The emergency department (ED) is commonly the point of entry to the medical system for older adults, who present with a wide variety of problems. Although the ED is generally thought of as a location for the diagnosis and treatment of acute medical and surgical emergencies, it may also be the access point for older adults with chronic conditions or social and psychiatric problems. For younger adults with single, acute problems, an emergency care model that incorporates history, physical examination, diagnostic testing, diagnosis, treatment, and disposition may be appropriate. However, there may be pitfalls when this approach is applied in the ED to older patients. ¹

  Older patients may present with vague symptoms or with atypical symptoms of serious disease, which could consequently go undetected. Cognitive impairment, common in older patients, may also go undetected. Comorbidities and polypharmacy are also common and may directly or indirectly affect the older patient's care. The ED may be a presenting location for an elderly patient with functional decline, or the acute illness or injury that provoked the ED visit may result in a decrease in his or her functional abilities. Additionally, treatment may affect the ability of the older patient to live independently; for example, immobilization of an extremity may impact the patient's ability to perform basic activities of daily living (ADLs).

  These factors have led to the development of a geriatric emergency care model that differs from the standard emergency care model. The geriatric model emphasizes the consideration of older ED patients as a special population, analogous to pediatric patients. Emergency physicians should include biologic, psychologic, and social factors in the evaluation of the older ED patient. ²

For emergency medicine, the MEDLINE search included the following MeSH headings: "Emergency Medicine," "Emergency Service, Hospital," or "Emergency Treatment." For trauma, the following MeSH headings were used: "Wounds, Penetrating," "Wounds, Non-penetrating," or "Multiple Trauma." This was combined using the Boolean search operator "AND" with articles with the following geriatric identifiers: "Geriatrics" or "Geriatric Assessment" as MeSH headings, or geriatric, geriatrics, old, older, or aged as title words. Limits placed on the search included English language, human, aged (> 65), and years 1980 to 2001. Articles from outside of the United States or Canada were included only if they provided unique information. They were not used if they presented demographic or observational information only.

The patterns of ED use among older patients have been well described. Reports of single-hospital studies, multicenter studies, and analyses of large multihospital databases reveal consistent patterns across all these settings.

  A recent population-based cross-sectional study of noninstitutionalized Medicare beneficiaries aged 66 years and older used a Medicare database from 1993. ³ It found that 18% of persons made at least one ED visit per year, including 17% among those aged 66 to 84 and 26% among those 85 years and older. The population-based visit rates were 30 per 100 persons for the group overall, and 28 per 100 in patients in the 66 to 84 age group, and 43 per 100 in the 85 and older age group, which is higher than the percentage of patients making at least one visit because some persons made more than one visit. Logistic regression identified the following as predictors of one or more ED visits over 1 year: age 85 and older (OR [odds ratio] = 1.23), less than 12 years education (OR = 1.22), living alone (OR = 1.15), worsening self-reported health, ADL deficiencies, and comorbidity. Odds ratios for the latter three vary by level of severity.

  A similar study using Medicare data from Washington State found identical visit rates but also showed that persons with physicians had fewer visits (185 per 1000 patient years) than did those without physicians (457 visits per 1000 patient years). ⁴ Older rural patients may also be less likely than their urban counterparts to visit the ED. ^5,6

  Analysis of the 1992 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, a national probability sample of ED use performed by the National Center for Health Statistics, found that patients aged 65 and older accounted for 12.6 million ED visits in 1992, or 13% of all ED visits (20% of adult ED visits). ⁷ The hospitalization rate was 42%, which was four times that of adults aged 18 to 64 years. Cardiopulmonary complaints were most common, with chest pain and dyspnea each constituting 11% of chief complaints. Abdominal pain, vertigo, and generalized weakness each constituted approximately 3% of visits.

  Other multicenter studies have shown that ED patients aged 65 and over are more likely to be admitted to the intensive care unit, to arrive by ambulance, to have comorbid illness, to have comprehensive visits, and to have higher rates of test utilization. ^8-10

The Society for Academic Emergency Medicine with the support of the John A. Hartford Foundation formed the Geriatric Emergency Medicine Task Force to evaluate the state of the care of older patients in the ED. The task force did an extensive review of the literature and carried out a series of integrated studies. These included surveys of physicians and patients, prospective and retrospective descriptions of differences between older and younger ED patients, and an analysis of existing data sets. ¹¹

EmergMed 4 (Level A): Following evidence-based identification of target areas for improvement, controlled studies of the effect of alterations in the micro-environment on outcomes for older emergency department patients should be performed. Such studies likely cannot be based on random assignments of individuals to interventions; rather, whole micro-environments will have to be compared.

