The Elderly Patient

The elderly patient population is growing and will make up to 20% of the total population by 2030.  They make up to 51% of total ED visits, and this number is growing.  These patients are sicker, have higher acuity and require admission at higher rates.  For this reasons, these patients need special consideration.

Abdominal Pain
60% ED cases are surgical, 20% go directly to the OR
Have a lower threshold

Pitfalls:

• Relying on normal lab results
  
• Misdiagnosing mesenteric ischemia as gastroenteritis
  
• Relying too heavily on classic presentations of common illnesses
  
• Over-reliance on positive UA as indicating cause of acute abdominal pain
  
• Relying on classic findings and history to rule out appendicitis
  
• Expecting abdominal rigidity when considering a visceral perforation
  

Mesenteric Ischemia

• SMA embolus - pain out of proportion, nausea, vomiting, diarrhea.  Seen in atrial fibrillation, valvular disease, cardiomyopathy.
  
• SMA thrombosis - "Intestinal angina."  Seen in atherosclerosis, smokers.
  
• SMV thrombosis - less severe pain than arterial disease.  Seen in OCP use, hypercoagulable state.
  
• Non-occlusive mesenteric ischemia - nonreproducible abdominal pain, unexplained GI bleeding in ICU patients, abdominal pain after dialysis.
  

Trauma

• Higher prevalence of cervical spine injuries.  About 50% due to ground level falls
  
• Higher incidence of higher level cervical spine injuries.  45% C2, 15% C1 injuries
  

Infection

• Blunted/absent fever response in 30%
  
• 89% have infection when fever is present
  
• High incidence of asymptomatic bacteriuria.  Reconsider antibiotics for these patients.
  

References

1. One, et al. Detection of cervical spine injuries in alert, asymptomatic geriatric blunt trauma patients: who benefits from radiologic imaging? American Surgeon.2006.
   
2. Rosens
   
3. Chen P. Emergency rooms are no place for the elderly. The New York Times. 2014.
   
4. American Geriatric Society
   
5. US Department of Health and Human Resources
   
6. Lee J. Growth of senior specific EDs holds quality promise but raises cost issues.  Modern Heatlhcare.  2014.
   
7. Wang et al. Geriatric trauma patinets with cervical spine fractures due to ground level fall.  Journal of Clinical Medical Research. 2013.
   
8. Lamoschitz. Cervical spine injuries in patients 65 years old and older. American Journal of Roentgenology. 2002.
   
9. Spaniolas, et al. Ground level falls are associated with signfiicant mortality in elderly patients. The Journal of Trauma Injury, Infection and Critical Care. 2010.
   
10. Parker, Simon and Arash Afsharpad. Ground-level geriatric falls: a not so minor mechanism of injury. Case Reports in Orthopedics. 2014.
    
11. Platts-Mills, et al. A modern day purgatory: older emergency department patients with non-operative injuries.  Journal of American Geriatric Society. 
    
12. Row and Juthani-Mehta. Diagnosis and management of urinary tract infections in older adults. Infectious Disease Clinics of North America. 2014.
    

Submitted by Dr. Kristina Morgan, PGY-3