Emergency Medical Care

Most elderly persons need emergency medical care at some time. The elderly use significantly more emergency medical services than do younger adults. In 1995, almost 16% of emergency department visits were made by persons >= 65 years. Of elderly patients who go to an emergency department, > 50% receive comprehensive services, with > 70% receiving diagnostic laboratory tests or x-rays. More than 40% of elderly patients seen in an emergency department are admitted to the hospital, 6% to intensive care units. More than 50% are prescribed new drugs.

Prehospital Care

The first responder to an emergency may be a basic emergency medical technician (EMT); basic EMTs receive about 150 hours of training and are certified to perform basic extrication and first aid procedures as well as CPR, splinting, spinal immobilization, oxygen support, and transport. Paramedics receive the highest level of training (1000 to 1500 hours); they must pass rigorous state certification examinations and operate under the license of their base station physician. However, specific geriatric training for emergency responders was uncommon in the past.

Because EMTs and paramedics often respond to elderly patients in their homes, they are able to assess the patient's home environment for risks to the patient's health and safety and can report their findings to the appropriate persons. Studies have demonstrated the effectiveness of such reporting when appropriate follow-up is done.

Emergency Department Care

In the emergency department, there is usually little privacy, long waiting times, few amenities, loud ambient noise, uncomfortable beds, and poor lighting. Staff members may not have enough time to relieve a patient's anxiety, relay test results, or explain necessary procedures. Although most emergency departments have special rooms that focus on the needs of pediatric patients, few provide amenities for geriatric patients, including lower, more comfortable beds; extra pillows; indirect lighting; and a quiet environment.

In many ways, care of an elderly patient is not different from that of other adults. The first priority is determining whether a patient needs treatment for a life- or limb-threatening condition. Once these conditions are reasonably ruled out, other diseases can be further evaluated in an outpatient setting by the primary care physician.

Presentation: An elderly patient's presentation to the emergency department is often complex (see Table 11-2). Elderly patients often complain of general weakness or "just not feeling themselves." Symptoms and signs may not be as clear as they are in younger patients. For example, < 50% of patients > 80 years with myocardial infarction present with chest pain. In many elderly patients, acute appendicitis does not produce the typical symptoms and signs. Only 50% of elderly patients with surgically proven appendicitis carry that diagnosis at the time of admission to the hospital.

Polypharmacy and adverse drug effects are common in the elderly and may be factors in emergency department presentation, diagnosis, and treatment. Adverse drug effects result in at least 5% of hospital admissions for elderly persons.

Factors that are not apparent may affect an elderly patient's presentation. For example, a fall may result from elder abuse, adverse drug effect (eg, oversedation from diazepam or other drugs), hazards in the home, or physical problems (eg, poor vision), or it may be related to depression or chronic alcoholism. Suicide risk, incontinence, and nutritional and immunization status can be reasonably assessed in the emergency department so that follow-up care can be arranged.

About 30 to 40% of elderly patients seen in emergency departments have not been diagnosed as having dementia but are cognitively impaired; in 10%, cognitive impairment consistent with delirium is unrecognized. Cognitive impairment of recent onset may indicate sepsis, occult subdural hemorrhage, or an adverse drug effect. When indicated, a standardized cognitive assessment should be performed in the emergency department.

Cognitive impairment affects the reliability of the patient history; it affects diagnosis and must be considered when planning the patient's disposition.

Communication among health care practitioners: Good communication among emergency department physicians and patients, caregivers, primary care physicians, and staff of long-term care facilities greatly enhances the outcome of elderly patients with complicated problems. Advance directives should be promptly and clearly communicated to emergency medicine practitioners. Baseline information from the patient's personal physician facilitates assessment and management planning in the emergency department. For example, knowing whether the onset of cognitive impairment is recent helps determine whether the deficit should be fully assessed in the emergency department. Reports to the patient's primary care physician should describe even simple injuries, such as an ankle sprain or a Colles' wrist fracture, because such injuries can dramatically affect an elderly person's functional ability and independence.

Some elderly patients may be brought to the emergency department by caregivers who need respite care. A social admission to the hospital results when the family caregiver abandons the elderly patient in the hospital, eg, by leaving or refusing to take the patient home.

Disposition: Discharge planning may be complex, because functional ability may be more impaired in the elderly patient by acute illness or injury. Assessment of functional status is essential for planning an elderly patient's disposition. A simple ankle sprain may be incapacitating unless the patient has good support at home. Discharge planning may be improved when nurses, social workers, and primary care physicians are involved. Issues raised during the emergency department assessment must be addressed during follow-up, such as depression, alcoholism, and the patient's cognitive and functional status. Discharge planning should also ensure that the patient is capable of taking drugs appropriately and obtaining the necessary care. An assessment of caregiver capabilities can avoid later problems. For example, providing home health care and meal services might relieve an elderly spouse's or partner's stress.