Descriptive information regarding emergency medical service (EMS) use among older adults comes from single-city retrospective studies. One third of patients aged 65 and older in the ED arrive by ambulance. ^8,10 Older patients are responsible for 22% to 39% of EMS runs, which is out of proportion to their representation in the population. ^15,16 Population-based estimates of the rate of paramedic runs for older patients show a rate of approximately 100 per 1000 population per year. ^15,17 This rate is nearly twice that of patients under age 65, and the rate in patients 65 and older increases with increasing age, to a rate of 291 per 1000 patients aged 85 years and older. ^15,17 Given that patients aged 80 and older are the most rapidly increasing demographic group in this country and that nearly one third of patients aged 85 or older require EMS transport per year, one can see that in the years to come an increasing proportion of EMS runs will involve older patients.

  Common reasons for EMS transport include respiratory distress (13.1%), unspecified pain (12.3%), and chest pain (12.0%). ¹⁷ Older patients are 2.6 times more likely than their younger counterparts to have a cardiopulmonary complaint, 1.8 times more likely to have a fall, and 1.7 times more likely to have a minor medical complaint. Additionally, they are more likely to require advanced cardiac life support care and have longer on-scene times. ¹⁶

Older patients who present to the ED commonly have cognitive impairment. This may impact the patient's care in many ways, from limiting the reliability of the medical history to reducing his or her understanding of and compliance with discharge instructions. Although recognized or unrecognized dementia is a likely cause of cognitive impairment, delirium is another common cause. Delirium is considered a medical emergency because of its multiple serious medical causes (eg, sepsis, myocardial infarction, drug toxicity, occult fracture, subdural hematoma). ¹⁹ For these reasons, the assessment of cognitive impairment is considered an integral part of the evaluation of elderly persons presenting to the ED.

  In a retrospective analysis of EMS transports in one county in 1990, Wofford et al reviewed patients aged 60 years and older to identify those transported for altered mental status. ²⁰ Five percent of 4688 transports during this time were for altered mental status, and 74% of these patients were hospitalized, with a mean length of stay of 28 ± 5 days. The diagnoses included infection (26%), toxic-metabolic causes (23%), and cerebro-vascular disease (20%).

  In a prospective cross-sectional study, Gerson et al used the Orientation Memory Concentration Test, a validated screening instrument for cognitive impairment, to screen ED patients aged 65 years and older. ²¹ Patients were excluded if they had a prior diagnosis of dementia. The instrument took 1.9 ± 0.91 minutes to perform. Of 547 patients evaluated, 34% had at least moderate impairment of cognition, and an additional 26% had minimal impairment. Only 40% of patients had no impairment of cognition. Using logistic regression, the researchers determined that age 80 and above (OR = 3.68) and nursing-home residence (OR = 13.8) were independent predictors of cognitive impairment. Delirium and dementia were not differentiated.

  Naughton et al conducted a prospective cross-sectional study on 188 patients in their ED who were aged 70 or older. ²² Using a combination of the Glasgow Coma Scale, the Folstein Mini-Mental Status Examination (MMSE), and the Confusion Assessment Method (a validated screening tool for delirium), they found that 8.5% of patients had impaired consciousness (patients who did not open their eyes spontaneously or in response to speech, respond to questions, or obey commands), 9.6% had delirium, 22% had cognitive impairment without delirium, and 60% were cognitively intact. Seventeen percent of patients with delirium were not admitted to the hospital. Patients with delirium had ED diagnoses of "congestive heart failure," "rule out MI," "mental status change," "sepsis," "hypertension," "seizure disorder," and "vomiting." Patients with impaired consciousness and delirium had a nonsignificant trend toward higher rates of admission and longer lengths of stay than patients who were cognitively intact. Naughton et al performed a second study to evaluate the use of computed tomography scanning in patients with delirium. ²³ Methods for determining cognitive impairment were similar to those of the prior study. In the second study, 4.8% were found to have impaired consciousness, 17% delirium, and 38% cognitive impairment without delirium. Scans were most often ordered for patients with delirium. The authors believe that the differences in the prevalence of cognitive impairment between the two studies may be due to the higher proportion of nursing-home patients in the second study.

  Lewis et al performed a similar prospective cross-sectional study of patients aged 65 years or older presenting to their ED. ²⁴ Using the Confusion Assessment Method, they found that 10% of 385 patients had delirium or probable delirium. Using a score of 3 or 4 as the standard, they determined that physician sensitivity for the diagnosis of delirium was 17%. Sixty-two percent of patients with delirium were admitted. The 3-month mortality was higher for those patients with delirium than for those without, but this did not reach statistical significance (14% versus 8%, P = .20). For patients discharged from the ED, the increased 3-month mortality in patients with delirium was significant (P = .048). The most common diagnoses for admitted patients with delirium was "rule out sepsis," "delirium," and "cerebrovascular accident." "Status post fall" was the most common diagnosis for delirious patients who were discharged from the ED.

