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TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
TAEM11: Geriatric Emergency
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TAEM11: Geriatric Emergency

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  1. Background  In 2000, there were 600 million people aged 60 and over; there will be 1.2 billion by 20251  The rate of ED visits increased and was greater for elder patients.  ED visits made by elder patients, the numbers of admissions and ambulance transports have grown at a rate faster than that for ED patients as a whole.2 1. www.who.int/ageing/en/ 2. Acad Emerg Med. 1998;5:1157-1162.
  2. ED utilization by elderly patients
  3. 14.8% 42.8% p<0.0001 χ2 test 45% 15.5% p<0.0001 χ2 test
  4. Emergency ward admissions and lengths of stay by age group and hospital
  5. Proportion of younger adult and elderly patients in different triage categories.
  6. Proportion of patients with investigations performed in the ED.
  7. Ten most common diagnoses in ED patients.
  8. Main complaint at the admission in the emergency room.
  9. Most Frequent Presenting Symptoms at ED
  10. Falls  การหกล้มในผู้สูงอายุไม่ใช่เรื่องปกติที่เกิดขึ้นตามอายุ  หากแพทย์ฉุกเฉินพบว่ามีผู้ป่วยสูงอายุมาตรวจด้วย อาการสาคัญคือหกล้ม แพทย์ฉกเฉินต้องประเมินทั้ง ุ  สาเหตุที่ทาให้ผู้ป่วยหกล้ม  ผลที่เกิดจากการหกล้มครั้งนี้ Tideiksaar R.Falls in the elderly. Bull N Y Acad Med 1988;64:145-63.
  11. Falls  ผลที่ตามมาจากการล้มอาจก่อให้เกิดการบาดเจ็บทาง ร่างกาย(physical injury) หรือ functional decline ได้  โดยการบาดเจ็บที่เจอบ่อยที่สุดจากการหกล้มในผู้สูงอายุคือ กระดูกหัก และกระดูกหักที่เป็นสาเหตุที่ทาให้ผู้ป่วยต้อง นอนรักษาตัวในรพ.บ่อยที่สุดคือ hip fracture  ร้อยละ 84 ของผู้ป่วย hip fracture เป็นผู้ป่วยที่มีอายุ 65 ปี ขึ้นไป  ที่สาคัญร้อยละ 40 ของผู้ป่วยสูงอายุทนอนรพ.ด้วยเรื่อง hip ี่ fracture จะเสียชีวิตภายใน 6 เดือน Tideiksaar R.Falls in the elderly. Bull N Y Acad Med 1988;64:145-63.
  12. Falls  ร้อยละ 60 มีป―ญหาเรื่องการเคลื่อนไหวอย่างมาก  ร้อยละ 25 ที่ช่วยเหลือตัวเองไม่ได้เลย  ส่วนผู้ป่วยที่ล้มแต่ไม่เกิดการบาดเจ็บทางร่างกายก็อาจมีภาวะ กลัวการล้มอีกครั้ง  จากัดการเคลื่อนไหวหรือกิจวัตรประจาวันจนทาให้เกิดป―ญหา ต่างๆตามมาเช่น joint contractures, pressure sores, urinary tract infections, muscle atrophy, psychological depression, และ functional dependency Tideiksaar R.Falls in the elderly. Bull N Y Acad Med 1988;64:145-63.
  13. Falls  การได้ประวัติของการหกล้มในผู้สูงอายุเป็นเรื่องที่ยากจากหลายสาเหตุเช่น1  ผู้ป่วยมีภาวะ cognitive impairment  กลัวการโดนจับผูกมัด  กลัวจะโดนพาไปอยู่บ้านพักคนชรา  amnesia ภายหลังการล้ม  บางการศึกษาพบว่าประวัติของการหกล้มและการเป็นลม(syncope) เชื่อถือ ได้น้อย โดยเฉพาะเมื่อผู้ป่วยไม่ทราบว่าสาเหตุของการหกล้มครั้งนั้นคืออะไร2  หากวินิจฉัยผิดพลาดเรื่องสาเหตุของการหกล้มก็จะมีผลต่อการรักษาเช่นกัน เนื่องจากยังไม่ได้รักษาสาเหตุที่แท้จริงของปัญหาที่เกิดขึ้น 1. Tideiksaar. Bull N Y Acad Med 1988;64:145-63 2. Shaw FE, Kenny RA. Postgrad Med J 1997;73:635-9.
