CRACKCast E181 – Approach to the Geriatric Patient

In CRACKCast, Featured, Podcast by Adam Thomas1 Comment

This episode of CRACKCast covers Rosen’s chapter 183, approach to the geriatric patient. Our geriatric patients can often mask serious diagnoses with vague presentations and multiple co-morbidities.

Shownotes–PDF HERE


Rosen’s In Perspective

Taking care of the elderly is hard! Given the Silver-Tsunami that is currently crashing down on us, we better get comfortable with this population.

But our classic history & gestalt can be difficult in the population

  • Difficult due to vague symptoms
  • Difficult history due to cognitive or physical deficits (hearing)
  • Blunted tachycardia response (use of beta blockers, antihypertensives)
  • Blunted immune response (Hyper or Hypothermia)

Screening tools are important:

Box 183.1 Identification of Seniors at Risk (ISAR) Tool

  1. Before the illness or injury that brought you to the emergency department, did you need someone to help you on a regular basis? (yes)
  2. Since the illness or injury that brought you to the emergency department, have you needed more help than usual to take care of yourself? (yes)
  3. Have you been hospitalized for one or more nights during the past 6 months (excluding a stay in the emergency department)? (yes)
  4. In general, do you see well? (no)
  5. In general, do you have serious problems with your memory? (yes)
  6. Do you take more than three different medications every day? (yes)

Each “yes” response counts as 1 point, for a total score ranging from 0 to 6. A patient is considered at high risk when the score is 2 or more.

Adapted from McCusker J, Bellavance F, Cardin S, et al: Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 47:1229–1237, 1999.

bCAM Assessment (Brief Confusion Assessment Method)

Figure 183.2

Need both of:

  1. Acute altered mental status or fluctuating course
  2. Inattention (months of year backward, or digit spans)

AND need one or more of:

  1. Disorganized thinking
  2. Altered level of consciousness

CAM Screen is positive if BOTH features 1 and 2 plus 3 or 4 are positive.

[1] List 10 items found on a functional assessment of the elderly (ADLs & IADLS).

Table 183.1: Functional Assessment

  1. Bathing
  2. Dressing
  3. Toileting
  4. Transferring
  5. Continence
  6. Feeding
  1. Telephone
  2. Shopping
  3. Food preparation
  4. Housekeeping
  5. Laundry
  6. Transportation
  7. Medication management
  8. Ability to handle finances

[2]  List 6 factors that lead to altered pharmacokinetics in the elderly. 

  • Altered GI motility and perfusion (blood flow)
  • Decreased hepatic function
  • Decreased renal function
  • Decreased lean body mass
  • Increased adipose tissue
  • Changes in protein binding

[3] List reason why the elderly are predisposed to adverse drug reactions.

  • Polypharmacy / drug interactions
  • Comorbidites
  • All of the pharmacokinetic reasons:
    • Altered GI motility and perfusion (blood flow)
    • Decreased hepatic function
    • Decreased renal function
    • Decreased lean body mass
    • Increased adipose tissue
    • Changes in protein binding

[4] List 15 Physiologic changes of aging that affect illness in the elderly, and list age-related changes to the cardiovascular system.  

  • Nervous System
    • Decreased BBB function = increased risk meningitis
    • Decreased temp responses = impaired thermoregulation
  • Skin
    • Atrophy of the skin = increased infections
    • Sweat gland function decreased = risk of hyperthermia
  • MSK
    • Osteoporosis = fracture risk
    • Lean body mass decreased = pharmacokinetic changes
  • Immune
    • Decreased antibodies = increased infections
    • Decreased cell-mediated-immunity = increased infections
  • CVS
    • Decreased inotropy = impaired Cardiac Output
    • Decreased chronotropy =  impaired Cardiac Output
  • Pulmonary
    • Decreased VC
    • Decreased compliance
  • Hepatic
    • Decreased hepatic blood flow = altered pharmacokinetics
    • Decreased p450 enzymes = altered pharmacokinetics
  • Renal
    • Decreased renal cell mass = altered pharmacokinetics
    • Decreased total body water = altered pharmacokinetics
  • GI
    • Decreased gastric mucosa = ulcer risk
    • Decreased bicarb = ulcer risk

Table 183.2: Age-related changes to the cardiovascular system.

Decreased arterial complianceIncreased afterload, left ventricular hypertrophy, hypertension
Myocardial cell hypertrophy, interstitial fibrosis, drop out of cardiac myocytesDecreased left ventricular compliance, increased contribution of atrial contraction to left ventricular end-diastolic volume (LVEDP)
Apoptosis of sinoatrial pacemaker cells, fibrosis and loss of His bundle cellsSlower intrinsic heart rate, varying degrees of heart block
Decreased responsiveness to β-adrenergic stimulation and reactivity to baroreceptors and chemoreceptorsIncreased circulating catecholamines
Fibrosis and calcification of heart valvesAortic valve sclerosis and stenosis

[5] Describe an approach to generalized weakness in the geriatric patient based on onset and focality.

See Figure 183.3

Focal Weakness 

Acute Focal Causes 

  • ICH
  • Ischemic Stroke
  • SAH
  • Tumor

Acute Bilateral Causes 

  • Brainstem stroke
  • SCI
    • trauma
    • infection
    • neoplasm
    • inflammatory
    • Guillain-Barre

Non-Focal Weakness 

Acute Non-Focal Causes

  • cardiac
  • delirium
  • metabolic
  • infection

Chronic Non-Focal Causes 

  • anemia
  • meds
  • inflammation
  • neurologic
  • deconditioning
  • malignancy

[6] List 8 predisposing risk factors for sepsis in the elderly.

See Figure 183.4

  1. Delirium and Dementia
  2. Decreased gag and cough reflex (aspiration risk)
  3. Endocrine deficiency (adrenal, gonads, thyroid)
  4. Poor nutrition
  5. Relative immunodeficiency
  6. Skin breakdown
  7. Multiple c0-morbidities
  8. Decreased cardiopulmonary reserve.

[7] What is sundown syndrome?

As per uptodate

“Sundowning — Delirium should be distinguished from “sundowning,” a frequently seen but poorly understood phenomenon of behavioral deterioration seen in the evening hours, typically in demented, institutionalized patients. Sundowning should be presumed to be delirium when it is a new pattern. Patients with established sundowning and no obvious medical illness may be suffering the effects of impaired circadian regulation or nocturnal factors in the institutional environment (eg, shift changes, noise, reduced staffing).”




[1] What are the most common medications implicated in adverse events for the elderly?

  • Most common = Cardiovascular meds
  • Diuretics
  • Opioids
  • Oral anticoagulants
  • Hypoglycemics

[2] List the reasons why diagnosing abdominal pain may be difficult to diagnose in the elderly.

  • Difficult history due to vague symptoms
  • Difficult history due to cognitive or physical deficits (hearing)
  • Blunted hemodynamic responses (BB/antihypertensives)
  • Blunted Immune Response (fever/WBC)
  • Decreased abdo wall muscles = decreased guarding / rebound
  • Shrinkage of omentum = decreased containment of intra-abdo processes
  • Increased rates of perforation (app/gall bag/bowel) = due to atherosclerosis / poor blood flow
  • Increased rates of mesenteric ischemia  = due to atherosclerosis / poor blood flow

[3] List the most common abdominal pathologies in the elderly.

 60% is surgical!

  • Cholecystitis
  • Appendicitis
  • Bowel obstruction
  • Hernia

This post was uploaded and copyedited by Owen Scheirer.

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..