Elderly patients in the ED: Be wise in their care
By Eric T. Boie, MD, FAAEM, Vice Chair and Clinical Practice Chair, Department of Emergency Medicine, Mayo Clinic; Assistant Professor of Emergency Medicine, Mayo Graduate School of Medicine, Rochester, MN.
Editor’s note: With our aging population, emergency medicine practitioners increasingly will face the challenges of care for the elderly in the emergency department (ED). A new report from the Centers for Disease Control and Prevention (CDC) notes that visits to U.S. EDs reached a record high in 2003 and attributes this rise to increased use by adults, especially those ages 65 and older.1 Elderly patients have higher risks for presenting to the ED. Atypical presentations require emergency physicians (EPs) to approach these patients with broader differentials; one cannot assume that things are actually as they seem with this patient population. Elderly patients often do not present typically with serious medical conditions. The author cautions emergency medicine practitioners to be wary of the pitfalls in caring for the elderly in the ED. Don’t let this edition lay around on your desk under a stack of the other journals. — Richard Pawl, MD, JD, FACEP
Introduction
EPs and nurses face daunting challenges when caring for elderly (ages > 65) ED patients. Comprising 12-21% of all ED encounters, elderly patients consistently are overrepresented in the ED population.2 ED visits for patients older than 75 years are twice that of the general population, representing the highest utilization by any age group.3 By 2030, 20% of Americans will be older than 65 years.4 EPs increasingly will become geriatricians as the proportion of elderly patients presenting to the ED rapidly expands.
Elderly are a high-risk patient population, both from a clinical and medical malpractice standpoint. Table 1 summarizes characteristics of the ED elderly population. Elderly ED patients are more acutely ill, have admission rates approaching 50%, and account for nearly half of all intensive care unit admissions from the ED.3,4 Evaluation of elderly patients is more time-consuming, requires more tests and procedures, and, therefore, results in longer ED length of stays and higher ED charges.2,3 A majority of EPs believe that clinical management of elderly patients is more difficult than that of their nonelderly counterparts.4
Table 1:
Characterization of the
ED Elderly Population
ED diagnosis in elderly patients is less accurate, as evaluation is obscured by atypical presentations, polypharmacy, and multiple comorbidities.2 Compromised communication as a result of diminished sight and hearing or acute illness adds to the diagnostic challenge. Consequently, elderly patients are dismissed with conditions that go unrecognized and untreated,4 leading to a higher incidence of adverse outcomes. In the first three months after an ED visit, elderly patients demonstrate a mortality rate of 10%, an ED recidivism rate of 24%, a subsequent hospitalization rate of 24%, and a substantial decrease in functional independence.2,5 Predictors of adverse outcome after ED visits for elderly patients are listed in Table 2. Severity of outcome (death and disability) is a powerful predictor of both malpractice actions and settlement values.6 When considering that EPs evaluate a large and growing population of elderly patients who are more acutely ill, more challenging diagnostically, more difficult to communicate with, and suffer more adverse outcomes, it is obvious that this population commands special consideration from a clinical practice and malpractice risk-management perspective.
Table 2:
Predictors of Adverse Outcomes
in the Elderly ED Patient
Finally, many of the common presenting illnesses and injuries among the elderly also are those most frequently litigated in emergency medicine (EM). Review of closed claims reveals that diagnoses related to chest pain, abdominal disorders, and fractures (often secondary to falls), are responsible for a majority of claims and dollar loss in EM.7 This article will focus on high-risk diagnoses among these broader categories. Awareness of these high-risk entities is the first step in targeting interventions to promote positive clinical outcomes, thereby reducing malpractice risk.8
Abdominal Pain
Elderly patients with abdominal pain differ from their younger counterparts in several ways. Elderly patients have higher rates of admission (63% vs. 18%),9,10 frequently require surgical intervention (42% vs. 9%), and have a lower incidence of undifferentiated abdominal pain (less than 15% vs. 25%).9 The mortality rate in patients with abdominal pain rises sharply after age 50; and for those older than 80 years, it is 70 times that of younger adults.11 High mortality rates are attributed to a high incidence of comorbid illness (65% with at least one coexistent disease)10 and poor diagnostic accuracy. Accurate diagnosis in elderly patients is made only 40-65% of the time.9 Presentations are rarely classic, but instead are subtle, confusing, or nonspecific.10 Table 3 lists the most common diagnoses in elderly patients with abdominal pain. The most common abdominal diagnoses in elderly patients include biliary tract disease (23%), diverticular disease (12%), and bowel obstruction (11%).12 Ten percent of elderly patients with abdominal pain have a diagnosis that is not referable to the gastrointestinal tract.10 The following cases illustrate the many pitfalls in the evaluation of the elderly patient with abdominal pain.
Table 3:
Common Diagnoses in the Elderly Patient
with Abdominal Pain
Table 4:
Take-Homes: Risk Management
in Elderly Abdominal Pain
Case #1. Tomlin v. Hopper13
Hubert Tomlin was a 68-year-old man who presented to a California ED with right lower-quadrant abdominal pain, vomiting, diarrhea, and fever. Examination revealed periumbilical tenderness. No diagnostic testing was performed. He was diagnosed with gastroenteritis and told to follow-up with his internist if his condition worsened. Three days later, he presented to his internist with a fever of 102º F, weakness, bloating, and anorexia. His white blood cell count was elevated, and urinalysis showed pyuria. He was diagnosed with pyelonephritis and prescribed Keflex. The patient re-ported by telephone the next day that he was improved. However, the following day he again contacted his internist complaining of increasing right lower quadrant abdominal pain. Subsequent work-up revealed a large appendiceal abscess requiring surgical drainage. The patient was hospitalized for 12 days. He brought suit against his internist for failure to diagnose appendicitis and to obtain timely surgical consultation. A verdict was returned for the defense.
Discussion
This case typifies cases of missed appendicitis. Mr. Tomlin initially was diagnosed with gastroenteritis. Among cases of missed appendicitis that ultimately are litigated, 42-50% had an initial diagnosis of gastroenteritis.14 While Mr. Tomlin did have both vomiting and diarrhea, EPs should guard against making a diagnosis of gastroenteritis, never using it unless all three cardinal features of nausea, vomiting, and diarrhea are present. If pain is a predominant presenting symptom, the diagnosis of undifferentiated abdominal pain is more appropriate.
Mr. Tomlin’s second diagnosis was pyelonephritis. Urinary tract infection is a frequent misdiagnosis in cases of missed appendicitis. Elderly patients have a high rate of asymptomatic pyuria, therefore, urinalyses often are abnormal. Pyuria or hematuria is not unusual in cases of appendicitis, given the position of the inflamed appendix relative to the ureter.15 As with gastroenteritis, a specific diagnosis should not be assigned unless it accurately represents the sum of presenting signs, symptoms, and clinical findings.
Mr. Tomlin suffered delayed diagnosis. Researchers reported the average time to correct diagnosis in cases of missed appendicitis was 39 hours after ED discharge.14 Delayed diagnosis is associated with a higher rate of appendiceal perforation. Elderly patients have comparable outcomes to younger patients in uncomplicated acute appendicitis, however, 53-89% of elderly patients have a perforated appendix on presentation.15
Perforated appendicitis is associated with significantly higher postoperative complication rates and mortality. Mortality rates of appendicitis in elderly patients is 10 times that of younger patients, and 50% of all appendicitis-related deaths are in patients older than 65 years.15
In analyzing Mr. Tomlin’s presentation, he did complain of fever. By contrast, most elderly patients with acute appendicitis or cholecystitis are afebrile and many present with hypothermia.9 Mr. Tomlin did show improvement in symptoms, termed “paradoxical improvement” as it signifies perforation. This temporary relief of pain is followed by a return of symptoms and generalized peritonitis.15
In reviewing cases of missed appendicitis that resulted in litigation, researchers identified several common features: presentation was atypical, a thorough examination was not performed, narcotic pain medicine was given intramuscularly just prior to patient dismissal, dismissal diagnosis was gastroenteritis, and appropriate discharge instructions and follow-up were not provided.14 Patients with undifferentiated abdominal pain, and particularly those where appendicitis is still a possible diagnosis, should be given a scheduled follow-up either in the ED or with their primary provider within 12 hours of their ED evaluation. Discharge diagnosis should be nonspecific abdominal pain when evaluation does not reveal a specific diagnosis.9 Indications for immediate return to the ED such as worsening pain, fever, or intractable vomiting should be described to the patient and provided in written form. Prior to dismissal, a repeat physical examination and pain assessment should be performed and documented.9
Case #2. Melsom v. Reed and South Gulf Coast Emergency Physicians16
Mrs. Barbara Melsom was a 66-year-old woman who presented to a Florida ED with abdominal pain and vomiting after eating dinner. She was cared for by Dr. Karen Bay Reed, who administered antiemetics and fluids. Dr. Reed also consulted the patient’s primary physician and admitted Mrs. Melsom to the hospital. The patient was not re-examined by her primary physician until late the next afternoon. Examination then revealed a possible abdominal mass. A CT scan was ordered but never completed because Mrs. Melsom suffered a fatal cardiac arrest two hours later. Autopsy revealed small bowel volvulus. The decedent’s husband filed suit against Dr. Reed, claiming negligence for failure to perform an adequate history and physical examination, order timely diagnostic testing, and obtain a surgical consultation. The jury returned a verdict for the defense.
