Pitfalls in the Management of Older Patients in the Emergency Department

Genitourinary symptoms

Dysuria, suprapubic pain or tenderness, frequency or urgency


>10 white blood cells (WBC)/mm3 per high-power field (HPF)


Urinary pathogen of ≥105 colony-forming units (cfu) per mL

Laboratory-confirmed UTI

Pyuria and bacteriuria

Asymptomatic bacteriuria

Bacteriuria in the absence of genitourinary symptoms

Symptomatic UTI

Bacteriuria in the presence of genitourinary symptoms

Uncomplicated UTI

Genitourinary symptoms, pyuria and bacteriuria in a structurally normal urinary tract

Complicated UTI

Genitourinary symptoms, pyuria and bacteriuria in a structurally abnormal urinary tract

Distinguishing UTI from ASB is problematic, as older adults may not present with typical signs and symptoms suggestive of UTI. Although challenging, it is particularly important, as antibiotics are necessary for the treatment of symptomatic UTI, but not for ASB. Moreover, there is a high risk to develop multidrug-resistant bacteria due to overprescription of antibiotics to older people with suspected UTI.

The pitfall with UTI is to diagnose, but not to overdiagnose the condition.

7.2.4 Pulmonary Embolism

The annual incidence of pulmonary embolus (PE) increases with age and corresponds to 3.5 per 1000 in the age group 60–74, but it almost triples to 9.0 per 1000 in the age group ≥75 [27]. The diagnosis is typically harder to identify due to increased incidence also for other cardiopulmonary conditions that may mimic the classical symptoms of PE. Compared to younger patients with PE, classical symptoms such as pleuritic chest pain and haemoptysis are less common, whereas hypoxia and syncope are more common [28]. These challenges may lead to delays in correct diagnosis and relevant treatment.

Moreover, for older patients, syncope seems to be a particularly important symptom as a study presented the incidence of syncope in 3% of younger patients but 24% in older individuals [28].

7.2.5 Thyroid Disease

Signs of primary endocrine disorder seem difficult to identify in older people. As an example, typical clinical characteristics of hypothyroidism such as lethargy, changes in cognition and constipation are often erroneously attributed to old age than signs of a primary endocrine disorder [29].

It is also difficult to identify hyperthyroidism in the old population, as classical signs such as tremor, irritability and nervousness are frequently absent. However, fatigue, anorexia, lethargy, angina, palpitations, heart failure and atrial fibrillation may occur. Age-related resistance to thyroid hormones is thought to cause these unconventional presentations in hyperthyroidism, and as many as 20% lack an enlarged gland and many lack ophthalmologic findings [30].

7.2.6 Common Electrolyte Problems

Hyponatraemia is the most common electrolyte imbalance in hospitalised older patients [3133] and is associated with an increased risk for 30-day hospital readmission, hospital length of stay (and costs), increase in ICU admissions (and costs) and risk of falls [34].

Hyperkalaemia [35]: If hyperkalaemia is discovered, the accuracy of the measurement must be verified. A repeat serum potassium concentration is often normal, mostly because of haemolysis, distribution or excretion of recently ingested potassium, diurnal variation or laboratory error. There is a high risk of inappropriate treatment if relying on one single test result; hence, always get a second test.

ACE inhibitors are known to frequently cause hyperkalaemia as an adverse effect. Hyperkalaemia may cause ECG changes: when serum potassium reaches 5.5–6.5 mmol/L, a peaked T-wave and prolonged PR segment may be seen on the ECG. However, it is important to know that ECG is insensitive in assessing the severity of hyperkalaemia, and profound hyperkalaemia may go without ECG changes at all.

7.2.7 Back Pain

Back pain in older patients is associated with a much higher risk of a severe cause than those younger than 65 years of age [36]. Due to this risk increase, a systematic evaluation and a broader diagnostic awareness are warranted in the older patient [37]. A fairly large portion of patients presenting with non-traumatic acute back pain in the ED was reported to suffer from conditions such as ureterolithiasis, pyelonephritis, aortic disease, pancreatitis and psoas abscess [38]. Underlying orthopaedic conditions are not confined to degenerative column and disc disease but also osteoporotic fracture and purulent spondylitis.

7.2.8 Abdominal Pain

The high morbidity and mortality in older patients with abdominal pain reflect the importance of increased awareness for clinical, radiologic and prognostic actions.

Abdominal pain is the main complaint in 3–13% of ED visits in older patients. Compared to younger patients, mortality rates are six to eight times higher and surgery rates are doubled [39]. As with many other conditions in older patients, it is difficult for ED staff to identify the underlying disease. For abdominal pain, discrepancies between ED and final diagnosis concern more often gallbladder disease, appendicitis, cancer and diverticulitis.

