Geriatric Emergencies E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: CTEM - Current Topics in Emergency Medicine
• Sprache: Englisch

Seitenzahl: 1498

Veröffentlichungsjahr: 2016

Beschreibung

The elderly represent the fastest growing segment of the population in developed countries, reflected in the patient population presenting to EDs and hospitals. These patients more often than not have greater co-morbidities, more complicated workups and utilize more laboratory and radiologic services.

This text is designed to teach emergency physicians how best to care for this specific demographic of patients. It addresses physiologic changes, high-risk conditions, and atypical presentations associated with elderly patients in the ED that result in frequent misdiagnosis or delays in diagnosis. It instructs the readers how best to care for elderly patients in order to minimize morbidity and mortality, addressing some of the difficult psychosocial issues that confront health care providers that care for elderly patients, such as psychiatric disease and end-of-life care. The utility of this text is not limited to emergency physicians, but it should be useful to all health care providers involved in the treatment of elderly patients with acute medical or surgical conditions.

Leseprobe

Table of Contents

Cover

Title Page

Copyright

List of Contributors

Chapter 1: General assessment of the elderly patient

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

References

Chapter 2: Physiologic changes with aging

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Cardiovascular system – a tired pump, hardened pipes, and frayed wires

Pulmonary – decreased endurance and a decrease in oxygen tension

Renal – a loss of mass, altered drug sensitivity

Hematology/immunology – waning defenses, dull weapons

Neurologic – preserved attention, difficulty learning new tricks

Musculoskeletal – keeping it together gets harder to do

Gastrointestinal – slow and uncoordinated

Genitourinary – incontinence is not a given

Endocrine – the salt, sugar, and spice of life

Section IV: Decision-making

References

Chapter 3: Functional assessment of the elderly

Section I: Case presentation

Section II: Case discussion

Functional assessment of the elderly

Activities of daily living

Performance testing

Gait speed

Timed up and go testing

Chair standing and balance testing

Grip strength

Formal test batteries

Short performance physical battery

The physical performance test

Vision and hearing assessment

Frailty

The geriatric emergency department

Conclusion

References

Chapter 4: Pharmacological issues in the elderly

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision making

References

Chapter 5: Altered mental status in the elderly

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Delirium treatment and management

Section IV: Decision Making

References

Chapter 6: Geriatric psychiatric emergencies

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

References

Chapter 7: Acute abdominal pain in the elderly: Surgical causes

Section I: Case Presentation

Section II: Case discussion

Section III: Concepts

Initial workup

Testing

Section IV: Decision-making

References

Chapter 8: Nonsurgical abdominal pain in the elderly

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-Making

References

Chapter 9: Back pain

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

Acknowledgment

References

Chapter 10: Headache

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Testing for patients with headache

Treatment

Section IV: Decision-making

References

Chapter 11: Dyspnea in the elderly

Section I: Case presentation

Section II: Case discussion

Case resolution

Section III: Concepts

Acute coronary syndrome (ACS)

Congestive heart failure

Atrial fibrillation

Pneumonia

Asthma and COPD

Pulmonary embolism

Section IV: Decision-making

References

Chapter 12: Acute chest pain in the geriatric patient

Section I: Case presentation

Section II: Case Discussion

Section III: Concepts

Section IV: Decision-making

References

Chapter 13: Acute cardiac disease in elder patients

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Acute coronary syndrome

Atrial fibrillation

Heart failure

Conclusion

Section IV: Decision-making

References

Chapter 14: Syncope in Geriatrics

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Background and epidemiology

Etiologies

Evaluation

Testing

Disposition

Conclusion

Section IV: Decision-making

References

Chapter 15: Stroke

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Types of strokes

Treatment

Conclusion

Section IV: Decision-making

References

Chapter 16: Infections

Section I: Case presentation

Section II: Case Discussion

Section III: Concepts

Sepsis in the elderly

Lower respiratory infections

Genitourinary infections

Skin/soft tissue infections

Central nervous system infections

Section IV: Decision-making

References

Chapter 17: Dizziness and vertigo in the geriatric population

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

References

Chapter 18: Weakness and functional decline

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Pathophysiology

Generalized weakness and nonspecific complaints

Frailty

Functional decline

Treatment and disposition

Section IV: Decision-making

References

Chapter 19: Emergency department evaluation of falls in the elderly

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

References

Chapter 20: Trauma in the geriatric patient

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

References

Chapter 21: Surgical considerations in the elderly

Section I: Case presentation

Case outcome

Section II: Case discussion

Section III: Concepts

Elderly physiology

Diagnosis

Laboratory diagnostics

Radiographic diagnostics

Management of surgical issues

Pain management

Pharmacology

Preoperative clearance

Elective versus emergent surgery

End-of-life issues

Section IV: Decision-making

References

Chapter 22: Oncologic emergencies

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Specific oncologic emergencies