Discussion
While small bowel volvulus is a rare diagnosis, it is representative of bowel obstruction, which is among the most frequent causes of abdominal pain in the elderly (12-25%).10,15 Bowel obstruction is second only to biliary disease as an indication for emergency abdominal surgery in this group.15 Small bowel obstructions (SBOs) most often are due to surgical adhesions, hernias, or neoplasms. Large bowel obstructions (LBOs) result from carcinoma or volvulus of the sigmoid colon or cecum and are more common in the elderly.
The key question to address in a case of bowel obstruction is whether bowel strangulation or a closed-loop obstruction exists. Each requires immediate surgical intervention. Neither should be treated with simple IV fluids, antiemetics, decompression, and admission to a medical unit.15 Closed-loop obstruction should be considered in any patient whose pain is sudden in onset, unremitting, out of proportion to exam findings, or is changing from colicky to constant pain. Physical examination should include also a diligent search for hernias as there is a high rate of incarceration with subsequent bowel ischemia in elderly patients.
Plain radiographic imaging will reveal SBO as the diagnosis in 60-75% of cases17 and also can demonstrate cecal and sigmoid volvulus. However, in patients with features suggestive of strangulation or closed-loop obstruction as described above, a CT scan should be obtained. CT imaging is highly sensitive and specific for obstruction; it can identify transition points, provide information on additional diagnoses (e.g., appendicitis), and demonstrate findings suggestive of bowel ischemia or strangulation.
Some authors feel all patients with bowel obstruction should have a surgical consultation prior to admission.15 Admission to medical services may delay surgery, if ultimately necessary, resulting in higher mortality.18 Patients with mild symptoms that are gradual in onset with plain film findings consistent with adhesive obstruction may not require either CT imaging or emergent surgical evaluation, but evidence is lacking.
Mrs. Melsom was appropriately admitted to the hospital, yet still suffered a poor outcome, illustrating that the diagnostic value of the ED evaluation should not be discounted. Researchers reported a mortality rate in elderly patients with abdominal pain of 19% if diagnosis occurred in the hospital, vs. 8% if a diagnosis was made in the ED.19 Hospital admission often is viewed as a safety net for the patient from a clinical perspective and the EP from a risk management perspective. While partially true, the need for a thorough search for a diagnosis while the patient is in the ED cannot be overemphasized.
Case #3. Brister, et al. v. Burson and Laughlin20
A 77-year-old woman with a history of chronic back pain was taken to a California ED after experiencing sudden onset of left lower-quadrant pain with pre-syncope and confusion. The evaluating EP order-ed a head CT scan, ECG, cardiac markers measurement, and a plain x-ray of the abdomen. All studies were interpreted as negative. The patient was too weak to walk without assistance, and thus, her primary provider was contacted. The primary physician saw the patient in the ED, diagnosed diverticulitis and pre-syncope secondary to medication, and admitted her to the hospital. The following morning, she coded and was found to have a pulsatile abdominal mass. She was taken to surgery for a ruptured abdominal aortic aneurysm (AAA) but did not survive. Survivors sued the EP and the primary provider for failure to diagnose a leaking AAA, specifically citing that a CT scan of the abdomen should have been ordered and would have resulted in the correct diagnosis. The jury return-ed a verdict for the defense.
Discussion
Ruptured AAA is common, lethal, and a frequent source of litigation for EPs who fail to make the diagnosis. AAAs are found in 2-4% of the population of older than 50 years with a reported prevalence of 5-10% in the elderly males.21 Mortality from ruptured AAA is 77-88% with 40-50% of patients dying before they arrive at a hospital.22
The case above exemplifies many of the common pitfalls in cases of missed AAA rupture. Sullivan23 reviewed AAA litigation citing the following themes: poor risk factor analysis, poor recognition of flank pain presentations, failure to obtain imaging studies to evaluate the aorta, delay in proper management, failure to recognize alternative presentations such as syncope, and failure of timely vascular surgery consultation.
