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Number of geriatric patients grows: You must prepare for distinct challenges
Diagnoses are less straightforward — protocols must be targeted
A 73-year-old woman who lives at home with her husband presented at the ED with progressive weakness and difficulty walking. Her chief complaint: "My legs just feel weak." After an extensive work-up, including a CAT scan, there were no clear answers, and she was admitted for further evaluation.
"I could have come up with an easy answer and sent her home, but she would have had difficulty getting around the house," the ED physician explains.
A neurologist saw her post-admission. She was given an MRI, and a neurological disease that only showed up with that test — a nonspecific demyelinating disease — was diagnosed.
This case typifies the challenges presented by geriatric patients, says the physician who handled this case: Steve Meldon, MD, associate professor at Case Western Reserve University in the department of emergency medicine and attending physician at MetroHealth Medical Center, both in Cleveland.
"Their symptoms are much less obvious," he observes. And as his example demonstrates, admission decisions may be complicated by the situation at home.
The special challenges presented by this population, combined with the steady graying of America, are making the emergency medical profession sit up and take notice. The Washington, DC-based American College of Emergency Physicians (ACEP) made the geriatric population one of the major foci of its Scientific Assembly this October. (See chart, below, for impact on EDs.)
J. Brian Hancock, MD, president of ACEP, says, "As the number of visits by older people to overcrowded emergency departments increases, emergency physicians have been focusing greater attention on their special care needs and leading research on improving diagnosis and treatment of geriatric diseases."
About four years ago, Scott T. Wilber, MD, FACEP, assistant professor of emergency medicine at Northeastern Ohio University College of Medicine in Rootstown, and associate director of the Emergency Medicine Research Center at Summa Health System in Akron, was practicing in an all-adult hospital.
"What drove this issue home for me was the realization that these were the toughest patients to take care of, and took the most time," Wilber says. Since then, he has focused on researching the geriatric population, and recently he authored an extensive chapter on geriatric emergency medicine in the American Geriatric Society’s (AGS’s) publication, "New Frontiers in Geriatric Research: An Agenda for Surgical and Related Medical Specialties." (The publication is available, at no cost, in its entirety on the AGS web site: www.frycomm.com/ags/rasp.)
With geriatric patients, you cannot focus just on what is medically wrong, but you also must consider their social situation at home, how well they are able to care for themselves, and indeed, whether they are cognitively able to provide you with a good history, Wilber says.
ED managers will face an increasing number of these patients in the next 25-30 years, notes Lowell Gerson, PhD, professor of epidemiology at Northeastern Ohio University College of Medicine.
"Older patients use the ED in proportion to their numbers in the population, and the fastest growing segment of the population is people over 65," he says. "In 25-30 years, there will be more people over 65 than we have pediatric patients today. They will be the biggest ED user group."
There are several conditions that, when seen in geriatric patients, call for different protocols than would be followed with younger patients, Wilber says.
One is abdominal pain, he observes. In younger patients, its treatment often is a lot more straightforward, Wilber says. "Even if I cannot say exactly what’s wrong, if they’re not too sick, you can tell them to go home," he says. "An older person could come in confused, have tenderness in the abdomen, and you may have to take many extra steps to find out what’s wrong."
Those steps, he says, could include more testing. "Lots of times a CT scan is ordered, where in a younger person, the pain is often where it should be in order for you to make an accurate diagnosis and determine whether to go to surgery," Wilber notes. In addition, he says, there is a tendency to want to have more time to observe the older patient, and that extra time often results in admission.
Injuries present another challenge in geriatric patients, Wilber says. "In younger patients, you take care of them and that’s that," he observes. In older patients, a lot of times, an injury would prevent them from functioning at home, Wilber points out. "Then, you must ask if they have the necessary social support, if they are able to dress themselves, to walk, or to feed themselves," he says. "If they don’t end up being admitted, that may lead to repeat emergency visits."
If caregivers are in their late 70s or 80s, says Melton, you must determine if they can care for the patient at home. "In addition, the patients may have mild dementia, or not be able to lift themselves up to bathe," he notes.
Pain treatment is another area that is significantly different when dealing with geriatric patients, says James A. Espinosa, MD, FACEP, FAAFP, chairman and medical director of the ED at Overlook Hospital in Summit, NJ, and founding co-chair of ACEP’s new Geriatric Emergency Section.
Espinosa says that working with John Gregory, a cardiologist involved in bioethics and palliative care, he learned of the World Health Organization’s (WHO) concept of total pain. "Its definition is really about total discomfort; not only that physical sensation we call pain, but to be anxious at the end of life, to be terrified, to be dehydrated, to have bouts of nausea, to have terrible diarrhea, overwhelming depression, to be air-hungry, to be separated from your loved ones," he says. This approach, says Espinosa, leads the ED physician to seek to relieve patient discomfort of all sorts.
Geriatric patients have the potential to adversely affect patient flow, notes Meldon.
"The model for the ER is what is the chief complaint, then a quick differential, and then take care of the complaint — but not with this patient," he observes.
"You need to do a functional assessment." Bearing that in mind, Meldon offers several suggestions for maintaining optimal flow. "You may want to send the patient to admission sooner," he advises. One strategy he used while on staff at the Cleveland Clinic was a nurse practitioner model for screening patients. "They could address questions such as whether they could fix their own meals, if they needed help with transportation, and so on," he explains. The reasoning behind the strategy was that most patients were in the ED for two or three hours anyway, so there was some built-in time if you had the personnel to do this screening, and it would not delay discharge.
"It can also be a rapid way to get referrals for a geriatric assessment, and that would be very helpful," he adds. "You need to work with your geriatricians." Also try to develop a brief screening tool for this population to assess problems that are not obvious, by asking questions such as whether the patient feels sad, suggests Meldon.
One such tool, called the TRST (Triage Risk Screening Tool), was developed by Meldon himself. (See recommended reading, below.)
A more formal abbreviated mental status exam also may be required if the patient has trouble with his or her memory or seems confused, he says. "If one suspects depression, a good follow-up to a single question [such as] depression is the Geriatric Depression Scale — short form," he notes. (For more information, see recommended reading, below.)
There is much your ED can do to make the environment more geriatric-friendly, says Wilber. "You should have discharge instructions in 14-point type or larger," he suggests, "And try not to have the area be too cold." Often such patients require assistance in going to the bathroom, so be sure to have volunteers and/or bedside commodes available, Wilber says. Remember, too, that hospital chairs may be more comfortable for these patients than standard gurneys, because of the back problems common in geriatric patients.
Finally, "make sure they don’t accidentally get too much fluid," he warns. A younger person can filter out the fluid, he notes, but an older patient with heart failure or kidney disease could wind up with pulmonary edema. Use intravenous clamps that can’t be accidentally opened, he advises.
Caring properly for your geriatric patients can be good business as well as good medicine, Wilber asserts. "This will be a good customer base to have. They are covered by insurance and/or Medicare, so from a management standpoint, they are good people to focus on."
For information on geriatric patients in the ED, contact: