Geriatric Literature Review: Revisited

Chana R, Noorani A, Ashwood N, et al. The role of MRI in the diagnosis of proximal femoral fractures in the elderly. Injury 2006;37:185–189. Objectives: To evaluate the role of magnetic resonance imaging (MRI) in diagnosing fractures of the proximal femur in older patients. Summary: Older patients presenting with hip fractures often have nondiagnostic plain radiographs on initial evaluation. This report characterizes MRI findings in relation to age in patients with high suspicion for hip fracture but nondiagnostic radiographs of the hip and pelvis. Thirty-five patients admitted to a single hospital in the United Kingdom over a 4-year period with high suspicion of hip fracture and negative plain radiographs were evaluated prospectively. A panel of consultant orthopedic surgeons and a single consultant radiologist specializing in musculoskeletal imaging reviewed all radiographs. High suspicion for fracture was Address correspondence to Dr. Michael Rich, North Campus, 660 S. Euclid Ave., Box 8086, St. Louis, MO 63110. E-mail: mrich@im.wustl.edu DOI: 10.1111/j.1532-5415.2009.02193.x From the Washington University School of Medicine, Cardiovascular Division, Barnes-Jewish Hospital, St. Louis, Missouri. JAGS 57:585–587, 2009 r 2009, Copyright the Authors Journal compilation r 2009, The American Geriatrics Society 0002-8614/09/$15.00 defined as persistent pain after hip trauma, inability to bear weight, or a painful straight leg raise or hip rotation test. Patients were divided into two groups: those aged 70 and older (n525) and those younger than 70 (n510). All 35 patients underwent MRI of the hip. Patients aged 70 and older were significantly more likely to have femur fractures requiring operative repair (Po.001). In older patients, 21 (84%) proximal femur fractures were identified using MRI, of which 17 had indications for operative repair and 13 underwent surgery. In those younger than 70, only five (50%) fractures were found, none involving the femur, and all of which were managed nonoperatively. Comment: Despite several major limitations (including small sample size, single institution, and lack of detail regarding methodology and sampling techniques), this article reinforces an important point regarding older patients with hip trauma. These patients are at high risk for hip fracture, and initial plain radiographs are often nondiagnostic. Failure to rapidly diagnose a nondisplaced femoral neck fracture can increase the risk of fracture displacement, delay operative repair, and increase the risk for subsequent morbidity and mortality. In older patients with high suspicion for hip fracture and nondiagnostic plain radiographs, urgent MRI should be strongly considered. Submitted by: Frederic Hustey, MD Cleveland Clinic Foundation 2006 Jahnigen Scholar Rathlev NK, Medzon R, Lowery D, et al. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med 2006;13:302–307. Objectives: To characterize the clinical presentation and prevalence of intracranial injury in patients aged 65 and older who experience blunt head trauma. Summary: In older patients, blunt head trauma may be associated with significant intracranial pathology despite seemingly trivial injuries and initially minimal symptoms. This prospective study characterized patterns of intracranial injuries and associated symptoms in older victims of blunt head trauma. Twenty-one emergency departments enrolled 13,326 patients with blunt head trauma, including 1,934 patients aged 65 and older (14.5%). Using predefined criteria, data on 16 potential predictors of intracranial injury were collected before imaging. All patients underwent computed tomographic (CT) head scans. Significant intracranial injury, defined as injury requiring procedural intervention or associated with persistent neurological impairment or long-term disability, was more common in older patients (9.2%, 95% confidence interval (CI)5 8.0– 10.6%) than in younger patients (6.1%, 95% CI5 5.7– 6.6%). Occult intracranial injury, defined as the absence of altered consciousness, neurological deficits, or signs of skull fracture, was also more common in older patients (2.2%, 95% CI51.6–2.9%) than in younger patients (0.8%, 95% CI50.7–1.0%). None of the 16 predictors of intracranial injury effectively stratified patients with or without significant abnormalities on CT scan. Comment: Although this study did not examine clinical outcomes, prior reports document that older patients have greater mortality and worse functional outcomes than younger patients after traumatic brain injury, even after controlling for injury severity (J Trauma 2002;52:907– 911). Clinicians must be particularly wary when caring for older head injury victims, because a small subset with significant intracranial injuries will have an occult presentation. Unfortunately, despite the large sample size and careful prospective data collection, Rathlev and colleagues were unable to define any factors, or any combination of factors, that were able to identify patients with very low risk for significant intracranial injury who might not benefit from undergoing a CT scan. Therefore, these data suggest that prolonged observation and liberal use of intracranial imaging should be considered when assessing otherwise asymptomatic, older patients who experience blunt head trauma. The cost-effectiveness of such an approach, as well as its effect on clinical outcomes, requires further investigation. Submitted by: Benjamin Sun, MD University of California, Los Angeles 2006 Jahnigen Scholar Han JH, Lindsell CJ, Hornung RW, et al. The elder patient with suspected acute coronary syndromes in the emergency department. Acad Emerg Med 2007;14:732–739. Objectives: To describe the evaluation and outcomes of older patients with suspected acute coronary syndromes (ACSs) presenting to the emergency department (ED). Summary: Using data from the Internet Tracking Registry for Acute Coronary Syndromes, 10,126 patients aged 18 and older presenting to eight U.S. EDs with suspected ACS were analyzed retrospectively. Women constituted 56% of the sample, and 43% of the patients were black. There were 1,157 patients (11.4%) aged 75 and older, of whom 170 (14.7%) had confirmed ACS based on cardiac biomarkers, 12-lead electrocardiogram, and other diagnostic tests. Patients aged 75 and older were more likely than those younger than 75 to be women (64.9% vs 54.5%), more likely to have a prior history of coronary artery disease (34.8% vs 16.4%), and more likely to have signs of heart failure at the time of presentation (13.1% vs 5.6%) (all Po.001). Conversely, older patients were somewhat less likely to present with typical ischemic chest pain (51.4% vs 55.3%; Po.001). Use of echocardiography, stress nuclear scintigraphy, and cardiac catheterization did not differ between older and younger patients, although older patients were more likely to be admitted (76.8% vs 53.1%, adjusted odds ratio (OR)52.2, 95% CI5 1.9–2.6) and to have confirmed ACS (14.7% vs 7.5%, adjusted OR51.8, 95% CI51.5–2.2). In addition, 30-day mortality was markedly higher in older patients (2.7% vs 0.7%, adjusted OR52.6, 95% CI51.6–4.3). Comment: This study represents the largest population-based series of unselected patients presenting to the ED with suspected ACS. The study confirms findings from previous reports that older patients are more likely to be female and to present with atypical symptoms, but despite these differences in presentation, older patients are more likely to have ACS confirmed by standard diagnostic testing. Moreover, although the use of diagnostic procedures was similar in older and younger patients, 30-day mortality was strikingly higher in the older cohort. These findings indicate that a high index of suspicion is required in older patients 586 RICH ET AL. APRIL 2009–VOL. 57, NO. 4 JAGS