  Similar results were also found by Elie et al in a prospective cross-sectional study in Montreal of ED patients aged 65 years and older. ²⁵ In this study, research psychiatrists used the MMSE and the Confusion Assessment Method to evaluate patients for delirium. Ten percent of the 447 patients screened had delirium; the sensitivity of ED physicians' diagnosis was 35%, and the specificity was 99%. Diagnoses in patients with delirium included neurologic problems in 65%, pulmonary problems (41%), cardiovascular problems (17%), endocrine problems (11%), infectious disease (7%), and metabolic problems (7%).

EmergMed 7 (Level B): Prospective cohort studies such as larger-scale longitudinal outcome studies of older patients with impaired cognition are necessary to confirm the finding that patients with undiagnosed delirium have worse outcomes than do those without delirium or with diagnosed and treated delirium.

EmergMed 8 (Level A): If research (EmergMed7) confirms that older patients with delirium that is not diagnosed in the emergency department ultimately have worse outcomes than do those either without delirium or with recognized and treated delirium, interventional trials should be designed to determine the effect on outcomes of better screening and management of cognitive impairment in older emergency department patients.

Functional assessment is important in the ED evaluation of many older patients. Subacute functional decline may precipitate a visit to the ED, or the acute illness or injury that precipitated the ED visit may cause functional impairment. This may result in frustration for the family if the emergency physician does not recognize the importance of these functional limitations. Likewise, the emergency physician may be frustrated if the patient's other physicians do not recognize the importance of these limitations.

EmergMed 10 (Level B): Case-control or cohort studies are needed to determine whether older emergency department patients with functional impairment have worse outcomes than do those without impairment.

EmergMed 11 (Level A): Controlled intervention trials are needed to determine whether the detection and management of functional impairment in older emergency department patients have an effect on these outcomes.

Explicit criteria for potentially inappropriate medication use in older patients have been defined. ²⁸ These include inappropriate medications as well as drug-disease interactions. In a prospective ED study, Chin et al found that 11% of patients presenting to the ED were already on potentially inappropriate medications, 3.6% were given one in the ED, and 5.6% were prescribed one on discharge from the ED. ²⁹ Drug-disease interactions were less common at presentation (5.2%), in the ED (0.6%), and on discharge (1.2%). The most common inappropriate medications on discharge were indomethacin, diphenhydramine, cyclobenzaprine, and propoxyphene. In the ED, meperidine was also a commonly used inappropriate medication. The study did not find any significant association between potentially inappropriate medications or adverse drug-disease interactions in revisit to the ED, hospitalization, or death over the 3-month follow-up period.

  Adverse drug interactions may also be important in the elderly age group. Older patients are more likely to be on multiple medications on presentation to the ED, and medications are commonly added in the ED (one half to two thirds of visits). ^30,31 One study showed that 42% of patients presenting to the ED had a drug interaction, but that only 10% were clinically significant. ³¹ Twenty-six percent of patients had a drug interaction due to medications initiated in the ED, but only 3% were clinically relevant. Multiple regression showed that age 60 and older was the only predictor of clinically significant drug interactions.

  Another study showed that 10% of patients who had a drug added in the ED had a potential drug interaction. ³⁰ The rate was significantly different in the two age groups examined by the authors, patients younger than 60 (4%) and patients over age 65 (18%). However, using multiple regression, the researchers found that age was not an independent predictor; rather, the number of medications at presentation and the number of ED medications prescribed were the only significant independent predictors. Eighty-nine percent of all interactions were found to have occurred with prescriptions for narcotics, nonsteroidal anti-inflammatory drugs, benzodiazepines, antacids, and diuretics. Adding medications in the ED may also increase medication complexity and decrease older patients' knowledge of their medications. ³²

EmergMed 13 (Level A): Interventional trials (randomized or by comparison of micro-environments) are needed of methods to reduce prescription of potentially inappropriate medications for older patients, such as educational sessions or computer-assisted decision support systems integrated into emergency department discharge instructions.

ED-based comprehensive geriatric screening has been evaluated in two studies. Miller et al performed a nonrandomized controlled trial of a 30-minute comprehensive geriatric assessment in the ED. ³⁴ Patients were enrolled over 11 months and were seen between noon and 8 pm on alternating days. Control patients were obtained by using the ED census to identify patients seen the prior day, matching by gender and age within 5 years. Control patients were not contacted initially and received standard ED care. The intervention group received evaluations by a geriatric nurse clinician who identified medical, dental, and social problems and made recommendations to the patient, family, and physicians. For the intervention group, 434 patients were approached and 385 patients consented to participate. Intervention and control groups were similar in demographic characteristics. Sixty-seven percent of intervention patients were found to be dependent in at least one ADL. Eighty-two percent had at least one geriatric problem identified, and 77% reported at least one unmet dental or social need. The cost of the intervention was low ($5 to identify each geriatric issue and $1 to identify each dental or social issue), but physicians complied with only 62% of suggestions and families with only 37% of suggestions. Mortality and nursing-home residence did not differ between groups at 3 months; however, there were trends toward fewer subsequent ED visits and more advance directives in the intervention group.

