The Beers' Criteria lists 34 classes of medications that may be potentially inappropriate for geriatric patients due to a high risk of complications including increased risk for falls. When prescribing medications from the emergency department in geriatric patients, try to avoid these categories if other options are available.
http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf
The WBC count is normal in up to 45% of elderly patients with bacteremia. The most predictive factors for bacteremia in the elderly are delirium, vomiting, bandemia, and tachypnea.
The 30-day mortality for patients < 65 years of age who are diagnosed with and treated for acute MI is 3%. In contrast, the 30-day mortality for patients > 85 years of age who are diagnosed with and treated for acute MI is 30%! Obviously the mortality is far higher if the patient's diagnosis is delayed or missed; or if the patient is not treated appropriately.
This simple statistic highlights the critical importance of being aggressive with diagnostic and therapeutic planning for elder patients with potential ACS. We cannot afford to be cavalier in their evaluation or treatment.
Elderly patients in general have a lower baseline body temperature than younger patients. Consequently, it makes sense to redefine the definition of what constitutes a "fever" in the elderly. Rather than using the typical oral temperature cutoff of 38o C (100.4o F) for defining a fever, instead consider using 37.2o C (99o F). Redefining fever in this way increases the sensitivity for detecting bacterial infections from 40% to 83% while retaining an 89% specificity.
Elderly patients are high risk for missed MI because of atypical presentations. Though this seems to be relatively common knowledge, it is not always remembered. So here's a reminder....
The most common sources of bacteremia and serious bacterial infections in the elderly are the GU tract, the respiratory tract, and #3-the abdomen.
This third source is a bit of a surprise to many clinicians but worth remembering. Always consider the abdomen as the source of dangerous infections in the elderly when the source is not clearly the lungs or urine!
Here are a few important points to keep in mind when evaluating elderly patients in the ED or when prescribing a new drug:
Pay special attention to medication lists and new prescriptions in the elderly....much more attention than with younger patients!
We already know that polypharmacy is a big issue in the elderly, but here are a few key points to keep in mind:
1. Adverse drug effects are responsible for 11% of ED visits in the elderly.
2. Almost 50% of all adverse drug effects in the elderly are accounted for by only 3 drug classes:
a. oral anticoagulant or antiplatelet agents
b. antidiabetic agents
c. agents with narrow therapeutic index (e.g. digoxin and phenytoin)
3. 1/3 of all adverse-effect-induced ED visits are accounted for by warfarin, insulin, and digoxin.
4. Up to 20% of new prescriptions given to elderly ED patients represents a potential drug interaction.
The bottom line here is very simple--scrutinize that medication list and any new prescriptions in the elderly patient!
Rib fractures are associated with significant morbidity and mortality in the elderly, and the risk increases dramatically with each successive rib fractured. An elderly patient with 3 rib fractures has a mortality of 20% and risk of pneumonia is 31%. As a general rule, you should really think twice about discharging home any elderly patients with rib fractures.
[credit to Dr. Joe Martinez for bringing forth this information]
Elderly patients are prone to hypovolemia for the following two major reasons:
1. They have a decreased thirst response.
2. They have decreased renal vasopressin response to hypovolemia.
The result is that elderly patients have an impaired ability to compensate for a decreased cardiac output, which causes them to develop shock earlier and more easily with stressor.
Takeaway point: Always assume that most elderly patients are hypovolemic, and when they are stressed, give them fluids early!
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.
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.
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!
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)!
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.]
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.
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.
Expect the atypical in elderly patients!
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.