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61-80 of 82 results with category "Geriatrics"
Adverse drug effects are a major issue in geriatrics.
Elderly patients take, on average, 5 prescription medications + 2 over-the-counter medications.
Adverse drug effects account for approximately 5% of all hospital admissions.
Nearly 20% of patients brought to the ED for psychiatric complaints have symptoms that are primarily caused by medication effects.
Be very wary whenever prescribing ANY new medications for even a short time to elderly patients.
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There is a correction factor for erythrocyte sedimentation rate in the elderly. The top normal ESR in the elderly is (age + 10)/2. For example, an 80 yo patients would have a top normal ESR of (80+10)/2 = 45. Most laboratories do not, however, report this correction factor, but simply list < 20 (or thereabouts) as normal.
Be certain to take this correction factor into account when using ESRs for workups for temporal arteritis or other similar conditions.
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Elderly patients are at higher risk for skin infections for numerous reasons:
1. Blunted immune system response of skin to infections.
2. Slower wound repair after 3rd decade.
3. More frequent exposure to infections, especially drug resistant infections, especially if the patient is frequently hospitalized or in nursing homes.
4. Frequent portals of entry for skin infections: indwelling tubes and lines, leg ulcers, fissures and maceration on feet and between toes.
A key takeaway point is to always check the skin thoroughly of your elderly patients when searching for infections, especially the feet and toes!
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The majority of "classic" symptoms and signs in elderly patients with pneumonia (fever, cough, sputum production, leukocytosis,chest pain) are unreliably present. However, tachypnea is one of the most reliable early findings in elderly patients with pneumonia, and in fact the same can be said about other serious bacterial illnesses in the elderly. The takeaway point here is simple: always count the respiratory rate in elderly patients (and don't trust those triage respiratory rates)!
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The WBC count is not an accurate predictor of bacteremia in the elderly. 20-45% of elderly patients with proven bacteremia have a normal WBC on presentation.
[from Caterino JM, et al. Bacteremic elder emergency department patients: procalcitonin and white count. Acad Emerg Med 2004;11:393-396.]
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The nitrite test on urine dipstick is commonly used for diagnosis of UTI. However, the test is only reliable in those bacteria that convert nitrates to nitrites, which primarily includes enterobaceriaceae. However, elderly patients often develop UTIs with Staph saprophyticus, pseudomonas, and enterococcus, none of which produce positive nitrites on dipstick testing. The takeaway point here is very simply....don't assume you've excluded UTI (esp. in elderly populations) just because the nitrite test is negative.
reference: Anderson RS, Liang SY. Infections in the elderly. Critical Decisions in Emergency Medicine, April 2010.
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Up to 25% of elderly patients with appendicitis are initially sent home from the ED, an indication of the high misdiagnosis rate for appendicitis in the elderly population. Why are elderly patients so often misdiagnosed when they have appendicitis? The answer is simple....they present very atypically.
- The classic migratory pattern (periumbilical pain that migrates to the RLQ) is absent in > 50%
- Nasea, vomiting, and anorexia are each absent in > 50%
- Fever is absent in up to 50%
- Guarding and rebound are absent in 50%
- The WBC is normal in up to 45%
- Up to 15% have pyuria or bacteriuria, leading to misdiagnoses of UTI
Expect the atypical in elderly patients!
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Fever is less common in infectious states in the elderly than in young patients. However, in contrast to younger patients, when an elderly patient does have a fever it is much more likely to be associated with a serious bacterial infection. It has been estimated that the source of fever in elderly ED patients is viral in only 5% of cases.
[from Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the emergency department, part I. Emergency Medicine Reports 2010;31(9):101-110.]
Elderly patients have slightly lower body temperatures than younger adults, and as a result it has been suggested that "fever" be defined as anything > 99 degrees F. One study found that by lowering the definition to this number improved the sensitivity and specificity to 83% and 89%, respectively.
from Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the emergency department, part I. Emergency Medicine Reports 2010;31(9):101-110.
study referred to: Castle SC, et al. Fever response in elderly nursing home residents: are the older truly colder? J Am Geriatric Soc 1991;39:853-857.
