Edited by: Jay Khapde, MD FAAEM and Michael C. Bond, MD FAAEM
Between the 2000 and 2010 U.S. Census, the population over age 65 increased at a higher rate that the overall U.S. population. For the purposes of this article, we will use age greater than 65 as the definition of a geriatric patient. By 2050, there will be over 83 million geriatric Americans, double the number from 2012.1 Currently, over 15% of emergency department (ED) visits, equaling 20 million total visits, are from geriatric patients.2 These numbers are certain to increase and will represent a unique challenge to the U.S. health care system, specifically to the ED. In this month’s “Resident Journal Review,” we focus on the evaluation, diagnosis, and treatment of geriatric patients presenting to the ED.
Medication Management for Pain and Agitation
One specific challenge emergency physicians (EPs) encounter with geriatric patients is medication administration, particularly with analgesic and sedatives. This patient population is at increased risk for adverse drug events (ADE); 40% of geriatrics take five or more medications while less than 20% of non-geriatrics take this many.3 Concerns about medications may lead to suboptimal care of geriatric patients despite evidence to suggest that these patients can be treated safely. Failure to provide these medications may also lead to adverse outcomes. Below, we review two articles regarding pain control and sedation of geriatric patients in the ED.
Calver L and Isbister GK. Parenteral sedation of elderly patients with acute behavioral disturbance in the ED. American Journal of Emergency Medicine. 2013;31:970-3.
Elderly patients with acute behavioral disturbances (ABD) often require pharmacologic restraint in the ED. In this prospective Australian study, Calvert and Isbister investigate the protocoled use of the antipsychotic, droperidol, for parenteral sedation. Forty-nine patients aged 65-93 (median 81years) presenting to the ED with ABD were included in the study. The study protocol called for an initial intramuscular dose of 10mg droperidol, followed by an additional 10mg dose if sedation was not achieved after 15 minutes.
Thirty patients received an initial dose of 10mg droperidol, 15 received 5mg droperidol, two patients received 2mg droperidol, and two received midazolam as the initial sedation agent. Of patients receiving 10mg droperidol, 33% (95% CI 18-53%) required additional sedation vs. 47% (95% CI 22-73%) of those who received 5mg droperidol. Five patients suffered ADE. Two patients receiving 10mg droperidol developed hypotension, one patient who received both 10mg droperidol and additional midazolam experienced airway obstruction, one patient who received 2.5mg droperidol was oversedated, and one patient treated outside the protocol guidelines was oversedated with a combination of midazolam and haloperidol. Evaluation of EKGs demonstrated no QT prolongation in any subject.
This study is limited by small sample size, lack of strict adherence to the study protocol, and limited availability of droperidol in the U.S. due to the QT prolongation black box warning, making it difficult to draw robust conclusions about optimal dosing for safety and effectiveness. The authors conclude with a recommendation to start with an initial 5mg dose of droperidol, with the expectation that many patients may require additional medication. The selection of droperidol, which the authors suggest may be superior to haloperidol in terms of both sedation and risk of QT prolongation, also merits further study in the elderly.
Boccio E, Wie B, et al. The relationship between patient age and pain management of long-bone fracture in the ED. American Journal of Emergency Medicine. 2014; 32: 1516-19.
Pain is one of the most common reasons patients present to the ED; however, delays often occur from presentation to administration of pain medication. Poor pain management in the ED may lead to worse patient outcomes.4 This article attempted to quantify the amount of time it took for patients, based on age, to receive pain medication for long bone fractures (LBF). This retrospective chart review examined time to first dose of pain medication in patients of all ages (divided as pediatric, adult, and geriatric) at a large, suburban, academic medical center.
A total of 1,255 patients were included in this study with the majority falling in the geriatric age group. Within the pediatric group, 78% of patients received medication, 86% in the adult group, and 80% in the geriatric group. The median and average times to initial medication administration were 44 and 52 minutes for pediatrics (95% CI 45.9-58.1), 39 and 54 minutes for adults (95% CI 48.8-58.4), and 55 and 73.2 minutes for geriatrics. Student t-tests showed a significant difference between the pediatric and geriatric groups as well as the adult and geriatric groups (both P<0.01). The authors further divided the geriatric group to those 65-84 and those 85 and above. The median and average times for the 65-84 age group was 49 and 67.2 minutes respectively. The older group had a further delay (P<0.01) in pain medication administration with median and average time to administration of 64 and 81.8 minutes (95% CI 73.6-90.0).