Extent of risk factor assessment in this case was not known to this reviewer. Detailed documentation of risk factors may convince a jury that the EP’s evaluation was thorough.24 Risk factors for AAA include advanced age, hypertension, atherosclerotic vascular disease, connective tissue disease, family history (first-degree relative), smoking, diabetes, and white race.24
While this patient’s initial diagnostic evaluation was extensive, no attempt was made to integrate her abdominal pain, back pain, and pre-syncope into a single plausible diagnosis. Abdominal aortic aneurysm should be considered in any older patient with a complaint of abdominal, flank, or back pain.23 Neither physician in this case recognized that her symptoms, either in isolation or collectively, were indicative of AAA rupture. The classic presentation of hypotension, abdominal pain, and pulsatile abdominal mass occurs only in 30-50% of cases.25 Presentations can be wide ranging from asymptomatic to shock. Diverticulitis is the misdiagnosis in 12% of cases of missed AAA rupture.24 Many AAA rupture into the left retroperitoneum resulting in left lower-quadrant pain or left lower quadrant mass. Ruptured AAA is well known to masquerade as renal colic — the No. 1 diagnosis in cases of missed AAA rupture.15 Sudden severe flank pain in any elderly patient should prompt evaluation for aortic pathology.24 Renal colic as a diagnosis in elderly patients with no prior history of kidney stones should be ascribed with caution. Finally, AAA should be considered in any elderly patient with unexplained syncope.24
Similar to the previously described cases where poor outcomes and litigation occurred, this case is another example of where timely CT imaging in an elderly patient with abdominal pain may have prevented a misdiagnosis and death. For hemodynamically unstable patients, bedside ultrasound is highly sensitive for detecting AAA, provided the aorta can be visualized.24 In an unstable patient with a history consistent of ruptured AAA and bedside ultrasound demonstrating AAA, no additional confirmatory testing is required prior to surgical intervention. In stable patients where the diagnosis is suspected but unclear, a CT scan of the abdomen should be routinely obtained.
Chest Pain
While the diagnostic possibilities in the elderly patient presenting with chest pain are broad, this discussion will focus on the catastrophic life threats of acute myocardial infarction (AMI) and aortic dissection (AD), both commonly encountered in the elderly population and frequently litigated in the malpractice arena for failure to diagnose and failure to initiate proper treatment. Both present diagnostic dilemmas that may result in delay to treatment and thereby increase the rate of adverse outcomes and death.
Case #4. Klocke v. Kloss and Gresic26
An obese 65-year-old woman with a history of hypertension began experiencing chest pain at a family gathering. A relative gave her a nitroglycerin tablet after which she began to experience weakness, dizziness, and dyspnea. EMS was dispatched. The patient complained of chest and abdominal pain that went through to the back. Upon arrival to the ED, she was triaged with abdominal pain. The EP ordered work-up for AMI and AAA, including an ECG, cardiac markers measurement, and CT imaging of the abdomen. The abdominal CT scan initially was read as negative. The radiologist later revised his reading recommending a contrast study, a revision never communicated to the EP. The patient was admitted to the hospital, where she died the next morning. Autopsy revealed AD. The plaintiff claimed the patient’s presentation was consistent with AD, and the EP and radiologist were negligent in failure to diagnose. The jury returned a defense verdict.
Discussion
This case exemplifies the formidable diagnostic challenge and catastrophic consequences of a missed diagnosis of AD, the most common and most lethal aortic emergency.27 AD is a disease more commonly seen in the elderly with peak incidence in males age 50-70 years.24 Among life-threatening causes of chest pain, AD has the highest mortality — an estimated 1-2% per hour for the first 48 hours.28 Unfortunately, as many as 65% of AD cases are missed on initial presentation.29
Presenting signs and symptoms of AD are dependent upon the location of the dissection and the vessels affected. Chest pain is the most common presenting complaint, present in more than 90% of patients with acute AD. The pain is typically abrupt, most severe at onset, and often migratory. A definitive work-up for AD should ensue in any patient presenting with one of the following identifiable clinical syndromes:29 Chest pain with neurologic symptoms, chest pain radiating to the back, chest pain with signs of vascular compromise, chest pain that is migratory, and chest pain with severe abdominal or back pain.
