CCP 330 Geriatrics π΄π» Flashcards
definition of a geriatric patient
- no consensus on the definition of a geriatric patient
- most authors define geriatric patients as those β₯ 65yo (no evidence to support this)
- evidence supports that a patientβs preexisting conditions and comorbidities may be a better way of defining βgeriatric patient statusβ in the older adult
mortality within 1yr of a geriatric hip fracture
- Mortality reaches 16% within 1 y after a hip fracture
these conditions pre-dispose geriatrics to cervical spine injury
- osteoarthritis (OA)
2. cervical stenosis
what percent of geriatric patients develop life threatening ICH following minor head trauma
Fifteen percent (15%)
what percent of the north american geriatric population is on anticoagulants
Ten percent (10%)
preferred option for treating acute agitation or delirium in geriatric patients
- AVOID BENZOS (2019 American Geriatric Society Beers Criteria)
- low-dose haloperidol 0.5-1 mg IV/IM/PO preferred
neurologic changes in geriatric patients
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- Underlying dementia, visual, auditory, and cognitive decline, slower reaction times, and concomitant medication use may influence mental status evaluation (eg, GCS)
- After the age of 40 y, brain volume β 5% per decade of life
- An occult brain bleed, commonly d/t shearing of the bridging veins resulting in a SDH, is possible given the β potential space d/t age-related brain atrophy that can be occupied by an intracranial bleed before clinical symptoms become apparent
- β cerebral autoregulation with aging renders the geriatric trauma patient with head injury more sensitive to hypotension
Cardiovascular changes in geriatric patients
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- after 40yo vasculature + myocardial connective tissue hardens d/t elastin and collagen changes
- β sympathetic activity and norepinephrine baseline levels lead to β SVR.
- These physiologic changes in aging lead to β vascular compliance and an β in systolic HTN.
- Ξ²-adrenergic responses to endogenous and exogenous stressors in the geriatric patient are also altered, resulting in an inappropriate ionotropic and chronotropic compensation for traumatic insults.
- Vital signs in the geriatric trauma patient may be unreliable and may appear normal, given that a baseline of HTN is common in this population.
- The blunted response may also be altered by medication use (eg, beta blockers).
pulmonary changes in geriatric patients
- β in elastic fibers, β intercostal muscle mass, β rib articulation, changes in thoracic vertebral body height, osteoporosis, β in alveolar surface area, β gas exchange, β mucociliary clearance and cough reflexes, and underlying pulmonary disease
- These changes lead to β pulmonary reserve, with β FEV, β FRC, β VC.
- Additionally, the elderly may mount only half of the compensations for hypoxia or hypercarbia compared to their younger counterparts, potentially leading to rapid decompensation
- The frail chest wall in the elderly patient β their susceptibility to trauma, as low-impact forces may result in sternal + rib fractures w/ pulmonary contusions, leading to β morbidity and mortality
Renal/Hepatic changes in geriatric patients
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- renal function decline is common in the geriatric population, GFR β approx ~7.5 mL/min per decade in geriatrics
- renal changes contribute to disturbances in electrolyte hemostasis and worsened autoregulation of volume status
- hepatic mass β up to 40% w/ advancing age, correlating with a β in function
- pharmacokinetics in the geriatric patient are affected by β renal + hepatic function, resulting in altered absorption, elimination, distribution, and metabolism of drugs
Musculoskeletal changes in geriatric patients
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- β in bony and cartilaginous mass and volume
- OA is a risk factor for fractures
- geriatric trauma patient is prone to β rates of fractures, even from low MOI
Explain considerations in geriatric pre-hospital trauma triage
ATLS recommends that patients older than 55 years old be transferred to a trauma centre regardless of injury severity score
- geriatric patients have blunted response to physiologic stressors β lack of recognition of the injury severity, especially in βlow mechanismβ MOI such as ground-level fall.
