Benzodiazepine use among elderly patients presenting at the emergency room

This study evaluated the prevalence of benzodiazepine intake by elderly patients presenting at the emergency room of a university hospital. Of 388 patients, 42.5% used one or more benzodiazepine (BZD) drugs in the week prior to admission. There were significantly more women among the BZD users (P < 0.05). Mean duration of intake was long (62 months), but daily dosage was adjusted to age. Of the BZD using patients, 27% took a BZD with long elimination half life. No relationship was found between the BZD intake and the occurrence of falls. Fallers were significantly older (P = 0.019) and were more often women (P = 0.046).     

Prevalence of anemia among elderly patients in an emergency room setting

PurposeAnemia is highly prevalent in geriatric patients and associated with increased morbidity, functional and cognitive decline. German prevalence data are rare and no treatment guidelines exist for the elderly. Anemia often remains unconsidered in this population. This study evaluates prevalence of anemia among geriatric patients in an emergency room (ER) setting and the performed diagnostic and therapeutic steps.SubjectsData of 1045 elderly patients > 70 years admitted to the ER at our university hospital between January and August 2010 were retrospectively analyzed (384 female and 474 male in-patients, 92 female and 95 male out-patients). Anemia definition: hemoglobin < 12 g/dL (female) and < 13 g/dL (male). Diagnostic and therapeutic steps, medication and hemoglobin (hb) characteristics at transfer from ER to other departments were evaluated.ResultsAmong in-patients anemia was found in 54.2%, among out-patients in 36.4% (P < 0.001). Hb was significantly lower in anemic in-patient men (P = 0.007) compared to anemic out-patient men. No such difference was found among women. Anemic patients’ age did not influence the hb level. There were department specific differences in hb level as well as diagnostics and therapy of anemia. Only 12% of all evaluable anemic in-patients received a non-drug anemia treatment, mostly consisting of transfusions.Discussion/ConclusionMore than 50% of all elderly patients suffered from anemia; less than one fifth received either anti-anemic medication or non-drug treatment; insufficiency of medical care in this study group can be assumed; close intersdisciplinary cooperation with geriatrician in ER is necessary with development of diagnostic and therapeutic guidelines for anemic elderly.     

Diagnostic role of copeptin in patients presenting with chest pain in the emergency room

BackgroundChest pain is a frequent symptom leading patients to the Emergency Room. Copeptin, the C-terminal fragment of arginin-vasopressin, is a marker of stressful situations. Recent studies showed that normal levels of copeptin combined with normal troponin accurately rule out the diagnosis of acute coronary syndrome (ACS). In this observational, prospective, multicenter study we evaluated if negative levels of copeptin combined with negative troponin (Tn-T) can correctly rule out the diagnosis of ACS and also of other life-threatening causes of chest pain.ResultsOf 472 enrolled patients (64.6% males, mean age 60.1 yrs), 28 (5.9%) were diagnosed with ST‐elevation myocardial infarction (STEMI), 28 (5.9%) with non ST‐elevation myocardial infarction (NSTEMI), 43 (9.1%) with unstable angina (UA), 13 (2.8%) with potentially life‐threatening non‐ACS pathologies (aortic dissection, pulmonary embolism, pulmonary edema, sepsis), 360 (76.2%) with benign causes of chest pain. Copeptin levels were significantly higher in ACS patients with STEMI and NSTEMI than in those with other diagnoses, but not in those with UA. The combination of copeptin and troponin‐T attained a negative predictive value of 86.6% for ACS, of 97.9% for other potentially life‐threatening non‐ACS diseases and of 85% for all potentially lethal diseases (ACS plus others).ConclusionsThe combined use of troponin and copeptin significantly improved the diagnostic accuracy of troponin alone both in ACS (STEMI and NSTEMI) and in other life-threatening diseases. Measurement of this marker might be therefore considered not only for a rule-out strategy but also as a warning sign of a life-threatening disease.     

The value of cardiac enzymes in elderly patients presenting to the emergency department with syncope

BACKGROUND: Most patients admitted to the hospital from the emergency department (ED) with syncope do not have a myocardial infarction (MI), yet a common practice is to draw serial cardiac enzymes. METHODS: To assess the value of serial cardiac enzymes in elderly patients who present to the ED with syncope, a retrospective chart review was performed on consecutive patients aged 65 and older with syncope in an urban teaching hospital ED between July 1, 1998 and June 30, 1999. Charts were screened for presenting history, cardiac risk factors, testing, and outcomes including acute coronary syndromes, MI, death, and patients returning to the ED or admitted within 72 hours of discharge. RESULTS: 319 patients met the study criteria of syncope with confirmed loss of consciousness in the absence of seizure or stroke. 141 of 228 admitted patients (62%) had creatine phosphokinase (CPK) drawn and 5% of these had Troponin I (TnI). 3 of 141 patients, or 2.1% (95% CI [confidence interval]: 0.04%-6.09%), had positive cardiac enzymes during their hospitalization. CPK was positive in all 3, and TnI, drawn in 1 patient, was also positive. Two of these patients had chest discomfort and ST segment and T-wave abnormalities on electrocardiogram (ECG) in addition to a syncopal event. The third patient had dementia and could not recall the details surrounding her syncopal event. In addition, her baseline ECG demonstrated a left bundle branch block, limiting ECG interpretation. CONCLUSIONS: Cardiac enzymes may be of little additional value if drawn routinely on elderly patients with syncope who are admitted to the hospital from the ED, unless they have other signs or symptoms suggestive of myocardial ischemia.     

An analysis of rheumatology cases presenting to the emergency room of a teaching hospital

We surveyed diagnoses on 5592 consecutive new cases presenting to a general hospital emergency room. The number of cases that could be judged "rheumatic" were analyzed further to determine the spectrum of rheumatologic problems that were seen in this facility. Four hundred eighty-three cases were studied. Precise diagnosis frequently could not be determined, but the largest group was soft tissue rheumatism. A wide variety of "rheumatologic" cases were seen initially in the emergency room. The clinical disposition and followup on these patients was also determined.     

Urinary thromboxane A2 metabolites in patients presenting in the emergency room with acute chest pain

Abstract. Objectives . The diagnosis of acute myocardial infarction (MI) is difficult in emergency rooms where large groups of patients present with chest pain. Confirmation of the diagnosis of MI based on the myocardial band of creatine phosphokinase may take a day. A more rapid diagnostic screening procedure is desirable and for this reason we evaluated urine thromboxane. Design . The study consisted of patients presenting with chest pain. Urine samples were obtained in the emergency room and on the following 5 days for those patients who were admitted to the hospital. The urine samples were used to determine the levels of immunoreactive 11-dehydro-thromboxane B₂ (i-11-dehydro-TXB₂) and 2,3-dinor-thromboxane B₂ (i-2,3-dinor-TXB₂). Myocardial infarction was defined as an increase in the myocardial band fraction of plasma creatine phosphokinase (> 5% of the total) and changes in the electrocardiogram. The patients' diagnoses were retrospectively correlated with thromboxane metabolite levels. Setting . The present study took place in the emergency rooms of two major hospitals: Georgetown University Medical Center. Washington DC, and Fairfax Hospital, Virginia, USA. Subjects . The study comprised 369 patients presenting with acute chest pain and consisted of 247 men and 122 women aged 30–94 years. Main outcome measures . The outcome measure of this study was the predictive value of i-11-dehydro TXB₂ and i-2,3-dinor-TXB₂, for the diagnosis of MI, in patients presenting in the emergency room with chest pain. Results . Patients undergoing an MI had significantly higher levels of both thromboxane metabolites in their urine in the emergency room, when compared to patients undergoing a cardiac event other than an MI or to patients with unstable angina. Thromboxane metabolite levels rapidly returned to normal on the days following admission to the hospital. Aspirin intake appeared to significantly decrease the levels of i-11-dehydro-TXB₂, but not that of i-2,3-dinor-TXB₂. Conclusions . The measurement of thromboxane metabolites in the urine may provide a more rapid, accurate and cost-effective means of diagnosing MIs in patients presenting with chest pain.     

The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital

Delirium is prevalent among elderly people presenting to an emergency department (ED). However, despite the fact that delirium is associated with longer hospital stays, an increased rate of institutionalization and higher mortality (especially in the case of undiagnosed delirium), this condition often goes undiagnosed by ED doctors. We examined the rate of mental status assessment and the prevalence of delirium in the ED among patients older than 65 years in a large teaching hospital in Southern Israel via a retrospective chart review. Surprisingly we found no diagnosis of delirium in the medical charts of representative sample of 319 elderly people. Furthermore, only 12.5% of people received either an adequate or even a partially adequate mental status assessment by the ED doctors. We attribute these negative findings not to a low incidence of delirium but probably to a combination of a heavy workload along with a lack of adequate training of ED physicians. We suggest that part of the solution involves providing appropriate education to ED physicians as well as adding a geriatric consultant to the ED roster.     

Psychiatric emergency consultations to elderly patients in a Canadian general hospital

The authors compared the demographic and clinical characteristics and treatment recommendations for elderly (greater than or equal to 60 years) and younger patients (17 to 59 years) seen for an emergency psychiatric consultation in a teaching general hospital. Findings revealed 11 distinctive characteristics that differentiated elderly from younger patients. Most notably, the elderly experienced their chief complaint for a longer time before referral to the emergency room by their primary care physician and had higher prevalence of affective disorders and psychologic factors affecting physical condition. Some of the implications of these results are discussed with the view to planning psychiatric services for the elderly and education programs.     

