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Acute critical care for geriatric patients Torna agli editoriali

Anna Giulia Cattaneo,DBSM

Emergencies occurring in old patients can represent a complex clinical problem, expecially because of staff members specialized in treating geriatric patients are frequently lacking in emergency departments. In the elderly the acute disease is often superimposed to other chronical conditions, simply linked to the aging itself. In general, there is no need of technical equipments different from those used in acute care of adult but jounger subjects, but special skill and competence should be auspicated. Other aspects of this problem are linked to the social and mental conditions of older patients: they should only be supported by inaffective relatives, unable to cohoperate at the best with the care givers, or even absolutely alone, as a number of aged individuals living at home. Aging potentially affects all the steps of clinical care.

1. Anamnestic records and diagnostic problems.
The first medical act, at least in usual conditions, is an accurate anamnestic record. This is often impossible or difficult to obtain in the case of emergencies, and the diagnostic skill of the staff can be the only support for a correct diagnosis. If the patient is an older one, additional problems can arise. In this eventuality, it is important to distinguish between what is due to the acute problem and what was prehexisting.

An old subject suffering form a recent stroke, as an exemple, can be unable of talking, but is its inability recent and due to the stroke itself, or is it, at least in part, linked to prehexisting conditions, like a dementia, Parkinson disease and other similar ones? Solving this problem can be important for diagnostical prediction, and when the patient lacks care givers or relatives which can answer the question an extra skilled diagnostical performance is required to the staff.
The problem can be hewever much more subtle. An aged unknown person cames in the emergency room in confusional state, a not infrequent occurrence in aging. He (or she) does not have any people at the present which can give very important informations: is the patients suffering from dementia, diabetes, dehydration, or other conditions possibly linked to its present state? Is he taking medication potentially motivating the confusion? Is the elder addict to drugs or alchool? Is he victim of an accident or perhaps of an abuse episode? Of course, every question can be answered, with the help of time and diagnostic procedures, but you have a very good occasion to train your ability in early diagnosis.
Even when the elder claims more physical symptoms, diagnosis can be difficult. Pain is often poorly reported by the aged, and an acute infarct can be misdiagnosed. Moderate abdominal pain can be the only indicator of a dramatically evolving events, like the rupture of an aortic aneurisma, but can even be the symptom of benign and minor conditions. Chronic prostatitis, urogenital inflammations, and even more benign prostatic enlargement are a frequent evenience in aging, but a serious consequence of these often not threatening conditions is acute urinary retention frequently, in which extreme pain not due to inflammation can be experienced.
Emergencies in elderly people can presents with unusual symptomatology, other than pain, or pathology itself can be unusual in younger individuals. Good practice requires both knowledge of the diseases most frequent in elderly, and of those unusual in general population, but more common at older age.
Inspection requires attention to eventual signs of poor hygienic and nutritional conditions. Ecchymoses can suggest falls, abuse or aggressive behaviour, accident or spontaneous bleeding, even from life threatening lesions.

2. Medication
Even when the most probable diagnosis has been reached, the age of the patient does not ceases to ask the doctor for its best. Drugs have a large number of side effects, some linked to the aging condition itself, and the need for no delay cannot support a not cautious medication. Side effects of the drug of choice and pharmacological interactions with drugs recently or chronically assumed by the patient must be carefully considered, even when the previous medication sheduling is unknown.
Updated reviews on this argument appear frequently in the international medical publications (Am J Emerg Med. 2006 Jul;24(4):468-78; Emerg Med Clin North Am. 2006 May;24(2):449-65, viii).

3. Surgery
The physical frailty of old persons enhances the risk of side effects in the case of challenging treatments and manipulations. Every invasive therapeutic measure performed in the aged can be much more destructive than in younger organisms, as a consequence of reduced tissue trophism, poor hygiene, nutrition or tissue hydration. Every type of catheterism is associated with an increased risk of hiatrogenic complications because of tissue frailty and lack of elasticity, and fistulae, ruptures or hemorrages may follow this kind of manipulations.

When superficial scares must be cured, alternative repair techniques (skin transplant, as an exemple) should be appropriate even in the case of minor lesions: the risk of infections and bleeding increases with the longer time required for skin repair.
Falls and fractures are so frequent that can be considered a special topic of the care of the aged person, requiring a multidisciplinar approach, with the need of radiological, medical, neurological, orthopedic and rehabilitative diagnostics and treatments.

4. Some acute conditions frequently presenting unusual features in the elderly.

This last point is not planned, of course, to be a complete discussion of the argument, but only to recall some occurrencies choiced from the most recent reports appeared in medical literature.
Age is the most important single risk factor associated with stroke, and this last is probably the most important cause of long-term disability in the industrialized world. However, other modifiable risk factors are recognized possibly influencing the prognosis. The scheduling and effectiveness of treatment are greatly influenced by the gap between the event and the request of medical help, but this kind of data are frequently undereported in the case of elderly patients.

Acute respiratory failure in the elderly is an important topic, but studies evaluating prognostic factors (mortality or long-term outcomes) have been considered lacking (Fagon JY, Crit Care. 2006;10(3):R82).

Acute psychiatric disorders, agitation and aggressive behaviour, confusion, amnesia, can be common in the older, and require an accurate diagnosis, as focused in a recent review on the argument (Emerg Med Clin North Am. 2006 May;24(2):467-90, viii). A wide class of drugs used to control agitation shows weak evidence for antiaggressive effects, atypical antipsychotics seem to be superior to others. The intramuscular formulation provides a powerfull mean of treating for emergency care. In the case of elderly patients with dementia, however, they are considered unsafe (J Clin Psychiatry. 2006;67, 1013-24 and Suppl 10:22-31). Seizures are another evenience which can be frequent in the elderly, not to be confused with agitation, stupor or confusional conditions.

Fever must be correctly diagnosed; acute toxicity of neuroleptics is one possibility between others.

Myocardial ischemia and infarct can present unusual features, the recently defined transient left ventricular apical balooning being a most elusive one (WMJ. 2006 May;105(3):49-54).
Spontaneous internal hemorrages and bleeding must be carefully considered, and surgical treatment never considered an obsolete or desperate measure at any age, even in the very old patient. Bleeding can occurs from varices, expecially in hepatic cirrhosis, and ileal varices can occur, in addition to more traditional localizations (J Nippon Med Sch. 2006 Aug;73(4):221-5).

Aortic sclerosis can be the source of aneurismatic ruptures, which can be poorly symptomatic even if seriously life threatening. An unusual case of retropharyngeal hemorrage presenting with cough, dysphagia, dyspnea, and cervical ecchymosis in an octuagenary male patient has been reported by Miller et al. (S D Med. 2006 Jul;59(7):295-7, 299).

Monitoring vital parameters during stressfull manipulations permits a safer procedure, with early detection of both gradual deleterious trends of pre-existing conditions and acute emergencies occurring during the treatment. Monitoring has been proposed as auspicable for elderly persons even during dental care (Int Dent J. 2006 Apr;56(2):102-8).

In summary, it seems to be auspicable that in the emergency departments several staff members should be expecially trained in treating the frail aged patient. In addition, it should be of great help a programmed intervention focused on social prevention of neglect and abuse of old persons living alone. Better connection between nursing homes or residential care givers and hospitals, and continuity of care after the emergency, actively involving general practitioners, nurses and nursing home staff, should be obtained with the help of special training programs.

Anna Giulia Cattaneo, DBSM, Università dell'Insubria, Via J-H Dunant,3 - 2100 Varese

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