ED Dementia Screening

Dementia

Diagnosing dementia constitutes "memory loss" in addition to one of the following:

• Apraxia (difficulty executing motor tasks)
• Aphasia (language impairment)
• Agnosia (difficulty recognising familiar objects)
• Loss of executive function (planning, organising)

More than 50% of the patients presenting to Emergency Department have dementia and in about 3/4 the of the patients, the diagnosis is not yet established. Patients with a new diagnosis of dementia may have several implications on continuation of care as dementia can be associated with poor drug compliance, self-neglect, depression, suicidal risk. It is paramount to discuss these concerns with social services prior to discharging these patients. 

Mini-Cog Assessment 

1. Ask the patient to repeat and then remember 3 unrelated words (ex. apple table tree)
2. Give the patient a piece of paper with a circle on it
3. Instruct the patient to place numbers on it to represent the face of a clock. After the patient puts the numbers on the clock face, ask him to draw the hands of the clock to read any specific time
4. Ask the patient to repeat the 3 previously presented words

Scoring Mini-Cog Assessment (Minimum score 0, Maximum 3)

Give 1 point for each recalled word 

• 0 - positive screen for dementia
• 1 or 2 with an abnormal clock -  positive screen for dementia
• 1 or 2 with a normal clock - negative screen for dementia
• 3 - negative screen for dementia

Patients who are called "poor historians" often have underlying dementia. If you suspect dementia in ED, then arrange follow up care with Neurology for thorough assessment. 

Discharge checklist for Dementia-

• Ask them their home address and how will they get there?
• Sucidal Thoughts/Depression screen? 
• Carers/Next of kin informed?

Further Reading:

Borson, S., Scanlan, J. M., Chen, P. and Ganguli, M. (2003), The Mini-Cog as a Screen for Dementia: Validation in a Population-Based Sample. Journal of the American Geriatrics Society, 51: 1451–1454. doi:10.1046/j.1532-5415.2003.51465.

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Acute Abdomen in Elderly

Working up an elderly population presenting with abdominal pain is always a challenging task. Almost always there are chances of potential mishaps due to delayed or missed diagnosis. Data suggests that abdominal pain is the most common ED presentation and the fourth most common complaint among elderly and nearly half of elderly patients with abdominal pain will require admission, and 1/3 will require  a surgical intervention. This makes it an important topic for us to be familiar with. Usual issues related to geriatric population (pharmacologic, social, cognitive) make evaluation extremely difficult. Click here to read more about how is elderly population different.

 

Key Issues:

• Present later in their disease course
• Present with vague symptoms (Only 1/6 present with textbook appendicitis presentation)
• Difficult Communication (hearing, visual, cognitive)
• Underreport symptoms (Poor pain perception, fear of hospitals and medical interventions)
• Physical exam has limited utility - Atrophy of abdominal wall musculature diminishes rebound and guarding
• Medications blunt or alter their response to disease
• Less likely to develop fever or leukocytosis

In A&E, we should have a low threshold to image elderly due to high likelihood of surgical illness and unreliable physical examination. Ideally, CT is the imaging of choice. Plain films are of limited utility. Due to unreliable history, misleading examination findings and unpredictable nature and course of the illness, admission for observation should be considered if no confusion is reached after ED work up. . 

Common Geriatric Abdomen Pathologies

Mesenteric Ischemia

• Risk factors include Atrial Fibrillation, Heart Failure. 
• Pain out of proportion to examination. Perform a quick assessment and come up with a plan. Involve your Surgical colleagues and Radiologists ASAP.
• May present with normal vital signs and laboratory values. Do not overly on White cell count and lactate. Lactate and EBC both are non-specific. 
• Imaging of choice is CT with IV contrast.
•  Rx them with Pain Relief, Fluids and electrolytes, NG Tube for gut decompression, Foleys Catheterisation , Broad Spectrum Antibiotics and immediate surgical consultation. 

