GEMCAST: Recent Episodes
Christina Shenvi
Welcome to GEMCAST! Shownotes and more info are available on https://gedcollaborative.com/resources/gemcast/ GEMCAST is a Geriatric Emergency Medicine Podcast created to help clinicians, nurses, or paramedics who take care of older adults, particularly in the Emergency Department setting. Welcome! I'm your host, Christina Shenvi. You can connect with me on twitter @clshenvi
Disclaimer: By listening to this podcast, you agree not to use this podcast or website as medical advice to treat any medical condition in either yourself or others, including but not limited to patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall this podcast, website, or any contributors to it be responsible for damages arising from use of the podcast. Furthermore, this podcast should not be used in any legal capacity whatsoever, including but not limited to establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast.
Our population is aging, and with that comes an increase in the number of older adults in emergency departments. Delirium affects up to 1/3 older adults who present to the ED and is a medical emergency that is often overlooked by ED clinicians. In this episode of GEMCast host Dr. Christina Shenvi discusses the importance of recognising delirium, documenting it, and intervening where possible in the ED with Dr. Kayla Furlong and Dr. Gillian Sheppard. Dr. Furlong and Dr. Sheppard are both emergency medicine physicians in St. John’s, Newfoundland & Labrador, who are experts in point of care ultrasound (POCUS). Dr. Furlong is a Clinical Assistant Professor in the Faculty of Medicine at Memorial University and is the Chair of the CAEP Geriatric EM Committee. Dr. Sheppard is an Associate Professor and Chair of the Discipline of Emergency Medicine at Memorial University. She is also a Diplomate of the Royal College of Physicians of Canada with an Area of Focused Competence in POCUS and is the education lead for the Canadian Association of Emergency Physicians Emergency Ultrasound Committee.They have taken a special interest in whether the use of POCUS increases the ED clinicians’ ability to determine the aetiology of a geriatric patient’s delirium or agitation, and in doing so have developed the ABLE approach. They discuss why and how POCUS can be a useful tool and provide helpful tips for ED clinicians for how to implement POCUS. Tune in to learn more about how to approach older adults in the ED considering delirium, agitation, and the challenges they present. For further show notes head to https://gedcollaborative.com/resource/delirium/delirium-agitation-and-the-role-of-pocus-in-older-adults-in-the-ed/
In today’s episode host Dr. Christina Shenvi is joined by Dr. Robert Sternberg, Ultrasound Director at Akron General to discuss ultrasound-guided nerve blocks for precise pain relief in older patients. Ultrasound-guided nerve blocks provide relief from one of the most common emergency department complaints: pain. In addition to their use in acute pain management, nerve blocks can help reduce the use of opioids, reduce hospital length of stay, and improve patient outcomes and experiences. Using case examples, Dr. Sternberg talks through how to perform 4 common types of nerve blocks you may use in the emergency department with an elderly patient: Fascia Iliaca Compartment Block (FICB), Pericapsular Nerve Group (PENG) Block, Serratus Anterior Plane (SAP) Block and Erector Spinae Block (ESB). Tune in to hear indications, key anatomical landmarks, dosing, and techniques for each of the nerve blocks.
In this episode learn about how the Generational Health Program at Sharp Memorial Hospital in San Diego was developed and expanded to create an extensive care program that provides specialised care for older adults. What started as a pilot program in 2019 is now a multidisciplinary age-friendly collaboration that begins right at admission. Host Christina Shenvi is joined by 3 experts from Sharp Memorial Hospital who provide insight into how this program operates to provide the highest level of care for older patients. Diane Wintz, MD, a trauma surgeon who was heavily involved in creating the Generational Health Program. Her goal was to change how traditional health care models approach elderly patients presenting to the ED. Kelly Wright, RN, trained as an oncology nurse and now serves as manager of the program, and Stacy Nilsen, PhD RN, who’s focus is on the feasibility, implementation, education and data assessment of the program. Together they discuss the creation and expansion of the program and highlight the most important aspects of what makes it a success.
Today’s episode provides an introduction and overview of the 5 domains of the CMS Age-Friendly Hospital Measure. Host Dr. Christina Shenvi is joined by Dr. Marcia Russell to help clarify what each of these domains entail and how they may be carried out in the ED. They also discuss concerns that may be brought about following the implementation of this measure on January 1, 2025, and how these issues might be addressed and minimised.Dr. Marcia Russel is a colorectal surgeon and Associate Professor at UCLA. She has a special interest in the surgical care of older adults and has worked with ACS to improve geriatric surgery through the ACS Geriatric Surgery Verification Program.
With the upcoming implementation of the new CMS age-friendly hospital measure, hospitals will be required to attest that they review medications to identify potentially inappropriate medications (PIMS) for older adults. Dr. Martin Casey, MD, MPH is an Assistant Professor in the Department of Emergency Medicine at UNC School of Medicine. Dr. Caseys’ work has focused on the identifying PIMS and finding opportunities to reduce the use of, and deprescribe, potentially harmful medications in the emergency department. In this episode, Dr. Christina Shenvi and Dr. Martin Casey will discuss strategies for ED physicians who face unique challenges when assessing older patients’ medications. Using case examples of deprescribing in practice, they illustrate how deprescribing is a nuanced skill and how to approach it.