Biochemical emergencies

Local tumor effects

Hematologic emergencies

Section IV: Decision-making

References

Chapter 23: Elder abuse and neglect

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

Conclusion

References

Chapter 24: Geriatric emergency pain management case

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Pain assessment

Pain scales

Pharmacologic pain management for elderly patients

Nonpharmacologic interventions

Discharge pain management

Pain management monitoring and quality assurance

Summary

Section III: Decision making

References

Chapter 25: Ethical issues and end-of-life care

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

References

Chapter 26: Geriatric dispositions and transitions of care

Section I: Case presentation

Section II: Case discussion

Case resolution

Section III: Concepts

Section IV: Decision-making

References

Chapter 27: The geriatric ED

Section I: Case presentation

Section II: Case discussion

Section III: Concepts

Section IV: Decision-making

Conclusions

References

Index

End User License Agreement

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Guide

Cover

Table of Contents

Begin Reading

List of Illustrations

Chapter 5: Altered mental status in the elderly

Figure 5.1 Confusion Assessment Method: the diagnosis of delirium requires a present/abnormal rating for criteria (1) and (2) and either (3) or (4). Adapted from Inouye SK,

et al.

Ann. Intern. Med. 1990; 113: 941–948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission.

Chapter 18: Weakness and functional decline

Figure 18.1 Cycle of frailty.

Chapter 19: Emergency department evaluation of falls in the elderly

Figure 19.1 The timed “get up and go” test begins with the patient seated in a chair without arms. The patient is asked to (1) rise from the chair without using their arms, (2) walk 10 feet, (3) turn around, (4) walk back to the chair, and (5) return to the seated position. The clinician measures the length of time necessary to complete the task. Completion of the test in 30 seconds or more indicates impaired mobility. Observing the “get up” portion of the test allows the clinician to evaluate quadriceps strength, while the gait observation allows for the identification of hesitant starts, broad-based gait, a deviated path, failure of the patient's heels to clear the floor, and arm extension.

Figure 19.2 Preparing the Functional Reach Test begins with the clinician attaching a yardstick to a wall at the patient's acromion level. The patient is asked to stand next to the wall and yardstick without touching them and is then asked to extend the arm closer to the wall to 90° of shoulder flexion with a closed fist, position A above. The location of the third metacarpal head on the yardstick is recorded as the starting position. The patient is asked to reach as far forward as possible without taking a step. The location of the third metacarpal is again recorded, position B above. The difference between the starting and ending positions is the reach distance. The inability to reach 6 inches. or more is indicative of an impaired base of support.

Chapter 20: Trauma in the geriatric patient

Figure 20.1 EAST guidelines for evidence-based care of the geriatric trauma victim.

Figure 20.2 Orthogeriatric care model for older adults with falls.

Chapter 25: Ethical issues and end-of-life care

Figure 25.1 (a–d) Theoretical trajectories of dying. Lunney

et al

. [6].

List of Tables

Chapter 2: Physiologic changes with aging

Table 2.1 Physiologic changes with aging and clinical implications

Chapter 4: Pharmacological issues in the elderly

Table 4.1 Beers criteria for potentially inappropriate medication (PIM) use in older adults (anticholinergic, antiparkinsonian, and antispasmodics)

Table 4.2 Beers criteria for PIM use in older adults (diuretics)

Table 4.3 Beers criteria for PIM use in older adults (cardiovascular)

Table 4.4 Beers criteria for PIM use in older adults (antithrombotics, antiplatelets, NSAIDs)

Table 4.5 Beers criteria for PIM use in older adults

Chapter 13: Acute cardiac disease in elder patients

Table 13.1 CHA2DS2-VASc scoring system

Table 13.2 CHA2DS2-VASc score and stroke rate

Table 13.3 HASBLED scoring system

Table 13.4 Risk of spontaneous major bleeding (%/year)

Chapter 16: Infections

Table 16.1 Traditional systemic inflammatory response variables and effect of aging

Table 16.2 Clinical variables of sepsis, severe sepsis, and septic shock

Chapter 17: Dizziness and vertigo in the geriatric population

Table 17.1 ATTEST

Table 17.2 Common differential diagnoses presenting with dizziness

Chapter 19: Emergency department evaluation of falls in the elderly

Table 19.1 Key emergency department assessments of alterations contributing to falls