  14. Intrinsic and extrinsic risk factors for falls J Emerg Nurs. 2000 Oct;26(5):448-5
  15. Most Frequent Diagnoses among Patients Presenting with Falls at ED
  16. Predictors of further falls Risk factors Odds ratio (95% CI) p Value ≥1 fall(s) in the previous year 1.5 (1.1 - 1.9) 0.001 The fall occurring indoors 2.4 (1.1 - 5.2) 0.021 Inability to get off the floor 5.5 (2.3 - 13.0) <0.0005 Polypharmacy (≥4 regularly 4.3 (1.9 - 9.6) <0.0005 prescribed drugs)
  17. Medications and falls  Medications commonly associated with increased risk for falls include  diuretics  hypnotics  sedatives  narcotics  antidepressants  psychotropics  some antihypertensive medications.  Medications can contribute to falls by causing drowsiness, poor balance, and postural hypotension. J Emerg Nurs. 2000 Oct;26(5):448-5
  18. Medications and falls  In older adults, the risk of falls is greatest for persons taking medications with a half-life of more than 24 hours J Emerg Nurs. 2000 Oct;26(5):448-5
  19. Key points  Evidence from a randomised controlled trial has shown benefit in assessing older people presenting to A&E with a fall—prevention of falls in the elderly trial (PROFET).  Using derived predictors of risk, it is possible to streamline referrals from the A&E department to a specialist falls service that is consistent with an attainable level of service commitment.
  20. http://emj.bmj.com/cgi/data/20/5/421/DC1/1 . Access : June 23, 2009.
  21. http://emj.bmj.com/cgi/data/20/5/421/DC1/1 . Access : June 23, 2009.
  22. Functional decline  คือการที่ผู้สูงอายุมีความสามารถเสื่อมถอยลงในการทากิจกรรมใน ชีวิตประจาวันเพื่อการอยู่อาศัยซึ่งไม่ได้เป็นไปตามอายุ Sanders AB, In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. New York: McGraw- Hill,2004:1896-900.
  23. Functional decline Activities of Daily Living (ADL) Instrumental Activities of Daily Living scale (Katz, et al) (IADL) scale (Lawton & Brody) Bathing Telephone use Dressing Walking Toileting Shopping Transfer Preparing meals Continence Housework Feeding Handiwork Laundry Take medicines Manage finances
  24. Functional decline  ADL (Activities of Daily Living) scale  ฐานะของแพทย์ฉุกเฉินประโยชน์ที่ได้รับจากการประเมินดังกล่าวคือ  หากความสามารถต่างๆเหล่านี้มีการเสื่อมถอยลงไม่เป็นแบบแผน คือจาก  อาบน้า >แต่งตัว>เข้าห้องน้ารวมการกลั้นอุจจาระป―สสาวะ>การ เคลื่อนย้ายตัวเอง>การรับประทานอาหาร  แสดงให้เห็นว่าผู้ป่วยรายนี้อาจมีภาวะความเจ็บป่วยทางกาย (organic disease) ที่ควรต้องสืบค้นเพิ่มเติมเช่น จากเดิมที่ช่วยเหลือตัวเองได้ดี กลายเป็นไม่สามารถรับประทานอาหารเองได้ ผู้ป่วยรายนี้อาจกาลังมี การติดเชื้อในกระแสโลหิต เป็นต้น Sanders AB, In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. New York: McGraw- Hill,2004:1896-900.
  25. Functional decline  Instrumental Activities of Daily Living (IADL) scale  เป็นเครื่องมืออีกชิ้นที่มีความซับซ้อนมากขึนในการประเมินดังกล่าว ้  หากมีความเปลี่ยนแปลงในสิ่งเหล่านี้อย่างรวดเร็ว ก็เป็นสิ่งบ่งบอกว่าเกิด acute medical condition ขึ้น  แพทย์ฉุกเฉินต้องทาการสืบค้นเพิ่มเติมเพื่อหาสาเหตุ เช่นจากกล้ามเนื้อ หัวใจขาดเลือด(myocardial infarction) ติดเชื้อในกระแสเลือด (sepsis) เลือดออกใต้เยื่อหุ้มสมอง (subdural hematoma) เป็นต้น Sanders AB, In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. New York: McGraw- Hill,2004:1896-900.
  26. Algorithm for the evaluation and management of functional decline in elderly patients Lachs MS, in Sanders AB (ed): Emergency Care of the Elder Person. St. Louis,Beverly Cracom publications, 1996
  27. - Laboratory tests : (CBC, glucose, Na, K, BUN, creatinin), UA and CXR. - After initial medical evaluation in the ED a diagnosis considered as acute because it required treatment without delay, was established in 129 of the 253 patients (51%)
  28. Pitfalls  Reasons for undertriage were 1. absence of vital signs measurement (n = 16) 2. poor recognition of neurological symptoms (n = 9) 3. atypical clinical presentation (n = 8)
  29. Acute chest pain in the elderly patients  Must first consider potential life-threatening causes.  Acute myocardial infarction (AMI)  Aortic dissection  Pulmonary embolism  Pneumothorax  Esophageal rupture  Pericarditis with cardiac tamponade
  30. Acute coronary syndrome  0.4% - 10% of patients who have AMI are incorrectly discharged from the emergency department  Clinician fail to consider the possibility of ACS and, therefore, fail to initiate the appropriate diagnostic workup.1  Specific subgroups that are at greater risk for misdiagnosis.2  Very young  Very old  Women  Diabetics 1. Emerg Med Clin North Am 2005;23:937–57. 2. ED Legal Letter 2003;14(10):109–20.
  31. Acute coronary syndrome  Women  Older than men who have ACS.  There are more comorbid diseases, such as DM or HT, and a family history of premature coronary heart disease.  More likely to present with neck and shoulder pain, nausea, fatigue, and dyspnea. Douglas PS, Ginsburg GS. N Engl J Med 1996;334(20):1311–5.
  32. Acute coronary syndrome  Diabetic patients  Silent ACS  Late presentations are common  More likely : exertional dyspnea, severe fatigue, or lightheadedness Cooper S, Caldwell JH. Clin Diabetes 1999;17:58–72.
  33. Acute coronary syndrome  Elderly patients  Chest pain accompanies AMI much less frequently.  In patients aged 85 years or older, dyspnea, not chest pain, is the single most common presenting symptom of angina1.  More frequently : fatigue, lightheadedness, worsening congestive heart failure, altered mental status, and syncope2 1. Konotos MC. Cardiol Rev 2001;9(5):266–75. 2. Haro LH, et al. Cardiol Clin 2006;24(1):1–17.
  34. Acute coronary syndrome  Diagnostic evaluation  ECG, CXR.  Serum cardiac biomarkers : CK-MB, Troponin T or I  Tend to rise 3 to 4 hours after the onset of an AMI.  Serial sampling over a 12- to 24-hour period will detect the majority of AMIs.  Further evaluation with provocative stress testing must be performed when UA is a possibility.
  35. Aortic dissection (AD)  Unrecognized AD carries a 1% to 2% mortality per hour for the first 48 hours.  The mortality reaches 90% at 1 year.  Physicians correctly suspect in 15-43% of patients at the time of presentation.  When AD is misdiagnosed as ACS, the consequences of giving thrombolytics can be disastrous.