  Gerson et al conducted a multicenter, prospective, uncontrolled trial of case findings in adults aged 60 and older in five hospital EDs. ³⁵ Medical students were trained in the ad-ministration of a 17-item protocol that took a mean time of 17.7 ± 10.2 minutes to com-plete per patient. Three quarters of 338 eligible patients participated, and 96% of patients had at least one condition detected (281 conditions detected). Most commonly detected conditions were impaired ADLs (79%), decreased vision (55%), lack of influenza vaccination (54%), unhealthy home environment (49%), impaired mental status (46%), falls (40%), and depression (36%). Seventy-six patients were evaluated at follow-up, 47 (17%) conditions were confirmed, and treatment plans were initiated for 25 conditions (9%).

  Sinoff et al in a retrospective review of geriatric consults in the ED found that 64% of patients who had consults were admitted, 34% died within 2 years, and 52% were admitted to long-term-care facilities. ³⁶ They found high rates of classic geriatric problems, including falls, incontinence, iatrogenic events, and confusional states. This was an observational study, and only patients for whom a geriatric consultation was obtained in the ED were included. Consultation was not mandatory and was generally initiated by the ED staff.

McCusker et al have published multiple studies on screening of ED patients. ^38-43 In a prospective, observational study of ED patients aged 75 years and older, they determined predictors of repeat ED visits within 90 days by using multivariate logistic regression. ⁴³ Twenty-four percent of patients made a repeat visit within 90 days. Predictors included male gender (OR = 7.06), living alone (OR = 10.48), and the number of self-reported problems (depression, confusion, incontinence, falls, mobility, and balance) (OR = 2.68).

  The Identification of Seniors at Risk (ISAR) screening tool was developed to improve the recognition of older ED patients who are at risk for adverse outcomes. ⁴² A screening questionnaire was developed from a literature review of predictors of functional decline and by adapting other questionnaires. The initial questionnaire had 27 questions on social, physical, and mental risk factors, on medical history, and on the use of medical services, medications, and alcohol. These questions were compared with validated tools, including the Geriatric Depression Scale and the CAGE questionnaire (Cut down, Annoyed by criticism, Guilty about drinking, Eye-opener). The screening questionnaire itself had good test-retest reliability; however, individual questions were more specific than sensitive and had only modest concurrent validity. The questions with the highest level of sensitivity and specificity were those on visual and hearing impairment, medications, and depression.

  A second study looked at the ability of the questionnaire, or a subset of questions from it, to identify patients at risk of adverse health outcome over 6 months (adverse health outcome was defined as death, institutionalization, or a clinically significant decline in physical function). ³⁸ This prospective observational study found that 30% of patients in the development phase had an adverse health outcome, including 10% who died, 3% who were institutionalized, and 16% who had increased functional dependence. The best subset of 6 questions (see Table 3.1) was based upon statistical analysis, as well as input from the ISAR Steering Committee. The area under the curve (AUC) for detection of an adverse outcome was 0.71 in the validation set. Two positive responses had a sensitivity of 75% and a specificity of 58%. Three positive responses had a sensitivity of 27% and a specificity of 81%, and four positive responses a sensitivity of 10% and a specificity of 93%.

  The ISAR screening tool and the complete 27-item screening questionnaire have also been found to be predictors of return visits to the ED over 30 days (AUC = 0.63), three or more visits over 6 months (AUC = 0.68), ⁴⁰ and hospital utilization over 6 months (AUC = 0.68). ³⁹

EmergMed 15 (Level B): The Identification of Seniors at Risk tool should be employed at independent sites to determine its value in selecting high-risk elderly patients for interventional trials of geriatric assessment.

Visual Deficit

Elder abuse is more widespread than many clinicians realize. Although child abuse is commonly evaluated and screened for in EDs, elder abuse is less so. In fact, surveys of practicing emergency physicians found that elder abuse protocols were available to 27% of respondents, whereas child abuse protocols were available to 75%. ¹² In teaching institutions, 93% had protocols for child abuse, but only 42% had protocols for elder abuse. ⁵² Estimates of the prevalence of elder abuse are that 10% of patients aged 65 and over are subject to some type of abuse. ⁵³ In a stratified random sample of community-dwelling older adults in Boston, Pillemer and Finkelhor found a prevalence of elder abuse of 32 per 1000 population. ⁵⁴ This included a prevalence of 20 per 1000 for physical abuse, 11 per 1000 for verbal abuse, and 4 per 1000 for neglect. In contrast to other studies and popular thought, 58% of perpetrators were spouses and only 24% were children. The proportion of abused older patients was nearly evenly split between men and women, but the risk among men was more than two times that for women, owing to their smaller representation in the population.