Table 19.2 Brief measures of balance and mobility

Table 19.3 Gait disturbances in ED fallers

Table 19.4 Medications contributing to falls in elders

Chapter 20: Trauma in the geriatric patient

Table 20.1 Specific geriatric trauma management recommendations and level of evidence

Chapter 21: Surgical considerations in the elderly

Table 21.1 ASA classification

Chapter 22: Oncologic emergencies

Table 22.1 Diagnostic tests for an acute anemia of uncertain cause

Table 22.2 Suggested laboratory analysis for an uncertain chronic anemia

Table 22.3 Characteristics of the “anemia of senescence” seen in the geriatric population

Table 22.4 Guidelines for the management of bleeding for hemophilia A

Table 22.5 World Health Organization classification of types of myelodysplastic syndromes

Table 22.6 Common causes of thrombocytosis

Table 22.7 Causes of erythrocytosis

Table 22.8 Characteristics and diagnostic criteria of polycythemia vera

Table 22.9 Signs and symptoms of leukostasis

Chapter 23: Elder abuse and neglect

Table 23.1 Characteristics of perpetrators of elder abuse [5]

Chapter 25: Ethical issues and end-of-life care

Table 25.1 Palliative Performance Scale

Chapter 27: The geriatric ED

Table 27.1 Potential environmental modifications for geriatric emergency departments

Table 27.2 Potential patient screening and assessment tests for geriatric emergency departments

Geriatric Emergencies

A discussion-based review

Edited by

Amal Mattu

University of Maryland School of Medicine, Department of Emergency Medicine, USA

Shamai A. Grossman

Harvard Medical School, USABeth Israel Deaconess Medical Center, Boston Massachusetts, USA

Peter L. Rosen

Harvard Medical School, USABeth Israel Deaconess Medical Center, Boston Massachusetts, USA

Associate Editors

Robert Anderson, MD

Christopher Carpenter, MD, MSC

Andrew Chang, MD, MS

Jon Mark Hirshon, MD, MPH, PhD

Ula Hwang, MD, MPH

Maura Kennedy, MD, MPH

Don Melady, MD, MSC(Ed)

Vaishal Tolia, MD, MPH

Scott Wilber, MD, MPH

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Cover image: © Dustin Diaz / EyeEm /Getty images

List of Contributors

Nissa J. Ali,

MD

Beth Israel Deaconess Medical Center

Harvard Affiliated Emergency Medicine Residency

Department of Emergency Medicine

West Campus Clinical Center

Boston, MA, USA

Robert S. Anderson, Jr.,

MD

Assistant Professor

Tufts University School of Medicine

Departments of Emergency Medicine and Internal Medicine and Division of Geriatric Medicine

