GERIATRIC EMERGENCY MEDICINE
Category: Emergency Medicine
Abstract : The Elder Patient - geriatric emergency medicine Older patients represent
a special population for emergency medicine. The approach that focuses on one
chief complaint and develops a differential diagnosis based on life-threatening
and common diseases may miss significant conditions in older persons. Older
patients are more time-consuming, more difficult to evaluate, and use more
reso
The Elder Patient - geriatric emergency medicine
Older patients represent
a special population for emergency medicine. The approach that focuses on one
chief complaint and develops a differential diagnosis based on life-threatening
and common diseases may miss significant conditions in older persons. Older
patients are more time-consuming, more difficult to evaluate, and use more
resources than do younger adult patients.
The complexity of their
presentations and dispositions, as well as communication problems with the
patients, their families, and primary care providers, all make the ED evaluation
of elderly persons more difficult as compared with younger adult patients. The
physiology of aging results in altered disease presentations, altered
pharmacodynamics, and decreased functional reserve, as well as social problems,
which must be dealt with in the setting of a busy ED.
Epidemiology
The
elderly population in the United States is growing rapidly, with projected
increases from 200 percent for the 65- to 74-year-old segment, 300 percent for
the 75- to 84-year-old segment, and more than 500 percent for those older than
age 85 years by the year 2050. Approximately 12 percent of the population was 65
years of age or older in 1990, whereas 20 percent of the population (or 55
million persons) will be 65 years of age or older by the year 2030.
As
noted, the oldest elderly, those age 85 years and older, are the most rapidly
increasing segment of the elderly population. This is also the population with
the most health problems and in greatest need for health care. There is great
variability in the physiologic age of individual patients. A 55-year-old with
multiple chronic diseases and poor physiologic reserve may have a physiologic
age much older than a healthy 80-year-old.
In 1995, almost 16 percent of
ED visits were made by patients age 65 years and older, and 46 percent were
admitted to the hospital. Older patients spend more time in the ED, require more
ancillary tests, and are more likely to be admitted to critical care units as
compared to younger patients. The National Center for Health Statistics (NCHS)
2000 survey documents that persons aged 75 years and older had 64.8 ED visits
per 100 persons per year, twice the rate for younger persons. The rate of
ambulance use increased with age, with 43 percent of persons age 75 and older
taking ambulance transport to the ED.
Pathophysiology
The basic
principles of geriatric emergency medicine have been defined (Table 307-1).
Older patients often present with ambiguous complaints, such as not feeling
right, feeling weak, or not doing usual activities. Vague complaints, such as
general weakness or functional decline, may indicate important diseases, such as
sepsis, subdural hematoma, or myocardial infarction. Assessment of functional
status can be used for classifying and evaluating these complaints.
Table
307-1 : Principles of Geriatric Emergency Medicine
1. The patient's
presentation is frequently complex.
2. Common diseases present atypically in
this age group.
3. The confounding effects of comorbid diseases must be
considered.
4. Polypharmacy is common and may be a factor in presentation,
diagnosis, and management.
5. Recognition of the possibility for cognitive
impairment is important.
6. Some diagnostic tests may have different normal
values.
7. The likelihood of decreased functional reserve must be
anticipated.
8. Social support systems may not be adequate, and patients may
need to rely on caregivers.
9. A knowledge of baseline functional status is
essential for evaluating new complaints.
10. Health problems must be
evaluated for associated psychosocial adjustment.
11. The emergency
department encounter is an opportunity to assess important conditions in a
patient's personal life.
Common diseases often present atypically in
older persons, resulting in missed diagnoses unless physicians understand and
suspect the atypical presentations in this population. For example, consider two
common presenting complaints - chest pain and abdominal pain - and common
diagnoses for each - myocardial infarction and acute appendicitis. Fewer than
half of patients 85 years of age and older will present with chest pain as a
symptom of acute myocardial infarction.
Instead, patients present
atypically with dyspnea, syncope, weakness, or dizziness. Older patients with
acute appendicitis are often diagnosed late and have a high perforation rate. A
large percent of patients with appendicitis are diagnosed more than 48 h after
the onset of symptoms, with up to 20 percent diagnosed after 3 days. The
abdominal pain is vague, and the symptoms may be poorly localized. Classic
patterns of pain and accompanying symptoms, such as nausea and vomiting, are
present in only a minority of older patients with acute appendicitis. Older
patients with acute abdominal conditions commonly lack physical findings of
guarding or rebound.