The delay in analgesia administration for geriatric patients was attributed to a decline in: the patients’ ability to effectively communicate with health care providers due to hearing, vision or other sensory deficits or memory or reduced cognitive and linguistic abilities. Delays were noted for younger pediatric patients (those under the age of 3), which enhances the argument that communication deficits may be a factor. Other possible contributing factors may be concerns about ADEs or the specific fracture as the LBFs seen in geriatric patients (predominantly femoral neck) were different than the pediatric and adult group (predominately radius/ulna).
Limitations of this study include its retrospective design, reliance on provider documentation, physician practice patterns and opinions regarding pain management, and no clear pain score assessment among patients. Despite these limitations, this study suggests geriatric patients disproportionately suffer delays in receiving appropriate analgesia for LBFs. Although caution should be used, EPs still must ensure timely pain control in this vulnerable population.
Diagnosis in Geriatric Patients
Geriatric patients may present atypically or without anticipated alterations in vital signs or laboratory values with certain diseases. These atypical presentations, combined with cognitive and sensory deficits, may make identification of time-sensitive diseases more challenging for the EP. Next, we review two articles aimed at improving diagnosis in geriatric patients.
Grosmaitrea P, Le Vavasseur O, et al. Significance of atypical symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments. Archives of Cardiovascular Disease. 2013;106: 586-92.
This retrospective, multicenter study examined how elderly patients with ST segment elevation myocardial infarctions (STEMI) presented to the ED and the impact on management and mortality of presentation without chest pain. Patients with a primary diagnosis of STEMI were identified from four French hospitals over a four-year period. Exclusion criteria included: age under 75, incomplete charts, no troponin levels, and an alternative diagnosis. Analysis included chi-square test of qualitative measures and student’s t test comparison of quantitative measures.
Of 255 STEMI patients identified, chest pain accounted for only 41.2% of presentations. Atypical presentations were faintness/fall (n=40, 16%), dyspnea (n=40, 16%), digestive symptoms/nausea (n=25, 10%), impaired general condition (n=17, 7%), delirium/impaired vigilance (n=13, 5%), and all other presentations (n=15, 6%). Residence in a nursing home (P=0.044), dementia (P<0.001), and impaired communication (P<0.001) were associated with atypical presentation, while diabetes was not (P=0.328). Symptom severity (Killip score >2) was greater in the atypical group (28%) versus the typical group (11%), (p=0.001), but the atypical cohort had longer prehospital delay times (P<0.001), longer delay to decision times (P<0.001), and less likelihood of reperfusion regardless of delay (P<0.001).
Limitations of this study include small numbers, underestimation of atypical STEMI, lack of uniform definitions of STEMI in the setting of a LBBB or pacemaker, lack of definition of impaired communication and elevated troponins, and no control for comorbid diseases.
The study’s authors conclude a more liberal use of EKGs may be prudent with geriatric patients as atypical presentations for acute coronary syndrome are common in this population.
Chung M, Huang C, et al. Geriatric Fever Score: A New Decision Rule for Geriatric Care. PLOS One. 2014; 9(10): e110927.
This observational, prospective cohort study sought to create a prediction rule for stratifying mortality risk and choosing the best disposition for geriatric patients who present to the ED with fever. Patients were enrolled from a university medical center in Taipei. A total of 7,650 patients were evaluated for enrollment. Of those, 350 were identified as geriatric patients with fever. Twenty patients were excluded, mainly for insufficient data. The patients were evaluated for 12 mortality predictors including: severe coma (using GCS), hypotension, tachypnea, stroke history, degree to which patient was bedridden (ECOG score), nasogastric tube (NG) feeding, congestive heart failure (CHF) history, nursing home resident, leukocytosis, thrombocytopenia, bandemia, and elevated serum creatinine. The primary outcome was survival at 30 days.
After multiple logistic regression analysis, leukocytosis >12,000 (P<0.001), GCS <9 (P=0.017), and platelets <150,000 (P=0.013) were determined to be independent predictors of mortality, and thus, used to generate the prediction rule. In using the rule, the authors suggested assigning 1 point to each of the three mortality predictors and stratifying patients into low risk (0-1 points) or high risk (≥2 point) with respective 30-day mortality of <4% vs. 30.3%. The authors conclude high-risk patients should be admitted to an intensive care unit.