Risk factors for AD include advanced age, hypertension, male sex, nonwhite race, connective tissue disease, bicuspid aortic valve, coarctation of the aorta, and drug use including methamphetamine and cocaine.27 In any patient with chest pain and one of the above risk factors, AD should be considered as a possible etiology of his pain.29 In the above case, the patient’s age, history of hypertension, and the fact that she had severe chest and abdominal pain that radiated to the back should have prompted a work-up for AD.
Definitive imaging for AD should occur immediately in any suspected cases, employing the test that is most readily available. Sensitivity and specificity of contrast-enhanced CT imaging approaches 100% for the diagnosis of AD.30 There are two likely reasons CT imaging did not detect the AD in the case above; imaging did not include the chest, and contrast was not utilized. Transesophageal echocardiography also is highly sensitive and has been shown to be safe in critically ill patients. Lack of widespread, 24-hour availability limits it use.31
Differentiating AD from acute coronary syndrome is critical yet complicated. Unfortunately, ECG evidence of AMI does not rule out concurrent presence of AD.28 Although a normal screening chest x-ray in the setting of AMI makes AD less likely, rapid definitive imaging is indicated when the clinical suspicion of AD is high. Conversely, in patients with a normal ECG or those not responding to treatment for acute coronary syndrome, AD should be considered. The fact that this patient’s symptoms did not respond to nitroglycerin and her work-up for acute coronary syndrome was unrevealing are pertinent negatives. Many patients with AD are admitted errantly to ED observation units or the hospital setting to rule out coronary syndrome. The diagnostic endpoint for patients presenting with chest pain cannot simply be to rule out underlying coronary disease. Alternative diagnoses (e.g., AD and pulmonary embolism) always need to be considered strongly.
In analyzing missed diagnoses of AD, several repeated patterns are noteworthy. These include failure to perform a detailed risk factor profile for AD, failure to recognize a classic presentation, and failure to integrate patient’s signs and symptoms.23 Frequently, diagnoses are given to patients that only partially fit the presenting symptoms, which when taken in sum could be better explained by AD. An example would be a musculoskeletal chest pain diagnosis in a patient presenting with severe chest and abdominal pain, diaphoresis, and dyspnea.
Freedman outlined risk management strategies for the timely diagnosis and management of AD.29
1. Maintain a high level of suspicion. If AD is not considered routinely, it will not be diagnosed with acceptable sensitivity.
2. Pursue definitive work-up in patients with chest pain and a) one or more risk factors; or b) one of the identifiable clinical syndromes described above.
3. Obtain definitive diagnostic imaging in cases of suspected AD using the test that is most readily available.
4. Initiate treatment aimed at preventing propagation immediately upon diagnosis of AD. This should include a combination of a vasodilator and a beta-blocker to lower blood pressure and heart rate.
5. Initiate specialty surgical consultation on a stat basis when AD is diagnosed or even highly suspected.
Case #5. Brunnett v. Armada32
Fred Brunnett was a 76-year-old man who presented to an Ohio ED with worsening of “flu symptoms.” Symptoms included fever, dizziness, disorientation, and dyspnea. Mr. Brunnett was evaluated by Dr. Phillip Armada who ordered a battery of tests. ECG was abnormal but nonspecific; a repeat ECG showed no change. The patient was observed in the ED for four hours and released with a diagnosis of urinary tract infection. Six hours after dismissal, he died of cardiac arrest. The plaintiff claimed that Dr. Armada failed to detect a potentially fatal cardiac condition. The jury returned a defense verdict.
Discussion
Annually, there are 1.1 million AMIs.33 Sixty percent of AMIs occur in patients older than 65 years; 80% of AMI-related deaths are in this same age group.34 Even with recognized and appropriately treated AMIs, mortality rates are three to seven times higher in elderly patients.35 The rate of “missed” AMI ranges from 2-8%.36
Missed AMI dominates malpractice litigation targeting ED and EPs.37 More malpractice dollars are paid out for missed AMI than for any other diagnosis.38 These statistics underscore the importance of acutely identifying AMI in elderly ED patients.
Elderly patients are at increased risk for missed diagnosis for several reasons:
1. Incidence of coronary artery disease increases with age. The majority of AMIs occurs in patients older than 65 years. One consequence of increased prevalence of this disease is an increase in false-negative ECGs and stress tests.35 Thus, diagnostic testing is not as helpful in ruling out disease in this population where disease is more prevalent.
