Authors: Anita N. Chary MD PhD, Alex Zirulnik MD MPH, Alice Gray MD MSc

Edited By: Angel Li MD, Shan Liu, MD, SD

Updated: 9/24/2021

Case Study

A 78-year-old woman presents from an assisted living facility with a chief complaint of “feeling unwell” over the last two weeks. The patient denies recent fevers, pain, dyspnea, or other specific symptoms. She presented to the ED because her energy levels were “too low” for her to move around her home over the past 2 days and she was unable to prepare her dinner this evening. She lives alone. A brief review of her chart shows a history of diabetes, hypertension, hypothyroidism, atrial fibrillation, coronary artery disease, and diverticulosis.

Objectives

By the end of this module, the student will be able to:

1. Understand key information to obtain in the geriatric history in the ED 
2. Develop strategies to facilitate history-taking with a geriatric patient with visual, hearing, or cognitive impairment
3. Understand basic physiological changes associated with aging and how these affect the physical exam
4. Apply the “4 Ms” Framework of Age-Friendly Health Systems to geriatric emergency care
5. Describe common conditions that lead older adults to present to the ED

Introduction

Approximately one fourth of emergency department (ED) visits in the United States occur with older adults over the age of 65 [Ref. 1]. Evaluating older adults can be challenging in the ED setting for a variety of reasons. Geriatric patients often have extensive past medical history and medication lists, which require time to review and interpret. Patients may have cognitive, visual, or hearing impairments, which can make history-taking and communication difficult. Chief complaints may be non-specific and have numerous possible meanings, such as “weakness,” “fatigue,” “feeling unwell,” or “dizziness” [Ref. 1-2]. 

Additionally, the physical exam can be difficult to interpret due to changes in physiology over time. Blood pressure increases over age, as vessels harden and become less compliant, so what appears to be a “normal” blood pressure may actually be low compared to a patient’s baseline. As cardiac conduction cells decrease over time, older adults have a decreased intrinsic heart rate and may also take antiarrhythmics such as beta blockers, calcium channel blockers, or digoxin, which can blunt tachycardia during infections or trauma. Older adults may not mount fevers, but rather present with hypothermia with infection. Finally, changes in perception and cognitive impairment can make assessments of pain unreliable [Ref. 3].

Initial Actions and Primary Survey

All ED patients require a rapid assessment of their hemodynamics, airway, breathing, and circulation to determine if they require immediate intervention. The same applies for geriatric patients. When entering a room, emergency clinicians must review a patient’s vital signs and quickly ascertain whether a patient is alert, phonating, and breathing spontaneously. If the primary survey is intact, we can dedicate our efforts towards performing a focused but thorough history and physical exam.

History

For geriatric patients, approach three key sources in taking a history. 

First, try to obtain information about the history of present illness from the patient directly whenever possible. Beyond the history of present illness, consider asking two questions routinely in your review of systems, one about medications and the other regarding falls. As up to 10% of geriatric hospital admissions are related to adverse medication side effects [Ref. 4], evaluating for recent medication changes and use of over-the-counter medications is high-yield. Additionally, one-third to one-half of community-dwelling adults over the age of 65 have a fall each year [Ref. 5]. Occult injuries can impact ED presentations for other issues, making evaluation for recent falls a helpful question.  

Second, spend several minutes reviewing the patient’s chart. Chart review is a routine aspect of care for all patients, but for geriatric patients, it is particularly important to review the problem list for key conditions such as dementia, which can affect the reliability of the information patients can provide, or for key conditions such as coronary artery disease or aortic stenosis, when associated with a chief complaint of chest pain. It is also imperative to review medications for anticoagulants or antiplatelet agents (warfarin, direct oral anticoagulants, aspirin, clopidogrel), antidiabetics (insulin, metformin, sulfonylureas), and medications with a narrow therapeutic window (digoxin, phenytoin), which account for nearly half of ED visits related to adverse medication effects [Ref. 6], as well as antiarrhythmics and sedatives, which are high-risk medications associated with falls and altered mentation [Ref. 1]. Electronic medical records often contain a section on advanced care planning about a patient’s desires for emergency life-sustaining treatments and the name of a health care proxy who would make medical decisions if the patient did not have capacity to do so. This information is crucial in cases of critical illness or sudden decompensation.

Third, obtain collateral information from others who engage with the patient. For patients with cognitive impairment or acute changes in mental status who are unable to provide their own history, reaching out to caregivers such as family members or home health aides is imperative. Call the sending facility to clarify transfer documentation and obtain a verbal handoff; doing so as soon as possible after the patient arrives increases the likelihood that you will reach a contact or provider who knows the patient. Caregivers can provide helpful information about the circumstances leading to the patient’s presentation to the ED, in addition to the patient’s cognitive and functional baseline. They can offer information about an older adult’s social support network that can help facilitate further care in the outpatient setting or indicate a need for increased support in an inpatient, rehabilitation, or short- or long-term care setting.