- Data shows that nearly half of geriatric trauma ptβs are under-triaged prehospitally
- up to 42% of trauma patients >65 with normal vital signs have occult hypotension
- Elderly patients w/ significant injuries have better outcomes when triaged to a level-1 or 2 trauma center
Ethical Considerations of the Critically Ill Geriatric Patient
Determine advanced directives and the desired level of intervention as early as possible
DNR DNI Patientβs wishes Selective treatment Family involvement substitute decision maker power of attorney
describe airway management changes in the geriatric patient
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- β Neck mobility d/t cervical spine degenerative changes
- poor pulmonary reserves + more susceptible to hypoxic insults
- difficult BMV d/t atrophy of the perioral musculature and edentulous
- lips are friable and prone to laceration, teeth susceptible to breaking
- Mouth opening may be affected by microstomia and TMJ arthritis
- β aspiration risk d/t swallowing muscle atrophy, β larynx sensitivity, β esophageal motility, and comorbidities (eg, Parkinsonβs disease)
- Vocal cord visualization may be obscured by bleeding (friable oral tissue trauma), masses, epiglottis floppiness, or pre-existing infections (Candida)
- Geriatrics are more sensitive to medications and doses used in RSI. more likely to develop peri-intubation hypotension and apnea and have an β risk of cardiac arrest. Dose adjustments for induction medications are recommending up to a 50% reduction in dose
Define and describe Elder Abuse and Neglect
- Abuse and neglect are defined as harm or a risk of harm due to action or negligence toward an older person who is vulnerable and targeted based on disability or age
- Abuse can be physical, sexual, verbal, or psychological, including neglect, isolation, and/or financial exploitation, with victims often experiencing multiple forms of abuse and an overall prevalence of up to 10%
- Elder abuse is associated with increased morbidity and mortality, including depression and dementia. Skilled nursing facility residents are also at risk for elder abuse
Signs and symptoms of elder abuse
- Trauma findings inconsistent with the MOI
- Various Bruising at different stages of healing
- Poor hygiene (soiled diaper and clothing, poor oral hygiene, elongated nails)
- Dehydration, malnourished appearance, weight loss
- Hypothermic
- Under-medicated
- Bed sores
- Withdrawn or changes in mental status from baseline
Define Dementia
- umbrella term for chronic disorders that result in impairment in two or more cognitive domains, including: memory loss, language, motor activity, object recognition, and disturbance of executive function
Define Delirium
- an acute confusional state with alterations in cognition
and attention
The most common chief complaints in older ED patients
chest pain, shortness of breath, and abdominal pain
Geriatric patients are susceptible to βhomeostenosisβ.
Define this term
a diminished ability to maintain homeostasis under stress
leading cause of death in men and women older than 65 years
Cardiovascular heart disease
prevalence of Acute heart failure in geriatric STEMI patients
πππMEGA PEARLπππ
Acute heart failure presents in ~50% of STEMI patients 85 years or older compared to only 1.7% of STEMI patients younger than 65 years
pathogenesis of acute heart failure in geriatric STEMI
- Myocardial ischemia impairs LV relaxation, which leads to an β in LVEDP
- This β LVEDP, superimposed on age-related β in LV
compliance, frequently results in β PCWP and heart failure.
Age-Related Changes to the Geriatric Cardiovascular System
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- β arterial compliance β Increased afterload, LVH, HTN
- Myocardial cell hypertrophy, interstitial fibrosis, drop out of cardiac myocytes β Decreased LV compliance,
β contribution of atrial contraction to LVEDP - Apoptosis of SA node pacemaker cells, fibrosis and
loss of His bundle cells β Slower intrinsic heart rate, varying degrees of heart block - β responsiveness to Ξ²-adrenergic stimulation and reactivity to baroreceptors and chemoreceptors β Increased circulating catecholamines
- Fibrosis and calcification of heart valves β Aortic valve sclerosis and stenosis
List 6 factors that lead to altered pharmacokinetics in the elderly.