Dr. Cristina Shenvi is joined today by a panel to explore Geriatric Emergency Medicine (GEM) from a global perspective. As the global population ages, the importance of GEM and its continued development as a subspecialty becomes increasingly evident. This episode will examine the unique challenges that arise as GEM evolves and how different healthcare systems are adapting to meet these challenges. The panel will also discuss innovative practices and solutions that have emerged in their respective countries to advance GEM and improve care for elderly patients.The expert panel features three distinguished guests: Dr. Mohd Idzwan Zakaria (@prof_idzwan), a senior consultant and professor of Emergency Medicine at University Malaya in Malaysia, specializing in innovative approaches to managing older patients; Dr. Rosa McNamara (@rosaMcNamara), a consultant at St. Vincent’s University Hospital in Dublin, Ireland, and GEM Special Interest Group Chair for the International Federation for Emergency Medicine, with extensive expertise in GEM and medical education; and Dr. Rasha Buhumaid (@Rbuhamaid), an Emergency Physician in Dubai, UAE, President of the Emirates Society for Emergency Medicine, working in both public health and private practice, and an Assistant Professor at Mohammed Bin Rashid University of Medicine and Health Sciences.
Alzheimer's disease (AD) begins developing in the brain 20-30 years before symptoms start to present in patients. Recent evidence suggests that up to 40% of AD cases could potentially be prevented by addressing modifiable risk factors such as insufficient education, hearing loss, hypertension, obesity, smoking, depression, social isolation, physical inactivity, diabetes, excessive alcohol consumption, air pollution, and traumatic brain injury. Dr. Christina Shenvi is joined once again by Dr. Richard Isaacson, M.D., a Harvard-trained preventive neurologist and world-renowned researcher at the Institute for Neurodegenerative Diseases in Florida. In 2013, he founded the Alzheimer's Prevention Clinic at Weill Cornell Medicine and New York-Presbyterian, the first of its kind in the United States. In this episode of GEMCast they focus on the importance of individualized intervention and prevention as the future of AD treatment.
Resuscitation of older adults in the emergency department poses unique challenges for physicians. Understanding the differences between a typical resuscitation process compared to a resuscitation of an older adult is essential to appropriately manage and treat this population. In this episode Dr. Cliff Reid joins Dr. Christina Shenvi to explore these differences and the associated challenges, and highlight some tools he uses in his own practice. Cliff Reid, MD, is an Emergency, Retrieval, and Critical Care Physician and educator in the greater Sydney area with a focus on resuscitation of adults and children.
In 2021 constipation related visits to the ED reached over 1 million.The prevalence of constipation in elderly individuals in the community is between 15-30% and for those living in nursing homes or long-term care facilities it ranges between 50-75%. While constipation itself is not usually life-threatening, it can be indicative of life-threatening diseases or disorders and therefore a comprehensive history and physical assessment of patients is essential to avoid missing a critical diagnosis.Sarah Lee is an emergency physician at the University of Maryland. In this episode she joins Dr. Christina Shenvi to discuss the presentation, risk factors, assessment and management of constipation in geriatric patients in the ED.
Dr. Christina Shenvi and Dr. Mike Craig discuss the "Home Hospital" model and its potential to transform the way we care for older adults, by bringing hospital-level care to patients' homes.
What ED Physicians need to know about Amyloid Targeting Treatments Part 2 by Christina Shenvi
What ED Physicians need to know about Amyloid Targeting Treatments Part 1 by Christina Shenvi
Join Dr. Christina Shenvi and Dr. Cameron Gettel as they talk about a paper that provides the first benchmarks for emergency care process outcomes in geriatric EDs compared with nongeriatric EDs.
Any transition of care has risks, especially for older patients. In this episode of GEMCast, Dr. Shenvi and Dr. Magidson talk about the importance of thoughtful and deliberate transitions of care for older adults.
Join Dr. Christina Shenvi and Dr. Teresita Hogan as they walk through the history of geriatric emergency medicine. Learn about the challenges, changes, and breakthroughs that have shaped this field over the past 40 years.
In this episode of GEMCast Dr. Christina Shenvi is joined by Dr. Chris Carpenter to discuss GEAR 2.0-Advancing Dementia Care. Learn how GEAR 2.0 identified and prioritized research gaps in emergency care for persons living with dementia and their care partners.
In this episode of GEMCast Dr. Christina Shenvi is joined by Pamela Martin and Dr. Ula Hwang to learn about Geriatric transitional care nurses and how they can be incorporated into an ED to improve care for older patients.
Dr. Christina Shenvi is joined by Dr. Lucas Da Silva for a conversation about the concept of patient experience and why it is important to older adult care in the emergency department.
In this episode, GEMCast host Dr. Christina Shenvi is joined by Dr. Katie Buck to discuss the challenges surrounding diagnosing older adults with pneumonia.
