Pelvic ring fractures (PRFs) are a leading cause of preventable deaths in trauma patients. A 2007 Australian study 1 found that the incidence of PRFs over a 12-month period was approximately 23/100,000 population with 10/100,000 population incidence of high-energy (HE) PRFs (mostly young males) and 10/ 100,000 population incidence of low-energy (LE) PRFs (mostly older females). The incidence of major bleeding was 1.3 /100,000 population. 60%
{"title":"Current Best Practice in Pelvic and Hip Fracture Management in the Older Adult Population","authors":"A. Joseph","doi":"10.17294/2694-4715.1055","DOIUrl":"https://doi.org/10.17294/2694-4715.1055","url":null,"abstract":"Pelvic ring fractures (PRFs) are a leading cause of preventable deaths in trauma patients. A 2007 Australian study 1 found that the incidence of PRFs over a 12-month period was approximately 23/100,000 population with 10/100,000 population incidence of high-energy (HE) PRFs (mostly young males) and 10/ 100,000 population incidence of low-energy (LE) PRFs (mostly older females). The incidence of major bleeding was 1.3 /100,000 population. 60%","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46085383","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ground-level falls are a leading cause of emergency department (ED) visits by older adults. In addition to understanding the cause of the fall, the assessment of potential fall-induced injuries such as traumatic intracranial hemorrhage can be highly challenging for emergency clinicians. Premorbid conditions, medications, and concomitant injuries can all interfere with the physical examination and impact the prevalence of signs traditionally associated with traumatic brain injury (TBI). When it comes to the decision to potentially investigate for a traumatic intracranial hemorrhage with brain imaging such as head computed tomography (CT), many potential predictors and factors will be considered. Symptoms, history, medications, frailty, functional status, level of care, cost, and access to imaging will all potentially influence that decision-making process. This brief review article will help make that decision in the interest of the patient and the health care system. 1. Explore goals of care early. Goals of care are often one of the last things we explore with patients in the ED. However, for frail older adults, exploring goals of care should be among the first things we do, particularly relative to the decisions to investigate or not. If the head CT shows a traumatic intracranial hemorrhage, would this patient consider neurosurgery as an option? Is it aligned with their wishes? If not, you can likely stop there. Imaging is not needed and you need to focus on what is important for the patient. 2. A patient over 65 years old and mild traumatic brain injury = head CT scan Not all head traumas are TBI. A TBI is defined as a head impact associated with at least one neurologic symptom (loss of consciousness, amnesia, confusion, etc.). The recommendation for older adults who have sustained a TBI is clear: A patient ≥ 65 years old following a TBI should be investigated with brain imaging. New data suggests that this 65+ age threshold could potentially be adjusted to >75, but the safety of this cutoff needs to be confirmed with more robust data. 3. TBI-related symptoms are less predictive of intracranial hemorrhage and are often delayed. Different physiological changes associated with aging such as cerebral atrophy increase the risk of traumatic intracranial hemorrhage, even following a minor head impact. These changes leave more places for a hemorrhage to expand before becoming symptomatic compared to younger adults. Therefore, it often requires more time and a larger intracranial hemorrhage before the patient displays neurological signs or a decreased GCS. A normal physical examination cannot rule out a traumatic intracranial hemorrhage. 4. Temporal and occipital external signs of trauma increased risk of intracranial hemorrhage. The absence of external signs of trauma decreases the odds of intracranial traumatic hemorrhage. In the opposite, external signs of trauma (bruising, hematoma, or laceration) located on temporoparietal or occipital regions are
{"title":"Head Injury in Older Adults: To Scan or Not to Scan? Ten Tips to Make the Best Decision","authors":"A. Brousseau, É. Mercier","doi":"10.17294/2694-4715.1050","DOIUrl":"https://doi.org/10.17294/2694-4715.1050","url":null,"abstract":"Ground-level falls are a leading cause of emergency department (ED) visits by older adults. In addition to understanding the cause of the fall, the assessment of potential fall-induced injuries such as traumatic intracranial hemorrhage can be highly challenging for emergency clinicians. Premorbid conditions, medications, and concomitant injuries can all interfere with the physical examination and impact the prevalence of signs traditionally associated with traumatic brain injury (TBI). When it comes to the decision to potentially investigate for a traumatic intracranial hemorrhage with brain imaging such as head computed tomography (CT), many potential predictors and factors will be considered. Symptoms, history, medications, frailty, functional status, level of care, cost, and access to imaging will all potentially influence that decision-making process. This brief review article will help make that decision in the interest of the patient and the health care system. 