- Altered GI motility and perfusion (blood flow)
- Decreased hepatic function
- Decreased renal function
- Decreased lean body mass
- Increased adipose tissue
- Changes in protein binding
list ACTIVITIES OF DAILY LIVING
- Bathing
- Dressing
- Toileting
- Transferring
- Continence
- Feeding
List reason why the elderly are predisposed to adverse drug reactions
- Polypharmacy / drug interactions
- Comorbidites
- All of the pharmacokinetic reasons:
Altered GI motility and perfusion (blood flow) Decreased hepatic function Decreased renal function Decreased lean body mass Increased adipose tissue Changes in protein binding
age-related changes to the CNS system (old people)
- Decreased BBB function = increased risk meningitis
2. Decreased temp responses = impaired thermoregulation
age-related changes to the skin
- Atrophy of the skin = increased infections
2. Sweat gland function decreased = risk of hyperthermia
aging related changes to the MSK system (old people)
- Osteoporosis = fracture risk
2. Lean body mass decreased = pharmacokinetic changes
age-related changes to the immune system (old people)
- Decreased antibodies = increased infections
2. Decreased cell-mediated-immunity = increased infections
age-related changes to the CVS system (old people)
- Decreased inotropy = impaired Cardiac Output
2. Decreased chronotropy = impaired Cardiac Output
age-related changes to the Resp system
- Decreased VC
2. Decreased compliance
age-related changes to the hepatic system (old people)
- Decreased hepatic blood flow = altered pharmacokinetics
2. Decreased p450 enzymes = altered pharmacokinetics
age-related changes to the renal system (old people)
- Decreased renal cell mass = altered pharmacokinetics
2. Decreased total body water = altered pharmacokinetics
age-related changes to the GI system (old people)
- Decreased gastric mucosa = ulcer risk
2. Decreased bicarb = ulcer risk
8 predisposing risk factors for sepsis in the elderly
- Delirium and Dementia
- Decreased gag and cough reflex (aspiration risk)
- Endocrine deficiency (adrenal, gonads, thyroid)
- Poor nutrition
- Relative immunodeficiency
- Skin breakdown
- Multiple co-morbidities
- Decreased cardiopulmonary reserve.
What are the most common medications implicated in adverse events for the elderly?
- Most common = Cardiovascular meds
- Diuretics
- NSAIDS
- Opioids
- Oral anticoagulants
- Hypoglycemics
List the most common abdominal pathologies in the elderly (60% of all cases will be surgical)
Cholecystitis
Appendicitis
Bowel obstruction
Hernia
explain how drug ABSORPTION is altered in the elderly (pharmacokinetics)
- Increased gastric pH, changing net absorption
- Delayed gastric emptying, changing net absorption
- Diminished splanchnic blood flow, delaying peak effects of ingested drugs
- Diminished bowel motility, altering peak effects of ingested drugs
explain how drug DISTRIBUTION is altered in the elderly (pharmacokinetics)
- Increased adipose tissue, resulting in increased accumulation and duration of effect for lipophilic medications
- Diminished total body water, resulting in a lower required loading doses for hydrophilic medications
explain how drug METABOLISM is altered in the elderly (pharmacokinetics)
- Diminished phase one metabolism, resulting in accumulation of phase-1-dependent medications
- Diminished hepatic blood flow, resulting in altered metabolism
explain how drug ELIMINATION is altered in the elderly (pharmacokinetics)
- decreased GFR β decreased renal drug clearance
2. in the setting of a shitty GFR/creatinine maybe decrease your drug dose
List 9 harmful drug interactions in the elderly
ACE Inhibitors/ARBβs β Hyperkalemia Benzos and Sedative-Hypnotics β Fractures, Falls CCBβs β Hypotension Digoxin β Toxicity Lithium β Toxicity Phenytoin β Toxicity Sulfonylureas β Hypoglycemia Theophylline β Toxicity Warfarin β Bleeding
key risk factors for falls in the elderly
- Cognitive impairment
- Vision and hearing loss
- Impaired thirst mechanism β dehydration, orthostatic hypotension
- Reduced respiratory reserve
- Cardiac disease β Arrythmias, poor CO, etc.
