Elsevier

Annals of Emergency Medicine

Volume 56, Issue 3, September 2010, Pages 261-269
Annals of Emergency Medicine

Geriatrics/review article
Older Patients in the Emergency Department: A Review

https://doi.org/10.1016/j.annemergmed.2010.04.015Get rights and content

Older patients account for up to a quarter of all emergency department (ED) visits. Atypical clinical presentation of illness, a high prevalence of cognitive disorders, and the presence of multiple comorbidities complicate their evaluation and management. Increased frailty, delayed diagnosis, and greater illness severity contribute to a higher risk of adverse outcomes. This article will review the most common conditions encountered in older patients, including delirium, dementia, falls, and polypharmacy, and suggest simple and efficient strategies for their evaluation and management. It will discuss age-related changes in the signs and symptoms of acute coronary events, abdominal pain, and infection, examine the yield of different diagnostic approaches in this population, and list the underlying medical problems present in half of all “social” admission cases. Complete geriatric assessments are time consuming and beyond the scope of most EDs. We propose a strategy based on the targeting of high-risk patients and provide examples of simple and efficient tools that are appropriate for ED use.

Introduction

Older patients represent an ever-increasing population in emergency medicine.1 Such patients often present with atypical signs and symptoms and multiple comorbidities that complicate diagnosis and treatment.2 They are at increased risk of emergency department (ED) return visits, hospitalization, and death.2 Furthermore, outcomes may be related in part to issues such as functional status,2, 3, 4 comorbidity score,2, 5 age,2 social supports,2, 3 polypharmacy,2 cognitive impairment,2 and depression.2, 3

Most emergency physicians have not been trained in specific geriatric approaches, and many report being less comfortable when dealing with older patients.6

This article reviews the most common conditions affecting older patients in the ED, points out the main pitfalls and difficulties that may be encountered, and provides a brief description of appropriate instruments that can be easily used in the ED setting to assess older individuals and target high-risk patients for referral to a specialized physician or ward.

Section snippets

Epidemiology

Overall, older people account for 12% to 24% of all ED visits7, 8, 9, 10, 11 (Table 1). They visit the ED more frequently than younger adults (during 2006, the annual ED visit rate was of 49/100 persons older than 65 years and 60/100 persons older than 75 compared with an overall rate of 41/100 persons in the United States12). ED visits of patients aged 65 to 74 years increased by 34% between 1993 and 2003.13

Older patients present with a higher level of emergency12, 14 and more serious medical

Neuropsychiatric Disorders

Impaired mental status occurs in approximately one quarter of all older patients presenting to the ED as a result of delirium, dementia, or both.18, 19 The Geriatric Emergency Medicine Task Force recommends a mental status assessment for all older patients in the ED.20

Delirium is by definition a result of an underlying condition, potentially severe and important to recognize quickly.18, 21 It occurs in 7% to 10% of this population18, 19, 21, 22 and is associated with increased mortality18, 23

Targeting “High-Risk” Elderly

Given the lack of time and important workload in the ED, considering every patient older than 65 years for a thorough geriatric evaluation is not realistic. Moreover, the needs of older patients in the ED concerning such evaluations vary. Appropriate screening and elaboration of specific intervention protocols may help emergency physicians target patients prone to benefit from a more detailed evaluation in the ED on one hand and better orient such patients toward the correct ward or community

Conclusion

Older people visit the ED ever more frequently and can benefit from a targeted approach. A greater knowledge of the atypical presentation of disease, the complex interrelated acute medical and psychosocial issues of such patients, and the appropriate use of available screening and assessment tools can help emergency physicians provide high-quality care to this increasing population.

References (104)

  • J. Monette et al.

    Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room

    Gen Hosp Psychiatry

    (2001)
  • S.W. Meldon et al.

    Depression in geriatric ED patients: prevalence and recognition

    Ann Emerg Med

    (1997)
  • S.W. Meldon et al.

    Recognition of depression in geriatric ED patients by emergency physicians

    Ann Emerg Med

    (1997)
  • D.A. Fabacher et al.

    Validation of a brief screening tool to detect depression in elderly ED patients

    Am J Emerg Med

    (2002)
  • M.T. Aschkenasy et al.

    Trauma and falls in the elderly

    Emerg Med Clin North Am

    (2006)
  • J.R. Center et al.

    Mortality after all major types of osteoporotic fracture in men and women: an observational study

    Lancet

    (1999)
  • L.R. Mack et al.

    The use of head computed tomography in elderly patients sustaining minor head trauma

    J Emerg Med

    (2003)
  • D.J. Magid et al.

    Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients

    Ann Emerg Med

    (2005)
  • C.M. Hohl et al.

    Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department

    Ann Emerg Med

    (2001)
  • S.H. Onen et al.

    Alcohol abuse and dependence in elderly emergency department patients

    Arch Gerontol Geriatr

    (2005)
  • L. Simoni-Wastila et al.

    Psychoactive drug abuse in older adults

    Am J Geriatr Pharmacother

    (2006)
  • D.G. Blazer et al.

    The epidemiology of substance use and disorders among middle aged and elderly community adults: national survey on drug use and health

    Am J Geriatr Psychiatry

    (2009)
  • D. Esses et al.

    Ability of CT to alter decision making in elderly patients with acute abdominal pain

    Am J Emerg Med

    (2004)
  • F.M. Hustey et al.

    The use of abdominal computed tomography in older ED patients with acute abdominal pain

    Am J Emerg Med

    (2005)
  • L.M. Lewis et al.

    Quantifying the usefulness of CT in evaluating seniors with abdominal pain

    Eur J Radiol

    (2007)
  • C.A. Marco et al.

    Fever in geriatric emergency patients: clinical features associated with serious illness

    Ann Emerg Med

    (1995)
  • M.C. Horattas et al.

    A reappraisal of appendicitis in the elderly

    Am J Surg

    (1990)
  • J.S. Jones et al.

    Elder mistreatment: national survey of emergency physicians

    Ann Emerg Med

    (1997)
  • M.S. Lachs et al.

    ED use by older victims of family violence

    Ann Emerg Med

    (1997)
  • J. McCusker et al.

    Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit

    Ann Emerg Med

    (2000)
  • J. Fan et al.

    Predictive validity of the triage risk screening tool for elderly patients in a Canadian emergency department

    Am J Emerg Med

    (2006)
  • L.C. Mion et al.

    Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: the SIGNET model

    J Am Geriatr Soc

    (2001)
  • J. McCusker et al.

    Return to the emergency department among elders: patterns and predictors

    Acad Emerg Med

    (2000)
  • J. McCusker et al.

    Predictors of repeat emergency department visits by elders

    Acad Emerg Med

    (1997)
  • S.N. Hastings et al.

    Adverse health outcomes after discharge from the emergency department—incidence and risk factors in a veteran population

    J Gen Intern Med

    (2007)
  • J.L. Wofford et al.

    Emergency department utilization by the elderly: analysis of the National Hospital Ambulatory Medical Care Survey

    Acad Emerg Med

    (1996)
  • K.H. Lim et al.

    The presentation of elderly people at an emergency department in Singapore

    Singapore Med J

    (1999)
  • S.R. Pitts et al.

    National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary

    Natl Health Stat Rep

    (2008)
  • W.H. Ettinger et al.

    Patterns of use of the emergency department by elderly patients

    J Gerontol

    (1987)
  • S.A. Baum et al.

    Old people in the emergency room: age-related differences in emergency department use and care

    J Am Geriatr Soc

    (1987)
  • G.R. Strange et al.

    Use of emergency departments by elder patients: a five-year follow-up study

    Acad Emerg Med

    (1998)
  • S.T. Wilber et al.

    An evaluation of two screening tools for cognitive impairment in older emergency department patients

    Acad Emerg Med

    (2005)
  • M. Elie et al.

    Prevalence and detection of delirium in elderly emergency department patients

    CMAJ

    (2000)
  • R. Kakuma et al.

    Delirium in older emergency department patients discharged home: effect on survival

    J Am Geriatr Soc

    (2003)
  • S.K. Inouye et al.

    Clarifying confusion: the Confusion Assessment MethodA new method for detection of delirium

    Ann Intern Med

    (1990)
  • C.M. Callahan et al.

    Six-item screener to identify cognitive impairment among potential subjects for clinical research

    Med Care

    (2002)
  • A.B. Sanders

    Older persons in the emergency medical care system

    J Am Geriatr Soc

    (2001)
  • D. Vanpee et al.

    Epidemiological profile of geriatric patients admitted to the emergency department of a university hospital localized in a rural area

    Eur J Emerg Med

    (2001)
  • J.P. Sloan

    Protocols in primary care geriatrics

    (1997)
  • L.E. Mitchell et al.

    Prevalence of hypotensive disorders in older patients with a pacemaker in situ who attend the accident and emergency department because of falls or syncope

    Europace

    (2002)
  • Cited by (463)

    View all citing articles on Scopus

    Supervising editors: Robert J. Zalenski, MD, MA; Michael Callaham, MD

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

    Earn CME Credit: Continuing Medical Education is available for this article at: www.ACED-EMedHome.com.

    Publication date: Available online July 9, 2010.

    Reprints not available from the authors.

    View full text