Geriatric Emergencies Regarding Falls Presented By Spencer by yurtgc548

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									Geriatric Emergencies
  Regarding Falls
          Presented By:
      Spencer Peterson MSIII
Mercer University School of Medicine
           July 5th, 2011
               Outline

1) Future of the Emergency Department (ED) in
regards to the increasing geriatric population

2) Falls

3) Fractures

4) Head Trauma
Impact of Baby-boomers
       on the ED
 In 2000, 35 million people (13.1%) were over age 65.

 By 2030, it is projected to be over 70 million or 20% of
 the population.

 A 28% increase in those >75 years while those >85 years
 are increasing at 3-4x the rate of younger cohorts.

 25-40% of patients in the average ED will be geriatric
 based on population statistics alone.

ACEP: The Future of Geriatric Care in our Nation's Emergency Departments: Impact and Implications
The Geriatric Population

•   Presently accounts for 15% of all ED patients

•   43% of all admissions

•   48% of all ICU admissions

•   Length of stay averages 20% longer

•   Require 50% more labs and radiology

•   400% more likely to require social services
   Elderly Have Poorer Clinical
       Outcomes in the ED
• Delayed or missed diagnoses such as acute MI, sepsis,
   appendicitis, ischemic bowel, pulmonary embolus, etc.

• Unsuspected diagnoses such as delirium, depression, cognitive
  impairment, drug/alcohol dependence, elder abuse,
  polypharmacy,etc.

• Under-treatment as exemplified by the low rates of PCI in acute
  MI, TPA for stroke, less surgical interventions, and inadequate
  pain management.

• Over-treatment as exemplified by the high rates of foley
  catheterization and adverse drug events with inappropriate
  medications, especially sedatives and hypnotics.
                Geriatric ED

•   Like the recent creation of pediatric emergency
    medicine and more advanced focuses on the level of
    acuity like trauma care, clinical decision units, fast-
    tracks, observation units, and chest pain units, it
    may be in the near future that a geriatric unit and
    geriatric team become a part of the emergency
    department.
 Most Common Geriatric
      Emergencies

Falls
•Change in mental status
•Cardiovascular / cerebrovascular events
•Respiratory problems
•Poly pharmacy
•Abuse and neglect
Risk Factors for Falls and
       Fractures
   MEDICAL RISK FACTORS

           •Osteoporosis
                                           DEMOGRAPHIC RISK FACTORS
                                                    •Female gender
           •Parkinson's                               •Older age
             •Diabetes                                •Caucasian
                                        •Low body weight and body mass index
              •Stroke                            •Low calcium intake
             •Arthritis                   •Smoking / excessive alcohol intake
                                             •Low level of physical activity
            •Gait deficit
                                               •Use of assistive devices
          •Balance deficit                 •Impaired activities of daily living
  •Psychotropic medication use

           •Depression

      •Cognitive impairment

•Personal history of fracture / falls

 •Family history of osteoporosis

 •Dementia / poor health / frailty

            •Poor vision
     Risk Factor            Mean RR or OR*
     Common
MostMuscle weakness Risk Factor for Falls in
                                4.4
    History of falls 16 Studies
                              3.0
     Gait deficit                   2.9
     Balance deficit                 2.9
     Use assistive device                 2.6
     Visual deficit                  1.5
     Arthritis                     2.4
     Impaired ADL                    2.3
     Depression                      2.2
     Cognitive impairment                 1.8
     Age > 80 years                      1.7
Drugs That May Increase the Risk of Falling



-Sedative-hypnotic and anxiolytic drugs (benzodiazepines)
-Tricyclic antidepressants
-Major tranquilizers (phenothiazines and butyrophenones)
-Antihypertensive drugs
-Cardiac medications
-Corticosteroids
-Nonsteroidal anti-inflammatory drugs
-Anticholinergic drugs
-Hypoglycemic agents
-Any medication that is likely to affect balance
    Falls in the Elderly
More than 1/3 of adults >65 will fall each year

Most common reason for injury visit

Leading cause of death from an accident in an
elderly person

Fractures or other serious injuries accompany
roughly 10% of falls

12% of deaths in the elderly are directly or
indirectly related to a fall.
•   Falls were found to cause 87% of all fractures
    in those aged 65 and over
      Injury Rate for Falls vs.
               MVAs