The study lacks external validation, especially significant given the findings come from a single center. Assuming mortality is higher in high-risk patients, there is no data suggesting ICU admission improves mortality. Also, the authors give no advice for the low risk group with regard to disposition home or admission to a non-ICU setting. Though blinded, the reviewers also gathered data after discharge by calling the patients for follow up, likely unblinding mortality. Hypotension (P=0.002), ECOG score=4 (P=0.001), NG tube feeding (P=0.007), CHF (P=0.029), bandemia >10% (P=0.038) and serum creatinine >2 (P=0.001) were also independent predictors of mortality. Though intended to be prospective, some of the data had to be collected retrospectively.
This study was an excellent attempt to create a much-needed rule for geriatric fever risk stratification. EPs could use these findings to assist in determining disposition but more work is needed to create a clinical decision rule with wide spread applicability.
Disposition of Geriatric Patients
Disposition of geriatric patients from the ED can be a challenge. These patients frequently require more resources both in the ED and at time of disposition. They use more social services than younger patients and follow up with primary care physicians is of particular importance in this group. Below, we review an article that evaluates short-stay hospitalizations of geriatric patient and resource utilization based on the challenges associated with dispositioning these patients.
Greenwald PW, Stern ME, et al. Trends in short-stay hospitalizations for older adults from 1990 to 2010: implications for geriatric emergency care. American Journal of Emergency Medicine. 2014;32:311-314.
As discussed above, geriatric patients are responsible for 15% of ED visits and this number is projected to increase to 25% by 2030. The authors of this retrospective study examined data from the National Hospital Discharge Survey (NHDS) to identify trends in short-stay admissions (hospitalizations lasting ≤3 days) in geriatric patients from 1990-2010. The NHDS is a yearly survey which collected abstracted discharge records from over 4 million hospital visits in non-federal hospitals in all 50 states during the study period. Patients retained in the hospital on observation status were not included in the survey.
A total of 42% of the hospitalizations in the study involved geriatric patients. Of these geriatric hospitalizations, 39% were short-stay admissions, with 11% ≤1 day. Hospital admissions originating in the ED from 2007-10 were analyzed separately to determine if the same trends applied to the ED geriatric population. Overall, the ED was the source of 52% of total geriatric admissions and 45% of geriatric short-stay admissions. Older patients represented a higher proportion of overall admissions from the ED, with the odds of an admission having originated from the ED increasing by 1.0287 for each year beyond age 65 (95% OR 1.0286-1.0288). The proportion of admissions from ED qualifying as short-stay also increased more quickly for the elderly than for younger adults over the study period; a 0.23% (0.04-0.4%) increase among ages 22-65, 0.9% (0.71-1.08%) ages 65-74, 1.0% (0.83-1.21%) ages 75-84, and 1.1% (0.96-1.3%) age ≥85.
Although these hospitalizations may represent appropriate disposition for geriatric patients with medical concerns that are quickly resolved, the authors suggest several alternative factors which may be driving short-stay admissions for these patients. One is that the elderly tend to have more comorbidities than their younger counterparts and are more likely to have atypical presentations of serious medical problems. Additionally, EPs may feel compelled to admit older patients when insufficient outpatient resources exist to guarantee timely follow up. Unfortunately, the scope of this study did not include analysis of the admission diagnoses or clinical context involved in these geriatric short stay visits. Patients admitted under observation status were also excluded from this study, but it was unclear what criteria, if any, was used in selecting observation vs. admission status.
Further study is needed to identify the reasons for this growing trend toward geriatric short-stay admissions and to explore barriers to outpatient management in this population.
Geriatric patients represent a growing population of ED patients. This demographic has unique biologic, physiologic, and social needs. Managing these needs, coupled with a continued focus on providing high quality, cost-effective care will require that EPs are familiar with the most current literature and techniques in the care of geriatric patients seen in the acute setting.
References:
1. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. US Department of Commerce, US Census Bureau. May 2014. Retrieved online at: www.census.gov/prod/2014pubs/p25-1140.pdf.
2. Albert M, McCaig LF, Ashman JJ. Emergency department visits by persons aged 65 and over: United States, 2009-2010. NCHS Data Brief, October 2013. Retrieved online at: www.cdc.gov/nchs/data/databriefs/db130.pdf.
3. National Center for Health Statistics. Health, United States, 2013: with special feature on prescription drugs. Retrieved online at: http://www.cdc.gov/nchs/data/hus/hus13.pdf#092.
4. Downey IV, Zun L. Pain management in the emergency department and its relationship to patient satisfaction. Journal of Emergency Trauma Shock. 2010; 3:326-30.
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