Dr. Christina Shenvi sits down with Dr. Kerstin de Wit to learn how much anticoagulation matters in terms of increasing the risk of intracranial hemorrhage after a ground-level fall.
How to Diagnose and Manage Vertebral Compression Fractures in the ED by Christina Shenvi
Dr. Shenvi sits down with Dr. Don Melady and Dr. John Schumacher to discuss their new book: Creating a Geriatric Emergency Department. The book is practical and accessible, providing essential guidance on assessing the ED care of older patients - and improving it.
Dr. Shenvi sits down with Dr. Maura Kennedy to discuss safe and effective management of agitated older patients, and the role of dementia in producing these symptoms.
Infections in older adults are common, and often present atypically leading to delayed diagnosis and increased morbidity and mortality - Dr. Shenvi and Dr. Khoujah discuss
Dementia in the ED is a critical and often overlooked issue. Dr Binkley and Dr. Shenvi discuss.
In this episode we discuss inadequate pain assessment in older adults, opiophobia, lack of current pharmacologic knowledge, and how to better manage pain in older adults in the ED.
Debra Eagles and Danya Khoujah discuss delirium as a medical emergency and how to prevent, recognize, diagnose, and treat delirium in the ED.
Dr. Selman and I discuss the value and importance of understanding and evaluating frailty in older adults in the Emergency Department.
Nicole Soria and Danya Khoujah join in as we discuss the importance of GU emergencies in older adults and get clinical tips to do better in your ED.
Dr. Kusum Mathews discusses her experience as the attending on the first week of the COVID ICU in her hospital. We discuss vent management, ethics, protecting our families, and coping skills. There are links to the surviving sepsis COVID-19 recommendations and other training resources at www.gempodcast.com
Dr. Tess Hogan and I discuss COVID-19 and the elderly. Mortality is highest in this population. What can we do to make sure we don't miss it, and to help prevent spread? See: www.gempodcast.com for show notes.
Image from cdc.gov.
Dr. Lauren Southerland describes her recent work in defining the four main models of geriatric ED care used by Geriatric EDs in the U.S. This is a practical blueprint for anyone interested in pursuing Geriatric ED Accreditation. See the reference and more at: gempodcast.com/2020/02/04/ged-models/
Christian Nickel describes and explains the 10 "commandments" of geriatric EM care. See www.gempodcast.com for references and more.
Paul Deknoing and Lauren Bailey run this session with fast-paced, high-yield principles of geriatric EM care.
See www.gempodcast.com for more info and references.
Dr. Lauren Southerland and I discuss her recent paper on the importance of and how to do a discharge risk assessment in elderly patients in the ED. For more, go to www.gempodcast.com
Leah Hatfield and I discuss the potential benefits of clevidipine for management of Hypertensive Emergencies. Learn more about indications, dosing, titration, and potential contra-indications. For full shownotes, credits, and references, see www.gempodcast.com
Drs. Ferdinando Mirarchi and Marie-Carmelle Elie explain the meaning and ramifications of different types of advance care planning orders and what they mean to physicians, APPs, or nurses caring for patients.
Image credit: pixabay.com/photos/business-signature-contract-962355/ Sound credit:www.freesound.org/people/HerbertBoland/sounds/128544/
Shan Liu talks about why we should avoid the term "mechanical fall" and how we can help prevent future falls from the ED. See www.gempodcast.com for references and more.
Dr. Sandy Schneider and I discuss a new toll released by ACEP for assessing and managing older adults with agitation and confusion. See the full show notes at www.gempodcast.com. The tool is available at www.acep.org/adept
Maura Kennedy discusses a recent paper on orthostatic vital signs. The conclusions may surprise you! See www.gempodcast.com for more info and the paper reference.
Sergey Motov discusses his recent paper on subdissociative ketamine in older adults. See www.gempodcast.com for more info and the full reference.
Mary Mulcare and I talk about how to diagnose and treat UTIs, the dangers of catheters, and how to protocolize catheter reduction. See https://gempodcast.com/2018/02/02/utis-in-older-adults/ for show notes, more info, and references.
Zara Cooper is an acute care and trauma surgeon at the Brigham and Women's hospital. See www.gempodcast.com for full details and show notes.
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image is from: https://pixabay.com/en/heart-first-aid-medical-medicine-2730784/
Chris Carpenter discusses the new ACEP accreditation of Geriatric EDs and what your ED would need to do to become accredited. See www.gempodcast.com for full shownotes and more info or to leave a comment.
Music credit: Bob Dylan, The Times They Are Changing, 1964, Columbia Records
David Silfen, an EMS provider describes a program he has helped initiate to intervene with older adults who have a high falls risk. See www.gempodcast.com for full details and show notes.
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image credit: https://pixabay.com/en/step-falling-tripping-danger-98822/
Dr. Alisha Benner discusses tips for palliative care in the ED. see www.gempodcast.com for show notes, references, information, and to leave comments! Follow @gempodcast on twitter.
