Preventing Falls in the Elderly: An EMS Story

step-98822_1280The risk of falls increases as we age. Unfortunately, so does the risk of injury, morbidity, and mortality following a fall. Falls risk is considered a geriatric syndrome, with multi-factorial causes. Falls are a the #1 cause of trauma-related mortality in older adults, and a major cause of ED visits, hospital admissions, and admission to nursing facilities. Often, a patient at high risk for falls is not identified until after they have suffered an injury. Orange County EMS developed a system to help identify patients who were at high risk for falls, perform a comprehensive home visit, and connect those individuals with appropriate services to help reduce the rate of future falls and help those patients maintain their independence and functionality in their home environment.

See below for references

References:

  1. The MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 2008 Online calculator
  2. Tinetti ME, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995;273(3):1348–1353. https://www.ncbi.nlm.nih.gov/pubmed/7715059
  3. Haentjens P, Magaziner J, Colon-Emeric CS, et al. Meta-analysis: Excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390 https://www.ncbi.nlm.nih.gov/pubmed/20231569
  4. Peck et al. Death after discharge: predictors of mortality in older brain injured patients. J Trauma Acute Care Surg 77;6, 2014 https://www.ncbi.nlm.nih.gov/pubmed/25248061
  5. CDC TBI facts and stats http://www.cdc.gov/traumaticbraininjury/index.html
  6. National Council on Aging Fall Prevention Facts and Statistics https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/
  7. Falls in Older Persons: Risk Factors and Prevention. https://www.ncbi.nlm.nih.gov/books/NBK235613/
  8. Zia et al. Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk. Postgrad Med  2015127 (3) https://www.ncbi.nlm.nih.gov/pubmed/25539567
  9. AHRQ Statistical Brief #268: Outpatient prescription anticoagulants utilization and expenditures for the US civilian noninstitutionalized population age 18 and older, 2007

 

This podcast uses sounds from freesound.org by Jobro and HerbertBoland.
Image credit [1]


Practical Tips for Providing Palliative Care in the ED

dante_gabriel_rossetti_-_study_of_dante_holding_the_hand_of_loveACEP’s 2013 Choosing Wisely campaign identified engaging palliative care or hospice services in the ED as one of their 10 recommendations. Palliative care can help with symptom management, support families and patients, and help clarify their goals of care. Most EDs, however, do not have real-time palliative care consults available at all times, or at all! So the emergency physician is usually the person providing palliative care for patients in the ED. In this episode Alisha Benner discusses what palliative care is and shares pearls for better symptom management, communication with patients, and active management at the end of life.

See below for show notes and references.

Defining the Terms

Palliative care, hospice, and DNR are terms that are often misunderstood or conflated. We will start with definitions:

Palliative Care can be provided to anyone who has a serious illness, from the time of diagnosis to end of life. It can be for any age, and during can be provided while curative efforts are underway and when patients are pursuing comfort care. It has 3 main goals:

  1. To provide active symptom management, along any stage of a serious illness, from onset to end of life, including through both treatments with curative intent and when goals of care have shifted to comfort measures or non-curative treatments.
  2. To help support the patient and family through the course illness.
  3. To ensure that the plan of care is in line with the patient’s goals of care and that there is a better understanding between patient and physicians of what those goals are.

Hospice is a specific insurance benefit that provides multi-disciplinary care and 24 hour nurse access for patients who are deemed by 2 physicians to have less than 6 months to live if their illness takes its expected trajectory. Hospice patients are ideally managed at home or the place of their residence (assisted living, skilled nursing, etc), but may need to come to the hospital if their symptoms cannot be managed at their place of residence. It is helpful to call the on-call hospice nurse to coordinate the patient’s care as they may be able to increase the home resources to manage the patient at home. Hospice can be revoked by the patient at any time if they wish to pursue more aggressive treatment.

DNR is a specific order generated by the patient that if their heart went into a non-perfusing rhythm, ie they lost pulses, that they would not want CPR done. It does not necessarily include DNI, although often patients request both DNR and DNI. It also does not imply that they do not want maximal treatment with curative efforts, including IV fluid resuscitation, pressors, central lines, surgery, and ICU admission.

Active Symptom Management

Symptom management is a major part of palliative care. Commonly treated symptoms include pain, nausea, constipation, insomnia, anxiety, dyspnea. Here are pearls for several of these:

  1. Pain: For patients who have chronic pain, such as from cancer or other chronic, painful conditions, first, look for any possible new causes of their pain before attributing it to the underlying chronic pain. You can give IV opioids in the ED to help control their pain, and if needed, can try switching to a different medication. For a patient on 10mg oxycodone Q6hours (40mg total), this would be equivalent to 15mg PO morphine Q6hours (60mg total) assuming complete cross-tolerance. However, there is not complete cross-tolerance, meaning the patient may be less tolerant to morphine, so the dose should be reduced by 25-50%, which would be 7.5mg – 11.2mg Q6hours of morphine PO. The equivalent IV doses can also be calculated for patients who are being treated as inpatients or who are NPO.
  2. Constipation: Treat aggressively and pre-emptively. Avoid Colace because it has very limited, if any, effect, and just increases the stool burden. For patients who are prescribed opioids, with slow down the gut, prescribe Senna, which increases gut motility, 1 tab BID (and can be titrated up), and miralax 1-2 capfuls daily. Both can be used safely long-term. For severe constipation, magnesium citrate can be used in patients without renal failure, as well as enemas or manual disimpaction.
  3. Dyspnea: While treating the underlying cause (eg COPD or CHF exacerbation), very low dose opioids, such as 2.5mg oxycodone PO, or 1mg morphine IV can help reduce the subjective feelings of air hunger and dyspnea, without causing sedation or respiratory depression at these miniscule doses.
  4. Nausea: Zofran is a good go-to for most causes of nausea and vomiting, although like other medications (compazine, reglan) it can prolong the QTc. For specific causes of nausea/vomiting, other agents may be more effective (see table below). For vertigo, phenergan, or meclizine may help better. For migraines, reglan tends to work well. For bowel obstruction, pro-motility agents such as reglan should be avoided, and Zofran or octreotide is likely better. For gastroparesis, by contrast, pro-motility agents may help more. All of them but Zofran will be sedating. Below are the commonly used anti-emetics, with trade name, generic name, and mechanism of action.
    1. Zofran = ondansetron; 5-HT3 receptor (serotonin) antagonist
    2. Reglan = metoclopramide; dopamine antagonist, and stimulates upper GI motility, sensitizes to ecetylcholine
    3. Compazine = prochlorperazine; a 1st gen antipsychotic, dopamine antagonist
    4. Phenergan = promethazine; central and peripheral histamine antagonist, and anti-cholinergic
    5. Antivert = meclizine; anti-histamine and anti-cholinergic
    6. Ativan = lorazepam; binds to and agonizes GABA receptors
    7. Haldol = haloperidol; 1st gen antipsychotic, dopamine antagonist.

Based on cause of the nausea, different agents may work better. Here are some options, adapted from reference 5.

nausea-treatment

  1. Delirium: Be aware of it. It can present in a hyperactive form (hallucinations, agitation), hypoactive (may appear depressed or less active), or can be mixed. Delirium is an independent risk factor for 6 month mortality. Always look for an underlying cause! For a whole podcast on delirium, go here.

Communicating With Families

Gaining an overall picture of how the patient has been doing in the last months to year can be incredibly helpful in discussing options with the family and goals of care and does not take much pain. Our goal is to help support the family and patient in their decisions, while making sure they understand the options and the risks and benefits. Reference 3 has some great advice.

Active Management at the End of Life

At the end of life, it is important to let patients and families know that just because curative efforts have ended or are unlikely to be effective that we as medical caregivers are not abandoning them, but will continue to actively manage their symptoms. Start by assessing their symptoms. See reference 4 for a more in-depth discussion, but here are a few medications that can help for common symptoms:

Opioids: Are helpful for pain, dyspnea, and cough, starting at a low dose, and titrating up as needed and depending on the goals of care and patient wishes. Some patients may want to be less sedated to communicate with family and will tolerate more pain or dyspnea. Others may want to reduce their pain even if it causes sedation.

Benzodiazepines: Can help with anxiety, myoclonic twitching, hiccups, insomnia.

Haloperidol: Can help with agitation, nausea, hallucinations:

Scopolamine patches: Can help with respiratory secretions. Other options include 1% atropine eye drops under the tongue Q8 hours, or glycopyrrolate 1mg PO or 0.2mg IV.

Relieving the Existential Suffering

Being diagnosed with or suffering from a severe illness can cause emotional stress, loss of sense of self, anxiety, depression, and fear. One way to help connect with patients is to make sure you sit down and take time to listen to them and their concerns. “Wish, Worry, Hope” statements such as “I wish things were different” or “I worry that the current treatment is not working”. Acknowledging that they have been suffering with a disease process if that is something they communicate to you, can also help validate them. Leave space for silence as patients process new information or diagnoses, or process their own thoughts.

References:

  1. Ebell MH, Jang W, Shen Y, Geocadin RG, Get With the Guidelines-Resuscitation Investigators. Development and validation of the good outcome following attempted resuscitation (GO-FAR) score to predict neurologically intact survival after in-hospital cardiopulmonary resuscitation. JAMA Intern Med. 2013;173(20):1872-1878. https://www.ncbi.nlm.nih.gov/pubmed/24018585
  2. Ohlsson MA, Kennedy LM, Ebell MH, Juhlin T, Melander O. Validation of the good outcome following attempted resuscitation score on in-hospital cardiac arrest in southern sweden. Int J Cardiol. 2016;221:294-297. https://www.ncbi.nlm.nih.gov/pubmed/ 27404694
  3. Ngo-Metzger Q, August KJ, Srinivasan M, Liao S, Meyskens FL,Jr. End-of-life care: Guidelines for patient-centered communication. Am Fam Physician. 2008;77(2):167-174. https://www.ncbi.nlm.nih.gov/pubmed/ 18246886
  4. Groninger H, Vijayan J. Pharmacologic management of pain at the end of life. Am Fam Physician. 2014;90(1):26-32. https://www.ncbi.nlm.nih.gov/pubmed/ 25077499
  5. Clary PL, Lawson P. Pharmacologic pearls for end-of-life care. Am Fam Physician. 2009;79(12):1059-1065. https://www.ncbi.nlm.nih.gov/pubmed/ 19530636
  6. Opioid Dosage Conversion phone app
  7. Palliative Care Fast Facts phone app
  8. Many resources and articles are available here from the American Association of Family Physicians
  9. Good Outcome Following Attempted Resuscitation (GO-FAR) Calculator

This podcast uses sounds from freesound.org by Jobro and HerbertBoland

Image credit [1]


Eye Emergencies in the Elderly – Part 2

eyes-1574829_960_720This is a continuation of our discussion of Eye Emergencies in the elderly with ophthalmologist and retina specialist, Dr. Bryan Hong. Many thanks to the Life in the Fast Lane blog for including eye emergencies part 1 in their LITFL Weekly Review!

See below the audio player for more notes!

Sudden painless vision loss

  1. Case: A 55yo M with sudden, painless, monocular vision loss typically has a vascular cause.
  2. CRAO – Typically occurs from an embolus from the carotids or cardiac valves. It is often very rapid onset with marked visual impairment (counting fingers to light perception). May have APD. Patients may have had previous episodes of transient vision loss (amaurosis fugax). On funduscopic exam the retina is pale, with a cherry red macula. These patients require workup to identify the source of the embolus (eg cardiac echo, carotid dopplers). Unfortunately vision often does not improve or return. The workup is to prevent further emboli and CVA. There is also overlap in the presentation with giant cell arteritis (discussed in part 1). Other causes may include sickle cell disease, Behcet’s, syphilis or collagen vascular disease. Ocular massage and anterior chamber paracentesis can be attempted but low likelihood of success.
  3. CRVO – Vision typically not as severe as with CRAO though can be, and patients can have an APD. The funduscopic exam has a “blood and thunder” appearance with intra-retinal hemorrhages. Can be due to hypercoagulable disorders, or syphilis. The main prognostic factor is their vision at the time of presentation.

Cataracts

  1. Case: Gradual painless loss of vision in 70 year old man who has difficulty with reading and driving (particularly at night). However, sometimes the patients will think the changes are more acute, as they compensate until the vision impairment is severe enough that it interferes with their reading or other activities.
  2. Evaluation: Vision, pupils, pressure. Thorough history of nature of vision loss. Typically describes colors as being dull, colors are not as vibrant, see starbursts when bright light is shone into eyes, things look hazy. The progression is often symmetrical, but you can check with the direct ophthalmoscope from 2-3 feet away for any decreased red reflex in one eye. You can use a pinhole occlude to get a better measure of their visual acuity through the cataract.
  3. Management: Non urgent referral to comprehensive ophthalmologist.

Chemical injury

  1. Case: 40 year old janitorial worker splashes oven cleaner in her eye and arrives with tearing/red eye and decreased vision.
  2. Evaluation: Gross measure of vision, followed by generous irrigation with Saline/LR/tap water. Topical anesthetic may be applied prior to irrigation. Upper and lower fornices should be swept with Q tip and everted prior to irrigation. All particulate matter should be removed. Time of injury? Time to irrigation? Type of chemical? Slit lamp exam with fluorescein staining looking for corneal epithelial defects or signs of corneal perforation.
  3. Management: Copious irrigation, checking for normalization of pH with Litmus paper. Consider cycloplegia if significant photophobia or pain, such as cyclopentylate 1% or homatropine 5%. Frequent artificial tears. Avoid phenylephrine use, which constricts blood vessels and can impair healing. Typically there will be an epithelial defect, in which case prescribe topical antibiotic drops. Avoid ciprofloxacin drops in large epithelial defects as it can precipitate out. Next morning consult with ophthalmologist—needs to be followed daily until stable. Alkali burns tend to penetrate more deeply into the ocular tissue and cause more permanent damage.

Image credit [1]. This podcast uses sounds from freesound.org by Jobro and HerbertBoland

 

 


Eye Emergencies in the Elderly – Part 1

L0036581 A selection of glass eyes from an opticians glas eye case.Eye concerns are a common reason for elderly patients to visit the ED. Their causes can range from benign to serious, time-sensitive, vision-threatening entities. In this episode, ophthalmologist and retina-specialist Dr. Bryan Hong talks us through his approach and initial management of four common ophthalmologic emergencies.

See more notes below the audio player!

Acute angle-closure glaucoma

  1. Case: 76yo female with a history of hyperopia (far sightedness), the patient may have had “perfect vision without glasses” as a child but became increasingly dependent on reading glasses at a relatively young age (presbyopia). The patient complains of intermittent “migraine” or headache over eyes that radiate from eyes in low lighting or at dusk/dawn. Tonight she had sudden onset severe left sided eye pain, headache, and associated nausea which brought her to the ED. The patient may have had recent laser treatment or surgery, retinal problems, recent dilation, sulfa medications.
  2. Evaluation: Check visual acuity, pupils (fixed and mid dilated), pressure if possible. Pain, blurred vision, colored haloes around lights, frontal headache, nausea, vomiting. Slit lamp exam if you have one: conjunctival injection; fixed, mid-dilated pupil.
  3. Management: Severe permanent damage can occur to optic nerve within hours. Lowering of IOP is urgent. Give maximum topical IOP lowering agents, oral or IV carbonic anhydrase inhibitor, and in some cases mannitol. Recheck IOP in 1 hour. If cannot lower IOP within first 2-3 hours, immediate ophthalmology consult. The medications we discussed in the podcast include:
  • Timolol 0.5% (Beta-blocker)
  • Brimonidine 0.1% (Alpha-2 agonist)
  • Latanoprost 0.005% (Prostaglandin analog)
  • Dorzolamide 2% (Carbonic anhydrase inhibitor)

Give the above 4 drops each 5 minutes apart, then check pressure at the 1 hour mark. If refractory or if very high pressures, consider:

  • Prednisolone acetate 1% (steroid)
  • Acetazolamide 500mg IV or PO (carbonic anhydrase inhibitor)
  • Mannitol 1-2g/kg IV (to reduce IOP)

Retinal detachment

  1. Case: 55yo Male high myope complains of 1 day of new floaters in the left eye preceded by flashes of light.
  2. Evaluation: Vision, pupils, pressure (always if possible). Confrontational fields to grossly localize defect. If available, ultrasound scan of eye looking for retinal detachment – can be misleading because vitreous hemorrhage or posterior vitreous detachment can masquerade as retinal detachment. A view of the fundus will usually be clear with a direct ophthalmoscope unless the picture is muddied by vitreous hemorrhage.
  3. Management: Needs urgent or emergent ophthalmology consult. The retina should be re-attached within 24hours of symptom onset. Keep NPO after midnight in case emergency surgery is warranted.

 

 

Vitreous hemorrhage

  1. Case: 62 year old Type 2 diabetic with new “chunky floaters” which have turned into cobwebs.
  2. Evaluation: Vision, pupils, pressure. The patient may or may not have reasons to have proliferative retinopathy, but would still get an ultrasound if it is available. You can get a gross idea of how dense the hemorrhage (or any other media opacity) is by using direct ophthalmoscope and shining the biggest brightest beam and checking for red reflex from a couple feet away. The view of the fundus will be impeded by hemorrhage to varying extent.
  3. Management: There is so much overlap between signs and symptoms of vitreous hemorrhage, posterior vitreous detachment, and RD that all complaints of “flashes, many new floaters, or curtain over vision” should be referred to an ophthalmologist for a same or next day consult. They should keep their HOB elevated and try to keep their eyes still to allow the blood to settle so that the retina can be better visualized.

 

Temporal or Giant Cell Arteritis

  1. Case: 87 year old man with h/o HLD and HTN comes in with sudden painless vision loss left eye. He has been having recent headaches and intermittent unexplained fevers. May be associated with a headache at the time of the presentation.
  2. Evaluation: Vision, check for APD! This is a disease of the very old, and it must ALWAYS be ruled out in an older patient with stuttering vision loss, because it is initially unilateral but can rapidly become bilateral without treatment. Look for history of unintentional weight loss, scalp tenderness, jaw claudication, polymyalgia rheumatica, or any other cranial nerve palsies (especially 6th nerve)—thorough evaluation of all CN nerves. Order Sed Rate, CRP, and CBC (thombocytosis). Look at nerve for pale, swollen disc with possible flame hemorrhages.
  3. Management: IV Steroids should be given immediately if suspecting GCA. Methylprednisolone 250 mg IV q 6 hrs for 12 does, then prednisone 80-100mg PO daily. Ophthalmology consult should be called for next day evaluation and for temporal artery biopsy within 1 week of steroid initiation, or earlier if the diagnosis is not clear.

More to come in Part 2….

 

Image credit [1]. This podcast uses sounds from freesound.org by Jobro and HerbertBoland


How to Reverse Oral Anticoagulants

brainThe number of new oral anticoagulants has grown dramatically in the last few years. And with that growth has come the need for new reversal agents. Reversing anticoagulation in patients with acute intra-cranial hemorrhages can be complex and dependent on what medication your hospital stores. It is important to know what is out there, what you can use, and how effective it is likely to be.

Anticoagulation use is certainly not unique to older adults, but is much more common because of the higher prevalence of a-fib and the concurrently higher CHADS-VASC score, as well as higher rates of valvular disease and venous thromboembolism. Older adults are also at higher risk of intra-cranial hemorrhage even without anticoagulation. Putting the risks of age and the higher rates of anti-coagulation use makes anticoagulation reversal an important topic for the care of older patients.

anticoagulant-use-by-age

In this episode Leah Hatfield, an ED pharmacist, and I discuss a hypothetical 70 year old female on a range of different anticoagulants who presents with a traumatic intra-parenchymal hemorrhage after a fall from standing.

SUMMARY OF RECOMMENDATIONS

table-of-anticoagulants

 

 

 

LISTEN TO THE PODCAST HERE:

References

 

  1. Barnes GD, Kurtz B. Direct oral anticoagulants: Unique properties and practical approaches to management. Heart. 2016;102(20):1620-1626. https://www.ncbi.nlm.nih.gov/pubmed/27402803
  2. Tummala R, Kavtaradze A, Gupta A, Ghosh RK. Specific antidotes against direct oral anticoagulants: A comprehensive review of clinical trials data. Int J Cardiol. 2016;214:292-298. https://www.ncbi.nlm.nih.gov/pubmed/27082776
  3. Rogers KC, Shelton MP, Finks S. Reversal agents for direct oral anticoagulants: Understanding new and upcoming options. Cardiol Rev. 2016. https://www.ncbi.nlm.nih.gov/pubmed/27548686
  4. Christos S, Naples R. Anticoagulation reversal and treatment strategies in major bleeding: Update 2016. West J Emerg Med. 2016;17(3):264-270. https://www.ncbi.nlm.nih.gov/pubmed/27330657
  5. Jaben EA, Mulay SB, Stubbs JR. Reversing the effects of antiplatelet agents in the setting of intracranial hemorrhage: A look at the literature. J Intensive Care Med. 2015;30(1):3-7. https://www.ncbi.nlm.nih.gov/pubmed/25492811
  6. Reddy S, Sharma R, Grotts J, Ferrigno L, Kaminski S. Incidence of intracranial hemorrhage and outcomes after ground-level falls in geriatric trauma patients taking preinjury anticoagulants and antiplatelet agents. Am Surg. 2014;80(10):975-978. https://www.ncbi.nlm.nih.gov/pubmed/25264642
  7. Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-8.e1-7. https://www.ncbi.nlm.nih.gov/pubmed/22626015
  8. Edavettal M, Rogers A, Rogers F, Horst M, Leng W. Prothrombin complex concentrate accelerates international normalized ratio reversal and diminishes the extension of intracranial hemorrhage in geriatric trauma patients. Am Surg. 2014;80(4):372-376. https://www.ncbi.nlm.nih.gov/pubmed/24887668
  9. Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): A randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613. https://www.ncbi.nlm.nih.gov/pubmed/27178479

 

Image credit [brain image]. This podcast uses sounds from freesound.org by Jobro and HerbertBoland