Older patients frequently will have confounding
comorbid diseases, and emergency physicians should evaluate whether the
presenting complaint reflects an exacerbation of one of the comorbid diseases or
a new disease process. Comorbid diseases, especially those treated with multiple
medications, may also affect the management and disposition of
patients.
Older adults take an average of more than four prescription
drugs and more than two over-the-counter drugs each day. Approximately 30
percent of older persons will develop adverse medication effects, and they are
twice as likely as younger adults to have adverse effects. Adverse medication
effects account for approximately 5 percent of hospital admissions. The number
of medications that a patient takes is directly related to the chance of adverse
drug effects. Normal aging results in a loss of cardiac, pulmonary, hepatic, and
renal functional reserve.
Thus, the margin of error decreases for many
medications, such as nonsteroidal anti-inflammatory drugs. The distribution of
drugs changes with age; as lean body mass decreases, the larger proportion of
adipose tissue increases the volume of distribution of drugs, such as
benzodiazepines, phenytoin, barbiturates, and phenothiazines, and prolongs their
duration of action. Drug clearance depends primarily on hepatic and renal
function. The decreased renal function with age may affect drugs such as digoxin
and the aminoglycoside antibiotics.
Drug receptor interactions also play
a role in pharmacodynamics. Older persons have an increased sensitivity to
warfarin and benzodiazepines. Common complications of medications or drug
interactions include delirium, depression, functional decline, worsening
dementia, orthostatic hypotension, weakness, dizziness, falls, and incontinence.
The impact of new medications prescribed in emergency departments, such as
anticholinergics, sedatives, and diuretics, as well as adverse interactions with
current medicines, should be anticipated.
Older persons frequently have
cognitive impairment that may not be recognized by health care providers.
Cognitive impairment includes both acute confusional states (delirium) and
dementia. Abnormal cognitive states in older patients affect the reliability of
the history and impact disposition planning. Acute cognitive impairment can be
an important symptom of sepsis, congestive heart failure, metabolic abnormality,
adverse drug effect, or subdural hematoma. When older ED patients are screened
for cognitive impairment, 30 to 40 percent of those who have no previous history
of impairment will have abnormal cognition based on formal mental status exams.
Approximately 10 percent of patients will meet formal criteria for delirium,
which should be considered a symptom of a medical emergency. Formal tools for
evaluation of cognition are recommended later in this chapter.
Accurate
laboratory test interpretation requires a knowledge of which "normal" values are
altered with aging. Although many laboratories control for age variations in
neonates and children, few list control values for older patients. For example,
laboratory parameters such as the sedimentation rate, glucose and creatinine
levels, and arterial blood oxygen tension change with physiologic
aging.
The likelihood of decreased functional reserve should be
anticipated in older persons. Most patients are asymptomatic until they are
stressed or reach a critical threshold in which symptoms are manifested. Most
organ functions decline with age. Resting cardiac output decreases at
approximately 1 percent per year after age 30 years. Pulmonary, renal,
neurologic, and immunologic functions also decrease with age. Chronologic and
physiologic age, however, may vary considerably, depending on genetics,
environment, health behaviors, diet, tobacco use, alcohol use, exercise, and
stress. When older persons are stressed, for example, by extreme heat or cold,
their regulatory mechanisms are not as effective as when they are not so
stressed.
Older persons should be viewed in the context of their home
environment and social support network. Simply addressing an injury or illness
may not be adequate. More than 20 percent report a change in their ability to
care for themselves following their ED visit. An independent-living 80-year-old
woman who sprains her ankle may become incapacitated. Enlisting the help of a
social service network and of home health providers will ensure that such
patients are able to carry on the functions of daily living.
In addition,
many older persons need to rely on caretakers, so an assessment of the
caretaker's ability to help the patient is important. Is the caretaker an
elderly spouse who will predictably injure himself or herself in trying to lift
a patient who is incapacitated by a new injury? Elder abuse and neglect is a
significant issue that should be assessed by questioning the patient and
caretaker separately.
The emergency health care professional can play a
key role in screening for such important conditions such as elder abuse,
depression, alcoholism, malnutrition, incontinence, falls, and immunizations. In
a multicenter study in which patients were screened, almost 80 percent of older
patients demonstrated a problem in one or more of these areas.
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