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image credit: https://commons.wikimedia.org/wiki/File:Dante_Gabriel_Rossetti_-_Study_of_Dante_holding_the_hand_of_Love.jpg
Ophthalmologist Dr. Bryan Hong continues to discuss his approach to some of the common eye emergencies that bring older adults to the Emergency Department.
see www.gempodcast.com for show notes and information and to leave comments.
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image credit: https://pixabay.com/en/eye-black-reds-female-red-color-1574829/
Ophthalmologist Dr. Bryan Hong talks about his approach to some of the common eye emergencies that bring older adults to the Emergency Department.
see www.gempodcast.com for show notes and information and to leave comments.
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image credit: https://commons.wikimedia.org/wiki/File:A_selection_of_glass_eyes_from_an_opticians_glas_eye_case._Wellcome_L0036581.jpg
Leah Hatfield discusses the new oral anticoagulants, and how to reverse them in cases of life threatening bleeds. To leave a comment and for the shownotes, see https://gempodcast.com/2016/09/30/how-to-reverse-oral-anticoagulants/
Tony Rosen discusses how to identify elder abuse and ways to intervene.
Elder abuse is a common and under-recognized problem among older adults. In the Emergency Department, we are uniquely positioned to identify patients who may be at risk. In this episode, Tony Rosen, an Emergency Physician and researcher with fellowship training in Geriatric Emergency Medicine, who works at Cornell in NYC discusses what constitutes elder abuse, its prevalence, how to identify it, and what to do when you suspect it.
For State requirements, see here: http://www.napsa-now.org/wp-content/uploads/2014/11/Mandatory-Reporting-Chart-Updated-FINAL.pdf
Please see https://gempodcast.com/2016/08/26/how-to-identify-and-intervene-in-cases-of-elder-abuse/ for the full show notes and references.
Amal Mattu talks about ACS presentations, workup, and management in older adults, and why the atypical is typical!
For the full shownotes and references, and to leave a comment, see: https://gempodcast.com
Chest pain is one of the most common reasons why people present to the ED. The chief complaint of Chest Pain typically triggers an automatic EKG, and potentially a workup for acute coronary syndrome. However, many patients who are having ACS do not present with chest pain. Instead, they may have dyspnea, diaphoresis, nausea, vomiting, abdominal pain, or other non-specific symptoms. Which patients are most likely to present this way? Older adults. And the older the patient, the more likely they are to be chest-pain free when they present with an NSTEMI or STEMI. So it is up to the medical provider to be vigilant, consider possible angina equivalents, and order the right workup.
Dr. Mattu talks us through some of the statistics of how often MIs occur without chest pain with age, how EKG interpretation may differ, and how management should differ vs how it does differ. Patients presenting with atypical symptoms are less likely to receive an aspirin or thrombolytics/PCI, and their mortality is higher.
Selected References: 1. Mattu A, Grossman SA, Rose PL. Geriatric emergencies - A discussion-based review. Wiley Blackwell; 2016.
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Glickman SW, Shofer FS, Wu MC, et al. Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. Am Heart J. 2012;163(3):372-382. http://www.ncbi.nlm.nih.gov/pubmed/22424007
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Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: Insights from the global registry of acute coronary events. Chest. 2004;126(2):461-469. http://www.ncbi.nlm.nih.gov/pubmed/15302732
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Cannon AR, Lin L, Lytle B, Peterson ED, Cairns CB, Glickman SW. Use of prehospital 12-lead electrocardiography and treatment times among ST-elevation myocardial infarction patients with atypical symptoms. Acad Emerg Med. 2014;21(8):892-898. http://www.ncbi.nlm.nih.gov/pubmed/25155289
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Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: A scientific statement for healthcare professionals from the american heart association council on clinical cardiology: In collaboration with the society of geriatric cardiology. Circulation. 2007;115(19):2549-2569. http://www.ncbi.nlm.nih.gov/pubmed/17502590
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Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813-822. http://www.ncbi.nlm.nih.gov/pubmed/22357832
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image credit: https://pixabay.com/en/pulse-trace-healthcare-medicine-163708/
Chris Carpenter, one of the authors of the Geriatric ED guidelines, presents 5 high-impact, low-cost ways to make your ED and your practice more geriatric-friendly.
For the full show notes with references and to leave comments, see: https://gempodcast.com/2016/06/29/5-ways-to-geriatricize-your-ed/
Geriatric EDs, or Senior EDs, have been popping up around the country. The idea behind them is that having a separate space, a distinct staff, and specialized protocols, can help provide better care to older adults. However, for many EDs and hospital systems this is simply not feasible. In this episode, Chris Carpenter (@GeriatricEDnews) presents five high-yield, low-cost ways that those of us working in non-senior EDs can take some of the principles of geriatric emergency medicine and apply them either to our own practice or implement them in our own EDs, without a lot of funding. For more about Geriatric EDs, check out this ALiEM blog post. https://www.aliem.com/2014/geriatric-emergency-departments-coming-hospital-near/
The full geriatric ED guidelines are available here: https://www.acep.org/geriedguidelines/
To learn more about many of the Geriatric EM ideas and concepts discussed here, check out the Geri-EM.com site, where you can also get free CME.