1. Explore goals of care early. Goals of care are often one of the last things we explore with patients in the ED. However, for frail older adults, exploring goals of care should be among the first things we do, particularly relative to the decisions to investigate or not. If the head CT shows a traumatic intracranial hemorrhage, would this patient consider neurosurgery as an option? Is it aligned with their wishes? If not, you can likely stop there. Imaging is not needed and you need to focus on what is important for the patient. 2. A patient over 65 years old and mild traumatic brain injury = head CT scan Not all head traumas are TBI. A TBI is defined as a head impact associated with at least one neurologic symptom (loss of consciousness, amnesia, confusion, etc.). The recommendation for older adults who have sustained a TBI is clear: A patient ≥ 65 years old following a TBI should be investigated with brain imaging. New data suggests that this 65+ age threshold could potentially be adjusted to >75, but the safety of this cutoff needs to be confirmed with more robust data. 3. TBI-related symptoms are less predictive of intracranial hemorrhage and are often delayed. Different physiological changes associated with aging such as cerebral atrophy increase the risk of traumatic intracranial hemorrhage, even following a minor head impact. These changes leave more places for a hemorrhage to expand before becoming symptomatic compared to younger adults. Therefore, it often requires more time and a larger intracranial hemorrhage before the patient displays neurological signs or a decreased GCS. A normal physical examination cannot rule out a traumatic intracranial hemorrhage. 4. Temporal and occipital external signs of trauma increased risk of intracranial hemorrhage. The absence of external signs of trauma decreases the odds of intracranial traumatic hemorrhage. In the opposite, external signs of trauma (bruising, hematoma, or laceration) located on temporoparietal or occipital regions are","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44760385","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Falls leading to hip injuries represent a quarter of all fall-related injury hospitalizations.1 A fall in a patient over 65 necessitating an Emergency Department (ED) visit carries a 15% mortality rate at one year.2 A neck of femur fracture is a common sequela that an Emergency Physician will manage after an older person falls. In Australia and New Zealand (ANZ) in 2021, there were 15,331 episodes of neck of femur fracture reported.3 Despite ongoing advances in standardization of care, the mortality rate of neck of femur fractures sits at 7.6% and 8.3% at one month in ANZ and the UK respectively with the 1-year mortality in ANZ sitting at 24.8% for 2021.3,4 The morbidity for this fracture is complex. An average length of stay of between 4 and 23 days illustrates the complexity of managing these patients on the wards. There is a 29.5% rate of postoperative delirium carrying its own mortality risk.5 At 120 days, only 70% of these patients will return home if they came from home and 60% will require mobility aid.3,4 Other issues that arise include pressure area prevention, comorbidity management, and frailty. The ANZ Hip Fracture Registry3 provides an approach for hospitals to audit the management of neck of femur fractures “against key markers of safe, high-quality care”. This registry aligns closely with the Australian Hip Fracture Clinical Care Standard.6 Issues highlighted in the standard and registry most pertinent to the ED include:
{"title":"Older Person Fracture Presentation and Management Including Tips for Pain Management","authors":"Timothy D W Arnold","doi":"10.17294/2694-4715.1056","DOIUrl":"https://doi.org/10.17294/2694-4715.1056","url":null,"abstract":"Falls leading to hip injuries represent a quarter of all fall-related injury hospitalizations.1 A fall in a patient over 65 necessitating an Emergency Department (ED) visit carries a 15% mortality rate at one year.2 A neck of femur fracture is a common sequela that an Emergency Physician will manage after an older person falls. In Australia and New Zealand (ANZ) in 2021, there were 15,331 episodes of neck of femur fracture reported.3 Despite ongoing advances in standardization of care, the mortality rate of neck of femur fractures sits at 7.6% and 8.3% at one month in ANZ and the UK respectively with the 1-year mortality in ANZ sitting at 24.8% for 2021.3,4 The morbidity for this fracture is complex. An average length of stay of between 4 and 23 days illustrates the complexity of managing these patients on the wards. There is a 29.5% rate of postoperative delirium carrying its own mortality risk.5 At 120 days, only 70% of these patients will return home if they came from home and 60% will require mobility aid.3,4 Other issues that arise include pressure area prevention, comorbidity management, and frailty. The ANZ Hip Fracture Registry3 provides an approach for hospitals to audit the management of neck of femur fractures “against key markers of safe, high-quality care”. This registry aligns closely with the Australian Hip Fracture