2. High portion of silent and medically unattended AMI. Studies have indicated that silent (asymptomatic) AMI and medically unattended (symptoms present, but care not sought) compose nearly 50% of AMI in the elderly population.38
3. Atypical presentations more common. Atypical presentations are a significant risk factor for delayed diagnosis and treatment, directly resulting in increased mortality in the elderly AMI patients. Atypical presentations include: a) presentations with uncharacteristic pain; or b) presentations with no chest pain where other symptoms predominate. Atypical chest pain presentations (e.g., sharp, stabbing) are common in the elderly. Ironically, in a study of patients presenting to EDs with chest pain, typical presenting signs and symptoms (substernal chest pressure radiating to jaw or arm) were associated with lower relative risk of AMI in patients older than 65 years. Although typical symptoms were present in many patients, they occurred more frequently in elderly patients not having AMI, and thus were less specific for AMI.39
Chest pain as the presenting symptom of AMI decreases with age from 76% at 65 years to 37% at 85 years.40 Dyspnea increases with age, becoming the predominant symptom in patients older than 80 years with AMI.40 Nausea, diaphoresis, weakness, delirium, and stroke all can be presenting symptoms of AMI. Mr. Brunnett’s presentation in the above case falls into the atypical category as he complained of only dizziness, dyspnea, and disorientation. Fever was likely a confounding factor in his evaluation. Patients with atypical presentations experience mortality rates twice that of patients with typical symptomatology.35
4. Frequent late presentations. Patients who arrive hours or days after AMI are termed late presenters. The elderly commonly are late presenters because of diminished perception of pain, less awareness of signs and symptoms of AMI, reluctance to seek care, and difficulty with transportation.35 Late presenters have worse outcomes because they are not candidates for primary catheterization or fibrinolytic therapy, and the infarcts are larger.
Due to the unique challenges in diagnosing AMI in the elderly population, the EP must maintain a high index of suspicion in the elderly, diligently rule out symptomatic coronary artery disease in patients with atypical pain, and assess for AMI in patients with nonspecific complaints in the history of coronary disease or multiple coronary risk factors.
Case #6. Stonner v. Ash41
A 68-year-old woman presented to a Missouri ED complaining of sharp stabbing chest pain relieved by Motrin. Prior to her arrival, she had experienced exertional pain radiating down both arms and nausea. All symptoms had resolved on arrival to the ED. She was diagnosed with chest wall pain and was prescribed ibuprofen and cyclobenzaprine. Five days later, she returned in cardiopulmonary arrest. The ECG revealed an acute ST-elevation MI. She was taken to the catheterization lab and subsequently died. A settlement of $295,000 was reached with the surviving family.
Case #7. Anonymous v. Anonymous42
A 65-year-old woman presented to a North Carolina ED with complaints of chest pain that had awakened her from sleep. The attending EP ordered an ECG and a gastrointestinal (GI) cocktail. The ECG had nonspecific but nondiagnostic changes. The patient improved after administration of the GI cocktail and was discharged two hours after arrival with a diagnosis of possible gastroesophageal reflux disease. The patient suffered cardiac arrest five hours later, secondary to a massive AMI. The case settled for $750,000.
Discussion
While elderly patients pose unique challenges in the diagnosis of AMI, EPs still must avoid common pitfalls in the evaluation of suspected AMI applicable to old and young patients alike. All three cases of missed AMI above demonstrate common, avoidable management pitfalls. Dunn and colleagues outlined risky practices to avoid in the evaluation of chest pain.37
1. Relying on reproducible chest wall pain to rule out acute coronary syndrome. The Stonner case above validates what studies have shown — reproducible chest wall pain is present in 6-15% of AMI cases.35,43
2. Using response to antacids or other treatment as definitive diagnostic aids. Patients with ACS can become pain-free for various reasons, and responsiveness to a GI cocktail does not rule out coronary artery disease.44 Application of this tenet in the case of the 65-year-old NC woman may have avoided the catastrophic outcome and subsequent litigation.
3. Failure to appreciate nonspecific ECG changes. ECGs for the patient in both Cases 5 and 7 were abnormal but nondiagnostic. Nondiagnostic changes may be ominous signs of evolving coronary syndrome or underlying coronary disease. These changes cannot be discounted, particularly in the high-risk elderly patient.