Cocaine-related symptoms in patients presenting to an urban emergency department

STUDY OBJECTIVES: Cocaine abuse is a serious social problem that precipitates a significant number of emergency hospital encounters. To determine the nature of cocaine-related symptoms, we studied patients with cocaine use presenting to all adult services of an urban emergency department. DESIGN: Review of consecutive cases, with analysis of clinical features. SETTING: All adult EDs of an urban teaching hospital. TYPE OF PARTICIPANTS: Patients acknowledging recent use of cocaine (within 72 hours) and/or with cocaine detected on a toxicologic screen. MEASUREMENTS AND MAIN RESULTS: Psychiatric complaints accounted for 44 (30.6%) presentations, followed by neurologic (17.4%), cardiopulmonary (16%), trauma (11.8%), and addiction-related (11.1%) symptoms. Cardiopulmonary symptoms were more frequently associated with intranasal than with IV or smoked cocaine (P = .003). Suicidal intent was the most common psychiatric reason for presentation, occurring in 24 patients (16.6%). Seventeen presented with trauma, including three involved in motor vehicle accidents. CONCLUSION: Cardiopulmonary symptoms such as chest pain and palpitations may be significantly more frequent in patients who use intranasal cocaine; suicidal intent is common among patients presenting with psychiatric symptoms related to cocaine; and the range of cocaine-related symptoms is varied, including not only psychiatric and cardiopulmonary symptoms but also trauma.     

Importance of two-dimensional echocardiographic assessment of left ventricular systolic function in patients presenting to the emergency room with cardiac-related symptoms

BACKGROUND. This prospective study was designed to test the hypothesis that the assessment of left ventricular systolic function at the time of emergency room (ER) presentation provides valuable diagnostic and prognostic information in patients with cardiac-related symptoms. METHODS AND RESULTS. The study is based on a 2-year follow-up of 171 consecutive patients evaluated in the ER for such symptoms. In the course of follow-up, one third of the patients (55 of 171) suffered a major cardiac event. For those with left ventricular systolic dysfunction (LVSD), the age-adjusted rate of early events (occurring within 48 hours of presentation) was more than eight times higher than for those without LVSD (26.9% versus 3.3%, p less than 0.01). For events occurring after 48 hours of ER presentation, LVSD was associated with a nearly fourfold excess of cardiac events (23.9% versus 6.4%, p less than 0.01). Other than advanced age, the most important confounder for early events included an abnormal electrocardiogram diagnostic for acute myocardial infarction. Confounders for late events included advanced age and a history of hypertension. LVSD on two-dimensional echocardiography (2DE) was the only finding associated with early and late events after controlling for other risk factors. In addition, the prediction of these events derived from the combination of historical, clinical, electrocardiographic, and 2DE findings was significantly improved when accounting for the presence or absence of LVSD (p less than 0.01). CONCLUSIONS. We conclude that the 2DE assessment of left ventricular systolic function provides valuable diagnostic and prognostic information in subjects presenting to the ER with cardiac-related symptoms.     

Correlation between NT proBNP and left ventricular ejection fraction in elderly patients presenting to emergency department with dyspnoea

ObjectiveShortness of breath is a common complaint for which the elderly seek medical attention in the emergency department (ED). Differentiating cardiac from respiratory causes of dyspnoea in this population is quite a challenge. N Terminal pro brain-natriuretic-peptide (NT proBNP) has been studied extensively as a biomarker of left ventricular (LV) failure.MethodsThe NT proBNP was measured in 100 patients above 60 years of age who presented to the ED with shortness of breath. The level was compared with echocardiographic findings to assess correlation with ejection fraction (EF).ResultsThe NT proBNP values increased significantly as the functional severity of heart failure (HF) increased (P < 0.001). The mean NT proBNP level was 1503.33 pg/mL. Patients with respiratory causes of dyspnoea had a mean NT proBNP level of 309.28 pg/mL with normal LV function.ConclusionThe NT proBNP levels had a good correlation with worsening LVEF.     