•   Falls: 40 per 1000 people age 65-74

•   Falls: 69 per 1000 people age 75+

•   MVA: 11 per 1000 people age 65-74

•   MVA: 9 per 1000 people age 75+
   Comprehensive
  Evaluation for Falls
Expanded history (ADLs, environmental
hazards, last eye examination)

Physical examination (Timed Get Up and Go
test, mental status examination)

Diagnostic studies and referral (geriatric
assessment, social services, optometry,
podiatry, physical therapy, occupational
therapy)
  Pathologic/Fragility
       Fracture

Fracture as a result of a disease process
leading to the weakness of the bone such that
normal activity led to a break

May be a result of an underlying bone disease
such as osteoporosis, cancer, or infection
      Pathologic/Fragility
           Fracture

•   Most Common: Hip fracture

•   Followed By: Vertebral fracture (mostly lumbar)

•   Then: Wrist Fracture

•   And: Rib Fracture
      Check Radiographic
           Findings
Bone pathology may be revealed

Think: bone composition, drugs,
cancer, nutrition, typical for abuse?,
does the break fit the story?, is it
consistent with a fall?
               Hip Fracture
•   300,000 per year in U.S.

•   2-3x higher in caucasians

•   2-3x higher in women

•   Lifetime risk of hip fracture in white women and men is
    15% and 5%, respectively

•   Mortality Rate: 15-20% but can be as high as 36% for up
    to a year after the fracture

•   48 hour delay in surgery lead to a 17% higher mortality
    rate the first month
                Hip Fracture

•   Morbidity from immobilization includes development
    of deep vein thrombosis, pulmonary embolism,
    pneumonia, and muscular deconditioning. Morbidity
    from surgical procedures includes complications of
    anesthesia, postoperative infection, loss of fixation,
    and malunion or nonunion
Most Common Hip Fracture


•   Femoral Neck Fracture




•   Intertrochanteric Fracture
    Avascular Necrosis


•   Interruption of blood flow to the bone

•   Due to several causes but can often be associated
    with a fracture or dislocation

•   Can lead to increased pain and disability

•   Treatment can involve bisphosphonates, NSAIDS,
    exercise, surgical replacement or decompression
       Projection of Hip
    Fractures in the Future

•   With the increasing geriatric population, it is
    estimated that there will be over 650,000 hip
    fractures in the year 2040
    One Year After Hip Fx

•   Only approximately 40% of surviving patients
    regain their previous level of mobility

•   Only approximately 25% regain their former
    functional status
           Osteoporosis




•   The World Health Organization (WHO) defines
    osteoporosis as having a bone mineral density
    2.5 standard deviations below the mean peak
    bone mass.
Osteoporosis Risk Factors


•   Non-modifiable: age, gender, decreased
    estrogen or testosterone, family history, and
    European or Asian descent.

•   Modifiable: Alcohol, Smoking, Malnutrition,
    Vitamin deficiency, Inactivity, Underweight,
    diet high in protein or soft drinks, Medications
       Treating Osteoporosis
•   Calcium, Vitamin D, Vitamin K

•   Aerobics, Weight Bearing, and Resistance Exercises

•   Anti bone resorption agents (Bisphosphonate, SERM,
    Calcitonin)

•   Bone anabolic agents (PTH like)
              Osteopenia

•   WHO defines osteopenia as having a bone
    mineral density 1.0-2.5 standard deviations
    below the mean peak bone mass.

•   Treatment is controversial, but it is considered
    a precursor to osteoporosis so an individual’s
    risk of fracture and benefit from intervention
    must be made
Osteoporosis vs. Osteopenia
Hip fractures per 1000 patient-years



WHO category   Age 50-64    Age > 64      Overall

Normal          5.3        9.4      6.6


Osteopenia       11.4        19.6      15.7


Osteoporosis     22.4        46.6      40.6
            Osteomalacia

•   Characterized as the softening of bone due to
    defective bone mineralization secondary to
    decreased amounts of calcium absorption in
    the gut and increased amounts of
    phosphorous loss through the kidneys

•   “Rickets” in children
         Paget’s Disease

                                        Punched-out
                                        bone lesions




•   Unknown etiology but likely genetic or viral.

