Skip to main content

Clinical Assessment and Management of Older People: What’s Different?

Abstract

Managing older people in any context, in particular urgent care settings, can be challenging. Unlike patient with single presenting problems, older people will usually present with a range of issues, not just medical, that require addressing in order to achieve an effective management plan. The key points to consider are the following:

  • Non-specific presentations

  • Multiple comorbidities and polypharmacy

  • Functional decline and altered homeostasis

  • Differential challenge

This is a preview of subscription content, access via your institution.

Notes

  1. 1.

    http://www.triagenet.net/en.

  2. 2.

    Phrase coined by Dr. Chris Roseveare, Southampton; @CRoseveare.

  3. 3.

    http://www.nice.org.uk/CG021.

References

  1. Limpawattana P, Phungoen P, Mitsungnern T (2016) Atypical presentations of older adults at the emergency department and associated factors. Arch Gerontol Geriatr 62:97–102

    CrossRef  Google Scholar 

  2. Jarrett PG, Rockwood K, Carver D et al (1995) Illness presentation in elderly patients. Arch Intern Med 155(10):1060–1064

    CAS  CrossRef  Google Scholar 

  3. Tudor Hart J (1971) The inverse care law. Lancet 297(7696):405–412

    CrossRef  Google Scholar 

  4. Samaras N, Chevalley T, Samaras D et al (2010) Older patients in the emergency department: a review. Ann Emerg Med 56(3):261–269

    CrossRef  Google Scholar 

  5. Woodard J, Gladman J, Conroy S (2010) Frail older people at the interface. Age Ageing 39(S1):i36

    Google Scholar 

  6. Fried L, Tangen C, Walston J et al (2001) Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci 56A(3):M146–M156

    CrossRef  Google Scholar 

  7. Rockwood K, Song X, MacKnight C et al (2005) A global clinical measure of fitness and frailty in elderly people. Can Med Assoc J 173(5):489–495

    CrossRef  Google Scholar 

  8. Conroy S, Dowsing T (2013) The ability of frailty to predict outcomes in older people attending an acute medical unit. Acute Med 12(2):74–76

    PubMed  Google Scholar 

  9. Adams ST, Leveson SH (2012) Clinical prediction rules

    CrossRef  Google Scholar 

  10. Ferguson C, Woodard J, Banerjee J et al (2010) Operationalising frailty definitions in the emergency department – a mapping exercise. Age Ageing 39(S1):i7

    Google Scholar 

  11. Caswell G, Pollock K, Harwood R et al (2015) Communication between family carers and health professionals about end-of-life care for older people in the acute hospital setting: a qualitative study. BMC Palliat Care 14:35

    CrossRef  Google Scholar 

  12. Bridges J, Flatley M, Meyer J (2010) Older people’s and relatives’ experiences in acute care settings: systematic review and synthesis of qualitative studies. Int J Nurs Stud 47(1):89–107

    CrossRef  Google Scholar 

  13. Williamson R, Lauricella K, Browning A et al (2014) Patient factors associated with incidents of aggression in a general inpatient setting. J Clin Nurs 23(7–8):1144–1152

    CrossRef  Google Scholar 

  14. Grafstein E, Bullard M, Warren D et al (2008) The CTAS National Working Group Revision of the Canadian emergency department information system (CEDIS) presenting complaint list version 1.1. Can J Emerg Med 10:151–161

    Google Scholar 

  15. Nemec M, Koller M, Nickel C (2010) Patients presenting to the emergency department with non-specific complaints: the basel non-specific complaints (BANC) study. Acad Emerg Med 17(3):284–292

    CrossRef  Google Scholar 

  16. Soar J, Nolan J, Böttiger B (2015) European resuscitation council guidelines for resuscitation 2015: section 3. Adult advanced life support. Resuscitation 95:100–147

    CrossRef  Google Scholar 

  17. Terrell KM, Hustey FM, Hwang U et al (2009) Quality indicators for geriatric emergency care. Acad Emerg Med 16(5):441–449

    CrossRef  Google Scholar 

  18. Falconer M, O’Neill D (2007) Personal views: out with “the old,” elderly, and aged. BMJ 334:316

    CrossRef  Google Scholar 

  19. Hustey FM, Meldon SW (2002) The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 39(3):248–253

    CrossRef  Google Scholar 

  20. Han JH et al (2011) Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 18:451–457

    CrossRef  Google Scholar 

  21. Swain DG et al (2000) Cognitive assessment in elderly patients admitted to hospital. Relationship between shortened version of AMT and the AMT and MMSE. Clin Rehabil 13(6):608–610

    CrossRef  Google Scholar 

  22. Carpenter CR, Bassett ER, Fischer GM et al (2011) Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer’s screen, short blessed test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med 18(4):374–384

    CrossRef  Google Scholar 

  23. Wilding L, Eagles D, Molnar F et al (2016) Prospective validation of the Ottawa 3DY scale by geriatric emergency management nurses to identify impaired cognition in older emergency department patients. Ann Emerg Med 67(2):157–163

    CrossRef  Google Scholar 

  24. Han J, Wilson A, Wesley E (2010) Delirium in the older emergency department patient: a quiet epidemic. Emerg Med Clin N Am 28:611–631

    CrossRef  Google Scholar 

  25. Young J, Inouye S (2007) Delirium in older people. BMJ 334:842–846

    CrossRef  Google Scholar 

  26. Han JH, Wilson A, Graves AJ et al (2014) Validation of the confusion assessment method for the intensive care unit in older emergency department patients. Acad Emerg Med 21(2):180–187