For the references see: https://gempodcast.com/2016/06/29/5-ways-to-geriatricize-your-ed/
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image from https://commons.wikimedia.org/wiki/File:Clock_Cogs.jpg
Jeff Kline talks about PEs in older adults. What's different and what's the same for older vs younger patients? Find out here!
See gempodcast.com/2016/06/02/pulmonary-emboli-in-older-adults/ for a full description, links, and to leave comments!
Not a day goes by that an Emergency Physician doesn’t at least consider PE in a patient who presents with chest pain, dyspnea, or syncope. We have become familiar with using risk stratification tools like the Wells Score and the PERC criteria. But what do you do in older adults? All of them will automatically NOT be PERC negative because of their age. In this episode, with PE guru Jeff Kline, we discuss the presentation of PE in older adults, including the demographics, diagnosis, and how treatment may differ from younger adults in small, sub-massive, and massive PEs.
Selected References:
- Zondag W, Vingerhoets LM, Durian MF, et al. Hestia criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function. J Thromb Haemost. 2013;11(4):686-692. http://www.ncbi.nlm.nih.gov/pubmed/23336721
- Beam DM, Kahler ZP, Kline JA. Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: A one-year preplanned analysis. Acad Emerg Med. 2015;22(7):788-795. http://www.ncbi.nlm.nih.gov/pubmed/26113241
- Kahler ZP, Kline JA. Standardizing the D-dimer assay: Proposing the D-dimer international managed ratio. Clin Chem. 2015;61(5):776-778. http://www.ncbi.nlm.nih.gov/pubmed/25816812
- Kahler ZP, Beam DM, Kline JA. Cost of treating venous thromboembolism with heparin and warfarin versus home treatment with rivaroxaban. Acad Emerg Med. 2015;22(7):796-802. http://www.ncbi.nlm.nih.gov/pubmed/26111453
- Zhang Y, Zhou Q, Zou Y, et al. Risk factors for pulmonary embolism in patients preliminarily diagnosed with community-acquired pneumonia: A prospective cohort study. J Thromb Thrombolysis. 2015. http://www.ncbi.nlm.nih.gov/pubmed/26370200
- Sharp AL, Vinson DR, Alamshaw F, Handler J, Gould MK. An age-adjusted D-dimer threshold for emergency department patients with suspected pulmonary embolus: Accuracy and clinical implications. Ann Emerg Med. 2016;67(2):249-257. http://www.ncbi.nlm.nih.gov/pubmed/26320520
- Kirschner JM, Kline JA. Is it time to raise the bar? age-adjusted D-dimer cutoff levels to exclude pulmonary embolism. Ann Emerg Med. 2014;64(1):86-87. http://www.ncbi.nlm.nih.gov/pubmed/24951413
- Kline JA, Kabrhel C. Emergency evaluation for pulmonary embolism, part 2: Diagnostic approach. J Emerg Med. 2015;49(1):104-117. http://www.ncbi.nlm.nih.gov/pubmed/25800524
- Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772-780. http://www.ncbi.nlm.nih.gov/pubmed/18318689
Image credit: http://anthrocolors.deviantart.com/art/Lungs-for-fresh-air-edited-298950224
This podcast uses sounds from freesound.org by Jobro and HerbertBoland
Tim Platts-Mills shares his pearls about pain management for older adults in the ED.
See here to leave a comment: https://gempodcast.com/2016/05/02/pearls-and-pitfalls-of-pain-management-in-older-adults/
Pain is the number one reason why people seek care in the Emergency Department (ED). One major goal of acute care is diagnosing the cause of the pain, but another is helping relieve the suffering associated with pain. In older adults, some of the risks of pain management with opioids are amplified, such as the risk of sedation and falls. With NSAIDs, there is a higher risk of acute renal insufficiency and electrolyte abnormalities, as well as cardiovascular risks with longer treatment. How should we approach acute pain management in the ED, and on discharge in older patients? In this podcast episode, Tim Platts-Mills, an expert and researcher on pain in older adults talks us through some ideas for non-opiates, opiates, and other adjuncts. We discuss some of the risks of over-treatment and under-treatment, and introduce the idea of the allostatic load created by chronic pain.