  36. Demographics and History of Patients with Acute Aortic Dissection
  37. Anterior–posterior chest radiograph demonstrating a widened mediastinum in a 67-year-old woman with chest pain and acute aortic dissection.
  38. Aortic dissection (AD)  Diagnostic evaluation  CXR  CT : MDCT-sensitivity 99%  MRI  Echocardiography : transthoracic or transesophageal  Aortography  Lab : D-dimer – sensitivity 100% but poor specificity  Lab : smooth muscle myosin heavy chains, and soluble elastin fragments – highly sensitive and specific for AD (not available)
  39. Aortic dissection (AD)  Patients must be asked to describe  the quality of the pain  intensity at the onset  the pain radiates  A retrospective review of confirmed thoracic AD patients  only 42% of conscious patients were asked these three simple questions. Rosman HS, et al. Chest 1998;114:793–5.
  40. Helical CT of the pulmonary arteries with intraluminal filling defects in the lobar artery of the left lower lobe (solid arrow) and the main artery of the right lung (open arrow) in a patient with a chest deformity.
  41. Am J Med. 2007; 120(10): 871–879
  42. Pulmonary embolism  Signs, Symptoms and Combinations According to Age  Most symptoms and all signs occurred with similar frequencies in patients ≥ 70 years old and younger patients.  In patients with pulmonary embolism, dyspnea or tachypnea occurred less frequently in elderly patients than in younger patients. Am J Med. 2007; 120(10): 871–879
  43. Symptoms in Patients with PE and No Pre-Existing Cardiac or Pulmonary Disease According to Age Am J Med. 2007; 120(10): 871–879
  44. Am J Med. 2007; 120(10): 871–879
  45. Am J Med. 2007; 120(10): 871–879
  46. Rate of Onset of Dyspnea Am J Med. 2007; 120(10): 871–879
  47. Clinical probability of pulmonary embolism clinical probability category Total points High >8 Intermediate 5-8 Low 0-4 Wells PS, et al. Thromb Haemost 2000;83:416-20. Wicki J, et al. Arch Intern Med. 2001;161:92-97
  48. The prevalence of pulmonary embolism* Low Moderate High Pretest Pretest Pretest Score Probability Probability Probability Wells 1-3% 16-28% 38-78% Geneva 7% 34-35% 77-85% - The study that compared both prediction rules reported similar results. - The area under the ROC curve for the Wells pulmonary embolism prediction rule ranged 0.52- 0.88 and the area for the Geneva pulmonary embolism prediction rule ranged 0.69-0.84.** * **
  49. Acute Abdominal Pain in the elderly patients  Acute abdominal pain in the elderly was the problem required most time-consumed diagnosis.1  Previous studies have demonstrated a diagnostic accuracy of only 40% to 65% in geriatric patients with abdominal pain.2-4 1. J Am Geriatr Soc.1987; 35: 398–404. 2. Arch Surg. 1978; 113:1149-52. 3. Br Med J. 1972; 3:393-8. 4. Emerg Med Clin North Am. 1996; 14:615-27.
  50. Demographic Characteristics of the Study Population Demographic N = 378 Gender (male : female) 175 : 203 Age (median (range)) 71(60-94) Underlying diseases N(%) 269 (71.2) - Hypertension 104 (27.5) - Diabetes mellitus 59 (15.6) - Cardiovascular disease 58 (15.3) - Malignancy 52 (13.8) - Pulmonary disease 38 (10.1) - Miscellaneous 170 (45.0)
  51. Miscellaneous group* 16.0 9.2 Myalgia 0.8 1.1 Urinary retention 1.1 1.1 Abdominal aortic aneurysm 0.8 1.1 Peritonitis 0.3 1.6 Acute appendicitis 2.4 2.4 Intestinal obstruction 4.5 4.0 5.3 Constipation 5.6 8.2 Overall Cholecystitis, cholelithiasis and biliary tract disease Urinary tract infection 7.1 7.9 N = 378 7.9 Calculus of urinary system 6.9 9.0 (100%) Acute gastritis, gastroenteritis or diarrhea 10.6 10.8 35.2 Non specific 39.2 0.0 10.0 20.0 30.0 40.0 Overall : Final diagnoses(%) Overall : Initial diagnoses(%)
  52. Non specific abdominal pain - What should we aware? 1. Cholecystitis, cholelithiasis or biliary tract disease = 4 2. Intestinal obstruction = 3 Overall 3. Acute pancreatitis = 1 378 Non Operative specific Revisited Procedures 148 & 8 Admitted 23 Non specific 9 Medical conditions 6
  53. Miscellaneous group* 8 6 Scrub typhus 0 2 Herpes zoster 0 2 Diverticulitis 2 1 Gastrointestinal ulcer 2 1 Hepatic conditions 0 3 Acute gastritis, gastroenteritis and… 3 2 Urinary tract infection 2 3 Calculus of urinary system 1 3 Admitted Patients 5 Acute pancreatitis 3 3 N = 100 Abdominal aortic aneurysm 4 Peritonitis 1 5 (100%) 9 Acute appendicitis 9 Intestinal obstruction 17 15 10 Non specific 23 Cholecystitis, cholelithiasis or biliary… 30 25 0 10 20 30 Admitted patients : Final Dx Admitted patients : Initial Dx
  54. 1. Cholecystitis, cholelithiasis or 14 biliary tract disease Admitted 2. Acute appendicitis 8 Patients 3. Intestinal obstruction 7 100 4. Gastrointestinal ulcer 2 5. Hepatic conditions 2 Operative Procedures 6. acute pancreatitis 1 38 7. abdominal aortic aneurysm 1 8. Calculus of urinary track 1 9. Hernia 1 10. Tubo-ovarian abscess 1
  55. Overall (N= 378)  This study  Lewis LM, et al*  Concordant diagnoses = 83%  Concordant diagnoses = 82%  Top 5 of Final diagnoses  Top 5 of Final diagnoses 1. Non specific 1. Non specific 2. Acute gastritis, gastroenteritis, 2. Urinary tract infection and diarrhea. 3. Intestinal obstruction 3. Calculus of urinary system 4. Acute gastroenteritis 4. Urinary tract infection 5. Gall bladder disease 5. Cholecystitis, cholelithiasis and biliary tract disease *Lewis LM, et al. J Gerontol A Biol Sci Med Sci 2005; 60: 1071-76.
  56. Hospitalized patients (N=100) This study Kizer1 Irvin2 Concordantstudy Kizer1 This diagnoses Concordant diagnoses Irvin2 66% 79% Biliary tract disease Non specific Intestinal obstruction 30% 26% 28% Intestinal obstruction Intestinal obstruction Non specific 17% 11% 22.5% Non specific Gastrointesitinal ulcer Cholelithiasis 10% 11% 8.9% 1. Kizer KW. Am J Emerg Med 1998; 16: 357-362. 2. Irvin TT. Br J Surg 1989; 76: 1121-1125.
  57. Concordant Discordant p-value diagnoses diagnoses Hospitalization 5.5 8.0 0.016 time (day) * (1.0-42.0) (2.0-136.0) Hospital costs 345.9 647.8 0.022 (USD) * (51.4-6667.4) (60.4-11681.1) *reported in median (range) calculated in hospitalized patients
  58. Summary  The patient's presentation is frequently complex.  Common diseases may present atypically in this age group.  A knowledge of baseline functional status is essential for evaluating new complaints.  The confounding effects of comorbid diseases must be considered.  Polypharmacy is common and may be a factor in presentation, diagnosis, and management.  The emergency department encounter is an opportunity to assess important conditions in a patient's personal life.(ie. caregiver needed) Lachs MS, in Sanders AB (ed): Emergency Care of the Elder Person. St. Louis,Beverly Cracom publications, 1996

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