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Analyzing TBI in Older Americans in the ED

Analyzing TBI in Older Americans in the ED

The management of older adults presenting to the ED is oftentimes complicated by frailty and comorbid chronic conditions. Traumatic brain injury (TBI) has emerged as a leading cause of injury-related morbidity and mortality among adults aged 65 and older in the United States. Previous studies suggest there are differences in both the treatment and outcomes of TBI for older people when compared with younger individuals. Older age has long been thought of as a predictor of receiving more procedures and medications for treatment of TBI in the ED. It is also believed to be a predictor of poorer outcomes after treatment in the ED. “Among older adults, falls are the leading cause of TBI,” says Lisa C. McGuire, PhD. “As age increases, the risk for hospitalization from TBI also rises. This could be due to the increased medical complexity of the patients presenting for treatment as well as other factors. As the U.S. population ages and continues to grow, there will be greater demand for emergency services to treat TBI in older Americans.” To better understand the use of emergency services for TBI among older people, Dr. McGuire and colleagues conducted a study using nationally representative ED data to characterize these visits. The study, published in the August 2012 Western Journal of Emergency Medicine, also compared ED visits for TBI with those made by people younger than 65. In particular, the study team assessed triage immediacy, receipt of a head CT and/or head MRI, and hospital admission by type. Assessing Use of ED Services for TBI The number of ED visits for TBI is increasing among adults aged 65...

Goal Setting for Older Adults With Diabetes

To successfully manage type 2 diabetes in older adults, clinicians must recognize and understand the unique challenges these individuals face. While the benefits of tight glycemic control in older adults are similar to those of younger patients, physicians need to understand that barriers may interfere with older adults’ ability to perform self-care before setting goals of care. When establishing overall health goals, there must be a balance between the perceived benefits of tight glycemic control and the risks of treatment, such as hypoglycemia. Diabetes management plans should be formulated for older adults after careful consideration of their health and social backgrounds. Recognize Comorbidities Older adults with diabetes are at higher risk for many medical conditions that are not typically associated with diabetes, including cognitive impairment, depression, and functional decline. Identifying these conditions before forming management plans is essential. Early identification of subtle cognitive dysfunction, especially executive dysfunction, can enable practitioners to simplify treatment plans to avoid complications. Executive functions are important for diabetes self-care. Depression in older adults with diabetes has been linked to poor glycemic control, decreased adherence to treatment strategies, increased functional disability, and higher mortality in clinical studies. To screen for depression, the Geriatric Depression Scale can be of help. Older people with diabetes are also at increased risk of falls due to lower limb dysfunction, cardiovascular disease, polypharmacy, and impaired balance. Since improved glycemic control can help prevent progression of diabetes-related microvascular and macrovascular complications, it may also decrease the fall risks. On the other hand, it’s important to prevent hypoglycemia as it may manifest as dizziness or weakness and increase fall risks. These patients...

Preventing Falls in the Elderly: Updated Guidelines

Falls are one of the most common health problems experienced by older adults and are a common cause of loss of functional independence. Studies show that unintended injuries are the fifth leading cause of death in the elderly, and falls cause about two-thirds of those injuries. Fortunately, research continues to evolve in fall prevention. In the January 13, 2011 online issue of the Journal of the American Geriatrics Society, the American Geriatrics Society (AGS) and the British Geriatric Society (BGS) updated the 2001 guideline on preventing falls in older persons based on an accumulation of new data and a literature review. Assessing Fall Risk Factors The first step in preventing falls is to determine if patients are at increased risk. The updated AGS/BGS guidelines recommend that yearly evaluations of elderly patients include questions about any recent falls as well as inquiries about balance and steadiness of gait. Balance and steadiness represent a new addition to the guidelines. These problems can result from a number of causes, so it’s important that physicians consider what may be contributing to the problem before recommending treatment. Patients should also be asked about side effects of any medications that may increase fall risk. Questions about a patient’s comfort with activities of daily living may also reveal areas of concern. If a patient has already sustained a fall, physicians should assess and treat any resulting injuries, evaluate what contributed to the fall, and then recommend interventions to prevent future falls. Take Preventive Measures to Reduce Falls In many cases, preventive measures can be taken to reduce the likelihood of falls. The appropriate course of action...

Hypnotics, Elderly, & the Risk of Falls

Research has shown that the prevalence of insomnia increases with age. The appropriate treatment of insomnia in older patients can be challenging for several reasons, including the prevalence of comorbid conditions, increased use of a variety of medications (espe­cially central nervous system active compounds), and a compromised ability to metabolize and/or excrete these medications. This compromised function has typically resulted in lower recommended doses for many therapies, especially for hypnotic agents for which starting doses for the elderly are often half or less than those for adults. The purpose of using lower doses is to minimize adverse events (eg, amnestic effects or residual sedation) and thereby maxi­mize daytime functioning and patient safety. “Minimizing the risks of falls and fall-related injuries is a paramount consideration in the treatment of insomnia in the elderly.” An important consideration for safety in the elderly popula­tion is the risk for falls and fall-related injuries. A recent article by Frey et al in the Journal of the American Geriatrics Society evaluated the effect of sleep inertia on balance and cognition during nighttime awakenings in both adults and the elderly. The authors found that zolpidem produced clinically significant balance and cognitive impairments upon awakening from sleep. However, the study did not directly evaluate the incidence of falls; instead, it used the results of performance on tandem walking as a predictor of falls. These tandem walks occurred 120 minutes after a scheduled sleep opportunity and, thus, were designed to test the effects of zolpidem and sleep inertia in the first half of the night when those effects would be greatest. While the study is methodologically sound, it...

Managing Diabetes in Older Adults

This Physician’s Weekly feature was completed in cooperation with the experts at the American Diabetes Association. Published research suggests that approximately 30% of people older than 65 have either diagnosed or undiagnosed diabetes, and the disease is of increasing concern for the aging population. It is expected that its incidence will grow rapidly in the coming decades as older individuals are living longer. “When compared with older adults without diabetes, those with the disease have higher rates of premature death, functional disability, and coexisting illnesses,” explains Medha N. Munshi, MD. These coexisting illnesses include coronary heart disease, stroke, peripheral vascular disease, renal failure, neuropathy, and retinopathy. In addition, older adults with diabetes are at greater risk for polypharmacy, depression, cognitive impairment, urinary incontinence, injuries from falls, and persistent pain. The care of older adults with diabetes can be challenging for physicians because of clinical and functional differences from patient to patient, Dr. Munshi says. “Some older individuals develop diabetes at an earlier age and may have complications by this time. Others develop the disease at an older age and present with a few diabetes-related complications.” Frailty, diabetes-related comorbidities, and other underlying chronic conditions are other important considerations for some older patients. Furthermore, the activity levels and comorbidities experienced by older adults vary considerably depending on each individual patient. Studies have shown that the life expectancy is highly variable for older patients, but often longer than clinicians realize. An Important Patient Population According to the American Diabetes Association’s Standards of Medical Care in Diabetes—2011, providers caring for older adults with diabetes must take the diversity of older patients into consideration when setting and...
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