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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, June 5, 2017

Non-Specific Weakness in Elderly

In a busy Emergency Department, it can be very challenging to obtain a detailed history and perform a complete physical exam. Our evaluation done in ED is quite often very focused. Patients are classified as "sick" v/s "not sick" or "admit" v/s "home". Seasoned physicians usually take only a few minutes to make this judgment but what happens when history is nebulous and exam is compromised due to frailty, low sensorium, cognitive issues etc. What happens when you are dealing with delirious octogenarian? Such scenarios are very demanding and consume significant amount of our time. And if this was not enough, imagine how would you proceed your evaluation when the presenting complaint is this:

Doctors, I am just not feeling right or  I am feeling weak

Evaluating weakness can be a daunting experience with a limited history and compromised exam. It is hard to define and there are a myriad of causes which can lead to this chief complaint. Current Literature reports that 1/5 elderly present to ED with a non-specific complain of weakness. More than half of these patients develop a significant illness within 30 days. 

Just like delirium and dizziness, "weakness" can also be multifactorial due to a combination of factors such as dehydration, medication side effects, depression, infections etc. Getting collateral history (Social Circumstances, Baseline Mental status, Mobility) from family, carers, paramedics, old records forms a crucial component of assessment to get a holistic picture. Onset of time (Acute v/s Chronic) and focality (Focal v/s true generalised weakness) are two important clues guiding further work up.




Neuro examination forms the cornerstone of physical exam. Literature suggests that the most common etiology for weakness in elderly are infections, metabolic issues and malignancies. Therefore, initial testing should be geared towards these issues. 



Investigations
  • FBC, ESR
  • CRP
  • Blood/Urine Cultures
  • Renal Function
  • Liver Function
  • TSH
  • CT/MRI Head (based of history)
  • ECG
  • CXR
  • Blood Gas - Includes Blood Glucose and Lactate (based on history)
  • Urine Analysis
  • POCUS (Assess Cardiac Contractility, IVC, Consolidation)

Common Causes of Weakness in Elderly (not a complete list)
  • Infections (Respiratory, Genitourinary, Skin, Abdomen)
  • Metabolic (AKI, Dehydration, Na/K/Mg/Phosphorus)
  • Malignancy
  • Endocrine (Thyroid, Adrenal, DM)
  • Neuro (Stroke, TIA, Myasthenia Gravis, Neuropathy, MS)
  • CVS (ACS, Heart Failure, Anemia)
  • Medications (Steroids, Diuretics, Hypnotics)
  • Autoimmune (Myopathies, PMR, Vasculitis)
  • Deconditioning


Do not jump to diagnosis of UTI, exclude other possibilities first and treat Urine Infections ONLY if patient is symptomatic. 


Take Home
The evauation of each patient should be individualised. For instance, Head Imaging may not be required for each one of them. A detailed history is imperative to ease further course of care. It is reasonable to start with quick bedside tests such as blood sugar, ECG, CXR, POCUS and then proceed with further work-up. Physical exam can classify weakness in terms of focality and onset to dictate what imaging/labs are preferable. 


Further Reading
  • Anderson RS, Hallen SA. Generalized weakness in the geriatric emergency department patient: an approach to initial management. Clinics in geriatric medicine. 2013 Feb 28;29(1):91-100.
  • Chew WM, Birnbaumer DM. Evaluation of the elderly patient with weakness: an evidence based approach. Emergency medicine clinics of North America. 1999 Feb 1;17(1):265-78.
  • Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical infectious diseases. 2010 Mar 1;50(5):625-63.
  • Nickel CH, Nemec M, Bingisser R. Weakness as presenting symptom in the emergency department. Swiss medical weekly. 2009 May;139(17-18):271-2.
  • Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, Laifer G, Bingisser R. Patients Presenting to the Emergency Department With Non‐specific Complaints: The Basel Non‐specific Complaints (BANC) Study. Academic emergency medicine. 2010 Mar 1;17(3):284-92.

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic


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