Elderly patient numbers are up — you’ll need your detective cap
Drug dosages, presentations, and social needs differ for elderly
An elderly woman came to the ED with congestive heart failure (CHF) and difficulty breathing, and she was treated medically. But when an ED nurse did an assessment, the woman broke down crying, and another problem was revealed.
"It turned out that her daughter wouldn’t get her medicines filled, and her mother thought she was trying to kill her," recalls Pamela Kidd, PhD, FNP-C, CEN, an ED nurse at Kentucky Injury Prevention and Research Center in Lexington. "When we talked to the daughter, we found out she couldn’t keep up with the demands of caring for her mother, but didn’t want to put her in a nursing home."
After interviewing the patient and caregiver further, the ED nurse explained the problem to the floor nurses and requested follow-up with social services. After the patient was admitted and discharged, she was placed in a nursing home.
"It was the best situation for both of them, because it re-established their bond, and she ended up loving the nursing home," says Kidd.
The ED nurse’s assessment and follow-up played a key role in resolving a complex social problem, Kidd stresses. "If it hadn’t been for those interventions, she would have been just another CHF patient treated, and she would have been back in a week," she adds.
When a 70-year-old woman came to MetroHealth Medical Center’s ED in Cleveland, complaining of cough and weakness, she was placed in a non-acute bed. "I interviewed her and found that she also had shortness of breath," notes Stephen Meldon, MD, an attending physician in the ED. "The EKG showed that she’d actually had a major MI two or three weeks earlier, which she thought was indigestion."
At the time of the MI, the woman had refused to come to the hospital. "That attitude is very common with elderly patients," notes Meldon. "She had gone to see her primary care physician, and he prescribed antibiotics for bronchitis because of shortness of breath and coughing. She was actually in mild heart failure by the time she came to the ED, which is why she was weak."
After a more detailed history was taken, the truth became clear. "We asked her how she felt last week, and the week before that. She told us that’s when it started, that she was throwing up and was sweaty," Meldon recalls. "Since she told the triage nurse she had bronchitis, she was put in a non-monitored bed, when in reality she had had a massive MI."
The above cases illustrate the detective work that often is needed with elderly patients in the ED. Expect such challenges to appear more frequently in your ED. The number of elderly patients is steadily increasing.
Elderly to double in 25 years
Currently, the elderly are about 13% of the population, or 35 million people. Projections for the number of elderly are to double in another 25 years to 68 million. Patients older than 85 are the fastest growing subset of the population and currently represent about 5 million people.1
As of 1995, the elderly comprised approximately 16% of all ED visits.
"Thirty-nine percent of all ambulance arrivals are with elderly patients, who are very likely to use EMS," Meldon adds. Also, almost half of all elderly patients are admitted, which accounts for 7 million hospital admissions, and almost half of all ICU admissions.2
Here are some ways to meet the unique needs of the elderly in your ED:
• Assist caregivers.
Family members may be concerned that they can’t take care of a patient at home, Meldon says. "In such a scenario, admission may be indicated," he says.
Another option is to arrange for a visiting nurse to help the caregiver. "That may give a little breathing room that the caregiver needs, especially with patients with cognitive impairment or Alzheimer’s, who are very hard to take care of," Meldon suggests. "Be aware of what your community offers, such as various aid or home overnight programs."3
• When complaints are vague, probe further.
"A lot of times, family members will tell you the patient is not eating or is not themselves.’ The patient may have a serious illness, but the elderly have so many atypical presentations of common and serious diseases, it is often difficult to see what is going on with them," says Meldon.
• Take time to perform a thorough history.
Often, there is no time to do a detailed history, so you need to cut it short to get the job done, but elderly patients shouldn’t be rushed when providing information. "They need longer time to process information and answer your questions," says Kidd. (See related stories on recognizing delirium and dementia and performing a mental status exam, p. 122.)
Complex social needs can’t always be ascertained in a quick appraisal. "The best thing you can do is to give them a little extra time for the history," Kidd recommends. "Explain to your colleagues that you are going in with an elderly patient and will be in there for awhile."
• Know the resources of your community.
You can prevent a repeat ED visit or potential abuse from occurring by knowing about resources such as respite services and eligibility criteria for senior day care, Kidd advises. "This is particularly important if you don’t have a social worker in the ED," she stresses. "Xerox all the information and have it ready to go.
With high-risk cases, make the call yourself. "You don’t have to do it necessarily during that crazy shift, but assign someone else to follow up," Kidd recommends.
Providing social services to elderly patients is a good marketing strategy for your ED. "You can say that in your ED, you try to work with the elderly to connect them with community resources," says Kidd. "There must be support from the top down, so nurses won’t be criticized for taking so long with elderly patients."
• Address unique needs of the elderly.
Geriatrics should be a recognized subspecialty of emergency care, just as pediatrics is, argues Terasita Hogan, MD, FACEP, director of emergency medicine residency program at Resurrection Medical Center in Chicago.
Just as there are pediatric rooms with cartoon characters on the wall, there should be geriatric rooms, Hogan argues. "The beds should be softer, doors should be closed so the patient can hear without background noise interfering, and brighter lights," she says. (See stories on unique geriatric needs pertaining to abuse, p. 122; trauma victims, p. 124; and falls, p. 125.)
• Provide adequate ancillary services.
"In many cases, if you are able to arrange meals on wheels or equipment to be delivered to the patient’s home, such as an oxygen tank or wheelchair, that alone may keep them out of the hospital," says Hogan. "EDs that can’t get those services may have to admit the patient."
• Know differences in drug dosages.
Just as with children, drug doses are different in the elderly. "For example, you might need to cut the Lidocaine dose in half, or the patient may get acute mental status changes and maybe even seizure disorders," says Hogan. "You also need to look for drug-drug interactions."
References
1. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multi-center base. Ann Emerg Med 1992; 21:819-824.
2. Strange G, Chen E. Use of emergency departments by elder patients: A five-year follow-up study. Acad Em Med 1998; 5:1,157-1,162.
3. Castro JM, Anderson MA, Hanson KS, et al. Home care referral after emergency department discharge. J Emerg Nurs 1998; 24:127-132.
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