The theme for October Food and Journal Club was Geriatric Emergency Medicine, hosted by our guru of Geriatric EM (and my mentor for residency and geriatric mini-fellowship) Dr. Joel Gernsheimer. Also in attendance from the faculty side was one of our other Food and Journal Club veterans, Dr. Sinert. We had a mix of junior and senior residents, and we all met at Hop Lee Restaurant in Chinatown. 

We started off with round after round of appetizers, and then as the entrees started rolling in, we began to discuss a review article on Delirium in the Elderly from the EMA “Acute Geriatrics Series” co-authored by Dr. Christopher Carpenter, a leader of Geriatric EM. The article is easy to read and provides a concise, general overview of delirium. 

The article describes a tool for diagnosing delirium, namely The Confusion Assessment Method, and discusses the best medical treatment options for delirium in the 65+ population. The mantra is to “START LOW AND GO SLOW,” and the verdict on the best agents is as follows:  

• Risperidone: 0.25-0.5 mg starting dose oral, sublingual, quicklets; no IV

• Haloperidol: 0.25-0.5 mg oral or IM (avoid in Parkinson’s Disease or Lewy Body dementia)

• Olanzapine: 1.25-2.5 mg oral, sublingual, IM, or IV

• Seroquel: 25 mg starting dose (second-line agent, good alternative for Parkinsonism or Lewy Body)

It may be best to avoid benzodiazepines, except in cases of alcohol/benzodiazepine withdrawal, as they can actually exacerbate delirium and have a host of unwanted side effects in this population (2-4).

The article also discusses the optimization of any emergency department (ED) to reduce delirium in the elderly. Geriatric ED accreditation is currently a hot topic, and levels exist just as they do for trauma centers and pediatric EDs (see https://www.acep.org/geda/ for criteria, guidelines, and a list of accredited EDs). I just returned from ACEP 2019 in Denver and there were wonderful talks and exhibitions on the Geriatric ED accreditation process. Dr. Gernsheimer and I visited the Level 1 Geriatric ED at Mount Sinai in NYC earlier this year. We hope to bring Geriatric accreditation to Kings County Hospital and SUNY Downstate in the near future.

Our second article was a study based out of the Department of Neurosurgery at the University of Alabama, Birmingham on the development of a prognostic score – Subdural Hematoma in the Elderly Score, or “SHE” score. This score is intended to predict 30-day mortality in elderly patients with acute subdural hematomas after minor trauma. The score is comprised of three variables: age, GCS score at admission, and SDH volume. A scoring tool is in place for SAH, but this is the first of its kind for SDH, though there is a need to evaluate its external validity and reliability. The utility of this score in clinical practice is questionable, but it may serve an important role in counseling families on the prognosis of their family member with a newly diagnosed SDH. 

To close the night, we went to The Original Chinatown Ice Cream Factory. Dr. Gernsheimer enlightened everyone on the magic of Durian ice cream. Some loved it, some liked it, and some thought it tasted a bit like a familiar antibiotic suspension from childhood. Overall, it was a wonderful night in Manhattan!

References: 

1 Alford, et al. Development of the Subdural Hematoma in the Elderly (SHE) score to predict mortality. Journal of Neurosurgery. April 12, 2019. 

2 Juergens, S M.Problems With Benzodiazepines in Elderly Patients. Mayo Clinic Proceedings. August 1993. Volume 68, Issue 8, Pages 818–820. 

3 Kruse WH. Problems and pitfalls in the use of benzodiazepines in the elderly. Drug Saf. 1990 Sep-Oct;5(5):328-44.

4 Markota, et al. Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies. Mayo Clinic Proceedings. November 2016. Volume 91, Issue 11, Pages 1632–1639. 

5 Nagaraj, G, et al. Is Delirium the medical emergency we know least about? ACUTE GERIATRICS. Emergency Medicine Australasia(2016) 28, 456-458. 

https://www.acep.org/geda/ 

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Surriya

PGY4 clinical monster in training/EMIM resident/improviser

Latest posts by Surriya (see all)

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