  Lachs et al identified 182 older victims of abuse reported to the regional Elder Protection Service. ⁵⁵ Of these patients, 114 had been seen in the ED over the preceding 5 years, with a median of 3 visits (range 1 to 46 visits). Thirty-eight percent had at least one visit with a high probability of abuse, and 66% had at least one injury visit. Only 9.1% of these visits resulted in a referral to the Elder Protection Service.

  Fulmer et al reported on a prospective pilot study of a screening instrument for elder abuse. ⁵⁶ They screened 484 patients and found a 7% rate of abuse, including physical abuse in 1%, psychologic abuse in 4.1%, and material deprivation in 2.2%. An additional 6% had suspected abuse.

EmergMed 17 (Level A): Screening for asymptomatic conditions in older patients in the emergency department should be done only if detection of the abnormality results in treatment of the disorder and this treatment results in improvement in outcomes. Randomized interventional trials are needed to assess short- and long-term outcomes of patients who have screening and treatment for these conditions.

Abdominal pain is the presenting complaint of 3% to 6% of older patients presenting to the ED. Surveys of emergency physicians and emergency medicine residency directors in the early 1990s found that abdominal pain was one of several complaints that physicians found more difficult to manage in the older patient. The mortality in older patients presenting with abdominal pain is 5%. Twenty-two percent will require surgery, and over half (52%) will be admitted to the hospital. Risk factors for death in older patients with abdominal pain include free air on radiograph (RR [relative risk] = 23), age over 84 (RR = 22), other significant radiographic findings (RR = 5.9), and bandemia (RR = 23). ⁵⁹ If free air is present on abdominal radiographs, the mortality is 75%. Risk factors for surgery include hypotension (RR = 4.7), abnormal bowel sounds (RR = 4.2), other radiographic abnormalities (RR = 4.1), dilated loops on radiographs (RR = 3.2), and leukocytosis (RR = 2.3). Diagnoses in older patients with abdominal pain include infection (19%), mechanical problems (16%), ulcers (8%), genitourinary disease (8%), malignancy (7%), biliary tract disease (6%), cardiac disease (4%), pulmonary disease (2%), other (29%).

  In one retrospective review, it was found that emergency physicians correctly classified 67% of patients with abdominal pain who were younger than 65 years but 44% of those who were 65 or older. ⁶⁰

  Older patients with cholecystitis commonly do not have classic symptoms. In a retrospective review, it was found that 84% had neither epigastric nor right upper quadrant pain, and 5% had no pain at all. ⁶¹ Fifty-six percent of patients were afebrile and 41% had a normal white blood cell count. No difference in the presence or absence of these findings was found for the young-old (65 to 74), the old-old (75 to 84), or the oldest-old (85 and older). This mirrors results from another retrospective review, which showed that elevated temperature and abnormal laboratory studies do not differentiate patients who were admitted and underwent surgery from those who did not undergo surgery. ⁶² Thirteen percent of patients who had normal values for all laboratory studies and normal temperatures required surgery.

  Only 20% of older patients with appendicitis present classically. Elevated temperatures are present in less than half (47%), and 23% have tenderness that is diffuse or localized to an area other than the right lower quadrant. ⁶³

EmergMed 19 (Level B): The value of history and physical examination findings, laboratory examination, and imaging studies in older emergency department patients should be prospectively evaluated.

Falls are both a common and serious event for older patients. Falls are the most common reason for injury visits in patients aged 65 years and older (52% of such visits). ⁶⁵ In one study 15% of EMS transports for patients aged 65 years or older were for falls. ¹⁷ The risk of falls in older patients increases with increasing age, and women fall more often than men. ^17,45 In older patients, fractures occur in 5% of falls, and other serious injuries occur in 5% to 10%. Twelve percent of deaths in the older population are directly or indirectly related to falls. ⁴⁵

  A practice guideline for the ED management of falls in older patients was published in 1997. ⁴⁵ This guideline recommended a comprehensive evaluation of ED patients who fall, including an expanded history (eg, ADLs, environmental hazards, last eye examination), physical examination (Timed Get Up and Go test, mental status examination), diagnostic studies and referral (geriatric assessment, social services, optometry, podiatry, physical therapy, occupational therapy). This guideline was implemented in three EDs that were part of a large health maintenance organization in southern California. The guideline was presented to emergency physicians at a 1-hour lecture and to ED nurses at a 30-minute in-service lecture. A pre-post intervention comparison over 2 years found that, following the education, more patients were diagnosed as having fallen as a result of loss of consciousness, stroke, or seizures. There was improved documentation of certain historical elements, visual acuity testing, and the Timed Get Up and Go test. However, there was still low compliance with many of these elements (visual acuity testing in 3.2%, Timed Get Up and Go test in 11.2%). Although there were small improvements in these aspects of the history, there was no difference in the rate of recurrent falls, hospitalization for falls, or hip fractures before and after the implementation of the guideline. ^66,67