- Osteophyte-arthritis anywhere β joint pain, immobility, decreased ROM
- Loss of fine motor skills and sensation
- Pharmacy β medications affecting cognition, balance, cardiac function
prevalence of polypharmacy in geriatrics
30% have >5 meds including ASA and BB and hypnotics
approach to RSI in geriatrics
- Reduced dosages of RSI meds (3/4 to 1/2 dose) [paralytic should be same?]
- Careful use (if any at all) of succinylcholine given risk for hyperkalemia
- Rocuronium 1mg/kg is preferred
discuss C-spine fractures in the elderly
At high risk for C-Spine fractures
- No rules exist to exclude the elderly from imaging, so imaging should be performed
- Canadian C-Spine β excludes >65
- Nexus included all ages, but most elderly people have C-Spine tenderness
- At increased risk for T, L, S spine fractures which are best imaged on CT
- AT higher risk for SCIWORA due to spinal stenosis and kyphosis
- high risk for central and anterior cord syndromes
discuss hypothermia in the elderly
At risk for hypothermia due to:
- Skin thinning
- Decreased muscle, increased fat
- Impaired thermoregulatory mechanisms
- Prolonged exposure
discuss TBI in the elderly
π£ π£ π£ KNOWLEDGE BOMB π£ π£ π£
TBI IS COMMON IN GERIATRIC TRAUMA
Geriatric specific pathogenesis/risk factors for TBI:
- Frequent anticoagulant use
- Brain size β by 10% β Less tortuous bridging veins and β intracranial free space β mobile brain β ICH
- Pre-existing cognitive impairment
Pearls:
- Get early invasive hemodynamic monitoring
- Reverse coagulopathy
- may be asymptomatic (more space for blood to go d/t age-related brain atrophy)
- Grave prognosis if: GCS < 8 with anticoagulation or initial GCS 3
discuss Thoracic trauma in the elderly
- β risk for rib, sternal #, pulmonary contusions, pneumothorax
- β risk for pneumonia d/t pain and splinting β atelectasis
discuss pelvic fracture in the geriatric trauma
πππMEGA PEARLπππ
- β risk for pelvic fracture. usually lateral compression
- at higher risk for hemorrhage
- 80% mortality rate if open book fracture
- +++ Need resuscitation, binding, blood, angiography
List some physiological differences between geriatric and adult populations
- CNS: β brain mass, β CSF content, Poor vision
- CVS: Stiff vasculature with β BP, Stiff ventricles w/ β EF, Presence of arrhythmia (Afib)
- RSP: β vital capacity, Presence of respiratory disease (COPD)
- GI: β saliva production, β esophageal activity, β gastric secretions and motility
- GU: β renal function, Predisposition to electrolyte issues (hyper-K, hypo-mag)
- MSK/DERM: Joint/mobility issues, Neuropathy, Thin fragile skin, osteoporosis/β bone density
annual % chance of standing fall in geriatric patients >65yo
27% chance of fall from standing height annually
discuss age-related Anatomic/physiologic/pharmacologic changes that affect the pathophysiology of head trauma in the elderly
- compared to young people, subdural hematomas (along with intraparenchymal bleeds) are the most common types of geriatric intracranial bleeds
- This is d/t β adherence of the dura to the skull in elderly patients β the underlying bridging veins in the elderly being more likely to be damaged in head trauma
- As the bridging veins bleed, intracranial subdural hematomas form (as opposed to epidural hematomas, which are more common in young patients)
- advancing age β to progressive brain atrophy β more room for β bleeding for the subdural hematoma within the cranial cavity
- This situation β delayed onset of symptoms β elderly patients to seek care later β Delay in presentation and delays in initiation of treatment
- higher incidence of chronic dementia in the elderly also β delays in presentation and treatment
- ~10% of geriatric population is on anticoagulation β increased risk of intracranial bleeding