Clinical Care Standard.6 Issues highlighted in the standard and registry most pertinent to the ED include:","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49156430","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"An Inflection Point to Improve Emergency Care for Older Adults","authors":"Jonny Macias Tejada, Michael Malone, Kevin Biese","doi":"10.17294/2694-4715.1054","DOIUrl":"https://doi.org/10.17294/2694-4715.1054","url":null,"abstract":"","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":"45 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135663480","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Excellent emergency care does not happen by chance. The standard emergency approach that excels in the young, fails in older patients. Older adults experience unnecessary morbidity and excess mortality in our emergency departments. This article describes the pursuit of excellent emergency care in the historically challenging older adult population. A pivotal point occurred once emergency physicians recognized older patients as a distinct population in need of unique evaluation and treatment. In the early 1990s, a group of geriatricians, philanthropists, and emergency physicians joined forces to improve older patient care. Geriatric Emergency Medicine (GEM) emerged as a subspecialty as these individuals systematically identified its distinctive knowledge, skills, competencies, literature, champions, research, fellowship programs, service lines, staffing, accredited geriatric emergency departments, and now its own journal. Early GEM advocates recognized that a legion of older patients would overwhelm providers lacking the training and resources to deliver adequate care for the aging population. They created education and grant programs, developed leaders, and overcame barriers of ageism, ignorance, and indifference. A review of this progress can inform new strategies and innovations providing a future of excellence in the emergency care of older adults.
{"title":"The History of Geriatric Emergency Medicine","authors":"T. Hogan, L. Gerson, Aurthur B Sanders","doi":"10.17294/2694-4715.1044","DOIUrl":"https://doi.org/10.17294/2694-4715.1044","url":null,"abstract":"Excellent emergency care does not happen by chance. The standard emergency approach that excels in the young, fails in older patients. Older adults experience unnecessary morbidity and excess mortality in our emergency departments. This article describes the pursuit of excellent emergency care in the historically challenging older adult population. A pivotal point occurred once emergency physicians recognized older patients as a distinct population in need of unique evaluation and treatment. In the early 1990s, a group of geriatricians, philanthropists, and emergency physicians joined forces to improve older patient care. Geriatric Emergency Medicine (GEM) emerged as a subspecialty as these individuals systematically identified its distinctive knowledge, skills, competencies, literature, champions, research, fellowship programs, service lines, staffing, accredited geriatric emergency departments, and now its own journal. Early GEM advocates recognized that a legion of older patients would overwhelm providers lacking the training and resources to deliver adequate care for the aging population. They created education and grant programs, developed leaders, and overcame barriers of ageism, ignorance, and indifference. A review of this progress can inform new strategies and innovations providing a future of excellence in the emergency care of older adults.","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45342314","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction Readmission to the hospital within 30-days has a high cost and represents a gap in care for older adults. Older adults are at significant risk for depression, particularly given their medical comorbidities and social factors such as isolation due to SARS-CoV-2. Many patients who screen positive for depression may have no known history of depression. This investigation examines the relationship between a positive geriatric depression screen and chief complaint as a function of 30-and 90-day readmission risk. Methods We examined the electronic medical record of 329 older adults aged 65 and older from February 1, 2020, to January 31, 2021, with a positive depression screen during an emergency department visit at a Midwest Geriatric Emergency Department. Their admission and final ICD-10 diagnosis coding groups (used as a surrogate to standardize chief complaint), social factors such as marital status, living environment, Orientation-Memory-Concentration Test score, and level of independence, were analyzed and considered as potential contributory factors. Results