Fever is a common presenting complaint of older ED patients. Morbidity and mortality are high. In one study of ED patients with oral temperatures ≥ 100°F, 18% were found to have positive blood cultures, 10% died within a month, and 7% required surgery. ⁷¹ Three fourths of patients had signs of serious illness (the above and hospitalization ≥ 4 days, intravenous antibiotics ≥ 3 days, or repeat ED visit within 72 hours). Predicting serious illness in ED patients with infectious symptoms is difficult. In this study, oral temperature > 103°F, respiratory rate ≥ 30, leukocytosis of 11,000 or more, presence of an infiltrate on chest x-ray, and pulse > 120 were found to be independent predictors of serious illness. However, 50% of patients with serious illness had none of these features.

  Although the specificity for bacterial infection of such findings as elevated temperature, leukocytosis, and bandemia is relatively high (85% to 97%, varying by cut-off used), the sensitivity is low (24% to 65%). Therefore, the absence of these findings cannot be used to exclude significant bacterial infections in older adults. ⁷²

  Another study found that the only predictive factors for bacteremia in older patients were altered mental status (OR = 2.88), vomiting (OR = 2.63), and bandemia > 6% (OR = 3.5). ⁷³ The sensitivity of ≥ 1 factor was 85%, specificity was 46%.

  Common infections in older patients with fever are pneumonia or bronchitis (31%), urinary tract infection (22%), sepsis (18%), and cellulitis (5%). ⁷¹ Age itself is a risk factor for more serious illness in patients with pneumonia and influenza. ^74,75 Patients aged 65 years or older with urinary tract infections are more likely to have multidrug-resistant pathogens (OR = 3.0). ⁷⁶

  Immunizations have become a routine part of ED practice, especially tetanus immunization. Approximately 50% of older ED patients do not have protective antibodies to tetanus. ^77-79 Half of these patients will not seroconvert in 14 days after immunization. ⁷⁷ One third of patients also have inadequate immunity to diphtheria. ⁸⁰

EmergMed 22 (Level A): Descriptive studies of emergency-department-based immunization programs have found them to be feasible. Intervention trials for older persons are necessary to determine if such programs are beneficial (because they access an underserved population) and whether they provide more cost-effective care and reduce adverse outcomes in comparison with usual care.

Chest pain in the older patient has been identified as an area of concern for emergency physicians, who rate this complaint as more time-consuming and requiring more resources to evaluate in older than in younger patients. ¹² Increasing age is an independent risk factor for the development of coronary artery disease. ^85,86 Of more concern to emergency physicians, though, age is an independent risk factor for acute coronary syndromes (ACS) in patients presenting with symptoms of possible ACS. ^86,87 Age is also a risk factor for mortality in patients with ACS. ^88,89

  Complicating the evaluation of older patients with possible ACS is the fact that they less commonly present with chest pain and other classic symptoms of ACS. Small, single-center studies and larger, multicenter databases have documented that increasing age increases the likelihood of myocardial infarction (MI) without pain. Bayer et al performed a retrospective study of patients aged 65 to 100 years and found chest pain to be present in the majority of patients up to age 85. ⁹⁰ After that, shortness of breath was the most common symptom. Approximately 20% to 30% of patients aged 65 to 79, 50% of those aged 80 to 84, and 62% of those 85 and older presented without chest pain. Other presenting complaints in this group included syncope, confusion, weakness, and stroke. Another single-hospital study showed a much higher rate of MI without chest pain, 75%, in patients aged 85 and older. ⁹¹ Perhaps the most generalizable study to assess this phenomenon is an analysis of the National Registry of Myocardial Infarction 2, a national registry of patients with confirmed MIs at 1674 hospitals. ⁹² In this study, one third of all patients did not have chest pain. This included 25% of patients under age 65, 33% of patients aged 65 to 74 years, 42% of patients aged 75 to 84, and 51% of patients 85 and older. Patients without chest pain had longer delays and were less likely to receive thrombolysis, primary angioplasty, aspirin, heparin, and Β-blockers. The in-hospital mortality of these patients was 2.21 times greater than that for patients with chest pain.