•   Bone is broken down faster than normal and
    the body attempts to rebuild faster but the new
    bone that forms is weak and brittle
       Head Injury After Fall

•   Assume potential head/neck injury if:

•   Patient reports fall

•   Patient was found on ground

•   Patient was seen to hit head or reports hitting head

•   Patient has altered mental status

•   Patient emesis or sign of head injury
    Subdural Hematoma




•   Common when head rapidly changes
    velocities and the small bridging veins tear

•   Common in alcoholics and the elderly where
    cerebral atrophy is present and increases the
    length of the bridging veins.
    Subdural Risk Factors

•   Patients taking anticoagulants like aspirin or
    warfarin

•   Elderly patients with shrinking brains and
    increased global atrophy

•   Patients prone to falls
    Diagnosing a Subdural




•   CT Scan is the standard to detect bleeding
    and any type of mass effect
        Treating a Subdural

•   Ensure that mass is not expanding, watch & wait

•   May need surgical clot removal or craniotomy

•   Monitor intracranial pressure
       Epidural Hematoma


•   Commonly involves the middle meningeal artery
    and a blow to the side of the head

•   Blood build up between dura mater and skull

•   Blood does not expand past suture lines of skull
Subdural vs. Epidural
     Coup/Contrecoup Injury




•   Coup at site of impact; Contrecoup at opposite side

•   Cerebral contusion, can lead to epidural hematoma
              Lucid Interval

•   Patient may initially lose consciousness at time of
    injury but then awaken and feel normal for a short
    period “lucid interval”

•   During this time an epidural hematoma may
    continue to expand causing increased swelling and
    intracranial pressure on the brain which can be fatal
    if unrecognized
Subarachnoid
Hemorrhage


•   Bleeding between the arachnoid membrane
    and pia mater often due to aneurysm but can
    occur after traumatic brain injury

•   Also a form of stroke, blood in CSF

•   “Worst Headache of My Life”
          After an ED Visit
       Risk Factors for Negative Outcomes




•   Age

•   Level of Functional Impairment

•   Living Alone

•   Social Support
             Overview
        Dx and Tx in the ED
•   Identifying the cause

•   Treatment of the acute problem without delay

•   Treating underlying problem

•   Reducing the number of return visits, patient
    education and follow-up

•   Rehabilitation, Physical/Speech/Occupational Therapy
                     Overview
    Prevention of Falls and Injury

•   Frequent Screening

•   Assistance and Equipment

•   Making the home safe (rugs, stairs, floor items)

•   Ability to call for help

•   Review drug list
              Home Safety Checklist
All living spaces
_____ Remove throw rugs.
_____ Secure carpet edges.
_____ Remove low furniture and objects on the floor.
_____ Reduce clutter.
_____ Remove cords and wires on the floor.
_____ Check lighting for adequate illumination at night (especially in the pathway to the bathroom).
_____ Secure carpet or treads on stairs.
_____ Install handrails on staircases.
_____ Eliminate chairs that are too low to sit in and get out of easily.
_____ Avoid floor wax (or use nonskid wax).
_____ Ensure that the telephone can be reached from the floor.
Bathrooms
_____ Install grab bars in the bathtub or shower and by the toilet.
_____ Use rubber mats in the bathtub or shower.
_____ Take up floor mats when the bathtub or shower is not in use.
_____ Install a raised toilet seat.
Outdoors
_____ Repair cracked sidewalks.
_____ Install handrails on stairs and steps.
_____ Trim shrubbery along the pathway to the home.
_____ Install adequate lighting by doorways and along walkways leading to doors.
FIGURE 2. Checklist for evaluating safety during the home visit.
Adapted with permission from Rubenstein LZ. Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Ambulatory geriatric care. St. Louis: Mosby, 1993:296-304.
                   References
http://newfrontiers.americangeriatrics.org/chapters/pdf/rasp_3.pdf

http://www.slideshare.net/taem/taem10-common-pitfalls-in-geriatric-emergency

http://emedicine.medscape.com/article/825363-overview#a0199

http://www.vhct.org/case4007/index.htm

http://www.aafp.org/afp/20000401/2159.html

http://www.emedicinehealth.com/head_injury/page6_em.htm

http://www.mayoclinic.com/health/avascular-necrosis/DS00650

http://www.cybermedicine2000.com/pharmacology2000/822_1/page1.htm

http://www.mayoclinic.com/health/osteoporosis/DS00128

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466388/

								
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