Geriatric Patients in the Emergency Department Aren't "Just Another..."
by W. S. Ernoehazy Jr., M.D., F.A.C.E.P.| Geriatric Times |  |
May/June 2001 | |
Vol. II | |
Issue 3 |
Over the past 20 years, emergency departments (EDs) nationwide have seen an increase in the number of geriatric patients presenting for evaluation. Whether in response to this increased geriatric volume or to the efforts of EDs to improve client satisfaction, marked strides have been made in how ED staffs discuss elderly patients under their care.
Offensive slang expressions, such as the infamous "Gomer" (which stands for "Get Out of My Emergency Room"), are no longer tolerated in training programs nor in community EDs. It should come as no surprise that these demeaning, derogatory expressions often resulted in less than appropriate care, and they are best relegated to works of fiction that deal with the house officer's experience (sensationalized or otherwise).
It is, perhaps, less obvious that there are still habits of speech in many EDs which can lead to patient care errors and adverse outcomes. These patterns are rooted in the natural reluctance to believe that major difficulties or unpleasantness are about to occur.
Unfortunately, in the desire to believe something bad is not happening, people often miss the opportunity to solve the problem early, rather than endure the consequences thereafter. Perhaps the most troublesome of these habits of speech for emergency clinicians, despite its apparent innocuousness, is the offhand assessment, "It's just..." or "Oh, the patient just has..."
If there was a single class of patients least suited to be discussed in this fashion, it would be the geriatric population. In the geriatric patient, symptoms are often atypical in nature, description, duration and intensity. It is common for such symptoms to be markedly less dramatic in the early phases of disease. By the time patients become grossly symptomatic, their diminished physiologic reserves often are nearly exhausted.
These facts, taken together, should promote caution and vigilance in approaching elderly patients in the ED. This is particularly important as these patients' histories are often not familiar to the ED clinician, who is without the extra information that a primary care physician can bring to the evaluation. Common versions of the "'just' fallacy" are found below.
"It's just old age." Considering the clinical realities cited above, citing this statement as an error waiting to happen may seem paradoxical. It is important, however, to balance recognition of the potential frailties of the geriatric patient with another, equally valid truth: There is nothing in the natural process of aging that, per se, causes symptomatic dysfunction or significant restrictions on the activities of daily life. Physiological functions and reserves diminish with age, but rapid loss of function is a marker of acute disease, not of normal aging.
"It's just heartburn." Geriatric patients are far more likely to have atypical presentations of angina, acute coronary syndrome and myocardial infarction than patients in the middle years. Although the most common of these atypical presentations is dyspnea of unclear origin, "heartburn" is also a common presenting complaint.
Gastrointestinal cocktails should not be used as a differentiating maneuver. Too often, coincidental cessation of the "heartburn" (by rest and increased oxygen during the initial workup) leads one to believe that the GI cocktail treated the cause of the pain. The consequences of missed acute coronary syndrome or myocardial infarction are dire and do not need elaboration.
"It's just dizziness." An uncritical acceptance of the chief complaint of dizziness can lead to errors in the evaluation of any patient capable of using the word. In geriatric patients, these errors can lead to serious morbidity and mortality. Vertigo, lightheadedness, general malaise and near syncope are all often characterized with the misleading overall description of dizziness. Needless to say, their implications are significantly different.
With the possible exception of clear-cut positional vertigo on history and examination, all of these symptoms can be harbingers of serious infection, neurological syndrome or cardiovascular disease. Workups in the ED must take these potential diseases into account. Special note should be taken here of infections because they often present with one of the dizziness symptoms, rather than fever.
"It's just a fever." Although elderly patients can have minor viral illnesses, just as can all other segments of the population, they are at high risk for severe infections and sepsis. Comorbid diseases such as diabetes and peripheral vascular disease can make an otherwise simple infection complicated. Furthermore, physiological consequences of aging (such as decreased skin thickness and resiliency, decreased cough reflex, and gut motility dysfunction) can render the geriatric patient much more vulnerable to the beginnings of infection. Elderly patients who present to EDs with fever as a primary complaint should have a thorough workup for potentially life-threatening septicemic infections_pneumonias, urinary tract infections, meningitis, cellulitis and osteomyelitis in association with bedsores or undertreated lacerations.
