Care of the Geriatric Patient

Key Concepts

The population is aging, with 10,000 Americans turning 65 every day, resulting in an increasing proportion of ED patients that are elderly. Older ED patients have the greatest resource use, longest lengths of stay, and highest admission rates of any age group.
Delirium, especially hypoactive delirium, is underrecognized by emergency clinicians; the diagnosis of delirium should prompt investigation for life-threatening emergencies, including infection, metabolic abnormalities, and acute coronary syndrome (ACS).
Nonspecific complaints, such as generalized weakness, are among the top ten presenting complaints for older ED patients, and are often the harbinger of serious underlying illness.
Atypical presentations of disease result in diagnostic challenges and can lead to misdiagnosis.
Many older patients with ACS present without chest pain, especially females and those older than 85 years. ACS in older adults is more often complicated by acute heart failure due to age-related decreases in left ventricular compliance. Current recommendations regarding medical and revascularization therapy in those with non-STEMI and STEMI have no age limitations.
Almost one-third of older ED patients presenting with abdominal pain are ultimately found to have a surgical condition causing the pain; therefore, there should be a low threshold for diagnostic imaging.
Mortality from sepsis approaches 40% for patients older than 85 years, with respiratory and genitourinary infections being the most common sources. Older adults with infection are less likely to present with fever or leukocytosis and may have SIRS-negative sepsis.

Foundations

Emergency department (ED) utilization for patients 65 and over is growing faster than for any other age group. The current growth in the population of older adults is unprecedented in the history of the world. In the United States approximately 10,000 of the “baby boomer” generation turn 65 years old each day, making those aged 65 years and older the fastest-growing segment of the population. By the year 2050, it is anticipated that they will comprise 21% of the population.

Older ED patients are a special population with unique needs and concerns. Altered homeostasis and decrease in physiologic reserve impacts their response to stressors and illness. Body composition changes predispose the older adult to dehydration and hypernatremia. Decreased subcutaneous fat places them at greater risk of hypothermia, and they are more at risk of developing hyperthermia when exposed to high ambient temperatures. The maximal heart rate achievable typically falls with age due to diminished responsiveness of the sympathetic nervous system, while resting heart rate may increase with age. Increases in heart rate may be blunted due to commonly prescribed medications. Reduced cardiac reserve predisposes to postural hypotension. Age-related decreases occur in hearing and vision that can markedly affect communication and functional status. Renal function, with creatinine clearance, declines with age. Changes in body composition and renal function result in pharmacokinetic and pharmacodynamic alterations that predispose older patients to medication adverse events. Polypharmacy is common in older patients, further increasing their risk of adverse drug reactions.

Emergency care should be approached in a holistic multidimensional manner with consideration for important confounding factors. Cognitive dysfunction, decreased functional reserve, frailty, mobility impairment, decreased hearing and decreased visual acuity can impact the ED evaluation and disposition decision making. The evaluation generally needs to be more comprehensive and extensive than those for younger patients. The average ED length of stay is longer for older adults who also have higher utilization of resources and rates of admission. They are more likely to have an emergent condition, higher morbidity and mortality, and are more likely to be misdiagnosed. Clinical presentations may be vague and nonspecific; “classic presentations” of disease are less likely in older patients. The differential diagnoses in the older adult are often expanded to included illnesses, such as mesenteric ischemia, aortic stenosis or giant cell (temporal) arteritis, that are not often seen in younger patients. Confounding chronic comorbidities, such as congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease, add to the complexities of evaluation and treatment. Adverse effects of home medications should be considered as a possible cause of their ED visit, especially for presentations of falls or altered mental status.

Cognitive impairment may impact obtaining an accurate history, performing a diagnostic evaluation, and designing a treatment and disposition plan. Corroborating sources of information, especially from caregivers are often needed to obtain a full and accurate history. Cognitive impairment may make sending the patient home potentially more dangerous, particularly if the patient is in the ED unaccompanied. Attention to transitions of care with an evaluation of home and social supports is often needed. However, hospitalization poses its own risks in that it is associated with increased rates of delirium, nosocomial infections, iatrogenic complications, and adverse drug reactions. It is common for admitted older patients to have a loss of one or more of their basic activities of daily living (ADLs) with a permanent impairment occurring in up to 40% of these patients.

Specific Issues and Disorders

Comprehensive Geriatric Assessment

The common multifactorial issues that affect older adults including chronic medical conditions, polypharmacy, cognitive problems, mobility and functional deficits, as well as psychosocial issues, are referred to as “geriatric syndromes.” The Comprehensive Geriatric Assessment (CGA) ( Box 178.1 ) is a multidisciplinary diagnostic and intervention process that identifies and addresses these issues that plague older adults. This approach addresses the complex geriatric syndromes while keeping in mind the patient’s goals of care, in an effort to improve the quality of life.

BOX 178.1

Comprehensive Geriatric Assessment (CGA) Elements Important for ED Assessment

Functional status
Cognition
Mood
Comorbidities
Polypharmacy and medications
Fall risk
Home situations and social supports

A complete CGA is time-consuming and not practical to be routinely performed for all older ED patients by busy emergency clinicians. However, identification of high-risk older adults may help target further evaluations and interventions and improve disposition planning. Widely disseminated geriatric ED guidelines recommend screening for high-risk patients. CGA in the ED has been linked to reduced need for hospitalization without an increase in mortality, thus reducing exposure of the patient to the hazards of hospitalization. The use of CGA adapted to the ED is an active area of research that will facilitate safe and efficient care for the older adult.

Cognitive Deficits: Delirium and Dementia

Older patients more often have cognitive, functional, and sensory impairments or depression that limit their ability to communicate. These conditions complicate the evaluation and management of older adults and may be underappreciated and underrecognized. Patients with cognitive dysfunction are less able to provide an accurate reason why they are in the ED and less able to comprehend discharge instructions. Patients and caregivers may have difficulties recalling all the details of a long and complex history or multiple medications; therefore, careful review of medical records and medication lists are important adjuncts to the history. Routine performance of a cognitive assessment in older patients is a geriatric quality indicator for EDs.

Delirium

Delirium, an acute confusional state with alterations in cognition and attention, occurs in 10% to 20% of older ED patients. Unfortunately, emergency clinicians miss recognizing delirium up to 75% of the time, especially with the hypoactive subtypes of delirium. There are several brief assessment tools available, including the well-established Confusion Assessment Method. The Delirium Triage Score with brief CAM (DTS and bCAM) is highly recommended for ED use ( Fig. 178.1 ).

Delirium is generally caused by decreased neurologic reserve plus one or more acute precipitants, such as infection, metabolic abnormalities, and acute coronary syndromes. Delirium and dementia are sometimes difficult to distinguish from one another, but the distinction is important because the presence of delirium should lead to concern for a potentially life-threatening medical emergency. Inattention or the inability to sustain focus is a key feature of delirium. Patients with underlying dementia are at high risk for development of delirium and recognition of delirium is even more difficult in patients with dementia. Older ED patients with delirium have higher intensive care unit (ICU) admission, 30-day mortality and 30-day readmission rates.

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