Maine Medical Center

Portland, ME, USA

Kevin Biese,

MD, MAT

Vice Chair of Academic Affairs

Department of Emergency Medicine

University of North Carolina at Chapel Hill Chapel

Hill, NC, USA

Michael C. Bond,

MD

Associate Professor, Residency Program Director

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore, MD, USA

Alexander Bromfield,

MD

Clinical Instructor, Department of Emergency Medicine

University of California San Diego Health System

San Diego, CA, USA

Kenneth H. Butler,

DO

Associate Professor, Associate Residency Program Director

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore, MD, USA

Colleen Campbell,

MD

Associate Clinical Professor

Department of Emergency Medicine

Division of Emergency Ultrasound

University of California San Diego Health System

San Diego, CA, USA

Alessandro Cancelliere,

MD PhD

Assistant Professor

Department of Emergency Medicine

University of Massachusetts Medical School

Worcester, MA, USA

Christopher R. Carpenter,

MD, MSc

Associate Professor

Division of Emergency Medicine

Washington University in St. Louis School of Medicine

St. Louis, MO, USA

Andrew K. Chang,

MD, MS

Vincent P. Verdile Vice Chair for Research and Academic Affairs

Professor of Emergency Medicine

Albany Medical College

Attending Physician

Albany Medical Center

Albany, New York

Eric A. Coleman,

MD, MPH

Professor of Medicine and Head, Division of Health Care Policy and Research

Director

Care Transitions Program University of Colorado Denver

Anschutz Medical Campus

Aurora, CO, USA

Elizabeth Couser,

MSW

Gerontology PhD Candidate

Doctoral Program in Gerontology

University of Maryland

Baltimore, MD, USA

Susanne DeMeester,

MD

Attending Physician and Director Emergency Observation Center

St Joseph Mercy Hospital

Ann Arbor, MI, USA

Jonathan Edlow,

MD

Vice-Chair, Department of Emergency Medicine

Beth Israel Deaconess Medical Center

Professor of Medicine and Emergency Medicine

Harvard Medical School

Boston, MA, USA

Benjamin W. Friedman,

MD, MS

Associate Professor of Emergency Medicine

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx, NY, USA

Shamai A. Grossman,

MD

Associate Professor of Medicine and Emergency Medicine

Harvard Medical School

Vice Chair for Health Care Quality

Director

Observation Medicine

Department of Emergency Medicine

Beth Israel Deaconess Medical Center

Boston, MA, USA

Kama Guluma,

MD

Clinical Professor

Department of Emergency Medicine

University of California San Diego Health System

San Diego, CA, USA

Marianne Haughey,

MD

Associate Professor of Emergency Medicine

Albert Einstein College of Medicine

Jacobi Medical Center

Bronx, New York, NY, USA

Bryan Hayes,

PharmD

Clinical Associate Professor

Department of Emergency Medicine

University of Maryland School of Medicine Baltimore, MD, USA

Jon Mark Hirshon,

MD, MPH, PhD

Professor

Departments of Emergency Medicine and of Epidemiology and Public Health

University of Maryland School of Medicine

Baltimore, MD, USA

Teresita M. Hogan,

MD

Director of Geriatric Emergency Medicine

Department of Medicine

Sections of Emergency Medicine and Geriatrics & Palliative Care

The University of Chicago

Chicago, IL, USA

Ula Hwang,

MD, MPH

Associate Professor

Department of Emergency Medicine

Brookdale Department of Geriatrics and Palliative Medicine

Icahn School of Medicine at Mount Sinai

New York, NY

Geriatric Research, Education and Clinical Center

James J. Peters VAMC

Bronx, NY, USA

Joshua W. Joseph,

MD

Fellow in Clinical Informatics

Department of Emergency Medicine

Beth Israel Deaconess Medical Center

Clinical Fellow in Emergency Medicine

Harvard Medical School, Boston, MA, USA

Maura Kennedy,

MD, MPH

Associate Director for Emergency Medicine Research

Department of Emergency Medicine

Beth Israel Deaconess Medical Center

Assistant Professor of Emergency Medicine

Harvard Medical School

Boston, MA, USA

Phillip D. Magidson,

MD, MPH

Departments of Emergency Medicine and Medicine

University of Maryland Medical Center

Baltimore, MD, USA

Amal Mattu,

MD

Professor of Emergency Medicine and Vice Chair

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore, MD, USA

Colleen M. McQuown,

MD

Associate Professor, Northeast Ohio Medical University

Rootstown, OH, USA

Associate Research Director

Department of Emergency Medicine

Summa Akron City Hospital

Akron, OH, USA

Don Melady,

MD, MSc(Ed)

Schwartz/Reisman Emergency Centre

Mount Sinai Hospital

Assistant Professor, Faculty of Medicine

University of Toronto

Toronto, ON, Canada

Siamak Moayedi,

MD

Assistant Professor

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore, MD, USA

Barbara Morano,

MPH, LCSW

Program Manager

Department of Geriatrics

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Carmen Morano,

PhD, LCSW

Associate Professor

Silberman School of Social Work at Hunter College

Director

Silberman Aging: A Hartford Center of Excellence in Diverse Aging

Managing Editor

Journal of Gerontological Social Work

New York, NY, USA

Denise Nassisi,

MD

Director of the Geriatric Emergency Department

Mount Sinai Medical Center

Associate Professor Departments of Emergency Medicine & Medicine Icahn School of Medicine at Mount Sinai

New York, NY, USA

Rebecca Nerenberg,

MD

Assistant Professor of Clinical Emergency Medicine

Department of Emergency Medicine

Montefiore Medical Center

Albert Einstein College of Medicine

Bronx, NY, USA

Charles W. O'Connell,

MD

Clinical Instructor

Department of Emergency Medicine

Division of Medical Toxicology

University of California San Diego Health System

San Diego, CA, USA

Ruben E. Olmedo,

MD

Director

Division of Toxicology

Department of Emergency Medicine

Mount Sinai Medical Center

Assistant Professor

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Jason Ondrejka,

DO

Summa Akron City Hospital

Department of Emergency Medicine

Akron, OH, USA

Leslie C. Oyama,

MD

Associate Clinical Professor

Associate Residency Director

University of California San Diego Health System

San Diego, CA, USA

Timothy C. Peck,

MD

Beth Israel Deaconess Medical Center

Harvard Affiliated Emergency Medicine Residency

Department of Emergency Medicine

West Campus Clinical Center

Boston, MA, USA

Peter L. Rosen,

MD

Senior Lecturer Emergency Medicine

Harvard Medical School

Attending Emergency Physician Beth Israel/Deaconess Medical Center

Visiting Clinical Professor of Emergency Medicine

University of Arizona School of Medicine Tucson

Emeritus Professor of Emergency Medicine

University of California

San Diego, CA, USA

Roxanna Sadri,

MD

Department of Emergency Medicine

University of California San Diego Health System

San Diego, CA, USA

Nicholas Santavicca,

MD

Fellow, Emergency Medicine/Internal Medicine/Critical Care Program

University of Maryland Medical Center

Baltimore, MD, USA

Davut Savaser,

MD

Clinical Instructor

Department of Emergency Medicine

Division of Hyperbaric and Undersea Medicine

University of California San Diego Health System

San Diego, CA, USA

John G. Schumacher,

PhD

Graduate Program Director, Associate Professor

Department of Sociology and Anthropology

University of Maryland

Baltimore County (UMBC), Baltimore, MD, USA

Kirk A. Stiffler,

MD, MPH

Department of Emergency Medicine, Summa Akron City Hospital

Associate Professor of Emergency Medicine

Northeast Ohio Medical University

Akron, OH, USA

Tania D. Strout,

PhD, RN, MS

Associate Professor

Tufts University School of Medicine

Director of Research

Department of Emergency Medicine

Maine Medical Center

Portland, ME, USA

Alison Southern,

MD

Associate Program Director, Department of Emergency Medicine

Summa Health System

Associate Professor of Emergency Medicine

Northeast Ohio Medical University

Akron, OH, USA

Vaishal Tolia,

MD, MPH

Associate Clinical Professor

Emergency & Internal Medicine

Medical Director & Director of Observation Medicine

Department of Emergency Medicine

UCSD Health System

San Diego, CA

Mercedes Torres,

MD

Clinical Assistant Professor

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore, MD, USA

Julie Watkins-Torrey,

MD

Resident Physician

Department of Emergency Medicine

University of California San Diego Health System

San Diego, CA, USA

Katren Tyler,

M.B.B.S.

Associate Professor and Associate Program Director, Geriatric Emergency Medicine Fellowship Director, Vice Chair for Faculty Development, Wellness and Outreach

Department of Emergency Medicine

University of California, Davis

Sacramento, CA, USA

Gabriel Wardi,

MD

Department of Emergency Medicine, Fellow, Division of Pulmonary and Critical Care Medicine, University of California San Diego Health System

San Diego, CA, USA

Scott Wilber,

MD, MPH

Chair, Department of Emergency Medicine

Summa Health System

Professor of Emergency Medicine

Northeast Ohio Medical University

Akron, Ohio, USA

Michael Winters,

MD

Associate Professor of Emergency Medicine and Medicine

Departments of Emergency Medicine and Medicine

University of Maryland School of Medicine

Baltimore, MD, USA

Richard E. Wolfe,

MD

Chief of Emergency Medicine

Beth Israel Deaconess Medical Center

Boston, MA, USA

Alexandra Wong,

BA

Research Associate

Department of Medicine

Section of Geriatrics and Palliative Care

The University of Chicago

Chicago, IL, USA

Kate D. Zimmerman,

DO

Assistant Professor

Tufts University School of Medicine, Associate Director of Medical Student Education

Department of Emergency Medicine

Maine Medical Center

Portland, ME, USA

Chapter 1General assessment of the elderly patient

Alison Southern & Scott Wilber

Department of Emergency Medicine, Summa Akron City Hospital, Northeast Ohio Medical University, Akron, OH, USA

Section I: Case presentation

The patient is a 96-year-old man who presented with a chief complaint of slurred speech and generalized weakness. A history was obtained from the paramedic run sheet and family, who arrived in the emergency department (ED) 15 min after the patient. His symptoms have been waxing and waning over the last few days. Today, he had slurred speech and left-sided weakness, which has now resolved.

The patient's daughter reported that since his wife died 3 months ago, he has had a 20 lb weight loss. He has decreased appetite, decreased activity, and decreased function, which has waxed and waned. For the last 2 days, he has required wheelchair transport to the cafeteria for meals and assistance with transfer. The family stated that he has not had a recent change in his confusion.