The Unique Needs of Elderly Patients in the Emergency Department (Part 2)

VickyRN, MSN, DNP, RN

This is Part 2 of a two-part series of articles on caring for the elderly in the ED setting.

Sanders (1996) developed 11 principles of geriatric emergency care that should be used when assessing older adults. These precepts are as follows:

Complex Presentation

Older adults, those at least 65 years of age, often present as complex patients for a number of reasons that extend beyond physical disease. It may be difficult to distinguish which symptoms are the patient's chief complaint, as well as which symptoms are the most important, as the elder may have multiple complaints. In fact, the clinician may feel overwhelmed by the deluge of complaints. The nurse needs to take the time to listen carefully, record each complaint, and ask insightful questions. For instance, late one evening, an infirm older adult came to the ED with complaints of back pain, indigestion, and headache. Upon further questioning, the patient mentioned that he was also experiencing chest discomfort, tightness, and pressure. It was interesting that "chest pain" was not even mentioned in his initial litany of complaints. Teasing out this vital information took quite a bit of time and effort.

Atypical Symptomology

The elderly patient often presents atypically. Because illness in older adults is complicated by the normal changes of aging and multiple chronic conditions, many older adults do not display the usual signs and symptoms of illness. Atypical presentation of illness in older adults includes absence of fever and cough, anorexia, confusion, dizziness, falls, fatigue, new-onset incontinence, lethargy, level of consciousness changes, malaise, self-neglect, and unexplained weight loss. For instance, the typical symptoms of pneumonia include chills, fever, cough, chest pain, labored breathing, fatigue, and bloody sputum. In the older adult patient, many of these signs and symptoms may be absent. The elder with pneumonia may simply present with level of consciousness changes and anorexia. Depression may be masked by nonspecific somatic complaints, such as multiple "aches and pains." Falls may signify serious illness in the frail patient. Confusion, lethargy, new-onset incontinence, and/or anorexia may signal a urinary tract infection or urosepsis. Atypical presentation often delays the diagnosis of acute illness with a resultant higher rate of mortality. It is essential for nurses to conduct careful and thorough assessments of older adults to consistently recognize vague presentations of illness and ensure appropriate and early treatment.

Multiple Pathology (Comorbidities)

The majority of the elderly contend with two or more chronic medical conditions, or comorbidity. Chronic diseases are more common than acute illnesses in the older age group. The chronic disorders most prevalent in the older population are ones that can have a significant impact on independence and the quality of daily life. Examples of comorbid conditions are cardiovascular disease, cancer, chronic obstructive pulmonary disease (COPD), diabetes, arthritis, hypertension, and Alzheimer's disease. Elderly patients with multiple chronic conditions often have worse outcomes and increased mortality. Indeed, chronic conditions account for 70 percent of all deaths in the U.S. Older adults usually visit the ED for an acute exacerbation of chronic disease such as heart failure or COPD.

Polypharmacy

The elderly are more likely to take multiple medicines. People aged 65 and over comprise 13 percent of the population but account for 34 percent of all prescriptions. On any given day, the average senior takes four or five prescription drugs and two over-the-counter (OTC) medications. Because they take more medications than younger people, the elderly have a higher risk of adverse reactions. As a matter of fact, 5 percent of all elder hospital admissions are related to an adverse drug event. It is vital to have an effective method of medication reconciliation in the ED. This includes accounting for all prescription medications, OTC products, herbals, and supplements.

Cognitive Impairment

An estimated 40 percent of all elderly ED patients have some form of cognitive impairment (i.e., dementia or delirium). Older patients with cognitive impairment are vulnerable, since they may be unable to make decisions for themselves or function independently when they visit the ED. This can pose many challenges for ED clinicians during admission, assessment, and treatment. Delirium is the most common cognitive impairment, and it is often under recognized and overlooked. Also known as an acute state of confusion, delirium is a medical emergency, with a fatality rate as high as acute MI or sepsis. It can present as lethargy, agitation, or a fluctuation between these two transient states. Correctly identifying cognitive impairment is critical for medical testing, effective treatment, and to facilitate safe and realistic discharge planning.

Physiological Efficiency

Aging results in a diminished ability to maintain homeostasis and regulate body systems. Organ function becomes less efficient with age, correlating with laboratory values. For instance, the glomerular filtration rate (GFR) of a ninety-year old is normally half that of a twenty-year-old. Other alterations include alkaline phosphatase, cholesterol, PSA levels, and sed rate values, which increase somewhat in seniors. To provide safe and effective care in the geriatric population, clinically significant changes in lab values need to be recognized and accurately interpreted.

Decreased Functional Reserve

As a result of the effects of aging on the physiological processes, the elderly have less functional reserve. While performing normal activities, the elderly may function well. When stressed by illness or injury, however, their functional reserve may be depleted quickly. As people age, functional reserve diminishes so that a stressful event can have much more severe consequences. Older people who develop acute illness or suffer a trauma usually require longer periods of recovery and have more complications from these conditions.

Importance of Family or Community Support

Does the older adult require assistance with performing daily activities? Are caregivers available to help him or her? Correctly assessing an elder's support system is critical to discharge planning.

Baseline Premorbid Health Status

It is important to know the older person's baseline health status to discern cognitive and functional decline and assist diagnosis and treatment. A simple strategy is to compare the presenting signs and symptoms with the elder's normal baseline that preceded this occurrence. Medical history provided by the family can provide important clues as to what is normal and abnormal for the patient and what may be the underlying cause of the presenting signs and symptoms.

Psychosocial Impact of Illness and Trauma

Social and personal concerns of the elderly are frequently not addressed in ED encounters. Emotional problems, such as depression, often influence somatic complaints and can disguise underlying health problems.

The Need for Comprehensive Assessment

Some specific areas that ED nurses can focus on include a more comprehensive approach to assessment and discharge planning, improved communication with the patient and their informal caregivers, substance abuse, and elder abuse and neglect. Failure to consider the possibility of abuse and neglect will mean that the appropriate diagnosis is not made and the older adult is returned to an unsafe environment. Danger signals are sudden weight loss, dehydration, medication over dosing or under dosing, injury marks, personal neglect, car accidents, forgetfulness, extreme suspiciousness, fires in the house, bizarre behavior, or disorientation.

Emergency department nurses are challenged to meet the needs of older patients, who have complex presentations and require comprehensive assessment and referral. Problems such as atypical presentation, chronic health conditions, altered cognitive state, and polypharmacy can complicate diagnosis and management. These 11 principles can assist clinicians in meeting these challenges and help ensure that older adult patients receive appropriate care in the ED setting.

References

Aging Effect on Laboratory Values

The Unlikely Geriatricians