Geriatrics/review articleOlder Patients in the Emergency Department: A Review
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.
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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.
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Publication date: Available online July 9, 2010.
Reprints not available from the authors.