Generation (comple)X: Answering the Call of a Geriatric Emergency
A 50-year-old patient has a rapid heart beat, tremors, weight loss, an increased appetite and increased sweating. The diagnosis: hyperthyroidism.
An 80-year-old patient has lost some weight, a decreased appetite, is apathetic and sits quietly without moving. The diagnosis: hyperthyroidism.
The generation of people who lived through the Great Depression and World War II has become one of health care’s most medically complex groups. Douglas K. Miller, MD, professor of internal medicine at Saint Louis University School of Medicine and associate director of geriatric medicine at Saint Louis University Hospital, uses the hyperthyroid scenario as a classic example of how older and younger adults can differ medically – even when diagnosed with the same disorder. That difference is what makes responding to older adults’ needs in emergency medical situations unique and challenging.
Understanding changes in the body and mindThe symptoms demonstrated by the 80-year-old patient with hyperthyroidism are atypical – not those usually expected from that diagnosis.
“Atypical presentations are common in older people, and they can range from a heart attack without chest pain to pneumonia without fever,” says Dr. Miller. “For instance, you may find less than 5 percent of younger adults with heart attacks who do not display the classic symptoms of chest pain, shortness of breath, sweating and nausea. In older adults, that number could be closer to 30 percent.”
Assessing older adults is further complicated by the fact that their symptoms are often nonspecific. Someone who is confused or has decreased function can just as easily be suffering from a urinary tract infection or acute metabolic problem, or damage to an important organ such as the heart.
Two suppositions are thought to explain why older adults have nonspecific and/or atypical symptoms. The first is that as people grow older they begin losing internal pain fibers, which results in reduced pain sensations. The second is a loss of brain reserve due to mini-strokes caused by clogs in the brain’s tiny blood vessels and to natural loss of neurons over time. Although older adults may function well in normal circumstances, when stressful events occur they have less brain reserve to call upon. This causes confusion and an inability to communicate how they feel physically.
“Over the years, older people also learn to adjust to aches and pains to the point where they come to expect them. Sometimes they simply overlook what’s going on in their bodies because it doesn’t seem unusual to them,” says Dr. Miller.
As if these physical variables aren’t enough, older adults often take multiple medications, increasing their risk for adverse drug reactions.
The assessment: two immediate actionsDr. Miller recommends that EMS providers take two immediate actions when caring for older adults. Because of the nonspecific presentations for heart attacks in the elderly, the first is getting patients on an electrocardiogram (EKG) monitor as quickly as possible.
“This is certainly standard practice for EMS professionals in many situations, but in older patients it is critical to ensuring heart attacks are not missed,” says Dr. Miller.
The second important action is looking for signs of delirium, a state that often goes unrecognized. Caused by physical problems such as imbalances in body chemistry, fever, shock, exhaustion, anxiety and drug overdose, delirium should always be considered a medical emergency until proven otherwise.
“Delirium has serious complications for older people, including an increased death rate compared to those not experiencing it, a greater likelihood of their being admitted to an intensive care unit, and prolonged hospital stays,” says Dr. Miller. “In addition, there’s strong evidence these patients are more likely to fall and injure themselves because they often aren’t able to distinguish steps and other hazards. It’s important to keep in mind that an older person who fell may be suffering from delirium brought on by a serious medical condition.”
Among the hallmarks of delirium are acute changes in mental status, difficulty concentrating and disorganized thinking often accompanied by agitation. In contrast, the decline in mental status in patients with dementia such as Alzheimer’s disease is usually gradual and does not fluctuate in the absence of other problems. One test Dr. Miller suggests involves asking patients to recite the days of the week or months of the year backwards several times during a routine assessment. If they fail these tests, then a more complete evaluation for delirium is warranted. Fluctuations in performance make it more likely they are suffering from delirium.
“If people close to the patient are available, asking them about recent changes will provide additional clues,” says Dr. Miller. “Has the patient been complaining of a physical problem in the last day or two? Is her breathing worse? Has there been a recent change in his ability to care for himself? Answers to these types of questions can help you determine if a patient’s confusion is something new and likely caused by a physical problem rather than being a symptom of an ongoing mental disorder.”
He adds, “In either case, it’s often not possible to get a reliable medical history, and a careful evaluation at a hospital is needed.”
EMS: Vital to physicians’ complete understanding of patientsWhen EMS professionals collect as much information as possible about older patients from collateral sources, this information becomes vitally important to emergency medicine and geriatric physicians. One example is the need for EMS providers to collect information about medications.
“All of us look for the obvious, which is prescription medications. But many times people don’t tell their doctors about over-the-counter and alternative therapies,” says Joseph Flaherty, MD, associate professor of internal medicine at Saint Louis University School of Medicine and director of the 23-bed Acute Care for the Elderly (ACE) Unit at SLU Hospital. The ACE Unit puts older patients under the care of a specialized health care team devoted to preventing functional decline during hospitalization. “And in times of stress, it’s difficult for patients to remember the dosage of the medicines they take. Locating prescription pill bottles and other remedies in places such as the medicine cabinet, by the bed or in the kitchen helps give a better picture of patients’ medical status.”
Looking around the patients’ living environment also provides a snapshot of older patients’ ability to care for themselves. Finding no food but candy bars, an untidy and dirty house, and even loose rugs and unsafe stairs is all useful information that helps physicians know if patients can return home.
“In a study we conducted that focused on geriatric patients sent to the Emergency Department, 40 percent of participants 65 and older had some measure of malnutrition,” says Dr. Miller. “Closely associated with patients’ ability to care for themselves is the support they receive from others. During the course of an emergency call, if EMS professionals see evidence of the patients’ family and friends already providing support and care, that is useful information on the positive side.”
Asking if medical records and advanced directives are available also makes the work of physicians easier. “We realize paramedics and EMTs have a lot to do on these emergency calls, and gathering information isn’t their first priority when they are fighting to save someone’s life,” says Dr. Miller. “But their ability to do some quick observations and ask probing questions really gives us an edge in providing the best care for the patients they bring to us. If they can identify medical records or advance directives and can encourage the patient or family member to bring them to the Emergency Department, these records also can be enormously helpful.”
Paying attention to detailsDr. Flaherty notes that EMS professionals can help their patients cope at the hospital by paying attention to a few details. Making sure older adults have their glasses and hearing aids may prevent patients from slipping into delirium. Being careful when placing the elderly on a stretcher can deter the start of pressure sores.
“Obviously, an older person is not as mobile as a younger patient, and strapping them to a stretcher or gurney inhibits their mobility even further,” explains Dr. Flaherty. “If they lay in that position very long, that’s when bed sores actually begin. Placing padding at obvious pressure points, such as near the straps, can help reduce the friction that leads to pressure ulcers.”
In addition, adjusting the way a patient with physical deformities, such as a curved spine resulting from osteoporosis, is placed on a stretcher can prevent discomfort and pain.
“One of the most important aspects of treating older adults in the hospital is preventing them from losing function so they can return to their homes rather than going into a nursing home,” says Dr. Flaherty. “EMS professionals play an important role in that process by being our first link to understanding our patients physical, emotional and socioeconomic status.”
