Geriatric Emergencies

A Discussion-based Review

Amal Mattu, Shamai Grossman, Peter Rosen, Amal Mattu, Shamai Grossman, Peter Rosen

• Publisher: Wiley-Blackwell
• Year: 2016
• Print ISBN: 9781118753347
• eBook ISBN: 9781118753330
• Edition: 1
• Topic: Medicine
• Subtopic: Emergency Medicine & Critical Care

The elderly represent the fastest growing segment of the population in developed countries, reflected in the patient population presenting to EDs and hospitals. These patients more often than not have greater co-morbidities, more complicated workups and utilize more laboratory and radiologic services. This text is designed to teach emergency physicians how best to care for this specific demographic of patients. It addresses physiologic changes, high-risk conditions, and atypical presentations associated with elderly patients in the ED that result in frequent misdiagnosis or delays in diagnosis. It instructs the readers how best to care for elderly patients in order to minimize morbidity and mortality, addressing some of the difficult psychosocial issues that confront health care providers that care for elderly patients, such as psychiatric disease and end-of-life care. The utility of this text is not limited to emergency physicians, but it should be useful to all health care providers involved in the treatment of elderly patients with acute medical or surgical conditions.

Chapter 1
General assessment of the elderly patient

Alison Southern & Scott Wilber

Department of Emergency Medicine, Summa Akron City Hospital, Northeast Ohio Medical University, Akron, OH, USA

Section I: Case presentation

The patient is a 96-year-old man who presented with a chief complaint of slurred speech and generalized weakness. A history was obtained from the paramedic run sheet and family, who arrived in the emergency department (ED) 15 min after the patient. His symptoms have been waxing and waning over the last few days. Today, he had slurred speech and left-sided weakness, which has now resolved.

The patient's daughter reported that since his wife died 3 months ago, he has had a 20 lb weight loss. He has decreased appetite, decreased activity, and decreased function, which has waxed and waned. For the last 2 days, he has required wheelchair transport to the cafeteria for meals and assistance with transfer. The family stated that he has not had a recent change in his confusion.

The past medical history was significant for dementia, gastroesophageal reflux disease, hypertension, aortic stenosis, and benign prostatic hypertrophy. His social history notes that he currently lives in an assisted living facility. His daughter visits daily and assists with instrumental activities of daily living (ADLs).

On examination, the vital signs were normal. Head, eyes, ears, nose, and throat examinations were normal. Results of cardiopulmonary, abdomen, and extremity examinations were normal. On neurologic examination, he was oriented to year and person. He was not oriented to day or month. He had 0/3 items on 3 item recall. The Six-Item Screener (SIS) score was 1. The modified Richmond Agitation and Sedation Scale (RASS) score was 0. The NIH Stroke Scale was 1 for confusion. The skin examination revealed a Stage 2 sacral decubitus ulcer.

The laboratory studies revealed an albumin of 2.3 and a hemoglobin of 9.

The family felt that the patient had been declining since his wife died and requested hospice evaluation, as a hospice had been beneficial for the patient's wife.

Section II: Case discussion

Dr Peter Rosen (PR): I would like to remind everyone what we tell our interns when we first get a presentation like this. We should have our exact vital signs instead of just saying normal, because normal may not be normal at this age. I think one of the critical assessment points of the older patient is to understand what are the normal changes in physiology as you age, so that you aren't fooled by them. Just as when you look at an infant, a resting heart rate of 120 doesn't bother you, which it would if the child were 10 years old. That's number one. Number two: it's impossible not to be that age without taking 42 different medications, so we really need to know what they are. Without those, it's really hard to get to the root of any geriatric problem. What are some of the physiologic changes you would expect in this age group?

Dr Amal Mattu (AM): You mentioned the vital signs, so we can start with that. To reiterate, vital signs can be unreliable. Elderly patients can have a resting bradycardia as opposed to the infants you mentioned who might have a resting tachycardia. In addition, if they're on beta-blockers, calcium channel blockers, or digoxin, any of these can produce a further reduction in the heart rate so that even in the presence of overwhelming sepsis they may not mount a tachycardia; or if they are bleeding out, they may not mount a tachycardia we've all been led to expect from those ATLS charts. Elderly patients often will have isolated systolic hypertension and may walk around with a systolic pressure of 180 or 190 torr. Thus, when they come in with a systolic pressure of 120 torr, it appears to be a normal pressure, but they may actually be in shock. These are the two vital signs that are the most misleading. Elderly patients tend to take longer to mount a fever as well. If they have an infection, they may also be more likely to develop a hypothermic response to the infection.

PR: Furthermore, not knowing what medications the patient is on prevents us from knowing what vital sign responses we can expect. Even though we are supposed to take temperatures on all patients, we frequently don't. It's just prudent to get used to having to ask for a temperature, if we don't see it right away. Can you think of any other physiologic changes to this age group that we should be aware of, such as vital capacity or respiratory rate or something to do with the neurologic system?

Dr Scott Wilber (SW): Dr Mattu mentioned the lack of tachycardia even in the case of overwhelming sepsis. One of the things we also see is that frequently tachypnea is a better indication of serious illness such as hemorrhage or infection, and you will frequently see a patient with only tachypnea as the manifestation of serious illness.

PR: The issues in this case are both medical and ethical. It seems to me that we rarely need to start ethical evaluations before we finish our medical evaluations, but here's a difference in the management of the geriatric patient. I think that unless you're willing to answer the ethical question of how much workup is this patient going to profit from, then you really can't do a good medical evaluation. This case seems to be a perfect example of that. Here's a patient with declining status, he can't take care of himself. Even from an already observed level of dementia, his family has noticed a decline. I think a good ethical question is at what point do workup and treatment become futile and an unnecessary expense rather than trying to reach the medical endpoint that we might try to achieve in someone, who was say 30 years younger leading a normal life.

