Skip to main content

Pitfalls in the Management of Older Patients in the Emergency Department

Abstract

This chapter summarises common pitfalls when evaluating older patients in the emergency department and bullet-point list below gives a glimpse of the chapter:

  • Vital signs in older frail people with several comorbidities can be misleading as reference values differ from younger people. Single-point measurements in the ED should be compared to each individual’s baseline values (when accessible).

  • Atypical presentations of pneumonia, for example, are common in frail older people and may only include altered mental state such as confusion, high respiratory rate and an acute decline in functional status.

  • One third of all the ADE-related ED visits refer to intake of one of these three medications: warfarin, insulin and digoxin. Tools such as STOPP-START can help guide clinical practice.

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

References

  1. Chester JG, Rudolph JL (2011) Vital signs in older patients: age-related changes. J Am Med Dir Assoc 12(5):337–343

    CrossRef  Google Scholar 

  2. Lakatta EG (2000) Cardiovascular aging in health. Clin Geriatr Med 16(3):419–444

    CAS  CrossRef  Google Scholar 

  3. Cronin L et al (2001) Stroke in relation to cardiac procedures in patients with non-ST-elevation acute coronary syndrome: a study involving >18 000 patients. Circulation 104(3):269–274

    CAS  CrossRef  Google Scholar 

  4. Mahaffey KW et al (1998) Risk factors for in-hospital nonhemorrhagic stroke in patients with acute myocardial infarction treated with thrombolysis: results from GUSTO-I. Circulation 97(8):757–764

    CAS  CrossRef  Google Scholar 

  5. Bemelmans RHH et al (2013) The risk of resting heart rate on vascular events and mortality in vascular patients. Int J Cardiol 168(2):1410–1415

    CrossRef  Google Scholar 

  6. Lipsitz LA (1989) Orthostatic hypotension in the elderly. N Engl J Med 321(14):952–957

    CAS  CrossRef  Google Scholar 

  7. Shaw BH et al (2015) Cardiovascular responses to orthostasis and their association with falls in older adults. BMC Geriatr 15:174

    CrossRef  Google Scholar 

  8. Thijs L et al (2004) Prevalence, pathophysiology and treatment of isolated systolic hypertension in the elderly. Expert Rev Cardiovasc Ther 2(5):761

    CrossRef  Google Scholar 

  9. Butt DA, Harvey PJ (2015) Benefits and risks of antihypertensive medications in the elderly. J Intern Med 278(6):599–626

    CAS  CrossRef  Google Scholar 

  10. Marco CA et al (1995) Fever in geriatric emergency patients: clinical features associated with serious illness. Ann Emerg Med 26(1):18–24

    CAS  CrossRef  Google Scholar 

  11. Storm-Dickerson TL, Horattas MC (2003) What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 185(3):198–201

    CrossRef  Google Scholar 

  12. Ramsay M (2015) Breathing is good. J Clin Monit Comput 29(2):221–222

    CrossRef  Google Scholar 

  13. Sharma G, Goodwin J (2006) Effect of aging on respiratory system physiology and immunology. Clin Interv Aging 1(3):253–260

    CAS  CrossRef  Google Scholar 

  14. Peterson DD et al (1981) Effects of aging on ventilatory and occlusion pressure responses to hypoxia and hypercapnia. Am Rev Respir Dis 124(4):387–391

    CAS  PubMed  Google Scholar 

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

    CrossRef  Google Scholar 

  16. Vanpee D et al (2001) Epidemiological profile of geriatric patients admitted to the emergency department of a university hospital localized in a rural area. Eur J Emerg Med 8(4):301–304

    CAS  CrossRef  Google Scholar 

  17. Lee C-C et al (2007) Comparison of clinical manifestations and outcome of community-acquired bloodstream infections among the oldest old, elderly, and adult patients. Medicine 86(3):138–144

    PubMed  Google Scholar 

  18. Chung MH et al (2014) Geriatric fever score: a new decision rule for geriatric care. PLoS One 9(10):e110927

    CrossRef  Google Scholar 

  19. Wallis SJ et al (2015) Association of the clinical frailty scale with hospital outcomes. QJM 108(12):943–949

    CAS  CrossRef  Google Scholar 

  20. Ellis G et al (2011) Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 343:d6553

    CrossRef  Google Scholar 

  21. Ferguson RP et al (2004) Consecutive autopsies on an internal medicine service. South Med J 97(4):335–337

    CrossRef  Google Scholar 

  22. O’Connor AE et al (2002) A comparison of the antemortem clinical diagnosis and autopsy findings for patients who die in the emergency department. Acad Emerg Med 9(9):957–959

    CrossRef  Google Scholar 

  23. Metlay JP et al (1997) INfluence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med 157(13):1453–1459

    CAS  CrossRef  Google Scholar 

  24. Strauß R et al (2014) The prognostic significance of respiratory rate in patients with pneumonia: a retrospective analysis of data from 705 928 hospitalized patients in Germany from 2010–2012. Dtsch Arztebl Int 111(29-30):503–508

