Sex & Gender in Acute Care Medicine

Sex & Gender in Acute Care Medicine Chapter 13A: Geriatrics in Emergency Medicine

Chapter 13A: Geriatrics in Emergency Medicine A Gender-based Approach Elena Kapilevich Bruce Becker

The Case of Mrs. V, Part I • Mrs. V is an 81-year-old woman who is brought to the ED by her daughter • She has fallen a number of times in the past few months • She has some bruises on her shin from “running into the dishwasher door” • Today she complains of pain in her right wrist, which is ecchymotic, swollen, and tender

The Case of Mrs. V, Part I • Mrs. V has lived alone since the death of her husband 6 years ago • Her daughter is “worried about her” • She has lost weight in the past few months and has stopped participating in her usual community activities • She is response and conversant in the ED, saying she is just busy and tired from household chores

The Case of Mrs. V, Part I • When asked the specifics about the housework, she is vague about details and makes a joke about the forgetfulness of old age • She is a bit defensive, stating, “I think I’m doing pretty well for my age.” • She is thin but alert and oriented x 3

The Case of Mrs. V, Part I • Except for the wrist, her exam is fairly unremarkable • Her daughter approaches you in the hallway and says: “She is not herself. She was always so energetic. I don’t think she should be living alone anymore.”

Introduction • On January 1, 2011, the first baby boomer turned 65, initiating a major demographic upshift • There are more than 77 million baby boomers living in the US, all of whom were born between 1946 and 1964 • In 2010, more than 40 million Americans, 13% of the population, were older than age 65

Introduction • By 2035, 1 out of 5 will be old • By 2050, this number will climb to almost 90 million • Demographic America is aging rapidly with substantial economic, social, and medical implications

Introduction • In most parts of the world, women live longer than men • The gender gap is most pronounced in industrialized nations such as the US and Canada • Effective public health interventions contributed to a dramatic rise in life expectancy in the 20th century

Introduction • In the US today, women outlive men by approximately 5.3 years (80.1 to 74.8 years) • The younger men are succumbing to childhood diseases, traumatic injuries, homicide, and substance abuse at higher rates • Men are twice as likely to die from heart disease • 20% more likely to die from stroke

Introduction • Men have greater mortality rates than women for all leading causes of death in the US • The “gender gap” is typically widest at birth and throughout young adulthood • Men have a greater infant mortality • More likely to die in utero than women • Genetic factors seem to contribute to this disparity

Introduction • This gender gap in life expectancy narrows as men and women age • The longevity of men surviving to 65 approaches that of women • Those men who reach 75 will have a lifespan equal to their female counterparts

Introduction • Currently, women make up 60% of adults over 65 and 75% of those over 85 • The remaining life expectancy of those women who survive to age 85 is an additional 6 years • A number of biologic, socioeconomic, developmental, and cultural factors support women’s advantage in mortality rates

Introduction • Hormonal differences are primarily responsible for women’s longevity • Particularly the opposing effects of estrogen and testosterone on lipids and, subsequently, vasculature and vascular disease • Testosterone is known to raise LDL and lower HDL, while estrogen has the opposite effect

Introduction • Estrogen is also thought to protect the vascular endothelium, a benefit that persists for years after menopause • May account for delayed onset of cardiovascular disease in women • Testosterone, on the other hand, may have immunosuppressant effects, accounting for men’s higher rates of death from infections

Introduction • Smoking is a major contributor to morbidity and mortality • Men are more likely than women to be current or former smokers, although this gap is rapidly closing • Among older men who are alive today, a greater proportion smoked at some point in their lives than older women

Geriatric Care in the ED • Older adults make up a large proportion of patients seeking treatment in the ED in the US • Almost 30% of individuals older than 75 report an ED visit in the past year, compared to less than 20% of those who are younger • As the population of elders increases, the number of ED visits among this demographic is expected to rise proportionately

Geriatric Care in the ED • This dramatic upward trend has many implications for EM providers • Diagnosis, treatment, and dispositions for elder patients are often vastly different from the approach to younger patients • Geriatric patients have higher prevalence of overlapping comorbidities, polypharmacy, cognitive deficits, and a distinctive subset of medical conditions and injury patterns

Geriatric Care in the ED • Elders have higher acuity complaints and are more likely to be hospitalized • Because older women outnumber older men, they make up a larger proportion of geriatric patients seeking treatment in the ED and being admitted for inpatient care • Acute care providers must have a broad understanding of the sex and gender issues that influence the care of these patients

Delirium, Dementia, and Neuropsychiatric Disorders • Almost 25% of elders treated in EDs have altered mental status as a result of dementia, delirium, or both • The incidence of dementia in these patients is directly proportional to their age • Some of these elder patients are at their baseline level of functioning

Delirium, Dementia, and Neuropsychiatric Disorders • For others, their altered mental status represents a subacute or acute deterioration • Ability of the clinician to obtain an accurate history and physical exam in the ED is often limited • Since it is difficult to ascertain the baseline, the degree of acute alteration and the exact cause of impairment can be difficult to discern

Delirium, Dementia, and Neuropsychiatric Disorders • Altered mental status in elder patients contributes to prolonged ED stays, increased use of imaging studies, and delays in diagnosis and disposition • Leading to the increased rate of admissions commonly seen in this elder patient population

Delirium, Dementia, and Neuropsychiatric Disorders • It has long been suggested that women have a higher rate of dementia than men, particularly the dementia of Alzheimer’s Disease (AD) • Several explanations have been proposed • Women have a longer life expectancy than men and the risk for AD increases with age • Brain anatomy also differs by sex

Delirium, Dementia, and Neuropsychiatric Disorders • Other hypotheses suggest the influence of sex-specific hormones on the development of AD and gender bias in diagnostic work-ups • Among men, heart failure, Parkinson’s disease, family history, and mild depression were significant risk factors for AD • Among women, mild and severe depression, increased fasting blood sugar, and BMI <24

Delirium, Dementia, and Neuropsychiatric Disorders • The issue of sex, gender, and dementia remains controversial • Several recent studies, controlling for life expectancy, level of education, and cardiovascular risk factors, reported equivalent rates of AD and vascular dementia • The literature also suggests that in AD, male sex is associated with greater mortality • This, too, remains controversial

Delirium, Dementia, and Neuropsychiatric Disorders • There may be more women with dementia today simply because there is positive selection pressure favoring the survival of women • Men die before they develop AD • Another confounding factor is that men who develop AD have a shorter lifespan than women with AD

Delirium, Dementia, and Neuropsychiatric Disorders • Delirium is an acute alteration in sensorium or a change in cognition with a waxing and waning of consciousness • Up to 10% of older ED patients are diagnosed with delirium • Delirium can often mask underlying medical problems and lead to difficulties in diagnosis • Patients can rarely provide a useful history or participate in a meaningful physical exam

Delirium, Dementia, and Neuropsychiatric Disorders • Delirium may be the only presenting symptom of a number of serious medical conditions • Sepsis, stroke, intracranial hemorrhage, or MI • Prompt recognition, diagnosis, and treatment of the underlying condition may be life-saving • Delirium in older ED patients is an independent predictor of increased 6-month mortality

Delirium, Dementia, and Neuropsychiatric Disorders • As many as 50% of patients presenting with delirium have a preexisting dementia • Making the differentiation between the two entities problematic for emergency clinicians • Delirium in elders is misdiagnosed by EM practitioners in up to 75% of cases

Delirium, Dementia, and Neuropsychiatric Disorders • Risk factors most strongly associated with delirium include preexisting dementia, followed by medical illness, alcohol abuse, and depression • These conditions have clear sex/gender specificity • Yet research focusing on the presentation and diagnosis of delirium has not focused on sex or gender at all

Delirium, Dementia, and Neuropsychiatric Disorders • Gender differences have been demonstrated in postoperative delirium, a condition that is more common among elderly patients • Incidence rates are as high as 55%, depending on type and duration of surgery • Longer and more critical surgery is associated with greater rates of delirium

Delirium, Dementia, and Neuropsychiatric Disorders • In a study of orthopedic surgery patients, men were 2x as likely to suffer postoperative delirium after hip fracture repair • Additionally, those men were more likely to exhibit hyperactive delirium with signs of aggression, requiring the use of antipsychotics • With their associated side effects and morbidity

Delirium, Dementia, and Neuropsychiatric Disorders • Women have the additional risk factors of greater age and lower BMI • Consequently, women treated acutely for hip fractures should be evaluated for dementia • Clinicians should be prepared for early diagnosis and intervention of acute postoperative delirium in women who screen positive for dementia

Delirium, Dementia, and Neuropsychiatric Disorders • Mental illness in elders is common and contributes to morbidity and increased risk for mortality • It is often unrecognized and, even when promptly diagnosed, often undertreated • Inadequately treated psychiatric illness can lead to lower overall quality of life, frequent ED visits, and institutionalization

