Assessment of Older Adults with Abdominal Pain in the Emergency Department: 10 Key Points

Assessment

1. Abdominal pain in older adults is more difficult to diagnose.

• Lack of signs and symptoms–   Older adults with serious abdominal pathology often present with subtle signs and symptoms.
• Delayed Presentation– Delay in seeking medical care is common due to cognitive impairment, blunted inflammatory response, transportation or financial issues, anxiety, depression, or the fear of losing independence.
• “Under-Triage”-  Older adults may be triaged to erroneously low Triage Acuity Levels, as they often don’t complain of “severe” pain or evidence “abnormal” vital signs when presenting with serious causes of abdominal pain.  This may increase wait times and cognitive bias toward more benign diagnoses.
• Difficulty in Data Gathering– An accurate history and physical exam is more difficult to obtain if cognitive impairment or delirium is present.
• Multi-morbidity and asymptomatic pathology increase risk of misdiagnosis.
  • Asymptomatic underlying pathology may mask an acute diagnosis (e.g., radiographic patterns suggesting constipation and urinalyses with WBC and bacteria are common but may lead to missed diagnosis).
  • Comorbid medical conditions can exacerbate an intra-abdominal process (e.g., an older adult with CHF and shortness of breath and abdominal pain may be diagnosed with CHF exacerbation alone).

2. Obtain a comprehensive history.

• Medical History– Document all abdominal pathology, especially those increasing risk: atherosclerosis, immune suppression, arrhythmia, diabetes, CHF, renal failure, smoking, and cancer.
• Surgical History– Ask about prior surgeries to inform risk of adhesions or internal or external hernias, and to identify organs no longer present.
• Social History– Consider substance use, living arrangement, and baseline functional status.
• Medications– Ensure accurate medication reconciliation, particularly anti-coagulants, immunosuppressants, opiates, NSAIDS, and antihypertensives.  Inspect medication bottles if available as medications may not be taken as prescribed.  Consider drug-disease interactions (e.g., analgesic use masking pain or diuretics worsening hypovolemia).< >- Review available nursing facility, ED, and hospital records with attention to procedures, recent visits/admissions, and test results.
• Records– Review available nursing facility, ED, and hospital records with attention to procedures, recent visits/admissions, and test results.

3. Evaluate abdominal complaints in older adults with cognitive impairment and/or delirium.

• Ask older adults with cognitive impairment about their symptoms.

• Gather history from caregivers, referring providers, family members, and nursing facility staff. Document baseline and change in cognitive, ambulatory, and functional status.
• Observe older adults with cognitive impairment for nonverbal signs of distress (e.g., agitation, facial grimacing, discomfort with movement, holding or rubbing their abdomen, refusal to eat or drink, closed eyes, increased respiratory rate, inconsolability).
• Screen for delirium by talking with caregivers and using the Brief Confusion Assessment Method (http://www.icudelirium.org/docs/bCAM_Flowsheet.pdf)

4. Physical exam and laboratory values are less reliable markers of disease severity in older adults with abdominal pain.

• Older adults do not evidence vital signs abnormalities as reliably as younger patients. They are less likely to develop a high temperature. Tachycardia may be masked due to medications. In older adults with a history of hypertension, a “normal” or “low normal” blood pressure may signal serious pathology and “relative shock”.
• Pain may manifest differently. Older adults are less likely to complain of pain or show peritoneal signs of guarding, rigidity, and rebound.
• Surgical scars inform the risk of adhesions, hernias, and organs no longer present.
• Perform a rectal exam to check for impaction and blood.
• Examine the suprapubic area and consider a bladder scan to assess for urinary retention.
• Laboratory values are notoriously unreliable in indicating the etiology, likelihood, or severity of abdominal pathology in older adults. (e.g., White blood cells may not be elevated).
• Liver function tests may be misleading. They are often normal in older adults with cholecystitis and their elevation does not necessarily indicate acute hepatobiliary disease.
• Abnormal hemoglobin levels may be acute or chronic. Review prior values.
• Asymptomatic bacteriuria is very common in older adults. The incidence is nearly 100% in older adults with chronic indwelling foley catheters.
• Do not ascribe a cognitively intact, community-dwelling older adult’s abdominal pain to “UTI” without a combination of genitourinary symptoms and a suggestive urinalysis.
• Lactic acid may be an important marker of tissue hypoperfusion in older adults in whom you have a high suspicion for a surgical or rapidly progressive intra-abdominal process.