AM: I agree managing expectations is going to be very important. I think we were very fortunate that in this case, the family is actually present, and we can have that discussion with them. Moreover, the patient is somewhat stable. We can query the family about what their expectations may be for the patient's care. Also, we need to determine whether the patient had been to other facilities or his primary care physician to see if any aggressive changes might have been made to the medication regimen that might have led to the today's ED presentation. Then, we can ask that question: how much should we be doing? Other providers may not have done that, and that could actually explain why that person is here.

Dr Shamai Grossman (SG): I think the problem we are raising reflects some of the limitations of emergency medicine. We rarely have all the information about the patient, and often this is the first time we are seeing this patient. If you just read this case, you would realize we're missing vital parts of the history. You know the patient has had decreasing function since his wife died. Is that depression? Is it a physiologic process going on? The problem is we're seeing this patient fresh in the ED, and we're not his primary care doctor. In an ideal world, all these things would have been worked out by the primary care physician. At best, we will have only a brief discussion with the family members, and making these decisions is going to be very challenging. I think approaching older adults in the ED, given all these limitations that we have, requires a different method. I think a major responsibility is determining the goals of care that the patient or by proxy, the family or the caregivers would like. It's new for emergency physicians to be thinking in terms like this. Then, when we understand the immediate care goals, we can begin to find out about intermediate, and then long-term goals.

PR: I think that's a very strong point, which can also affect decision-making in terms of how aggressively you manage that patient. In any patient, you need to discover why they are there, and I think it can be useful to ask what are the expectations from the emergency care that this family wishes to derive. If he's having a stroke, do they want us to treat that stroke? If he's just declining, then why did they bring them to the ED? Often, the primary care physician may have the answers, but they frequently don't share them with the ED. What would you suggest in terms of the workup for what sounds to be a transient ischemic attack (TIA)?

AM: I would again start with trying to find out what the family's goals are in terms of the short-term and long-term outcomes. If this were a younger patient who had fewer medical problems and many years ahead of him, then you would probably get a head CT scan, and have neurology come and do the full workup that we usually perform for TIA and stroke. On the other hand, if this is a patient for whom the family just wants to make the patient comfortable, then we do not need to do much of anything. The family requested a hospice, which certainly suggests comfort care, and may preclude doing anything but giving that comfort care.

SW: I think oftentimes it does take a few minutes of conversation with the family to explain to them the different kinds of evaluations we can do in the ED. For instance, in this situation, the family may say they do not want a stroke aggressively treated, they may not want surgery to evacuate a subdural hematoma, but if the patient had a urinary tract infection (UTI) and needed antibiotics, they might consent to that. Or, if the patient were hyponatremic, and needed some IV fluids for a day, they might consent to that. I therefore might spend time with the family just to explain the kind of testing we can do, and what that would lead to. In this particular situation, a CT scan often may lead to more aggressive treatment than checking the patient's electrolytes or checking a urinalysis.

SG: I might add one more thing. We are concentrating on the wishes of the family, but what we need to be sure of is that these also are the patient's wishes. If the patient can't articulate what he really thought, we are obliged to make sure that the person you're talking to is really the healthcare proxy and make sure that when you talk to the family that they're actually communicating the patient's best wishes and not the family member's vested interests, and that they're not trying to make someone who potentially has some viability into a hospice patient. I think it's an ethical imperative that when we talk about patient autonomy, it's not solely the family's autonomy. When the patient is decisionally incapacitated, then you have to do the next best thing, which is to try to figure out what the patient would want.

SW: The ethical terms we use are using substituted judgment rather than best interest. Whenever possible, we want to substitute for our judgment what the patients would want, rather than just acting in their best interest. When we have no ability to ascertain what the patient would have wanted, then we act using the patient's best interest, but whenever possible, we use substituted judgment.

PR: A number of EDs have benefited from having a pharmacologist available in the department to help in the evaluation of complex drug interactions. I think that's particularly useful in the geriatric population because they have so many different medications that none of us can keep all the interactions in our head. We need to be cautious because the patient may have been taking inappropriate and just wrong medications, which somehow became the patient's or...

Table of contents

• Cover
• Title Page
• Copyright
• Table of Contents
• List of Contributors
• Chapter 1: General assessment of the elderly patient
• Chapter 2: Physiologic changes with aging
• Chapter 3: Functional assessment of the elderly
• Chapter 4: Pharmacological issues in the elderly
• Chapter 5: Altered mental status in the elderly
• Chapter 6: Geriatric psychiatric emergencies
• Chapter 7: Acute abdominal pain in the elderly: Surgical causes
• Chapter 8: Nonsurgical abdominal pain in the elderly
• Chapter 9: Back pain
• Chapter 10: Headache
• Chapter 11: Dyspnea in the elderly
• Chapter 12: Acute chest pain in the geriatric patient
• Chapter 13: Acute cardiac disease in elder patients
• Chapter 14: Syncope in Geriatrics
• Chapter 15: Stroke
• Chapter 16: Infections
• Chapter 17: Dizziness and vertigo in the geriatric population
• Chapter 18: Weakness and functional decline
• Chapter 19: Emergency department evaluation of falls in the elderly
• Chapter 20: Trauma in the geriatric patient
• Chapter 21: Surgical considerations in the elderly
• Chapter 22: Oncologic emergencies
• Chapter 23: Elder abuse and neglect
• Chapter 24: Geriatric emergency pain management case
• Chapter 25: Ethical issues and end-of-life care
• Chapter 26: Geriatric dispositions and transitions of care
• Chapter 27: The geriatric ED
• Index
• End User License Agreement