4. Ignoring epigastric or upper abdominal pain as a potential sign of inferior myocardial infarction. An ECG should be obtained in any elderly patient with epigastric pain.
5. Discounting previous symptoms. Even when symptoms are resolved on presentation to the ED, they still must factor into risk in assessment and subsequent management.
Finally, it is noteworthy that both decedents in the final two cases were women. Missed AMI occurs more frequently in women.45 Postmenopausal women assume the same risk as their male counterparts with coronary artery disease. Women, however, tend to present with longer delay from symptom onset, have higher incidence of comorbid disease, tend to be older than their male counterparts, and more commonly have atypical presentations.45
Falls
Falls occur annually in more than 30% of elderly individuals living independently and are even more frequent in nursing home patients.46 A fall often is a sentinel event for an elderly person, heralding functional decline or a presenting symptom of a new or worsening medical condition.47,48 Forty to fifty percent of falls result in minor injury. Fractures are the result of 5% of all elderly falls with an additional 5-10% causing other significant injuries.47 Falls are the most common cause of injury-related death in the elderly population.46,49 Two-thirds of elderly patients who fall will fall again in the following six months. Up to 50% of older people requiring hospitalization for injuries sustained from a fall die within one year.47 The cases and discussions below focus on clinical evaluation and risk management of falls in the elderly, emphasizing that the EP must not only evaluate the injuries sustained, but also determine the cause of the fall and carefully consider measures to prevent subsequent falls.
Case #8. Abruzzo v. Condell Medical Center50
Cecellia Abruzzo was an 82-year-old woman who fell outside her home and lay in the sun for hours before being taken to the ED at Condell Medical Center. Mrs. Abruzzo was evaluated briefly and dismissed from the ED. She was readmitted nine hours later suffering from shock, acidosis, severe hypovolemia, and acute myocardial infarction. She experienced multisystem organ failure and died three weeks later. The plaintiff alleged failure to obtain appropriate history, perform a physical examination, and to diagnose dehydration. Defendants argued that they were not given a history of prolonged heat exposure and that the patient did not exhibit signs or symptoms of dehydration, shock, or hypovolemia on her first evaluation. The jury returned a verdict for the defense.
Discussion
While it is common for EPs to focus on the injury sustained from a fall, this tragic case underscores the importance of carefully investigating the cause of the fall. Causes of falls of the elderly can be divided among the three broad categories: functional decline, environmental factors, and medical problems — either acute or chronic.51 Weakness, poor balance, or impaired vision or hearing develop with aging and all are contributors to falls in the category of functional decline. Environmental factors contributing to falls include poor lighting, slippery surfaces, loose rugs, steep stairwells, bad footwear, and other similar hazards. Most falls result from a combination of host and environmental factors.52 Elder abuse is a real but underdiagnosed environmental contributor to falls. In elderly patients with frequent visits for falls with injury, consideration always should be given to the possibility of intentionally inflicted injuries.53 Finally, a broad range of both acute and chronic medical problems can result in falls with special attention to conditions resulting in syncope and delirium. Syncope accounts for 2-15% of all falls in elderly patients.53 Delirium often goes unrecognized in elderly patients and may present as a variety of complaints including falls.52 While not all inclusive, Table 5 details a listing of medical causes of falls.
Table 5:
Medical Problems that Cause
Falls in the Elderly
Table 6:
Take-Homes: Risk Management
for Falls in the Elderly
The key to determining the cause of a fall is a careful history, which should include the location of the fall, reported cause, long lie (greater than five minutes), inability to get up on own, as well as number of falls in the last few months.52 Directed systems review for syncope, seizure, loss of consciousness, change in mental status, and melena also should be elicited. Medication use and changes are an important consideration as 25% of elderly patients are on medication that contributes to drowsiness, poor balance, and postural hypotension.54 Social history including alcohol use, living situation, ability to live independently, and safety also should be included.49
A careful history may have identified that Mrs. Abruzzo had a prolonged down time, putting her at risk for poor outcome. Patients who cannot rise from the fall unassisted are more likely to experience decline in ability to live independently, be hospitalized, and die early.55 The defendant in this case denied any knowledge of a prolonged down time — knowledge that potentially would have affected the extent of diagnostic evaluation and the disposition decision.
