1. The patient’s presentation is frequently complex.
It is more difficult to ascertain “sick or not sick” in older adults. Physiologic changes, medications and dementia and/or delirium may alter or mask vital signs and physical exam findings that more often signal significant disease in younger patients.
- Older patients often present with subacute illness and with multiple, ill-defined chief complaints.
- It is important to define “What Has Changed Today?”. What is the reason the patient, a caregiver, or a facility decided the older adult should be evaluated today? Taking time to adequately address this question on initial evaluation will align the patient’s needs with an efficient and patient-centric ED evaluation and disposition.
- The history will take longer to obtain and often involves contacting family, caregivers, referring physicians, and nursing facility staff.
2. Confounding and masking effects of aging physiology and comorbid disease must be considered.
- A vulnerable older adult has a much higher likelihood of a potentially fatal diagnosis than a younger patient; even if they do not appear seriously ill.’
- Always consider “Worst Things First” when constructing a differential diagnosis, paying particular attention to disease processes that are more common in the elderly (e.g., aortic disaster, stroke, ischemic gut, cholecystitis/cholangitis, occult sepsis, and “silent” acute coronary syndrome).
- Avoid premature diagnostic closure. Do not diagnose “constipation”, “gastroenteritis”, or “anxiety” until adequately ruling out more serious diagnoses.
- Contemplate whether falls and/or accelerated functional decline are the presenting symptoms of significant illness.
- If the diagnosis remains unclear, list the patient’s symptoms instead of a presumptive diagnosis.
3. Anticipate how decreased functional physiologic reserve will affect the patient’s acute presentation.
- Anticipate rapid decompensation with physiologic stress. Re-evaluate the patient frequently.
- Delirium is a failure of cognitive reserve. It is a marker of a serious disease process, and is often not recognized. Evaluate and re-evaluate older adults for delirium using a brief screen such as the Brief Confusion Assessment Method (http://www.icudelirium.org/docs/bCAM_Flowsheet.pdf).
- Consider organ dysfunction when formulating treatments. Adjust drug dosing in patients with renal insufficiency. Avoid using sedating or anticholinergic medications, especially in patients with frailty or dementia.
4. Common potentially life-threatening diseases may present subtly and atypically in older adults, especially those with baseline cognitive impairment.
- Acute MI: shortness of breath, change in mental status, abdominal pain, or weak/dizzy without chest pain.
- Surgical abdomen: absence of guarding, rigidity, rebound, fever, or elevated WBC count.
- Subdural hematoma: subtle, nonfocal neurologic changes, confusion, or falls.
- Sepsis: generalized weakness, change in mental status, often without fever.
- Traumatic hemorrhage: late recognition of shock due to blunted tachycardia and delayed hypotension.
5. Adverse medication events are common and should be considered in the differential diagnosis.
- The patient’s presentation may be the result of an adverse drug event, or a new medication may worsen a previously stable underlying medical condition.
- Systematically evaluate for recent medication changes including: new medications, dose adjustments, abrupt cessation, and the interaction of a long-standing medication with a new or evolving disease process.
- Medication errors and nonadherence are common. Do not assume medications are being taken exactly as prescribed.
- Seek to understand how an older adult is taking their medication. Review Medication Administration Records from nursing facilities. Discuss medication administration with caregivers. Call the patient’s pharmacy. Perform a “Brown Bag Biopsy” of medications brought to the ED; reviewing how they are taken, when and where they were last filled, and how many pills remain. Encourage your EMS colleagues to bring in older adults’ medication bottles if possible.
- Consider consulting the “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” to inform the likelihood of an adverse drug event. (http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPub… ).
6. Diagnostic tests may be misleading.
- Values that appear normal may mask acute pathology, as in the absence of an elevated WBC count in sepsis or with a surgical intra-abdominal process.
- Chronic abnormalities may be interpreted as acute, as in chronic renal insufficiency, anemia, bacteriuria, and leukocyturia. Obtain prior values for comparison from hospital, ED, family, or nursing facility records.
7. Knowing baseline and current functional and cognitive status is essential to evaluate new complaints.
- A patient with a history of dementia who is acutely more confused or lethargic should be considered delirious.
- If the patient is not awake, alert, and attentive, assume they have delirium.
- Undiagnosed dementia is present in approximately 30% of older adults in the ED. Dementia impairs the clinician’s ability to obtain an accurate history, increases the risk of delirium and patient dissatisfaction, and is associated with longer ED length of stay. In older adults with suspected dementia and whom you do not consider delirious, consider screening for dementia using the Short Blessed Test (http://alzheimer.wustl.edu/adrc2/Images/SBT.pdf) or Six Item Screener (https://www.scanhealthplan.com/media/1473/6-item-recall.pdf).
- Determine baseline ability to perform self-care. Can this patient perform basic physical tasks like transferring and toileting? Can they perform more complicated tasks like meal preparation, home cleaning, and medication management?
- Ask how quickly and drastically functional and cognitive status has declined. Was your patient showering independently two days ago, and today couldn’t get off the recliner?
- For patients presenting to the ED from a facility, consider the level of assistance they receive in that setting when evaluating current symptoms. Was the patient transferred from Assisted Living, Acute or Subacute Rehabilitation, or Long Term Care? A different level of function is required to reside in each setting.
- Perform a “Road Test”, a provider-witnessed trial of assisted ambulation to inform current ambulatory status. Ask patient and caregivers how the patient performed on the test relative to recent baseline.