As noted above, many elderly patients will not have a fever in the face of significant infection. The presence of fever should thus raise the ED clinician's level of concern.
"She's just demented." Many elderly patients do, in fact, suffer from chronic dementias. All too often, clinicians assume that a rapid degradation in mental function is simply due to progression of the patient's dementia.
This assumption is not valid; rapid changes in mental function denote delirium, not chronic dementia, and they mandate thorough evaluation for the cause of the acute deterioration (the list is extensive, including coronary artery disease, congestive heart failure, sepsis, uremia, electrolyte disturbances, dehydration, untoward drug interactions, transient ischemic attack and strokes). Many of these processes are reversible; if properly diagnosed and treated, the change in the patient is gratifying.
"He's just depressed." Another common mistake is to assume that depression in the elderly is the cause for mental status changes. Although this can certainly occur in severe cases, to hang one's hat on this assumption is to risk missing the diagnosis of organic disease that may be reversible or palliable. All the caveats raised with respect to dementia and delirium also apply to depression; a rapid degradation of mental function is not normal, nor is it a natural outcome of chronic progressive disease. Acute onset of symptomatology mandates aggressive workup and diligent treatment.
"They just fell." To begin with, not all falls are the result of simple loss of balance. The patient may be suffering from the effects of an untoward drug interaction, cardiac dysrhythmia, or a central nervous system event such as a transient ischemic attack or frank stroke. The patient's history must be carefully attended to, so as not to miss these diseases.
Even if one of these disease processes is not the cause of the fall, elderly patients are markedly more vulnerable than other patients to serious injury from falls. Their bones tend to be more brittle, predisposing them to fractures that may be more severe than in other patient populations. For example, a geriatric patient who falls against a railing and then to the floor may not just sustain a hip fracture, but multiple rib fractures and the resulting pulmonary contusion from direct impact.
Furthermore, geriatric patients are often on chronic medications (such as anticoagulants), which add to the risk of serious internal bleeding. This risk is especially marked if there has been any blow to the head, as cerebral atrophy of aging and brittle intracranial vessels can easily lead to intracranial hemorrhage. Any fall that involves the head should cause the clinician to consider a computed tomography scan of the brain, especially in the face of concomitant usage of drugs with coagulopathic effects.
"It's a hospice patient; just…" This is perhaps the most pernicious "just" statement of all. The presence of terminal disease should not prevent the diagnosis and therapy of readily reversible diseases. Neither should advance directives, which express the desire to forego extraordinary measures, forego appropriate care. Furthermore, even when the patient's problems are found to be due to terminal illness, well-chosen palliative measures can often relieve suffering, improve function and allow the patient's final time to be lived with dignity and considerable quality of life.
Workups of the elderly in the ED can be daunting. Their atypical, often protean symptoms can be difficult to unravel, and their tendency to comorbidities can lead to difficult treatment decisions. Thus, it is understandable how well-meaning clinicians want to believe that, just this once, the next elderly patient will have simple, easily treated problems.
It is important to note, however, that there are times when the elderly present with and have simple problems. In order not to miss serious disease early, though, it would be well for ED clinicians dealing with the elderly to just say no to "just."
Dr. Ernoehazy graduated from the University of Florida's Emergency Medicine residency in 1993. After two tours in the Naval service, he entered private practice. He is currently with CompHealth Inc., in the Emergency Medicine division.
Further Reading
Resnick NM (1998), Geriatric medicine. In: Harrison's Principles of Internal Medicine, 14th ed., Fauci AS, Braunwald E, Isselbacher KJ et al., eds. New York: McGraw Hill Publishers, pp37-46.
Woolard RW, Becker B, Haronian T (1996), Geriatric considerations. In: The Clinical Practice of Emergency Medicine, 2nd ed., Harwood-Nuss AL, Linden CH, Luten RC et al., eds. Philadelphia: Lippencott-Raven Publishers, pp1559-1565.