    PubMed  PubMed Central  Google Scholar 

  25. Caterino JM et al (2009) National trends in emergency department antibiotic prescribing for elders with urinary tract infection, 1996–2005. Acad Emerg Med 16(6):500–507

    CrossRef  Google Scholar 

  26. Rowe TA, Juthani-Mehta M (2014) Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin N Am 28(1):75–89

    CrossRef  Google Scholar 

  27. Oger E (2000) Incidence of venous thromboembolism: a community-based study in western France. Thromb Haemost 83(5):657–660

    CAS  CrossRef  Google Scholar 

  28. Timmons S et al (2003) Pulmonary embolism: differences in presentation between older and younger patients. Age Ageing 32(6):601–605

    CrossRef  Google Scholar 

  29. Gambert SR, Escher JE (1988) Atypical presentation of endocrine disorders in the elderly. Geriatrics 43(7):69–71. 76-8

    CAS  PubMed  Google Scholar 

  30. Nordyke RA et al (1988) Graves’ disease: influence of age on clinical findings. Arch Intern Med 148(3):626–631

    CAS  CrossRef  Google Scholar 

  31. Douglas I (2006) Hyponatremia: why it matters, how it presents, how we can manage it. Cleve Clin J Med 73(Suppl 3):S4–12

    CrossRef  Google Scholar 

  32. Ghali JK (2008) Mechanisms, risks, and new treatment options for hyponatremia. Cardiology 111(3):147–157

    CAS  CrossRef  Google Scholar 

  33. Palmer BF (2010) Diagnostic approach and management of inpatient hyponatremia. J Hosp Med 5(Suppl 3):S1–S7

    CrossRef  Google Scholar 

  34. Deitelzweig S et al (2013) Health care utilization, costs, and readmission rates associated with hyponatremia. Hosp Pract 41(1):89–95

    CrossRef  Google Scholar 

  35. Sterns RH, Grieff M, Bernstein PL (2016) Treatment of hyperkalemia: something old, something new. Kidney Int 89(3):546–554

    CAS  CrossRef  Google Scholar 

  36. Waterman BR, Belmont PJ Jr, Schoenfeld AJ (2012) Low back pain in the United States: incidence and risk factors for presentation in the emergency setting. Spine J 12(1):63–70

    CrossRef  Google Scholar 

  37. Kahn Joseph H, Magauran BG, Olshaker Jonathan S (2014) In: Magauran BG, Kahn Joseph H, Olshaker Jonathan S (eds) Geriatric emergency medicine - principles and practice. Cambridge University Press, New York, p 379

    Google Scholar 

  38. Nagayama M, Yanagawa Y, Aihara K, Watanabe S, Takemoto M, Nakazato T, Tanaka H (2014) Analysis of non-traumatic truncal back pain in patients who visited an emergency room. Acute Med Surg 1(2):94–100

    CrossRef  Google Scholar 

  39. Lewis LM et al (2005) Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. J Gerontol A Biol Sci Med Sci 60(8):1071–1076

    CrossRef  Google Scholar 

  40. Esses D et al (2004) Ability of CT to alter decision making in elderly patients with acute abdominal pain. Am J Emerg Med 22(4):270–272

    CrossRef  Google Scholar 

  41. Omari AH et al (2014) Acute appendicitis in the elderly: risk factors for perforation. World J Emerg Surg 9(1):1–6

    CrossRef  Google Scholar 

  42. Gelbard R et al (2014) Falls in the elderly: a modern look at an old problem. Am J Surg 208(2):249–253

    CrossRef  Google Scholar 

  43. Laybourne AH, Biggs S, Martin FC (2008) Falls exercise interventions and reduced falls rate: always in the patient’s interest? Age Ageing 37(1):10–13

    CAS  CrossRef  Google Scholar 

  44. Baraff LJ (1998) Emergency department management of falls in the elderly. West J Med 168(3):183–184

    CAS  PubMed  PubMed Central  Google Scholar 

  45. Costa AP (2013) Older adults seeking emergency care: an examination of unplanned emergency department use, patient profiles, and adverse patient outcomes post discharge. In: The School of Public Health and Health Systems. University of Waterloo, Waterloo

    Google Scholar 

  46. Sanders AB (1999) Changing clinical practice in geriatric emergency medicine. Acad Emerg Med 6(12):1189–1193

    CAS  CrossRef  Google Scholar 

  47. Ollivere B et al (2012) Optimising fast track care for proximal femoral fracture patients using modified early warning score. Ann R Coll Surg Engl 94(4):267–271

    CAS  CrossRef  Google Scholar 

  48. Tinetti ME, Williams CS (1997) Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 337:1279–1284

    CAS  CrossRef  Google Scholar 

  49. Tinetti ME (2003) Clinical practice. Preventing falls in elderly persons. N Engl J Med 348:42–49

    CrossRef  Google Scholar 

  50. Oliver D et al (1997) Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ 315(7115):1049–1053

    CAS  CrossRef  Google Scholar 

  51. Dionyssiotis Y (2012) Analyzing the problem of falls among older people. Int J Gen Med 5:805–813

    CrossRef  Google Scholar 

  52. Townsend AB, Valle-Ortiz M, Sansweet T (2016) A successful ED fall risk program using the KINDER 1 fall risk assessment tool. J Emerg Nurs 42(6):492–497. Available online May 06 2016