5. Consider serious illnesses that are much more common in older adults.

• Gallbladder and biliary tract disease is the most common surgical cause of abdominal pain in older adults.It is more often complicated by acalculous cholecystitis, ascending cholangitis, gallbladder perforation, emphysematous cholecystitis, and gallstone ileus.
• Bowel obstruction is the second most common surgical cause of abdominal pain in older adults.Small bowel obstruction, while usually secondary to adhesions or hernias as in younger patients, may be due to gallstone ileus or malignancy in older adults.Large bowel obstruction is usually caused by malignancy, diverticular disease, or sigmoid volvulus.
• The risk of abscess or perforation complicating diverticulitis or appendicitis increases with age.
• Pancreatitis is twice as common after age 65 years, and is more often due to gallstones than alcohol in older adults.
• The risk of abdominal aortic aneurysm rupture increases with age. The classic presentation of hypotension, abdominal pain, and palpable abdominal mass is often absent.
• Peptic ulcer disease and perforation is more subtle and may not present with pain.
• Intestinal ischemia presents on a spectrum from intermittent abdominal pain to rapidly progressive bowel necrosis and peritonitis.
• Consider ischemia in all older adults with abdominal pain, especially among patients with thromboembolic risk factor or among patients with low flow states. Intestinal ischemia often presents with bowel emptying (vomiting and diarrhea). If misdiagnosed as “gastroenteritis” or another self-limited illness, mortality is very high, approaching 90% in patients with bowel necrosis.

6. Consider extra-abdominal causes of abdominal pain in older adults.

• Consider a cardiac etiology for older adults with upper abdominal pain, as abdominal pain is a common presentation for older adults with acute coronary syndrome.
• Pneumonia and pneumothorax may present as abdominal pain in older adults.
• Diabetic ketoacidosis and hypercalcemia present with abdominal pain.Obtain a metabolic panel and consider these diagnoses in older adults with diabetes, malignancy, or parathyroid disease.
• Consider retroperitoneal and rectus hematoma in older adults with abdominal, groin, back, or flank pain who are on anti-coagulation or who have had a recent cardiac catheterization.
• Genitourinary causes of abdominal pain in older adults include kidney stones, pyelonephritis, cystitis, renal infarction, and acute urinary retention.
• In the setting of fall or trauma, palpate and inspect for bruising of the thorax and abdomen, paying particular attention to the left and right upper quadrants due to possible splenic / hepatic injury.
• Inspect the skin for a rash consistent with shingles.

7. Consider abdominal pathology in older adults who don’t present with a chief complaint of abdominal pain.

• Older adults with serious underlying abdominal pathology often present with nonspecific complaints (e.g., generalized weakness, mental status change, functional decline). Place abdominal pathology high on the differential diagnosis of these complaints and consider abdominal imaging in acutely ill or decompensating older adults.
• Intra-abdominal disease may present with pain referred outside the abdomen (e.g., hepatobiliary disease referred to the chest, back or shoulder; pancreatitis and peptic ulcer disease presenting as back or flank pain.)

8. Utilize advanced imaging liberally to avoid missed or delayed diagnosis.

• Plain Films- Be cautious with ordering and interpreting X-rays to evaluate abdominal pain in older adults. They lack the sensitivity and specificity requisite this high risk presentation.
• Ultrasound- Ultrasound is useful as an initial test for patients with suspected biliary tract disease. Bedside ultrasound can rapidly evaluate the aorta and should be employed liberally in older adults with abdominal pain.
• CT is the most useful imaging test for evaluating older adults with abdominal pain.
• A non-contrast CT decreases misdiagnosis and may be done quickly, limiting delay in making time-sensitive diagnoses.
• Older adults are at increased risk of contrast nephropathy due to age, co-existing medical conditions (diabetes, renal insufficiency, CHF), medications (diuretics, glucophage), and volume depletion.
• Oral contrast is important for the diagnosis of internal hernias in patients who have had gastric bypass or multiple abdominal surgeries.
• Intravenous contrast is important in evaluating vascular disease such as intestinal ischemia and aortic pathology.

9. Nonsurgical conditions are diagnoses of exclusion in older adults presenting to the ED with abdominal pain.

• Older adults are frequently misdiagnosed with constipation, gastroenteritis, or UTI. Initial misdiagnosis significantly increases morbidity and mortality.
• Avoid the “Anchoring Bias”.Older adults may minimize the likelihood of serious disease, ascribing their symptoms to constipation, food borne illness, “a bug”, or heartburn. Do not attach to the patient’s self-diagnosis while conducting a thorough “worst things first” evaluation.
• Two thirds of the mortality associated with acute gastroenteritis in the United States is in patients over 70 years.
• Fecal impaction is not a benign presentation, as it may cause bowel perforation or ischemia.