Case #9. Brezniak v. Baez56
Morris Brezniak was an 80-year-old man who fell at home. He was brought to a Florida ED where he was diagnosed with multiple contusions to the face, lip, and right arm. He was dismissed and instructed to follow up with his primary care physician. Later that evening, Mr. Brezniak became slow to respond. He was taken to the ED, where he began to vomit. Chest x-ray showed a right upper lobe pneumonia. A head CT scan revealed a left parietal subdural hematoma with midline shift. Shortly after returning from the CT department, the patient began exhibiting signs of pending herniation. Despite emergent neurosurgical intervention, the patient died. The plaintiff claimed that Dr. Baez was negligent in failing to diagnose the subdural hematoma on initial evaluation and that emergent CT imaging was indicated in the setting of head trauma in an anticoagulated patient. The jury returned a verdict for the defense.
Discussion
Aside from identifying the possible cause of a fall, the EP must also evaluate injuries sustained and explore means to prevent subsequent falls. Mr. Brezniak had an unwitnessed fall in the bathroom. Until ruled out, this should be presumed a syncopal event with diagnostic work-up for the same. Mr. Brezniak was on chronic Coumadin anticoagulation therapy and had evidence of facial trauma. Threshold for head CT imaging in anticoagulated patients should be low as clinical evaluation is an unreliable predictor of intracranial injury.57,58
Four aspects of the physical examination should be emphasized in patients who fall:59
1. Vitals: Abnormalities (e.g., fever, tachycardia, and hypotension) may provide clues into the likely etiology of a fall.
2. Mental status: Changes in function from baseline and new delirium should be assessed.
3. Skeletal: Head, spine, pelvis, and extremities should be examined for evidence of fractures, lacerations, and contusions, as these are the most frequently injured in falls.
4. Neurologic: The Get-Up-and-Go test is considered by some to be as important as vital signs in the assessment of elderly fall victims.59 This is a simple test of the patient’s ability to rise from the gurney and ambulate. It simultaneously assesses for presence of lower extremity or pelvic injury as well as giving insight into gait, strength, balance, and general function.
Several questions must be addressed when determining disposition for the elderly fall victim:
1) Is the cause of the fall a potentially threatening condition that requires further inpatient evaluation (i.e., syncope, stroke)?
2) Does the patient have injuries or impairment that may prevent safe function at home?
3) Is the patient at high risk for subsequent falls? Risk factors for frequent falls include age older than 75 years; use of psychoactive or cardiac medication; use of more than four prescription medications; impaired cognition strength, balance, or gait; and multiple falls in the last three months.50
4) Does the patient have little social support, poor access to primary care follow-up, or a potentially unsafe home environment?
5) Is it unlikely that immediate measures may be taken to prevent subsequent falls (i.e., environmental changes)?
An affirmative answer to any of these questions should prompt consideration for admission. In circumstances where etiology of the fall is known and benign, injuries are minimal, social supports are good, access to follow-up is rapid, and where potential falls could be prevented, patients could be considered for outpatient management. Additionally, tapping ED or hospital-based social services and community-based resources, when available, is advisable for home-going patients. With the growing number of elderly, authors are advocating EDs consider formalizing programs for multi-factorial intervention that can occur in the outpatient setting to decrease incidence of subsequent falls and prevent the associated morbidity and mortality.48.51.59
Conclusion
This article examined common life-threatening entities encountered in the elderly population. The unifying characteristic of all these diseases is the diagnostic challenge they present — a diagnostic challenge accentuated by characteristics of the elderly ED population. Compromised communication, delayed and atypical presentations, alterations in physiologic response, and the presence of significant comorbid illness all increase the degree of difficulty for the EP in evaluating the elderly patient. EPs and nurses will need to become increasing adept at managing the elderly patient as the population ages. Awareness of the life-threatening diseases that afflict this population, the impediments to evaluation, and the increased risk of morbidity and mortality in this population is a critical step in modifying practice to promote positive clinical outcomes and minimize the risk of litigation.
Acknowledgement: The author would like to thank Ms. Cyndra Franke for her patience, hard work, and dedication in the preparation of this manuscript.
Endnotes
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With our aging population, emergency medicine practitioners increasingly will face the challenges of care for the elderly in the emergency department. A new report from the Centers for Disease Control and Prevention notes that visits to U.S. EDs reached a record high in 2003 and attributes this rise to increased use by adults, especially those ages 65 and older. Elderly patients have higher risks for presenting to the ED.
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