Abdominal computed tomography (CT) is well studied and has proved its efficacy for the elucidation of causes of abdominal pain aetiology. It may also modify admission decisions, prescriptions of antibiotics and need of surgery [39]. It often modifies the primary suspected diagnosis [40].

Even though appendicitis is known to be a disease of the younger age groups, the incidence is rising due to increase in life expectancy. Perforation rates in older patients are as high as 40%. This condition carries a high risk for postoperative complications and death [41]. Moreover, appendicitis is a condition that is difficult to identify as so many have atypical presentations (75%) that, in turn, result in general delays in admission and treatment [11].

It is recommended to have a high level of suspicion and being more liberal using CT in order to avoid an unfavourable outcome (see also Chap. 15) [41].

7.3 Falls

Falls are the leading cause to morbidity and mortality in older patients [4244].

In ED patients aged 65 years or older, about 15–30% had a recent fall as a cause of the visit, and the prevalence of an old patient having had a fall within the last 90 days has been reported to be 37% [45]. The prevalence increases with age.

Up to 10% of all falls result in a serious injury requiring hospitalisation. About 4–6% of all falls result in fractures and 1–2% cause hip fractures [44, 46, 47]. Early mobilisation is recommended in injuries following falls, such as contusion of muscles and sprains. However, hip fracture is one important exception.

Falls cause, independently of other conditions, restricted mobility and a need of assistance as these patients suffer declines in activities of daily living (ADL), e.g. dressing, bathing, shopping or housekeeping. Moreover, a fall is an independent risk factor for nursing home placement [48]. Although there is a clear relation between falling and the number of medications, the risks associated with individual classes of drugs have been more variable. However, serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic drugs, benzodiazepines, anticonvulsants and some classes of antiarrhythmic medications have been coupled to an increased risk of falling [49].

No screening tool is able to assess the risk of falling among older people either in the community or in nursing homes, and no tool has been used or certified all over Europe. However, the following tools are examples that have been used in a number of tests and clinical sites. Several assessment tools for frail older patients contain some questions around falls due to both the high risk of lethal events and the high frequency of events. One example of assessment tool for fall risks is “STRATIFY” (St Thomas Risk Assessment Tool in Falling Older Inpatients) [50, 51], which is validated for hospitalised patients although not specifically for the ED setting. A tool specifically developed for the ED is KINDER 1 and includes the following risk factors: (1) fall reason for ED visit, (2) age > 70, (3) altered mental status (including alcohol intoxication or substance use), (4) impaired mobility and (5) nurse judgement (evaluating incontinence, orthostatic hypotension and medications). A recent study showed promising results in reducing the number of falls in the ED when including KINDER 1 in Kotter’s framework for a change process; however, the tool has not yet been validated [52].

A multifactorial fall-risk assessment coupled with adequate interventions to community-dwelling people over 75 years who present to the ED due to an injurious fall may prove to be helpful [53], so older people with falls or at risk of falls who attend the ED should be referred on.

In summary, the ED doctor in charge should at least check for orthostatic blood pressure before discharge, check list of medications for those associated with falls and ask about previous falls within 90 days. If the latter is positive, it is recommended to perform a fall assessment including status of vision, hearing, muscle strength, home safety and a review of the medications—usually by referral on disposition (see also Chap. 9).

7.4 Delirium and Dementia

One fourth to one third of older ED patients have an altered mental status as a result of delirium (7–10%) and dementia (15–26%) [54, 55] (Chap. 13 ). Due to the high prevalence of delirium, it is recommended to screen all older ED patients for cognitive dysfunction [56] and to minimise the risk of adverse outcomes as increased risks for hospital admission [55] and mortality [57]. However, 50% of the patients with delirium suffer also from dementia, and differentiating between them is not easy. Studies have shown the sensitivity for an ED physician to detect delirium in an old patient to be 24–35% [55, 58, 59]. About one third of the patients with delirium (37%) are discharged to home [55], and these patients have nearly twice the short-term mortality rate than their non-delirious counterparts. It is recommended to admit these patients to a hospital ward, unless the cause of the delirium is known and easily reversible, and there is adequate home supervision and support for the patient (see also Chap. 14).

7.5 Coronary Artery Disease

As older people frequently have atypical presentations of myocardial infarction and as older people have much worse outcome, clinicians in the ED must have a high level of suspicion for an acute cardiac event. Symptoms such as falls [46], nausea, vomiting, syncope and shortness of breath [60, 61] should alert the ED staff to consider a cardiac problem unless there are other obvious reasons for symptoms to occur.

Only 40% of patients older than 85 years and with non-ST-elevation myocardial infarction (non-STEMI) and 57% with STEMI have chest pain as their main complaint compared with 77% non-STEMI and 90% STEMI patients younger than 65 years [61]. Moreover, ECG is non-diagnostic in 43% of patients older than 85 years and with non-STEMI compared with only 23% of patients younger than 65 years [60].

