The Greatest Generation. There’s a reason the oldest patients in our Emergency Departments have earned this title. They’re resilient, stoic, and sometimes even sneaky. They’re our absolute favorite patients to care for. And if your ED is anything like ours, there are days where it seems like the average age in the department is over 75. In this episode, Paul Dekoning, MD, and Lauren Bailey, MD, PhD discuss some of the unique aspects of geriatric emergency care, how they present (and how they don’t), as well as some tips and tricks we’ve learned along the way. While some of these tips may seem tongue-and-cheek, we’ve found them to be reliable and easy to remember. Listen for ideas, wit, and wisdom you can use on your next shift.
Principles of Geriatric EM Care
Posted in General Principles
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How to Do a Discharge Risk Assessment in the ED
For older patients, there are risks of being discharged home, but also risks of being admitted to the hospital. In some cases in the ED the decision to admit or discharge a patient is not cut and dry. In this episode, Dr. Lauren Southerland and I talk about some of the issues and walk through how to do a discharge risk assessment. This podcast is inspired by a recent paper published by Dr. Southerland with colleagues in the US, Australia, and New Zealand that can be found here.
Hypertensive Emergency Management with Clevidipine
If you haven’t used clevidipine for hypertensive emergencies, you may want to give it a try. It comes as a pre-mixed bottle, has a fast onset (2 minutes), you can titrate up at 90 second intervals, and the terminal half-life is 15 minutes! Its onset and half-life are very similar to propofol, so if the BP drops due to other factors (hemorrhage, loss of sympathetic tone, etc) then you can easily titrate it down.
Listen in to learn more about indications, dosing, titration, and potential contra-indications! You can listen by clicking the play button below, or subscribing to GEMCAST on iTunes. If you prefer to read the details, here is an article Leah and I wrote on the topic in EP Monthly.
Advance Care Planning – What does it all mean?
This month we are looking at advance directives, DNR orders, living wills, MOST, and POLST forms. If you don’t understand what all of those are, then you should definitely listen! I am joined by Drs. Ferdinando Mirarchi and Marie-Carmelle Elie who are researchers and leaders in the realm of palliative care and advance care planning.
Unfortunately, advance care planning is complicated by regional differences, policies, and differing scopes of definitions for orders. Listen for more information and ideas.
This episode is timed to coincide near April 16th which is National Healthcare Decisions Day! This exists (per their website here) “to inspire, educate, and empower the public and providers about the importance of advance care planning.”
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Retiring the Term “Mechanical Fall” for Older Patients
ED physicians and APPs see older patients in the ED for falls every. single. shift. On this episode, geriatric EM expert Shan Liu talks about preventing future falls from the ED, and the fact that we should retire the term “mechanical fall”. Unfortunately, this term is potentially misleading and can downplay the serious nature of the patient’s falls risk.
Falls are very common among older adults and come with a high risk of future falls and also of trauma-related morbidity and mortality. There is more we could be doing in the ED to prevent future falls.
Posted in Systems and Administration, Trauma
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Be ADEPT: An approach to the older patient with confusion or agitation
Older adults often present to the ED for or with confusion or agitation. It is important to have a framework for assessing these patients, diagnosing the presence of delirium or dementia, looking for underlying causes, preventing worsening, treating the underlying condition, and sometimes treating the symptoms. The ADEPT tool is the newest one in a toolbox of resources being released by ACEP to provide quick access to basic clinical guides while on shift. This episode is introduced by former ACEP president, Sandy Schneider, and covers the details of the ADEPT tool.
Are Orthostatic Vital Signs Helpful in the ED?
There is some confusion, disagreement, and misunderstanding surrounding orthostatic vitals in the ED. Older patients have a high rate of incidentally-found positive orthostatic vital signs, typically because of heart-rate changes. So emergency physicians may be reluctant to request orthostatics. However, in patients with syncope or falls, the presence of orthostatic hypotension and of symptoms may actually be helpful. It can help clarify the cause of syncope, potentially help avoid unnecessary testing or hospitalization, and can also help direct treatment and interventions to prevent future syncope or falls. In this episode, Maura Kennedy (@MauraKennedyMD) talks us through a recent paper she authored on orthostatic vitals in older adults in the ED.
Subdissociative Dose Ketamine in Older Adults? – Maybe
IV subdissociative dose ketamine (SDK) is used with increasing frequency for acute pain management in the ED. However, most studies have excluded older adults in assessing its efficacy and safety. In this episode, Sergey Motov (@painfreeED) discusses his recent paper “Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial” published in the American Journal of Emergency Medicine in May 2018.
Urinary Infections and Catheters in Older Adults
UTIs, UICs, and CAUTIs in older adults! In this episode, Mary Mulcare, EM and geriatric-EM-trained physician in NYC and I discuss how to diagnose UTIs in older adults, and the confounding factors of asymptomatic bacteriuria, sterile pyuria, and colonization. We discuss how to diagnose a UTI, how to pick medications, dos and don’ts of when to place a urinary catheter, and how to create a protocol at your institution to reduce IUCs and CAUTIs. You may think this topic is simple, cut, and dry, but it is not. Treating a non-existent UTI can do harm, because of all the side effects of medications. But not treating a true UTI can also do harm, as it can lead to sepsis. Placing urinary catheters sometimes is absolutely required, and other times is less clear. It too has risks and benefits. Particularly in frail elderly patients, UTIs and also IUCs can lead to delirium and deconditioning.
Trauma in Older Adults
Older adults who suffer traumatic injuries have worse outcomes than younger patients. In this episode Dr. Zara Cooper (acute care and trauma surgeon at Brigham and Women’s hospital) and I discuss some of the reasons for this, and also ways to avoid missing injuries in older adults. Falls are the most common cause of trauma in older patients, and understanding how falls are a geriatric syndrome can help you understand how to help prevent future falls.
Posted in Medications and Adverse Drug Events, Trauma
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