{"title":"Geriatric Depression Screening and Chief Complaint: What is the Risk for 30- and 90-day Readmission?","authors":"E. James, J. M. Moccia, V. Lucia","doi":"10.17294/2694-4715.1045","DOIUrl":"https://doi.org/10.17294/2694-4715.1045","url":null,"abstract":"Introduction Readmission to the hospital within 30-days has a high cost and represents a gap in care for older adults. Older adults are at significant risk for depression, particularly given their medical comorbidities and social factors such as isolation due to SARS-CoV-2. Many patients who screen positive for depression may have no known history of depression. This investigation examines the relationship between a positive geriatric depression screen and chief complaint as a function of 30-and 90-day readmission risk. Methods We examined the electronic medical record of 329 older adults aged 65 and older from February 1, 2020, to January 31, 2021, with a positive depression screen during an emergency department visit at a Midwest Geriatric Emergency Department. Their admission and final ICD-10 diagnosis coding groups (used as a surrogate to standardize chief complaint), social factors such as marital status, living environment, Orientation-Memory-Concentration Test score, and level of independence, were analyzed and considered as potential contributory factors. Results","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47336086","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Geriatric Emergency Departments as Laboratories for Innovation","authors":"Brian W Patterson, Manish N Shah","doi":"10.17294/2694-4715.1046","DOIUrl":"https://doi.org/10.17294/2694-4715.1046","url":null,"abstract":"","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":"27 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136051642","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mario C de Andrade Junior, C. V. Morinaga, Christina May M. Brito, I. Moraes, W. P. Yamaguti, P. Curiati
Falls are the main cause of morbidity among older adults. In this context, assistive gait devices are used to improve function and safety. However, inadequate selection and use can result in poor gait and risk of injury. All patients admitted to our emergency department (ED) undergo a medical evaluation in which, based on their clinical condition, the protocol for indication and training in the use of walking aids can be triggered. Patients need to be clinically stable and have enough physical and cognitive function to benefit from it. Once the patient is deemed able, the next step is an assessment of needs and potential benefits. After the patient and his proxy agree to undergo specific evaluation and training, the physician or the ED nurse calls the physical therapy team to carry out a broader assessment that includes the Timed Up and Go (TUG) test. Following the functional evaluation, the physical therapist identifies the mobility needs of the patient and indicates the most appropriate walking device. The TUG test is performed again with the use of the mobility aid device and the results are compared to confirm the improvement in the patient's performance regarding balance and mobility. Finally, the physical therapist refers the patient to the rehab center of our hospital for further rehabilitation, if applicable, and provides a written document with the type of the suggested device and possible purchase locations.
{"title":"Indication of Mobility Aids and Training of Older Patients in a Geriatric Emergency Department: Abiding by International Guidelines","authors":"Mario C de Andrade Junior, C. V. Morinaga, Christina May M. Brito, I. Moraes, W. P. Yamaguti, P. Curiati","doi":"10.17294/2694-4715.1047","DOIUrl":"https://doi.org/10.17294/2694-4715.1047","url":null,"abstract":"Falls are the main cause of morbidity among older adults. In this context, assistive gait devices are used to improve function and safety. However, inadequate selection and use can result in poor gait and risk of injury. All patients admitted to our emergency department (ED) undergo a medical evaluation in which, based on their clinical condition, the protocol for indication and training in the use of walking aids can be triggered. Patients need to be clinically stable and have enough physical and cognitive function to benefit from it. Once the patient is deemed able, the next step is an assessment of needs and potential benefits. After the patient and his proxy agree to undergo specific evaluation and training, the physician or the ED nurse calls the physical therapy team to carry out a broader assessment that includes the Timed Up and Go (TUG) test. Following the functional evaluation, the physical therapist identifies the mobility needs of the patient and indicates the most appropriate walking device. The TUG test is performed again with the use of the mobility aid device and the results are compared to confirm the improvement in the patient's performance regarding balance and mobility. Finally, the physical therapist refers the patient to the rehab center of our hospital for further rehabilitation, if applicable, and provides a written document with the type of the suggested device and possible purchase locations.","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44930229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Dead End: Challenges in Healthcare Delivery to Older Adults with history of Dementia and Incarceration- A Case Report","authors":"Shruti Anand, S. Saxena","doi":"10.17294/2694-4715.1035","DOIUrl":"https://doi.org/10.17294/2694-4715.1035","url":null,"abstract":"","PeriodicalId":73757,"journal":{"name":"Journal of geriatric emergency medicine","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41370451","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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