    CrossRef  Google Scholar 

  53. Pohl P et al (2014) Community-dwelling older people with an injurious fall are likely to sustain new injurious falls within 5 years - a prospective long-term follow-up study. BMC Geriatr 14(1):1–7

    CrossRef  Google Scholar 

  54. Gray L, Peel N, Costa A, Burkett E, Dey AB, Jonsson P, Lakhan P, Ljunggren G, Sjostrand F, Swoboda W, Wellens N, Hirdes J (2013) Profiles of older patients in the emergency department: findings from the interRAI multinational emergency department study. Ann Emerg Med 62(5):467–474

    CrossRef  Google Scholar 

  55. 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 

  56. Wilber ST et al (2005) An evaluation of two screening tools for cognitive impairment in older emergency department patients. Acad Emerg Med 12(7):612–616

    CrossRef  Google Scholar 

  57. Kakuma R et al (2003) Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 51(4):443–450

    CrossRef  Google Scholar 

  58. Elie M et al (2000) Prevalence and detection of delirium in elderly emergency department patients. CMAJ 163(8):977–981

    CAS  PubMed  PubMed Central  Google Scholar 

  59. Han JH et al (2009) Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 16(3):193–200

    CrossRef  Google Scholar 

  60. Alexander KP et al (2007) Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on clinical cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 115(19):2570–2589

    CrossRef  Google Scholar 

  61. Alexander KP et al (2007) Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 115(19):2549–2569

    CrossRef  Google Scholar 

  62. Magid DJ et al (2005) Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients. Ann Emerg Med 46(1):14–21

    CrossRef  Google Scholar 

  63. Psaltis PJ, Nicholls SJ (2016) Management of acute coronary syndrome in the very elderly. Lancet 387(10023):1029–1030

    CrossRef  Google Scholar 

  64. Tegn N et al (2016) Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (after eighty study): an open-label randomised controlled trial. Lancet 387(10023):1057–1065

    CrossRef  Google Scholar 

  65. Hohl CM et al (2001) Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med 38(6):666–671

    CAS  CrossRef  Google Scholar 

  66. Chin MH et al (1999) Appropriateness of medication selection for older persons in an urban academic emergency department. Acad Emerg Med 6(12):1232–1241

    CAS  CrossRef  Google Scholar 

  67. Beers MH (1997) Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 157(14):1531–1536

    CAS  CrossRef  Google Scholar 

  68. American Geriatrics Society Beers Criteria Update Expert Panel (2015) American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 63(11):2227–2246

    CrossRef  Google Scholar 

  69. Budnitz DS et al (2007) Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 147(11):755–765

    CrossRef  Google Scholar 

  70. O’Mahony D et al (2014) STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 44(2):213–218

    CrossRef  Google Scholar 

  71. Wolf RS (1992) Victimization of the elderly: elder abuse and neglect. Rev Clin Gerontol 2(03):269–276

    CrossRef  Google Scholar 

  72. Lachs MS, Pillemer KA (2015) Elder abuse. N Engl J Med 373(20):1947–1956

    CAS  CrossRef  Google Scholar 

  73. Jones JS et al (1997) Elder mistreatment: national survey of emergency physicians. Ann Emerg Med 30(4):473–479

    CAS  CrossRef  Google Scholar 

  74. Nemec M et al (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 

  75. Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, Wiese M, Wilson I (2012) Management of proximal femoral fractures 2011. Anaesthesia 67:85–98

    Google Scholar 

  76. Mason S et al (2012) A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trial). Emerg Med J 29(1):47–53

    CrossRef  Google Scholar 

  77. Vicente V et al (2014) Randomized controlled trial of a prehospital decision system by emergency medical services to ensure optimal treatment for older adults in Sweden. J Am Geriatr Soc 62(7):1281–1287

    CrossRef  Google Scholar 

  78. Carpenter CR 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 

  79. Roedersheimer KM et al (2016) Self-reported versus performance-based assessments of a simple mobility task among older adults in the emergency department. Ann Emerg Med 67(2):151–156

    CrossRef  Google Scholar 

  80. Kessler C et al (2013) Transitions of care for the geriatric patient in the emergency department. Clin Geriatr Med 29(1):49–69

    CrossRef  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Fredrik Sjöstrand .

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

Sjöstrand, F., Nickel, C. (2018). Pitfalls in the Management of Older Patients in the Emergency Department. In: Nickel, C., Bellou, A., Conroy, S. (eds) Geriatric Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-19318-2_7

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-19318-2_7

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-19317-5

  • Online ISBN: 978-3-319-19318-2

  • eBook Packages: MedicineMedicine (R0)