10. Many older adults will have a diagnosis of “undifferentiated abdominal pain” after a thorough ED evaluation.

• Reevaluate frequently and consider repeating laboratory studies.
• Consider admission or observation for patients with undifferentiated abdominal pain.
• Discuss the case with a surgical consultant.
• Many older adults with abdominal pain can be safely discharged. Collaborate with the patient, caregivers, PCP, and specialists to create a workable discharge plan. Insure understanding of discharge instructions. Always instruct the patient to return to the ED if symptoms worsen, persist, or recur.

Context

Older adults presenting to the emergency department with abdominal pain.

Action

Apply key concepts in the evaluation of older adults with abdominal pain.

Incidence / Prevalence

• Abdominal Pain is the third most common chief complaint among ED patients over 65 years, representing 6.6% of all older adult visits nationally. Only Chest Pain (7.8%) and Shortness of Breath (7.1%) are more common.
• Sixty percent of older adults presenting to the ED with abdominal pain will be admitted, 20-30 percent will require surgery, and 5-10 will die from their disease.

Underlying Sciences

Physiologic changes associated with aging cause subtle and delayed presentations of serious abdominal disease in older adults.  These include: atherosclerosis, decreased physiologic reserve, blunted adrenergic response, decreased abdominal wall musculature, decreased pain fiber function, and high incidence of asymptomatic underlying pathology.

Science Principles

Impaired homeostasis

Post-mitotic tissue and age related degeneration

Objectives

1. Recognize acute abdominal pain in older adults as a common, distinct, high risk clinical entity.
2. Develop a comprehensive approach to the timely evaluation of older adults with abdominal pain.
3. Minimize delayed diagnosis and misdiagnosis when evaluating older adults with abdominal pain.

Keywords/Tags

Review of Systems (ROS)

Gastrointestinal

Geriatric Topics

Complex or Chronic Illness in Older Adults

ACGME Compentencies

Medical Knowledge

Patient Care

Science Principles

Impaired homeostasis

Post-mitotic tissue and age related degeneration

References

1. Biese, Kevin, et al. “Abdominal Pain in the Elderly”. The American Geriatrics Society.  Slideshow. (https://www.google.com/search?client=safari&rls=en&q=kevin+biese+abdominal+pain+slide&ie=UTF-8&oe=UTF-8)
2. Blaha, Steven, et al. “Abdominal Pain in the Elderly”.  AHC media.com.  Sept, 2008. (http://www.ahcmedia.com/articles/14962-abdominal-pain-in-the-elderly)
3. Bryan, David, et al. “Abdominal Emergencies in Elderly Persons”.Medscape. December, 2015. (http://emedicine.medscape.com/article/776663-overview)
4. Esser, et al. “Ability of CT to Alter Decision Making in Elderly Adults with Acute Abdominal Pain”.  Am J Emerg Med. 2004 Jul:22(4)270-2.
5. “Emergency Department Measures Data Guide”. Emergency Dept. Benchmarking Alliance.  2012.
6. Green, Gemma, et al. “Emergency Laparotomy in Octogenarians: A 5 year study of Morbidity and Mortality”.  World J Gastroint Surg 2013 Jul:5(7):216-21.
7. Lewis, Lawrence. “Etiology and Clinical Course of Abdominal Pain in Senior Patients: A Prospective, Multicenter Trial”.  J Gerontology 2005 Aug:60(8)1071-6.
8. Mattu, Amal. “Abdominal Pain in the Elderly”.  EM:RAP.  Episode 56.  May, 2006.
9. McNamara, Robert. “Abdominal Pain in the Elderly- Part I”.  EM:RAP. Episode 92. May, 2009.
10. McNamara, Robert. “Abdominal Pain in the Elderly- Part II”.  EM:RAP. Episode 93. June, 2009.
11. McNamara, Robert. “Abdominal Pain in the Elderly- Part III”.  EM:RAP. Episode 93. June, 2009.
12. Sachs, Carolyn. “Tips Help Evaluation of Abdominal Pain in the Elderly”. ACEP News.  July, 2008.
13. Shenvi, Christina. “Geriatric Abdominal Pain”. EM:RAP. Episode 153.  June, 2014.
14. Shenvi, Christina. “Ten Tips for Approaching Abdominal Pain in the Elderly”. ALIEM.com. Oct, 2013. (http://www.aliem.com/2013/ten-tips-for-approaching-abdominal-pain-in-the-elderly/)
15. Spangler, Ryan. “Abdominal Emergencies in the Geriatric Patient”. Int J Emerg Med 2014 Oct:7:43.
16. “Urinary Tract Infections May Be Inappropriately Diagnosed and Treated in Nursing Home Residents Evaluated in Emergency Departments”. AGS 2014 Annual Scientific Meeting July 2014.
17. Warden, V. et al. “Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale”. JAMDA. 2003 Jan-Feb:4(1)9-15.

Authors

Adam Perry

MD

Bio

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.

Publications

Michael Malone

MD

Bio

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.

Selected Publications