Selected References
- Hwang U, Platts-Mills TF. Acute pain management in older adults in the emergency department. Clin Geriatr Med. 2013;29(1):151-164. http://www.ncbi.nlm.nih.gov/pubmed/23177605
- Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US emergency department patients are less likely to receive pain medication than younger patients: Results from a national survey. Ann Emerg Med. 2012;60(2):199-206. http://www.ncbi.nlm.nih.gov/pubmed/22032803
- Hwang U, Richardson LD, Harris B, Morrison RS. The quality of emergency department pain care for older adult patients. J Am Geriatr Soc. 2010;58(11):2122-2128. http://www.ncbi.nlm.nih.gov/pubmed/21054293
- Terrell KM, Hui SL, Castelluccio P, Kroenke K, McGrath RB, Miller DK. Analgesic prescribing for patients who are discharged from an emergency department. Pain Med. 2010;11(7):1072-1077. http://www.ncbi.nlm.nih.gov/pubmed/20642733
- Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med. 2005;352(13):1324-1334. http://www.ncbi.nlm.nih.gov/pubmed/15800228
- Siddall PJ, Cousins MJ. Persistent pain as a disease entity: Implications for clinical management. Anesth Analg. 2004;99(2):510-20, table of contents. http://www.ncbi.nlm.nih.gov/pubmed/15271732
- Jakobsson U, Klevsgard R, Westergren A, Hallberg IR. Old people in pain: A comparative study. J Pain Symptom Manage. 2003;26(1):625-636. http://www.ncbi.nlm.nih.gov/pubmed/12850645
- Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet. 1999;354(9186):1248-1252. http://www.ncbi.nlm.nih.gov/pubmed/10520633
- Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE study group. systematic assessment of geriatric drug use via epidemiology. JAMA. 1998;279(23):1877-1882. http://www.ncbi.nlm.nih.gov/pubmed/9634258 This podcast uses sounds from freesound.org by Jobro and HerbertBoland Image credit: https://pixabay.com/en/heart-3d-stone-white-pain-old-1463424/
Bryan Hayes and David Juurlink explain why several common meds we use in the ED can cause dangerous complications for older patients.
See http://gempodcast.com/2016/03/30/dangerous-med-combos-in-older-adults/ to leave a comment.
Look twice at the med list before you prescribe these! Two distinguished guests join me this month, David Juurlink (@DavidJuurlink) and Bryan Hayes (@PharmERToxyGuy) to discuss medication interactions. There are many medications that we commonly prescribe in the ED that can have potentially deadly side effects when combined with other meds that a patient is already on. It is important to always check the patient’s medication list prior to writing a new script. We present two examples of clinical cases in which commonly used medications could prove dangerous in combination with other medications: cellulitis, and a community-acquired pneumonia. We discuss potential side effects from medication interactions (with a little pathophysiology thrown in), and some alternative medications that may be safer.
References: 1. Baillargeon J, Holmes HM, Lin YL, Raji MA, Sharma G, Kuo YF. Concurrent use of warfarin and antibiotics and the risk of bleeding in older adults. Am J Med. 2012;125(2):183-189. http://www.ncbi.nlm.nih.gov/pubmed/22269622 2. Ho JM, Juurlink DN. Considerations when prescribing trimethoprim-sulfamethoxazole. CMAJ. 2011;183(16):1851-1858. http://www.ncbi.nlm.nih.gov/pubmed/21989472 3. Fralick M, Macdonald EM, Gomes T, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: Population based study. BMJ. 2014;349:g6196. http://www.ncbi.nlm.nih.gov/pubmed/25359996 4. Juurlink DN, Mamdani M, Kopp A, Laupacis A, Redelmeier DA. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;289(13):1652-1658. http://www.ncbi.nlm.nih.gov/pubmed/12672733 5. Juurlink DN. The cardiovascular safety of azithromycin. CMAJ. 2014;186(15):1127-1128. http://www.ncbi.nlm.nih.gov/pubmed/25096666 6. Wright AJ, Gomes T, Mamdani MM, Horn JR, Juurlink DN. The risk of hypotension following co-prescription of macrolide antibiotics and calcium-channel blockers. CMAJ. 2011;183(3):303-307. http://www.ncbi.nlm.nih.gov/pubmed/21242274
Sound credits: This podcast uses sounds from freesound.org by Jobro and HerbertBoland
Katren Tyler and Dane Stevenson talk about their protocolized pathway to make sure patients with hip fractures get the best care possible.
See http://gempodcast.com/2016/03/01/hip-fracture-management-pathways-in-older-adults/#more-130 for the full shownotes and to leave a comment!
Hip fractures are a common injury among older adults and have a staggering one-year mortality of 20-30%. In this episode we discuss a multi-disciplinary pathway to improve the acute care of patients with hip fractures. It can help standardize care, improve pain control, decrease pain-related delirium, reduce the time from the ED to the operating room, and decrease the hospital length of stay. Also, if you have never heard of the fascia iliaca compartment block for pain management in patients with hip fractures, this could be practice-changing for you!
References and Resources:
Femoral Nerve Block podcast from the ultrasound podcast: http://www.ultrasoundpodcast.com/2012/03/episode-24-femoral-nerve/
Fascia Iliaca block Video: https://www.youtube.com/watch?v=p6X0IiYolIk
Femoral Nerve Block video: https://www.youtube.com/watch?v=5ht_N8j2KL8
This is a description of guidelines from the UK on recommendations for hip fracture management.