Aortic Diseases (AAA, Dissection)

• Be cautious whenever you attribute flank/abdo pain to Renal Stones in elderly.
• AAA May present with weakness, dizziness, uneasiness or syncope
• Classic presentation is pain abdomen, pulsalitle mass and hypotension
• Use bedside USG to measure aorta and also look for a dissecting flap
• Maintain BP enough to perfuse brain and do not give too much fluids
• Arrange blood for transfusion and involve vascular surgeons ASAP

Gall Bladder Disease and Pacreatitis

• Perforation, gangrene, emphysematous cholecystitis, ascending cholangitis, gallstone ileus, choledocholiathisis, and gallstone-induced pancreatitis are all more prevalent 
• More than 50% with acute cholecystitis will lack nausea, vomiting, or fever. Leukocytosis may be absent in 30% to 40% of those with acute cholecystitis.31 Evaluation by ultrasound may be less helpful given the increased prevalence of acalculous cholecystitis as well as cholodocolithiasis and delay in surgery may result in an increased mortality.
• More than 50% cases pancreatitis and elderly are due to Gall Stones. 

Small Bowel Obstruction

• Classical symptoms are not seen early in the course of disease
• May present with diarrhoea due to hyperperistalsis distal to the obstruction point
• Gallstone disease may contribute to 25% of bowel obstructions in elderly

Diverticulitis

• Diverticular bleeding is one of the most common causes of lower GI bleeds
• Acute diverticulitis occurs when the diverticula become obstructed by fecal matter, resulting in lymphatic obstruction, inflammation, and perforation. 
• Usually presents with LLQ pain, with or without bloody stools, nausea, and fever but 1/3rd of the geriatric presentations of acute diverticulitis do not have abdominal tenderness on examination. Once the acute phase resolves, endoscopy should be performed to rule out carcinoma after an acute episode of diverticulitis. 
• Most can be managed medically, with antibiotics, intravenous fluids, and bowel rest. If there are larger perforations or abscess formation, surgery or percutaneous drainage may be indicated.

Large Bowel Obstruction

• Common causes are diverticulosis and malignancy. 
• Classically present with abdominal pain, vomiting, and constipation/obstipation, 
• Often diagnosed late in their course 
• Sigmoid and cecal volvulus account for a smaller subset of large-bowel obstructions, but more often requires emergent surgical intervention. 
• Sigmoid volvulus, causing close to 80% of volvuli, causes a more gradual onset of pain, whereas cecal volvulus presents more acutely.
• Sigmoid volvulus can often be decompressed with a rectal tube, sigmoidoscope, or barium enema, whereas cecal volvulus requires surgical repair. Volvulus of either site is at risk for perforation and should be decompressed urgently. 
• Functional impairment and decreased motility of the GI tract can lead to acute colonic pseudo-obstruction, or Ogilvie syndrome i.e. functional obstruction of the GI tract. This is more commonly seen in elderly and debilitated patients. Treatment is conservative medical management. Neostigmine can be very effective but requires careful monitoring due to potential of bradycardia. 

Constipation

• May be associated with fecal impaction and fecal incontinence. Fecal impaction can cause mucosal ulceration, bleeding, and anemia. 
• Often caused by Medications, comorbidities, inactivity, and decreased gastric-emptying time and GI malignancies 
• Perform a rectal examination should be performed on all patients with constipation to rule out mechanical obstruction of stool.
• Treat chronic constipation with dietary and activity changes, followed by bulk laxatives and warm water enema

Malignancy

• Ask for h/o unintentional weight loss, night sweats, and fatigue, hematuria, hematochezia. 
• May also present with peritonitis, ascites, perforation, obstruction, or abdominal mass

Appendicitis

• Difficult to diagnose in elderly patient and missed in more than 50% cases. The classic presentation is rarely seen. Literature now supports the use of non-contrast CT imaging for suspected appendicitis.
• Elderly have a higher risk for mortality and morbidity following appendectomy. 

Extra-Abdominal Causes

• Congestive heart failure
• Acute Coronary Syndromes
• Pneumonia, Pulmonary embolism
• Prostatitis 
• Urinary retention/infection (antihistamines, anticholinergics, technical obstruction, Pyelonephritis)
• Herpes zoster involving thoracic dermatomes 
• Rectus sheath hepatomas if they are on anticoagulants

Take Home

• Think of Vascular causes of pain abdomen in elderly (AAA, Dissection, Bowel Ischemia)
• GB disease (Cholecystitis, Cholangitis, Pancreatitis) and Bowel Obstruction are common in geriatric population
• Do a rectal exam to assess prostate, look for blood/malena
• Do a broad work up including lab tests and have a low threshold for imaging and admission for observation

Further Raeding: 
Leuthauser A, McVane B. Abdominal pain in the geriatric patient. Emergency Medicine Clinics. 2016 May 1;34(2):363-75.


Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Getting better at diagnosing Delirium

Delirium can be defined as an acute confusional state caused due to medical or pharmacological triggers. Up to 10% of all older patients in EDs have delirium and only about one-third of them are recognized. As frontline healthcare providers, it is essential to recognize delirium as the symptom of a life-threatening underlying medical or surgical condition. The consequences of a missed delirium can be disastrous as they can bounce back with florid sepsis, trauma, seizures. In elderly, delirium may be the only sign of an underlying infection (Pneumonia, Sepsis, ACS, Abdominal infection, Intra-cerebral event). Delirium is often multifactorial in etiology and each cause should be investigated. 

DSM IV defines delirium as:

• Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
• Change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia
• Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day
• There is evidence from the history, physical exam, or lab findings that the disturbance is caused by the consequences of a general medical condition

This can be remembered as:

A - Acute and fluctuating (Often reported by a family member or carers)

I - Inattention (Inattention is a hallmark feature of delirium - Can test with months of the years backwards, WORLD or serial 7s)

D - Disorganised thinking (incoherent, rambling, circumstantial, or vague. (irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)

A - Altered Mental Status (hyperactive, drowsy, stuporous, comatose)

  

Causes of Delirium:

• Systemic Diseases (Infections, ACS, Hepatic Enceph, Metabolic - Na/Glucose/Ca disturbances)
• Medications (Anticholinergic, Antiparkinsonian, Antiemetics)
• Withdrawal (Discontinuation or overdose of any medication, alcohol, sedative hypnotics)
• CNS Pathology (CVA, Subdural hematoma, Meningitis, Seizures – non convulsive, Hypertensive encephalopathy)

Infections are the most commonly encountered cause of delirium in elderly and medications are the most common reversible causes of geriatric delirium.

Why is Delirium missed in ED? 

We frequently assume that most older people have baseline cognitive impairment. Collateral History and paying attention to what caregivers say is crucial. Delirium can present in hypoactive, hypoactive or mixed form. Therefore, it does not always present as restlessness or agitation, in fact hypoactive delirium is the commonest. Using formal assessment methods is the best way to avoid such mishaps. 

Managing Delirium

Most delirious patients need admission unless we find a single, reversible cause and patient has good social support and someone to observe him at home. 

Non-Pharmacologic 

• Manage pain and avoid unnecessary restraints including catheters and non-essential monitor leads
• Promote mobility and encourage to eat and drink
• Address bowel and bladder function
• Increase sensory stimulation (hearing aid, eye glasses)
• Enhance orientation and familiar faces (family)
• Minimize medication changes 

Pharmacologic 

Medications should be used if evaluation is prevented or if the patient gets severely agitated. Haloperidol remains the drug of choice (Not Benzodiazepines). Use BZD only in case of drug withdrawals. Use Haloperidol 0.5mg-1.0mg PO/IM/SC/IV every 30min to 1hr and frequently reassess. Haloperidol is a potent anti-psychotic with limited anti-cholinergic effects though it may cause problems in Parkinsonian patients because of increased extra pyramidal symptom.

Preventing Delirium

ED Stay > 8 hrs itself is a risk factor for delirium. High Risk groups include dehydrated patients, demented and restrained patients, those who were left in the corridor overnight, visually and hearing impaired. 

Further Reading

• Altered Mental Status in Older Emergency Department Patients - Wilber, Scott T. Emergency Medicine Clinics , Volume 24 , Issue 2 , 299 - 316 
• The Acutely Confused Elderly Patient

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Falls Assessment - Part 2

Several studies report that falls are the most common reason for geriatric trauma. Injuries in elderly tend to be more severe as compared to young even with similar mechanisms and severity. While evaluation an elderly with a fall, we also need watch for complications of prolonged immobility as well such as rhabdomyolysis, pressure sores, dehydration. 

What makes them fall?