Delirium, Dementia, and Neuropsychiatric Disorders • The early, subtle signs and symptoms of psychiatric illness in elders may be mistaken for normal aging or dementia • Providers must remember that even though elders often experience increased chronic and acute illness, decreased functional status, and premature loss of loved ones, depression or other mental illness is never “normal”

Delirium, Dementia, and Neuropsychiatric Disorders • The 3 most common major psychiatric disorders in elderly patients are depression, bipolar disorder, and schizophrenia • Late onset depression is the most common geri-psych disorder • This diagnosis includes patients with a past history of depression who now present with a depressive episode; • those who develop a first depressive episode after age 65

Delirium, Dementia, and Neuropsychiatric Disorders • Clinically significant depressive symptoms affect between 8 and 20% of elders (65+) • Depression in elders (as in their younger peers) is more common in women • Elder women who are not depressed are more likely than men to become depressed • Depressed women are less likely to receive aggressive pharmacologic treatment • Also less likely to die while depressed

Delirium, Dementia, and Neuropsychiatric Disorders • More than 7% of women older than age 65 have clinically significant major depression • Up to 12% have symptomatic depressive disorders • Depression in this demographic group is correlated with an increased frequency of falls, greater probability of unhealthy BMI, and a higher incidence of fractures

Delirium, Dementia, and Neuropsychiatric Disorders • Several factors may account for this gender discrepancy • Men are less commonly diagnosed with depression than women • Elder men present differently, often coming to medical attention due to anger, agitation, anhedonia, withdrawal, or apathy • Men are less likely to acknowledge or admit feelings of sadness

Delirium, Dementia, and Neuropsychiatric Disorders • Men with non-dysphoric depression showed overall poorer long-term outcomes and an increased risk of death at 13-year follow-up than women • Men were also less likely to seek help from a physician or mental health professional • And had higher suicide completion rates than women

Delirium, Dementia, and Neuropsychiatric Disorders • While adults >65 make up 13% of the total population, they account for 24% of completed suicides in the US • White men older than age 85 have the highest rate of successful suicides • Most were in their first episode of depression at the time of successful suicide

Delirium, Dementia, and Neuropsychiatric Disorders • Bipolar disorder and schizophrenia account for a significant proportion of mentally ill older adults • Geriatric patients with bipolar disorder tend to be mostly female • Similarly, women account for the majority of patients presenting with late onset schizophrenia (3:2, women to men)

Delirium, Dementia, and Neuropsychiatric Disorders • This finding is vastly different from that of younger cohorts • In which men with new onset schizophrenia predominate at a ratio of 1.4:1 • One interpretation is that women are more predisposed to psychiatric illness later in life • However, the ratio of women to men increases with age

The Case of Mrs. V, Part II • Mrs. V has some concerning symptoms: • Avoidance of social activities (isolation) • Disinterest in leaving her home (anhedonia) • “Forgetfulness,” a jocularity about her forgetfulness • Weight loss (poor nutrition, vitamin and mineral deficiency, osteoporosis, occult malignancy) • Minor trauma • Falls

The Case of Mrs. V, Part II • She also has social risk factors: • Widowed • Lives alone • Female • She should be screened for early dementia and depression

The Case of Mrs. V, Part II • She screened positive on the CES-D for depression and a basic MSE revealed some deficits in recall and drawing tasks • Additional labs were obtained, including B12, folate, TSH, and VDRL • The ED physician should inform her PCP that Mrs. V would benefit from outpatient evaluation for depression

Traumatic Injuries • Trauma remains a major cause of morbidity and mortality among older adults • Patients over 65 account for almost 25% of all trauma patients • The elderly account for 5.9% of all injury-related ED visits • Treating the injured elderly in the ED costs twice as much as treating younger patients

Traumatic Injuries • Falls account for 2/3 of elders’ accidental deaths, followed by motor vehicles accidents • Polypharmacy is the leading risk factor for elder falls – but only if the patient is taking one of the established fall risk-increasing drugs • Diuretics, quinine and derivatives, or psychotropics

Traumatic Injuries • While both men and women are predisposed to fall injuries, older women are more likely to fall than older men • Women were more likely than men to inform others of their fall • More likely to seek treatment in an ED • Also more likely to need hospitalization for their traumatic injuries

Traumatic Injuries • Nevertheless, if men required hospitalization, their length of stay for acute care and rehabilitation exceeded that of women • Men were also less likely to return to their homes and independent living • It has been well-established that elders who live alone are more likely to sustain falls • This is especially true for women

Sex & Gender in Acute Care Medicine