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. PMID 7715059
Godoy Monzon, D., et al. (2007). “Single fascia iliaca compartment block for post-hip fracture pain relief.” Journal of Emergency Medicine 32(3): 257-262. PMID 17394987
Gottschalk, A., et al. (2015). “The Impact of Incident Postoperative Delirium on Survival of Elderly Patients After Surgery for Hip Fracture Repair.” Anesthesia and Analgesia. PMID 25590791
Hogh, A., et al. (2008). “Fascia iliaca compartment block performed by junior registrars as a supplement to pre-operative analgesia for patients with hip fracture.” Strategies Trauma Limb Reconstr 3(2): 65-70. PMID 18762870
Kates, S. L., et al. (2015). “Financial Implications of Hospital Readmission After Hip Fracture.” Geriatr Orthop Surg Rehabil 6(3): 140-146. PMID 26328226 http://www.ncbi.nlm.nih.gov/pubmed/26328226
Lees, D., et al. (2014). “Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites.” European Journal of Emergency Medicine. PMID 24949565
Marcantonio, E. R., et al. (2000). “Delirium is independently associated with poor functional recovery after hip fracture.” Journal of the American Geriatrics Society 48(6): 618-624. PMID 10855596
Mouzopoulos, G., et al. (2009). “Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study.” Journal of Orthopaedics and Traumatology 10(3): 127-133. PMID: 19690943
Mundi, S., et al. (2014). “Similar mortality rates in hip fracture patients over the past 31 years.” Acta Orthopaedica 85(1): 54-59. PMID 24397744
Stoneham, M., et al. (2014). “Emergency surgery: the big three–abdominal aortic aneurysm, laparotomy and hip fracture.” Anaesthesia 69 Suppl 1: 70-80. PMID 24303863
Sound credits: This podcast uses sounds from freesound.org by Jobro and HerbertBoland
Image credit: https://www.flickr.com/photos/mac_filko/5132451119
May Yen, toxicologist, talks about Digoxin and CCB toxicity in older adults.
For the full description and to leave comments, please go to: http://gempodcast.com/2016/02/11/geriatric-toxicology-part-3-digoxin-and-ccbs/
Connect on twitter: @gempodcast
Digoxin and Calcium Channel Blockers are both medications that can cause unstable bradycardias. Patients who overdose on them can present extremely ill-appearing, and require rapid intervention and stabilization. In this final geri-tox episode, Dr. May Yen talks about identifying and managing patients, particularly older adults, with these overdoses. Who needs digibind? How much insulin is used in high-dose insulin euglycemic therapy? What are some last ditch efforts for severe calcium channel blocker overdoses? We also drop some board review pearls. For example, those halos classically associated with cardiac glycosides such as digoxin seem to be much more prevalent on board exams than in real life.
Image credit: en.wikipedia.org/wiki/File:Van_Go…_Art_Project.jpg
Sound credits: sounds from freesound.org by Jobro and HerbertBoland
May Yen describes the signs, symptoms, and treatment of acetaminophen overdoses in older adults.
For the Show Notes, see the gemcast website: http://gempodcast.com/2016/01/11/geriatric-toxicology-part-2-acetaminophen/
Connect on twitter: @gempodcast
Acetaminophen overdoses can be deadly if they are not rapidly identified and treated. While the treatment is relatively simple, there are still subtleties and ambiguities. How do you identify who needs treatment? Which patients should be transferred to a facility that has liver transplantation capabilities? What are “line-crossers”? In this episode, May Yen talks us through some of the finer points of identifying and managing acute and chronic acetaminophen overdoses, particularly as it relates to older adults.
Image Credit: https://en.wikipedia.org/wiki/Paracetamol#/media/File:Tylenol_rapid_release_pills.jpg Sound credits: sounds from freesound.org by Jobro and HerbertBoland
May Yen talks us through acute and chronic salicylate toxicity in older adults, the symptoms, and management.
For the Show Notes, see the gemcast website: http://gempodcast.com/2015/12/15/geriatric-toxicology-1-salicylates/
Connect on twitter: @gempodcast
Toxicologic emergencies can present differently in older adults compared with younger patients. The physiologic changes of aging make older patients more prone to accidental overdoses because of a narrowed therapeutic window. In this podcast, toxicology-trained Emergency Physician, Dr. May Yen, talks about why older adults are at risk for therapeutic misadventures. We then discuss the management of acute and chronic salicylate toxicity. Patients with severe salicylate overdoses can be some of the sickest and most difficult to manage patients in the ED.
This will be part one of a series on geriatric toxicology. Stay tuned for 3 more cases in future episodes!
Image credit: https://it.wikipedia.org/wiki/Salicilati Sound credits: sounds from freesound.org by Jobro and HerbertBoland
For the Show Notes, see the gemcast website: http://gempodcast.com/2015/11/11/high-risk-medications-and-adverse-drug-events/
Adverse drug events (ADEs) are a major problem among older adults who present to the Emergency Department. ADEs come in 5 types. 1 in 6 hospitalizations among older adults involves an ADE, and half of the hospitalizations for ADEs are deemed preventable. What medications should be used with caution or avoided in older adults? What are safer alternatives? In this podcast we discuss the types of ADEs, which patients are at greatest risk, the highest risk medications, alternatives to the high-risk medications, and ways to prevent ADEs. Leah Hatfield, an ED pharmacist, shares her wisdom.