  Although a comprehensive review of the treatment of ACS is beyond the scope of this paper, several points of concern to emergency physicians must be mentioned. Although improvements in care have been documented, there is considerable room for improvement in the acute care of the older patient with ACS. A review of changes in the management of MI between 1987 and 1990 in patients aged 65 and over using Medicare databases found significant improvements in both 30-day mortality (26% to 23%) and 1-year mortality (40% to 36%). ⁹³ During the same period, increases in angiography (13% to 21%), revascularization (13% to 21%), angioplasty (5% to 10%), and bypass (8% to 11%) were noted. However, older patients commonly do not receive as aggressive treatment as their younger counterparts, even though there is evidence to suggest that older patients have greater absolute benefits from such therapy. ^94,95 Part of the reason for this may be that older patients are less likely to have indications for and are more likely to have contraindications for thrombolytics. In the Multicenter Chest Pain Study, only 18% of patients aged 75 and older presented with ST elevation or new Q waves on electrocardiogram in less than 6 hours from the onset of their pain, whereas 34% of younger patients did so; 12% of patients aged 65 and over who were eligible by electrocardiogram and time criteria had other contraindications to thrombolysis. ⁹⁶ However, in a retrospective analysis of Medicare patients in Connecticut, Krumholz et al found that 56% of patients 65 and older who were eligible for thrombolytic therapy and not referred for direct angioplasty or bypass did not receive thrombolytics. ⁹⁷ Predictors of not using thrombolytics include increasing age, lack of chest pain, altered mental status, presentation after more than 6 hours of symptoms, left bundle branch block, Q waves, ST elevation of less than 6 mm total, and ST elevation in only two leads. Even in "ideal" patients for thrombolytic therapy, ie, those presenting with chest pain, ST elevation, and within 6 hours of the onset of symptoms, 25% of patients did not receive thrombolytic therapy. Although this rate of thrombolytic administration seems low, other studies have shown that only 5% of MI patients aged 75 and older received thrombolytics, and patients in this age group had an 18% mortality. ⁹⁸ In a prospective study of 4223 patients, Fleming et al found that patients aged 75 years and older were 2.5 times more likely not to be admitted to the coronary care unit, even if the diagnosis was myocardial infarction (RR = 7.1) or exclude MI (RR = 1.5). ⁹⁹

EmergMed 24 (Level A): Older patients should be included in intervention trials of acute coronary syndromes treatment.

There have been multiple prospective and retrospective studies on the outcome of out-of-hospital cardiac arrest in older patients. ^100-119 Although the results vary, overall, several points become apparent. Some studies have found that age is an independent predictor of mortality from cardiac arrest, ^100-102,120 but other studies refute this. ^105,109-111 Older patients, including octogenarians and nonagenarians, have acceptable rates of survival to hospital discharge (5% to 10%), ^{100,102,105,107,109,113,118} especially when the presenting rhythm is ventricular tachycardia or ventricular fibrillation (14% to 24% survival to hospital discharge). ^100,107,113 In one prospective cohort, patients aged 90 or over were found to have only a 1% survival rate. ¹⁰² However, another retrospective cohort study found patients aged 90 or over to have a 4.4% rate of survival; if the presenting rhythm was ventricular tachycardia or fibrillation, the survival to hospital discharge was 17%. ¹⁰⁰ Cerebral outcomes and quality of life are acceptable in both younger and older survivors of out-of-hospital cardiac arrest. ¹²¹ In an analysis of the Brain Resuscitation Clinical Trials data, Rogove et al found no difference in neurologic recovery by age. ¹⁰⁶ Long-term survival rates appear similar in older and younger patients who survive to hospital discharge (65% in each group in one study). ¹¹⁷

  Data on resuscitation of nursing-home patients with cardiac arrest is mixed. Benkendorf et al performed a prospective cohort study comparing nursing-home with community-dwelling patients with cardiac arrest and found that no nursing-home patient survived, but that 5.6% of community-dwelling patients did. ¹⁰³ Seventy-five percent of nursing-home patients had an asystolic rhythm. Appelbaum et al found similar poor outcomes in their retrospective study, with 2% of nursing-home patients and 11% of community-dwelling patients surviving to hospital discharge. ¹¹⁴ However, another retrospective study found similar rates of survival to hospital discharge in nursing-home (10.5%) and community-dwelling (9.2%) patients. ⁶⁶ Tresch et al found a 5% survival to hospital discharge rate in nursing-home patients with cardiac arrest, but a 27% survival when the arrest was witnessed and the rhythm was ventricular tachycardia or fibrillation. ¹⁰⁸ Eighty percent of survivors had a functional status similar to their pre-arrest status, and 40% lived for more than 1 year.

EmergMed 26 (Level B): Prospective, multicenter, longitudinal studies on the clinical course of older emergency department patients with important conditions (abdominal pain, fever, acute coronary syndromes) are needed (see also Key Research Questions in Emergency Medicine, end of chapter).