Elderly patients should be considered immunocompromised for several reasons:
1. T cell function and reduced cellular immunity occur as we get older.
2. B cell antibody production decreases.
3. Host defenses against infection are reduced with aging, such as reduced circulation and thinning skin.
4. Miscellaneous factors, such as malnutrition and co-existing illnesses contribute to increased risk of infection as well.
[Good reference and suggested reading: Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the emergency department: Part I. Emergency Medicine Reports 2010;31(9):103-111.]
When prescribing quinolones to elderly (e.g. for UTI) patients that are taking iron supplements, advise them to take the antibiotic several hours before taking the iron. Iron will bind the antibiotic in the GI tract and reduce its bioavailability.
[Anderson RS, Liang SY. Infections in elderly patients. Critical Decisions in Emergency Medicine, 2010;24(8):13-18.]
Up to 10% of elderly patients in the ED meet criteria for acute delirium, though misdiagnosis rates are very common.
The most common cause of delirium in the elderly, overall, is medication effects. Other common causes are infections (UTIs most common), CNS abnormalities, cardiovascular abnormalities, electrolyte/metabolic abnormalities, and temperature abnormalities (fever or hypothermia).
A handful of lab abnormalities occur as a normal part of aging. Elderly patients will often demonstrate the following lab abnormalities without these indicating pathology:
1. ESR increases...use the following correction factor: top normal ESR < (age + 10)/2
2. creatinine falls
3. alkaline phosphatase may be elevated 2-3 fold
4. urinalysis may show asymptomatic pyuria or bacteriuria
5. ABGs demonstrate lower PaO2s and elevated A-a gradients
6. the top normal D-dimer level elevates slightly
7. the top normal BNP level elevates slightly
8. the ECG may show a first degree AV block, poor R-wave progression, leftward axis, and PVCs
It's no secret that the elderly are at high risk for adverse drug effects. The average elderly patient takes 5 prescribed medications plus two over-the-counter medications. As many as 5% of admissions in the elderly are attributable to adverse drug effects.
Anytime you prescribe a new medication to an elderly patient, ALWAYS check for the possibility of drug interactions.
Elderly patients are at higher risk of barotrauma with positive pressure ventilation (e.g. CPAP, BiPAP, and especially after intubation) because of decreased vital capacity and lung compliance. Watch those plateau pressures closely!
If an elderly patient develops hypotension within minutes of endotracheal intubation, always consider tension PTX (and don't forget about hypovolemia, as we've discussed before).
The most common cause of delirium in the elderly is infection, and the most common type of infection is just a simple UTI. The second most common cause of delirium is medication effects. ALWAYS look carefully for signs of infection and look carefully at medication lists whenever evaluating an elderly patient with a change in mental status.
When caring for elderly patients that are having dysrhythmias, especially ventricular dysrhythmias, or in cardiac arrest, give strong consideration to empiric use of magnesium. Elderly patients are more likely to be hypomagnesemic because of diuretic use, poor GI absorption, poor daily intake, and diabetes.
[Narang AT, Sikka R. Resuscitation of the elderly. Emerg Med Clin N Am 2006;24:261-272.]
Be wary of the limitations of correlating a temperature with infection in the elderly:
1. The elderly are 3-4x more likely to develop hypothermia in response to serious infections. Never rule out a serious infection simply based on a low or normal body temperature.
2. The elderly take longer to mount a fever than younger patients.
3. The elderly have a slightly lower body temperature at baseline, possibly 1 degree lower. As a result, "fever" in the elderly is sometimes defined as 99.5 degrees rather than the traditional 100 or 100.4 used in younger patients.
Hypovolemia is very common in the ederly for two reasons:
1. The elderly have a decreased thirst response...in other words, it takes longer for them to develop thirst in the setting of dehydration.
2. The elderly have a decreased renal vasopressin response to hypovolemia.
From a treatment standpoint, one should always assume an elderly patient is hypovolemic. Hydration is incredibly important during resuscitation of the elderly patient.