Heart fatty acid-binding protein offers similar diagnostic performance to high-sensitivity troponin T in emergency room patients presenting with chest pain

BACKGROUND: The aim of the present study was to evaluate the diagnostic accuracy of high-sensitivity troponin T (hsTnT) in patients with suspected acute coronary syndrome (ACS) in comparison to heart fatty acid-binding protein (H-FABP), high-sensitivity C-reactive protein, myeloperoxidase (MPO), and pentraxin 3 (PTX3). METHODS AND REsults: Patients (n=432) with chest pain were recruited for the analysis. ACS was diagnosed in 298 patients (69%). The diagnostic accuracy of measurements obtained at presentation, as quantified by the area under the receiver operating curve (AUC), was highest for hsTnT (AUC=0.82; 95% confidence interval [CI]: 0.78-0.87) and H-FABP (AUC=0.83; 95%CI: 0.78-0.87). Sensitivity (87.9%) and negative likelihood (LH; 0.2) for hsTnT were the highest and lowest, respectively, but H-FABP had the highest specificity (78.5%) and positive LH (3.6). Among patients who presented within 2h after the onset of chest pain, MPO had the highest AUC (0.82; 95%CI: 0.69-0.94). Combined use of H-FABP and MPO measurements yielded a sensitivity of 69.2%, specificity of 84.2%, positive LH of 4.4, and negative LH of 0.4. CONCLUSIONS: The hsTnT assay offers excellent diagnostic performance to rule out ACS, but it is prone to false-positive results. H-FABP offers similar overall diagnostic performance, while the combination of H-FABP and MPO assays may improve the diagnosis of ACS, particularly in patients with recent onset of chest pain.     

Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department

STUDY OBJECTIVES: We sought to document the degree of polypharmacy, the frequency of adverse drug-related events (ADREs) leading to emergency department presentation that were recognized by emergency physicians, and the frequency of potential adverse drug interactions (PADIs) in medication regimens of elderly patients in the ED. METHODS: We conducted a retrospective chart review on 300 randomly selected ED visits made by patients 65 years of age and older between January 1 and December 31, 1998. ADREs were defined according to a standardized algorithm. PADIs were identified by using the drug interaction database PharmVigilance. RESULTS: After excluding 17 patient visits with inadequate documentation, 283 were left for review. Of these, 257 (90.8%) patients were taking 1 or more medications (prescribed or over the counter). The number of medications consumed ranged from 0 to 17 and averaged 4.2 (SD+/-3.1) drugs per patient. ADREs accounted for 10.6% of all ED visits in our patient group. The most frequently implicated classes of medications were nonsteroidal anti-inflammatory drugs, antibiotics, anticoagulants, diuretics, hypoglycemics, beta-blockers, calcium-channel blockers, and chemotherapeutic agents. Thirty-one percent of all patients in our group had at least 1 PADI in their medication list. Among patients who presented because of an ADRE, 50% had at least 1 PADI in their medication list that was unrelated to the ADRE with which they presented. CONCLUSION: ADREs are an important cause of ED presentation in the elderly. PADIs are found in a significant proportion of medication lists. Emergency physicians must be vigilant in monitoring elderly patients for medication-related problems.     

Can elderly patients without risk factors be discharged home when presenting to the emergency department with syncope?

Age is often a predictor for morbidity and mortality. Although we previously proposed risk factors for adverse outcome in syncope, after accounting for the presence of these risk factors, it is unclear whether age is an independent risk factor for adverse outcomes in syncope. Our objective was to determine whether age is an independent risk factor for adverse outcome following a syncopal episode. We conducted a prospective, observational study enrolling consecutive patients with syncope. Adverse outcome/critical intervention included hemorrhage, myocardial infarction/percutaneous coronary intervention, dysrhythmia, antidysrhythmic alteration, pacemaker/defibrillator placement, sepsis, stroke, death, pulmonary embolus or carotid stenosis. Outcomes were identified by chart review and 30-day follow-up. We found that of 575 patients, adverse events occurred in 24%. Overall, 35% with risk factors had adverse outcomes compared to 1.6% without risks. Age ≥ 65 were more likely to have adverse outcomes: 34.5% versus 9.3%, p < 0.001. Similarly, among patients with risk factors, elderly patients had more adverse outcomes: 43%; 36–50% versus 22%; 16–30%, p < 0.001. However, among patients with no predefined risks, there were no statistical differences: 3.6%; 0.28–13% versus 1%; 0.04–3.8%. This was confirmed in a regression model accounting for the interaction between age > 65 and risk factors. Although the elderly with syncope are at greater risk for adverse outcomes overall and in patients with risk factors, age ≥ 65 alone was not a predictor of adverse outcome in syncopal patients without risk factors. Based on this data, it may be safe to discharge home from the ED patients with syncope, but without risk factors, regardless of age.     

Nonsteroid anti-inflammatory drugs in elderly patients

Incidence of side effects of nonsteroid anti-inflammatory drugs is greater in elderly patients. The author describes the reason why these drugs cause frequent and serious side effects. Particularly important is the difference between elderly and young patients in terms of metabolism and excretion of nonsteroid anti-inflammatory drugs. In general, nonsteroid anti-inflammatory drugs with a long half-life should not be given to elderly patients. The author also describes guidelines for nonsteroid anti-inflammatory drugs treatment in elderly patients.