Table 1. Strategies to Facilitate History-Taking with an Older Adult

Physical Exam

In addition to standard elements of the physical exam such as the cardiac, pulmonary, and abdominal exam, special attention should be paid to the neurological and skin exams in geriatric patients. A full neurological assessment includes testing of mental status and gait. Impairments in memory and attention are not part of normal aging, and their presence may suggest delirium or dementia [Ref. 3]. Delirium refers to acute brain dysfunction characterized by fluctuating attention and represents a medical emergency.  It may be provoked by serious underlying illness such as infection or trauma. In contrast, dementia is chronic and progressive [Ref. 7]. While gait testing is often deferred in the ED, assessing a patient’s mobility can provide essential information about functional status and ability to be safely discharged. For example, an older adult who lives alone at home who presents to the ED with a stable pelvic fracture, but can no longer walk without assistance due to acute pain, is a better candidate for admission or rehabilitation than discharge home.

Table 2. Delirium and Dementia

Patients should be fully assessed to evaluate for sores and areas of skin breakdown, which can become infected, and for bruising suggestive of prior falls, injuries, occult trauma, or potential abuse [Ref. 3]. The skin examination should include evaluation of catheters (e.g. urinary, suprapubic), tubes (gastrostomy, gastrojejunal), and lines (port, peripherally-inserted central catheter) for signs of infection.

A useful framework for approaching your initial geriatric assessment is the “4 Ms” [Ref. 8]. After evaluating your patient, ask yourself if you have obtained information regarding each of the following domains. Consider how this information shapes your plan for workup, treatment, and disposition.

Table 3: The 4 Ms Framework of Age-Friendly Health Systems Applied to Geriatric Emergency Care

Presentation

Pathology in older adults can manifest in a variety of ways. Geriatric patients may not necessarily display “classic” presentations for common diseases. For example, while features of cardiac chest pain are traditionally described in medical education as crushing substernal chest pain associated with diaphoresis and exertion, older adults may experience dyspnea, nausea, or vomiting rather than overt chest pain. Some might describe these symptoms as “atypical,” but it is important to bear in mind that a significant proportion of acute coronary disease occurs in older adults, which should make us consider their symptoms “typical” for this population. Additionally, older adults’ chief complaints can be the manifestation of a serious underlying etiology. As one example, a patient may present to the ED for a fall, which could have been caused by a cardiac arrhythmia, sepsis, elder abuse, substance use, or a medication toxicity.

Abdominal pain as a presenting concern should be taken very seriously. Older patients presenting with abdominal pain have a 50% risk of requiring admission and a 30% risk of requiring surgery. It is important to have a low threshold  to search for abdominal pathology with diagnostic imaging, as older adults may not present with classic abdominal findings on exam, such as peritonitis. [Ref. 9]

Table 4 lists several conditions for which older adults commonly present to emergency care in the United States, based on a review by Samaras et al. [Ref. 1].

Table 4. Common Reasons for ED Presentation among Older Adults in the United States as Outlined by Samaras et al. [1]

Diagnostic Testing

Trainees may hear clinicians describe feeling boxed into doing a “shotgun” workup in geriatric emergency care. This term reflects the common challenges in evaluating geriatric patients, particularly those with cognitive impairment who cannot provide history. It also reflects the observation that older adults can “hide pathology,” which leads clinicians to perform broader workups. Diagnostic testing can and should still be guided by the highest items on the differential diagnosis, but it is reasonable to maintain a broad differential and pursue a broad workup for older adults with acute complaints. For the conditions listed in Table 4, an EKG and basic labs--such as a complete blood count (CBC), basic metabolic panel (BMP), and coagulation studies depending on a patient’s history and medication list--are a common starting place. Decisions to obtain imaging are usually specific to a chief complaint and presentation and should similarly follow from the overall assessment of the patient.

It may also be common practice to obtain a urinalysis and urine culture on older patients presenting with altered mental status. It is important to recognize that a high proportion of older adults will have asymptomatic bacteriuria, especially if they reside in care homes or have indwelling catheters. Positive urine findings should be carefully interpreted in the context of presence of fever and/or lower urinary tract symptoms, such as suprapubic pain, flank pain, dysuria, or new frequency/urgency/incontinence.  In patients with cognitive impairment, other causes of delirium must be considered first before anchoring on a positive urine as the culprit.