8. Evaluate health problems in context of the patient’s psychosocial needs.
Ask the patient and caregivers:
- their “biggest worry” about current symptoms
- how they are coping with the patient’s condition
- about mood, stressors, and substance abuse
- If depression, anxiety, caregiving difficulties, and/or caregiver strain may have affected the need for ED evaluation.
- Whether elder abuse, neglect, and self-neglect may have created the need for ED evaluation.
- Repeated medical evaluations without evident new or evolving illness may signal the need to explore psychiatric symptoms and the caregiving environment.
9. Social support systems may have changed, or may not be adequate to accommodate increased functional dependence.
- Expand social history to understand an older adult’s social support system. Who do they live with? Who helps with bathing, dressing, and medication administration?
- Be mindful of the community-dwelling vulnerable older adult living alone and inquire about paid or unrelated caregivers.
- Note specifics of which functions have been recently lost. How does this affect the patient and caregiver in the current living environment? How successfully they have compensated for increased dependence?
- When discharging an older adult, construct an effective, workable plan for outpatient care. It is imperative the older adult and caregivers demonstrate an appropriate understanding of discharge instructions. Assess the patient’s access to medications, outpatient therapies, and timely follow-up, including transportation to appointments. Arrange for home support as needed.
10. Recognize and address the palliative care needs of older adults with serious or incurable illness.
Identify older adults most likely to benefit from incorporation of a non-curative, symptom management (palliative) approach in the ED, or a palliative care consultation.
These patients may include those with:
- Advanced dementia
- Metastatic cancer
- Severe CNS disease with progressive decline and poor functional status
- Advanced CHF or COPD with recurrent recent admissions
- Long Term Care patients with unclear care goals and/or recurrent recent admissions
- Extremely limited baseline function regarding ambulation, self-care, and oral intake
- Hemodialysis dependent renal failure
- The “Surprise Question”; those patients whom you would not be surprised if they died during this hospitalization or within six months
- Patients currently enrolled in hospice
- Assess the patient’s medical decision-making capacity and work with the ED team to identify and contact a surrogate decision-maker if necessary. ((http://canadiem.org/determining-capacity-in-an-emergency-the-curves-mnemonic/)
- Elicit the patient’s values and goals, and work towards aligning these with ED treatments and procedures. If the patient is rapidly decompensating, ask them or a surrogate decision maker “What treatments or procedures would be unacceptable?”
Evaluation of vulnerable older adults in the emergency department.
Perform an efficient and effective evaluation of a vulnerable older adult in the emergency department.
Incidence / Prevalence
In 2010, 15% of ED visits nationally were by adults over 65 years of age, with 9% of all ED visits by those 75 years of age and older.
On average, there are 50 visits per 100 people per year for those 65 years and older.
Approximately 43% of hospital admissions nationally are among those who are aged 65 years and older.
Older adults have much longer ED length of stay, use more laboratory and imaging, and are much more likely to require social service assistance.
Seventy-five percent of older adults visit an ED in their last six months of life.
Reduced functional reserve
Increased susceptibility to adverse medication events
Increased functional dependence and dependence on the social determinants of health
Increased susceptibility to iatrogenic illness
- Master geriatric-specific diagnostic considerations in the assessment of an older adult in the emergency department.
- Assess the bio-psycho-social needs of a vulnerable older adult in the emergency department.
Review of Systems (ROS)
- Alagiakrishnan, K. “An approach to drug induced delirium in the elderly”. Post Grad Med J 2004: 80: 388-393.
- American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
- deJong, M et al. “Drug Related Falls in older patients; implicated drugs, consequences, and possible prevention strategies”. Ther Adv Drug Saf. 2013 Aug: 4 (4): 147-154. “Geriatric Emergency Department Guidelines”. Jointly published by AGS, SAEM, ENA, and ACEP in 2013. (http://www.ncbi.nlm.nih.gov/pubmed/24746437)
- Isaacs, Eric. “Palliative Care in the ED: Don’t Just Do Something…Stand There”. www.ucsfcme.com/2014/mem14001/slides/11IsaacsPTPalliativecareintheed.pdf
- Lawson, BJ et al. “Palliative Care Patients in the Emergency Department”. J Palliative Care. 2008 Winter; 24 (4):247-55.
- Rosenberg, Mark et al. “Palliative Medicine and Geriatric Emergency Care”. Clin Geriatric Med 29 (2013) 1-29.
- Sanders, A. B., & Society for Academic Emergency Medicine (U.S.). (1996). Emergency care of the elder person. St. Louis: Beverly Cracom Publications.
Dr. Adam Perry is a community emergency physician and fellowship-trained geriatrician. Current positions include faculty with The Geriatric Emergency Department Collaborative; reviewer with ACEP’s Geriatric Emergency Department Accreditation program; educational consultant; and independently-contracted emergency physician with Commonwealth Health System in Northeastern Pennsylvania. He has worked emergency departments ranging from rural “critical access” to urban trauma centres; as well as in Post-Acute and Long-Term Care, and house call medicine.
Dr. Michael Malone is the Medical Director of Aurora Health Care - Senior Services and the Aurora at Home. He is a Clinical Adjunct Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. He also serves as the Director of the Geriatrics Fellowship Program at Aurora Health Care. Dr. Malone received his undergraduate and medical degrees from Texas Tech University in Lubbock, Texas; he completed his internal medicine residency and geriatric fellowship training at Mt. Sinai Medical Center in Milwaukee. His Aurora Health Care practice is to home-bound older persons in inner-city Milwaukee.