• 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.

• 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.

• 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.

• 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… ).

• 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.

• 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.

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

Consider:

• 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.

• 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.

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?”

Behavioral & Social Sciences including Bioethics

Impaired homeostasis