    CrossRef  Google Scholar 

  27. Grossmann F, Hasemann W, Graber A et al (2014) Screening, detection and management of delirium in the emergency department – a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified confusion assessment method for the emergency department (mCAM-ED). Scand J Trauma Resusc Emerg Med 22(1):19

    CrossRef  Google Scholar 

  28. Han JH, Wilson A, Vasilevskis EE et al (2013) Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 62(5):457–465

    CrossRef  Google Scholar 

  29. Bellelli G, Morandi A, Davis D (2014) Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 43:496–502

    CrossRef  Google Scholar 

  30. Dellinger RP, Levy MM, Carlet JM et al (2008) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36(1):296–327

    CrossRef  Google Scholar 

  31. Shapiro NI, Fisher C, Donnino M et al (2010) The feasibility and accuracy of point-of-care lactate measurement in emergency department patients with suspected infection. J Emerg Med 39(1):89–94

    CrossRef  Google Scholar 

  32. Jain P, Parada J, David A et al (1995) Overuse of the indwelling urinary tract catheter in hospitalized medical patient. Arch Intern Med 155(13):1425–1429

    CAS  CrossRef  Google Scholar 

  33. Hazelett S, Tsai M, Gareri M et al (2006) The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care. BMC Geriatr 6:15

    CrossRef  Google Scholar 

  34. Elpern E, Killeen K, Ketchem A et al (2009) Reducing use of indwelling urinary catheters and associated urinary tract infections. Am J Crit Care 18:535–541

    CrossRef  Google Scholar 

  35. Scottish Intercollegiate Guidelines Network (2006) Management of suspected bacterial urinary tract infection in adults

    Google Scholar 

  36. Banerjee J, Conroy S (2012) The silver book: quality care for older people with urgent & emergency care needs. Secondary the silver book: quality care for older people with urgent & emergency care needs. http://www.bgs.org.uk/index.php/bgscampaigns-715/silverbook

  37. Misch F, Messmer AS, Nickel CH et al (2014) Impact of observation on disposition of elderly patients presenting to emergency departments with non-specific complaints. PLoS One 9(5):e98097

    CrossRef  Google Scholar 

  38. van der Wardt V (2015) Should guidance for the use of antihypertensive medication in older people with frailty be different? Age Ageing 44(6):912–913

    CrossRef  Google Scholar 

  39. Ogliari G, Westendorp RGJ, Muller M et al (2015) Blood pressure and 10-year mortality risk in the Milan geriatrics 75+ cohort study: role of functional and cognitive status. Age Ageing 44(6):932–937

    CrossRef  Google Scholar 

  40. The Eastern Association for the Surgery of Trauma (2001) The EAST practice management guidelines workshop: practice management guidelines for geriatric trauma

    Google Scholar 

  41. Abbey J, Piller N, De Bellis A et al (2004) The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs 10(1):6–13

    CrossRef  Google Scholar 

  42. Chan EW, Taylor SE, Marriott J et al (2010) An intervention to encourage ambulance paramedics to bring patients’ own medications to the ED: impact on medications brought in and prescribing errors. Emerg Med Australas 22(2):151–158

    PubMed  Google Scholar 

  43. Gill TM, Gahbauer EA, Han L et al (2010) Trajectories of disability in the last year of life. N Engl J Med 362(13):1173–1180

    CAS  CrossRef  Google Scholar 

  44. Krumholz HM (2013) Post-hospital syndrome – an acquired, transient condition of generalized risk. N Engl J Med 368(2):100–102

    CAS  CrossRef  Google Scholar 

  45. Sager MA, Franke T, Inouye SK et al (1996) Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 156(6):645–652

    CAS  CrossRef  Google Scholar 

  46. McCusker J, Bellavance F, Cardin S et al (2000) Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit. Ann Emerg Med 36(5):438–445

    CAS  PubMed  Google Scholar 

  47. Mion LC, Palmer RM, Meldon SW et al (2003) Case finding and referral model for emergency department elders: a randomized clinical trial. [see comment]. Ann Emerg Med 41(1):57–68

    CrossRef  Google Scholar 

  48. Meldon SWML, Palmer RM et al (2003) A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med 10:224–232

    CrossRef  Google Scholar 

  49. Lee JS, Schwindt G, Langevin M et al (2008) Validation of the triage risk stratification tool to identify older persons at risk for hospital admission and returning to the emergency department. J Am Geriatr Soc 56(11):2112–2117

    CrossRef  Google Scholar 

  50. Carpenter CR, Shelton E, Fowler S et al (2015) Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med 22(1):1–21

    CrossRef  Google Scholar 

  51. Di Bari M, Salvi F, Roberts AT et al (2012) Prognostic stratification of elderly patients in the emergency department: a comparison between the “identification of seniors at risk” and the “silver code”. J Gerontol Ser A Biol Sci Med Sci 67(5):544–550

    CrossRef  Google Scholar 

  52. Graf CE, Giannelli SV, Herrmann FR et al (2012) Can we improve the detection of old patients at higher risk for readmission after an emergency department visit? J Am Geriatr Soc 60(7):1372–1373

    CrossRef  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Gertrude Chikura .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and Permissions

Copyright information

© 2018 Springer International Publishing Switzerland

About this chapter

Verify currency and authenticity via CrossMark

Cite this chapter

Chikura, G., Conroy, S., Salvi, F. (2018). Clinical Assessment and Management of Older People: What’s Different?. In: Nickel, C., Bellou, A., Conroy, S. (eds) Geriatric Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-19318-2_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-19318-2_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-19317-5

  • Online ISBN: 978-3-319-19318-2

  • eBook Packages: MedicineMedicine (R0)