Additionally, left bundle branch block on ECG is present in 34% of patients older than 85 years and with STEMI compared with only 5% of those younger than 65 years, making diagnosis harder. Because ECG abnormalities are relatively common at an advanced age, it is particularly important to obtain old ECG results whenever possible so that findings in the ED can be compared with previous changes and interpreted accordingly (Table 7.2).

Table 7.2 Comparison of coronary artery disease symptoms and ECG signs between age groups.

[60, 61]


ECG non-diagnostic
















Atypical presentation, difficulties in diagnostics and uncertainties in evaluating benefits and risks of a potential treatment are tough challenges for many clinicians. These issues may decrease the likelihood for a doctor prescribing treatment to an older patient. Compared to a group of 60-year-old patients with acute myocardial infarction, the matched group of 80-year-old patients receive less medication. Twenty percent of the eligible older patients were not administered with aspirin, and 40% did not get β-blockers [62].

Recent evidence suggests that invasive strategy is superior conservative strategy in reducing adverse outcomes in 80-year-old (or older) patients with NSTEMI although the efficacy of the invasive strategy decreased with increasing age [63, 64].

7.6 Adverse Drug Effect (ADE)

In a general population being admitted to the ED, only a small proportion (1–4%) have a problem related to adverse drug reactions (ADEs) . In older patients the prevalence increases to 11% [65]. The risk for ADE increases by age and number of medications. In one study [65], 13% of all older patients had eight or more medications (range 0–17), and 11% had at least one inappropriate medication [66], according to the Beers Criteria, the criteria which define certain medications to be inappropriate for use in older patients [67, 68].

Almost 40% of older adults require supervision to manage their daily medications [54] (which is a part of the instrumental activity of daily living assessment, IADL). Hence, when home care situation gets unstable, the risk that the patient will suffer from an ADE increases.

It is crucial for the ED clinician to be aware of this common pitfall and to take an active part in trying to avoid future ADE problems by prescribing wisely and selecting appropriate medications. Research indicate that one third of all the ADE-related ED visits refer to intake of one of these three medications: warfarin, insulin and digoxin [69]. Tools such as STOPP-START can help guide clinical practice [70].

7.7 Abuse and Neglect

The American Medical Association defines older abuse or neglect as “actions or the omission of actions that result in harm or threatened harm to the health or welfare of the older”. It includes battery, psychological abuse, abandonment, exploitation and neglect and may be intentional or unintentional.

The most important risk factors are a relationship of dependency, social isolation and psychopathology of the abuser [71].

Most studies indicate that women are at higher risk than men. Among older adults, a younger age is associated with a greater risk of abuse and neglect [72]. It is possible that a reason for this is that the “young old” more often live with a spouse or with adult children, the two groups that are the most likely abusers.

Statistics from the United States show that about one out of ten older patients living at home with an informal caregiver would suffer from neglect or abuse [73]. The lack of specific protocols and time constraints makes it difficult to detect older abuse in the ED, which result in less referral to the appropriate authorities. One study showed that approximately half the suspected cases evaluated in the ED were not reported [73].

The ED utilisation and admission data in this population suggest that older abuse victims have high health-care utilisation [52]. An effective strategy to address family violence in outpatient settings could improve the situation and perhaps reduce health-care costs at the same time.

This is indeed an area that needs further research and until reliable protocols are produced, clinicians have to raise questions whenever their experience and clinical judgement may have detected a suspicious case.

7.8 “Social Admissions” and the Search for Hidden Diseases

This refers to patients in the ED who are thought to suffer from poor home care services, and due to this, inadequate care is the primary cause of their ED visit. These patients are at an increased risk of mortality, hospital admission and ED revisits [45, 74].

In the emergency department, about three fourths of these patients have at least one “geriatric syndrome”. They are dependent on others to cope with ADL declines and cognitive impairments. Even a minor acute illness might cause an altered mental status [54]. Hence, for the ED physician in charge, it is important to learn what the patient’s baseline status was and, furthermore, search for causes that changed the situation.

Key in the management of acute geriatric patients is collaboration across disciplines. Fast-track management for conditions, such as stroke and hip fracture, have been shown to have potential [47, 75]. A similar fast-track management for frail older people as the primary cause of ED admittance has been suggested, but to date, data supporting this are lacking. Collaborations with ambulance services are another possibility [76]; alternatively, skilled EMS personnel may directly admit frail patients to a non-acute service after telephone consultation with a geriatrician [77].

7.9 Discharge Planning

Besides the search of a hidden disease, another key action is discharge planning, which focuses on what care the patient requires after having come home from the ED. A simple screening tool that selects those in need of extra services would be good to have, but so far, the screening instruments that have been published have had rather poor results regarding validity and reliability [78].

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May 1, 2018 | Posted by in Uncategorized | Comments Off on Pitfalls in the Management of Older Patients in the Emergency Department
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