• CNS – slower nerve conduction, slower reflex response, poor co-ordination, decreased proprioception and vibration sense
• MSK – arthritis, decreased muscle mass 
• CVS - Arrythmias, Orthostatic drop
• Visual impairment
• Medications:  antihypertensives, sedatives, diuretics, autonomic meds, Anticoagulants complicate things further and lead to worse outcomes
• Infections and related weakness
• Environmental Hazards 

Here is a list of risk factors that can precipitate a fall:

Elderly are often poor historians

Ask next of kin, paramedics, neighbours, other informants and witnesses to get a better history. Do not rely 100% in a 90 year old with dementia. Follow this rule in cognitively impaired, 

IF IT WAS NOT WITNESSED, IT WAS NOT MECHANICAL 

Mechanical Fall v/s Syncope
Mechanical Fall (Simple Fall) is referred to a fall due to environmental reasons (tripped, slipped, loose rugs etc.) but not as a result of primary CNS, CVS. MSK etiology. 

Common causes of syncope elderly are:

1. Cardiac syncope (ECG every patient who comes with a fall esp if it was unwitnessed)

Advise or arrange follow up with Holter monitoring in unexplained falls. 

2. Orthostatic hypotension (Symptoms are more important than numbers)

In older people baroreceptor function and adrenergic sensitivity is less. Medication such as beta-blockers, calcium channel blockers complicate the picture further. 

3. Carotid sinus hypersensitivity  (neck massage and look for a drop in HR)

4. Micturition/defecation/cough syncope

Fall examination

• Sensorium (Document Baseline)
• GCS
• Pallor, Pedal Edema, Calf Tenderness
• Vitals: Fever, tachycardia, tachypnea, Low sats, Hypotension, postural drop
• Massage carotid (if no bruit) to look for coated hypersensitivity 
• RS/CVS/Abdo (suspect abdominal catastrophes, pneumonia)
• Vision
• CNS- Speech, Pupils, Joints ROM, Strength in limbs, gait assessment (if possible)
• Skin - hidden abscesses, sores
• AMT
• Head to toe exam like secondary ATLS survey 

Delirium and tachypnea are two big signs of underlying infection

Assessing dependence and ADLs 

Assessment of ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living) – will help to determine how functionally independent the person was before the fall. This is helpful to plan discharge and assessing their functional abilities. 

Activities of Daily Living

1. Transferring
2. Toileting
3. Bathing (first to be lost)
4. Dressing
5. Feeding (last to be lost)
6. Continence

Instrumental Activities of Daily Living

1. Meal preparation
2. Housekeeping
3. Medication management
4. Finances
5. Transportation/Driving
6. Shopping
7. Phone and use of technology

Assess function, need for carers and Mobility

At our shop, we are blessed in this regards as we have out super-efficient STARRS (Short -Term Assessment, Rehabilitation and Reablement Service) team to handle these issues for us. They often arrange home visits to double check if everything is okay. 

Falls Labs (with some clinical judgement) - Do not order everything for everyone

More testing leads to more false positives, unnecessary further work-ups and possible harm. 

• CBC, CRP, Renal Function, Coags (if on Anti-Coagulants)
• ECG
• CT based on exam/suspicion of injury (Head, Spine, Chest, Abdo) 
• Relevant X Rays (CXR, Pelvis, Others)
• Urine dip
• Cultures/Lactate if infectious ethology is suspected

DO NOT TREAT ASYMPTOMATIC BACTERIURIA (DON'T EVEN DO A URINE DIP IF THEY ARE ASYMPTOMATIC AND COGNITIVELY INTACT)

Imaging elderly

Have a low threshold for imaging (CT head/spine and CXR and Pelvis X ray) even in minor trauma. There are no long-term consequences of radiation exposure in this elderly. And remember, CT is just a snapshot, safety net them regarding the possibility of delayed subdural in future. 

Discharge Planning

New injuries may have a significant impact on the older person’s ability to function. Try and see things from their perspective or think - would you be happy to discharge your grandmother is she comes in with a similar problem?" For instance, they may not be able to climb two-floors with a knee injury, she may not be able to eat, cook with a sub on her dominant hand.

Preventing Falls

Small efforts towards prevention can make a huge difference. 

• Document frequency and situation and look for a similar pattern
• Request a thorough Geriatric Assessment (for Bone and Muscle weakness, Depression, Mobility, CNS) in case of frequent falls
• Assess balance and gait as part of your physical exam (they might need walking sticks or frames for support)

Further Reading:

Aschkenasy MT, Rothenhaus TC. Trauma and falls in the elderly. Emergency Medicine Clinics. 2006 May 1;24(2):413-32.

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic