Clinics in geriatric medicine
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The ethical framework established for most health care decision making should apply to elderly patients in the ED, i.e., the authority to decide should rest either with the competent patient or, in case of incapacity, with the patient's surrogate. Whenever possible, ethical dilemmas in the ED should be prevented from occurring through the judicious use of advance directives crafted in the doctor's office. DNR orders should be based upon the wishes of a competent patient or upon a surrogate's estimation of the patient's values and best interests. ⋯ Attention to these important problems bearing on the substance and procedures for life and death decision making in the ED should not obscure the manifest injustice of the context in which these decisions are often made. At many inner-city hospitals serving a largely poor and elderly clientele, the ED has become nothing short of a torture chamber for many critically ill elderly persons. An ethical framework for decision making, no matter how urgently needed, will not address the unnecessary pain and confusion of frail elderly patients subjected to an impersonal, overcrowded, and depersonalizing environment.
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Elderly individuals not only live longer but are also more active than in the past. Accompanying this increase in activity is the number of older trauma victims. The effect of aging on response to injury is reviewed, and the initial evaluation and treatment of geriatric trauma are delineated in this article. Specific injuries of note include head and chest wall injury; pulmonary and cardiac contusion; abdominal trauma; and aortic, spinal, and musculoskeletal injury.
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Infectious diseases continue to be a common cause for emergency department visits among the elderly population. This phenomenon may be due to the existence of comorbid diseases as well as alterations in immune function with senescence. Diagnosis and acute management of specific infections are discussed in this article, including meningitis, endocarditis, urinary tract and skin infections, septic shock, and fever of unknown origin.
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This article examined issues in the care of the injured elderly patient. Past studies have documented variable potential for functional recovery in survivors of serious trauma in the elderly population, and trauma care for this subgroup uses health care resources at an exaggerated rate. Excessive health care costs arise from increased postinjury morbidity and mortality in the elderly population; factors that predict mortality include injury severity, advanced age, and complications. ⋯ Current recommendations for care of these patients include aggressive treatment of all injuries according to standard trauma practice. Routine ICU admission with a low threshold for the institution of invasive monitoring to guide therapy is recommended for all geriatric trauma victims with moderate to more serious injury. The development of specialized management approaches for care of the injured elderly patient will result from ongoing study of this population, as research efforts provide more information about the physiologic and metabolic responses to injury in the elderly population.
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Clin. Geriatr. Med. · May 1992
ReviewLate life schizophrenia and its treatment: pharmacologic issues in older schizophrenic patients.
Schizophrenia in late life includes both chronic early-onset schizophrenia and late-onset schizophrenia. Treatment with neuroleptics in relatively low doses is often useful in controlling psychotic symptoms in these patients. The value of neuroleptics is limited, however, by the risks of side effects such as tardive dyskinesia.