References: 1. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American geriatrics society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015. 2. Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. J Am Geriatr Soc. 2015. 3. Alhawassi TM, Krass I, Bajorek BV, Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014;9:2079-2086. 4. Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. 2013;87(5):331-336. 5. Passarelli MC, Jacob-Filho W, Figueras A. Adverse drug reactions in an elderly hospitalised population: Inappropriate prescription is a leading cause. Drugs Aging. 2005;22(9):767-777. 6. Saedder EA, Lisby M, Nielsen LP, Bonnerup DK, Brock B. Number of drugs most frequently found to be independent risk factors for serious adverse reactions: A systematic literature review. Br J Clin Pharmacol. 2015;80(4):808-817.
Image credit: https://pixabay.com/en/pill-capsule-medicine-medical-1884775/ Sound credits: sounds from freesound.org by Jobro and HerbertBoland
Judith Tintinalli discusses her thoughts about caring for an older patient with a severe ICH as part of a multidisciplinary team.
For the show notes and blog site, see: http://gempodcast.com/2015/11/11/15/
What does Dr. Tintinalli do when she has a dying patient and a family who needs help to make decisions and understand the options? – She gets involved. She calls the PCP. She gets palliative care on the line. She advocates for the patient to help make sure their wishes are understood and honored. There comes a time when you go from prolonging life to prolonging death. Knowing when that point is can be hard. Listen to hear her thoughts in this post from 10/2015.
There are many models for how palliative care can work in an ED. We can provide it ourselves to a certain extent, and in some cases, can consult palliative care services to help with end-of-life decisions. But we should do something to make sure we consider the patient’s wishes before performing aggressive measures that could leave the patient with a quality of life that would not be meaningful for them.
References: 1. Rosenberg M, Rosenberg L. Integrated model of palliative care in the emergency department. West J Emerg Med. 2013;14(6):633-636. PMID: 24381685 2. Rosenberg M, Lamba S, Misra S. Palliative medicine and geriatric emergency care: Challenges, opportunities, and basic principles. Clin Geriatr Med. 2013;29(1):1-29 PMID: 23177598 3. Grudzen CR, Richardson LD, Hopper SS, Ortiz JM, Whang C, Morrison RS. Does palliative care have a future in the emergency department? discussions with attending emergency physicians. J Pain Symptom Manage. 2012;43(1):1-9. PMID: 21802899 4. Grudzen CR, Richardson LD, Morrison M, Cho E, Morrison RS. Palliative care needs of seriously ill, older adults presenting to the emergency department. Acad Emerg Med. 2010;17(11):1253-1257. PMID: 21175525 5. Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: New subspecialty, new opportunities. Ann Emerg Med. 2009;54(1):94-102. PMID: 19185393 6. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: Effects on hospital cost. J Palliat Med. 2010;13(8):973-979. PMID: 20642361 7. Penrod JD, Deb P, Luhrs C, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006;9(4):855-860. PMID: 16910799 8. Beemath A, Zalenski RJ. Palliative emergency medicine: Resuscitating comfort care? Ann Emerg Med. 2009;54(1):103-105. PMID: 19346031 9. Ciemins EL, Blum L, Nunley M, Lasher A, Newman JM. The economic and clinical impact of an inpatient palliative care consultation service: A multifaceted approach. J Palliat Med. 2007;10(6):1347-1355. PMID: 18095814 10. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182(6):563-568. PMID: 20231340
This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image from: http://news.unchealthcare.org/som-vital-signs/2013/nov-7/2013-berryhill-lecture-video-available
Kevin Biese describes the signs and symptoms of delirium in older adults, and drops some pearls on how to manage it safely.
For the shownotes and blog site, see: http://gempodcast.com/2015/11/11/diagnosing-and-managing-delirium-in-older-adults/
Welcome to GEMCAST! In this inaugural episode, first published 09/2015, Kevin Biese talks us through some practical tips for preventing, identifying, and managing delirium in older adults in the Emergency Department. Delirium is incredibly common among older adults in the ED, but is easy to miss. It is also an independent predictor of 6 month mortality. How is it diagnosed? Why does it matter that we identify it? How can you prevent it? How do you safely treat symptoms of agitation in an older adult? How can you differentiate it from dementia in the acute care setting? – Take a listen. References: 1. Barrio K, Biese K. Delirium, dementia, and other mental health disorders of older adults. In: Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s emergency medicine: A comprehensive study guide. 8th ed. ; 2011. Accessed 07/23/2015. 2. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922. PMID: 23992774 3. Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol. 2015;14(8):823-832. PMID: 26139023 4. Han JH, Eden S, Shintani A, et al. Delirium in older emergency department patients is an independent predictor of hospital length of stay. Acad Emerg Med. 2011;18(5):451-457. PMID: 21521405 5. Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: An independent predictor of death within 6 months. Ann Emerg Med. 2010;56(3):244-252.e1. PMID: 20363527 6. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency department patients: Validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013;62(5):457-465. PMID: 23916018 7. Marcantonio ER. Delirium. In: Pacal JT, Sullivan GM, eds. Geriatrics review syllabus: A core curriculum in geriatric medicine. 7th ed. New York, NY: American Geriatrics Society; 2010
This podcast uses sound 173181 from freesound.com by jobro