generation antipsychotics 7. Zolpidem 8. Metocloprimide
A recent study shows marginal improvement in not prescribing these medications to older ED patients.
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This article describes a paramedic run community health initiative to assist people with dementia transition to home after an ED visit. They describe:
“Persons living with dementia (PLWD) frequently use the emergency department (ED) for unscheduled care and experience significant challenges during the ED-to-home transition.
The Community Paramedic-led Transitions Intervention (CPTI) is a structured, coaching-based program delivered by community paramedics that includes a home visit and follow-up calls to support PLWD and care partners during the 30?days after ED discharge.”
Could your ED use a program like this to prevent readmissions?
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A narrative review of literature involving older patients and constipation found:
“Major contributing factors include physical inactivity, sarcopenia, dehydration, inappropriate defecation posture, and polypharmacy, particularly opioids and anticholinergic agents. Importantly, these factors interact through the brain–gut–microbiota axis, contributing not only to gastrointestinal dysfunction but also to systemic outcomes such as frailty, cognitive decline, and increased healthcare burden, thereby supporting a multidimensional disease framework.”
It isn’t as simple as adding a laxative.
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The article outlines how instead of looking at medications as the cause of symptoms, we often add more medications to treat the medication induced symptoms. Here is an example of how we get to polypharmacy in older patients
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A modified 2 round Delphi study was used to create 57 learning objectives in geriatric care for European prehospital providers. Based on in-hospital learning objectives and literature, these experts came up with what appears to be a very reasonable and helpful list of education objectives for pre-hospital providers that could easily apply to emergency medicine learners as a whole. Here is their table:
https://link.springer.com/article/10.1186/s13049-026-01550-3/tables/3
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Using a database of 300,000 patients and applying a predictive measure for mortality, these authors found that patients over 66 with a high likelihood of 6 month mortality at the time of presentation were more likely to be admitted to an ICU when they presented to an ED. The authors conclude there is much work to be done regarding discussion of goals of care based on this information.
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Bottom Line: arrival temperature had no prognostic value in non-septic older patients. Hypothermia in sepsis, but not fever, predicted mortality.
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Tramadol has been viewed as a safer alternative for pain control than opioids. This study says differently.
“Tramadol use was associated with increased risk of multiple ER utilizations, falls/fractures, CVD hospitalizations, safety event hospitalizations, and mortality (new users only) compared to nonuse.”
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In 261 ED patients over age 65 receiving first generation antihistamines, 15% had an adverse reaction. Most common was delirium and urinary retention. Age over 85, previous cognitive impairment and multiple doses increased the risk of adverse reaction. Along with previous literature, this should discourage use of first generation antihistamines in older ED patients.
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The Geriatric Measurement Tool (GMT) was used in this study prospectively to assess 24 hour mortality rate in ED patients over age 65. The GMT is a combination of FRAIL Questionnaire and Barthel index for Activity of Daily Living. The study found:
“ From 700 enrolled patients, GMT categorization revealed that 53.6% of patients were in Category-4 (moderate/more dependent and frail), while 34% were in Category-1 (independent or slight dependency, prefrail/fit). The 24-h mortality rate was 9%. GMT Category-4 demonstrated high sensitivity (87.3%) for mortality prediction, but low specificity (49.7%). Conversely, GMT Category-1 showed low sensitivity (44.1%) but high specificity (90.2%) for predicting discharge.”
Probably the biggest take away is we should be thinking about assessing our older patient's health status using some validated scale/tool to help us have conversations with patients and families regarding prognosis and interventions.
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The Geriatric Measurement Tool combines the FRAIL Questionnaire with the Barthel Index For Daily Living to give a prognosis on your patient's mortality. First used to predict mortality in older patients with pneumonia during COVID-19 pandemic. Now being investigated for other ED patient populations.
FRAIL Questionnaire: Fatigue, Resistance, Aerobic, Illness, Weight loss. https://www.activeagingweek.com/pdf/abbott/FRAILQuestionnaire.pdf
Barthel: Ten questions about ADL's to create a score 0-100. https://www.mdcalc.com/calc/3912/barthel-index-activities-daily-living-adl
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This study is a reminder of the efficacy of regional nerve blocks for older patient's with hip fractures. The authors trained EM physicians for 2 hours then evaluated delirium levels in patients who did and did not receive nerve blocks for hip fractures.
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A prospective cohort of South Korean patients over 65 years admitted from the ED with critical illness had Clinical Frailty Scale (CFS) performed on them. Those with a high CFS had increased 3 month mortality. CFS helps us prognosticate morbidity and mortality in our older critically ill patients.
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In reviewing the limited literature available, the authors found that fascia iliaca blocks did not improve mortality but did improve hospital length of stay, decreased opiate use, and decreased delirium rates. More research is needed, however this tool should be added to our multimodal pain control toolbox.
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These authors looked at survival to discharge pre and post-implementation of a single dose epinephrine protocol for out of hospital cardiac arrest as it relates to age ranges. They found that older patients had a survival rate of 12% in the single dose protocol compared to 6% in the multidose protocol. Younger and middle aged patients had no difference in survival pre and post-implementation. At least in older adults, epinephrine does not seem to offer much benefit when given more than one time during cardiac arrest.
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This study looked at older patients admitted to the hospital with a diagnosis of one of the following: RSV infection, UTI, influenza, fracture. Those patients with RSV had longer stays, higher mortality, higher ICU length of stay and interestingly more cardiovascular complications up to one year after hospitalization. Further evidence we should be testing for RSV in our ill older patients and encouraging vaccination.
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These authors used information available from both the medical record as well as from a survey instrument given in the emergency department to created this fall risk score. A score over 6 had a 63% sensitivity and 75% specificity of predicting future falls.
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Reenforcing the recent pearl on geriatric trauma patient care, here is the National Association EMS Physicians statement on prehospital care.
"EMS clinicians should use age-adjusted, physiologic criteria to guide decisions to transport geriatric trauma patients to the most appropriate level of trauma center available in the community.
Geriatric trauma patients should be promptly evaluated for pain and should receive analgesic interventions in a timely manner. Analgesic medications should be dosed following weight-based guidance and should be administered with consideration of potential drug interactions and age-related changes in drug metabolism and side effects.
EMS clinicians should consult advance care planning documents, e.g., Physician Orders for Life-Sustaining Treatment (POLST), when available, to guide care in emergency scenarios, including management of traumatic injuries.
While older patients are at higher risk for spinal injuries, including lumbar and cervical spine fractures, traditional spinal motion restriction practices may not be suitable for older patients due to age-related anatomic changes in spinal alignment and increased risk for cutaneous pressure-related injuries. EMS clinicians should exercise judgment to determine when and how to best achieve spinal motion restriction if spinal injury is suspected in geriatric trauma patients."