Disposition

Disposition of older adults from the ED--whether a patient can be discharged or should be admitted to the hospital--depends on a variety of factors. Abnormal vital signs, acuity of a patient’s condition, or need for further monitoring or treatment are indications for admission. If considering discharging an older adult from the ED, a clinician must appreciate whether the patient’s social supports--including ability to obtain any needed follow-up care--would allow them to safely leave the hospital and function in their usual environment. Conditions that impede an older adult’s ability to perform the activities of daily living that they usually do independently may result in admission or observation for physical and occupational therapy as well as referral to a short-term rehabilitation or care facility. A common example is a humeral head fracture of the dominant arm, which is treated with a sling and outpatient orthopedic follow-up, but can significantly impair a patient’s ability to toilet, bathe, cook, or mobilize with an assistive device in the home. Additionally, some illnesses that are fairly benign in young, healthy adults, such as influenza, may pose a more significant risk for decompensation in older adults. In these cases, clinicians may elect to observe an older patient overnight when they would likely discharge a younger patient with the same condition.

Pearls and Pitfalls

• Evaluating older adults can be challenging in the ED setting due to clinician time constraints and patients’ extensive and complex medical histories and medication lists; patients’ visual, hearing, or cognitive impairments; and physiologic changes associated with aging that can affect vital signs and the physical exam.
• Pathology in older adults can manifest in a variety of ways, which are sometimes non-specific or vague.
• Review medication lists for high-risk therapeutics, including anticoagulants or antiplatelet agents, antidiabetics, medications with a narrow therapeutic window, antiarrhythmics and sedatives.
• Obtaining collateral information from caregivers and other health care providers is imperative for patients with cognitive impairment, but can also be helpful for patients with non-specific symptoms, those who present at the urging of relatives, or in individuals you suspect may be minimizing their symptoms.
• Special attention should be paid to the neurological and skin exams in geriatric patients to evaluate for delirium, problems with gait/mobility, signs of trauma, and potential sources of infection.
• The 4 M’s framework offers important domains that should be considered in the geriatric assessment: mentation, medications, mobility, and what matters most.
• It is reasonable to maintain a broad differential and pursue a broad workup for older adults with acute complaints.
• Disposition of the older adult is multifactorial and depends on illness severity, need for further monitoring or treatment, ability to perform activities of daily living, social supports and healthcare goals.

Case Study Resolution

On speaking with the patient and reviewing her chart, you uncover that her INR was recently subtherapeutic and she had her warfarin dose increased about two weeks ago. The patient did not make it to a follow-up appointment to recheck her INR due to a transportation issue. Since then, she has intermittently noticed tarry stools. Her EKG demonstrates her baseline atrial fibrillation. Labs reveal that her hemoglobin has dropped from 9.5 to 6.3 and her INR is mildly supratherapeutic compared to 2 weeks ago. You surmise that the likeliest cause of her feeling unwell and decreased functional status is gastrointestinal bleeding. Considering the 4 M’s framework, you note that the patient is mentating at baseline, is experiencing an adverse medication side effect, and has compromised mobility in the setting of acute blood loss. It is within her goals of care to be hospitalized for further testing and assistance with activities of daily living, as her functional status has declined with the acute illness. You place two large bore IVs, administer Pantoprazole and a blood transfusion, and admit her for GI consultation.

References

1. Samaras N, Chevalley T, Samaras D, Gold G. Older Patients in the Emergency Department: A Review. Annals of Emergency Medicine, 2010;56(3):261–269. doi:10.1016/j.annemergmed.2010.04.015
2. Southern A, Wilber S. General assessment of the elderly patient. 2016. Pp. 1-12 in: Mattu A, Grossman A, Rosen P. eds. Geriatric Emergencies: A Discussion-Based Review, 1e West Sussex, United Kingdom: John Wiley & Sons, Ltd.
3. Zimmerman K, Anderson R. Physiologic changes with aging. 2016. Pp. 13-27 in: Mattu A, Grossman A, Rosen P. eds. Geriatric Emergencies: A Discussion-Based Review, 1e West Sussex, United Kingdom: John Wiley & Sons, Ltd.
4. Halter J, Ouslander J, Tinetti M, et al. 2009. Hazzard’s Geriatric Medicine and Gerontology, 6e New York, McGraw Hill Professional.
5. Carpenter CR, Cameron A, Ganz DA, Liu S. Older Adult Falls in Emergency Medicine: 2019 Update. Clin Geriatr Med. 2019;35(2)205-219. doi:10.1016/j.cger.2019.01.009
6. Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007;147:755-765.
7. Alvarez A, Morrissey T. 2019. Approach to Altered Mental Status. In Sekhon N. ed. Clerkship Directors in Emergency Medicine M4 Curriculum, Society for Academic Emergency Medicine. Accessed June 7, 2021: https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-approach-to/approach-to-altered-mental-status
8. Institute for Healthcare Improvement. 2020. Age-Friendly Health Systems: Guide to Using the 4 Ms in the Care of Older Adults. Accessed June 7, 2021 at: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf
9. Marco C, Schoenfeld C, Keyl P, Menkes E, Doehring M. Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes. Acad Emerg Med.1998;5(12):1163-1168