Injuries in patients aged 65 and over caused 37,560 deaths in 1998, a rate of 109 per 100,000 population. Injuries are therefore the seventh leading cause of death in this age group. Both the crude number of deaths and the death rate increase with age in those aged 65 and over; by age 75, the rate per 100,000 population exceeds all other age groups. ¹²² In addition to its high mortality, trauma in the older patient can result in significant morbidity, including functional decline and loss of independence.

The Northeastern Ohio Trauma Study was a time-stratified random sample of visits to EDs in 1977. ^123,124 This large epidemiologic study showed falls to be the leading cause of injury in patients aged 65 and over, followed by motor vehicle crashes. The injury rate for falls was 40 per 1000 population for patients 65 to 74 years, and 69 per 1000 population for patients 75 and older. The injury rate for motor vehicle crashes was 11 and 9 per 1000 for these age groups, respectively. The study also found that the hospital admission rate for injuries rises markedly after age 65 (21% for patients 65 to 74, 34% for patients 75 and older). Population-based mortality rates also increase in older patients, but more striking are case fatality rates, which show sharp increases in patients aged 65 and over (case fatality rate is the death per 1000 injuries). The rate of fractures also increase sharply after age 65; falls were found to cause 87% of all fractures in those aged 65 and over.

  Covington et al analyzed the North Carolina Trauma Registry, a statewide registry of all trauma patients admitted for at least 24 hours or dead on arrival in that state's eight level 1 and 2 trauma centers. ¹²⁵ The researchers found that patients 65 and older have longer stays in the hospital and intensive care unit, higher hospital charges, and higher mortality at all levels of injury severity. Sixty-eight percent of the injuries were caused by falls, and 22% were transportation related.

In studies of older trauma patients, in-hospital mortality varies from 15% to 45%. ^127-135 Finelli et al provided a secondary analysis of data from the Major Trauma Outcome Study of the American College of Surgeons. ¹³⁵ This was a study of 46,613 major trauma patients admitted to 120 trauma centers between 1982 and 1986; it included 3669 patients aged 65 and over. The elderly group had an 18% case fatality rate; the most common mechanism of injury was fall (46%, 12% mortality), followed by motor vehicle crash (28%, 21% mortality) and pedestrian hit (10%, 33% mortality).

  Mortality in trauma patients is related to several factors, including injury severity, host factors, timeliness of care, and quality of care. ¹³⁶ Several studies have attempted to identify factors that are associated with mortality in older trauma patients, focusing on host factors and injury severity.

  One early study of 100 patients aged 70 and over admitted to a single trauma center found that age, sex, Injury Severity Score (ISS), pre-injury ADL dependence, and pre-existing disease do not differ between survivors and nonsurvivors. ¹²⁷ Central nervous system injury and the presence of shock (blood pressure < 80 systolic) were found to be significantly different between groups. A second study of 39 severely injured patients aged 60 and over also found that ISS is not predictive of mortality, nor is the Trauma Score (TS). ¹²⁸ These studies are limited by low power to detect an association between predictive variables and mortality. They also had varying inclusion criteria (the former included patients with burns, penetrating injuries, and same-level falls; the latter included only severely injured surgical patients in intensive care who required a pulmonary artery catheter and arterial line). Older patients with isolated hip fractures have been found to have a mortality rate higher than that predicted by anatomic injury scales; ¹³⁷ thus, the inclusion of this patient subgroup in the former study may have made it more difficult to detect an association between ISS and age.

  DeMaria et al retrospectively analyzed 82 patients aged 65 and over admitted to a single center's trauma service between 1982 and 1984. ¹³⁸ Patients with thermal, penetrating, or isolated orthopedic injuries were excluded. The mortality rate was 21%; factors associated with mortality by univariate analysis included age, ISS, and the Anatomic Injury Severity score for head and neck. Discriminant analysis showed that four variables were associated with survival—ISS, age, and the presence of cardiac or septic complications. A "geriatric trauma survival score" was developed and prospectively tested on 61 additional patients, with 92% accuracy in prediction of mortality. However, one recent study of 326 patients found no difference in this score between survivors and nonsurvivors. ¹³⁴ Additionally, this score requires knowledge of complications, which limits its use in the early evaluation of trauma patients.

  Knudson et al conducted a retrospective study of 852 patients aged 65 and older with blunt trauma identified by trauma registries of three trauma centers and found the ISS to be the single variable that correlates most closely with mortality. ¹³³ In this study, overall mortality was 18.4%. Other risk factors for death were TS < 7 (RR = 6.62), Glasgow Coma Scale score of 3 (RR = 6.11), respiratory rate < 10 (RR = 4.83), blood pressure< 90 (RR = 4.77), abdominal injury (RR = 3.21), chest injury (RR = 2.27), head injury (RR = 2.17), and male sex (RR = 2.07). The authors developed a model for the probability of death using TS, age, and sex, and found this to have similar discriminating ability to the ISS in predicting mortality (sensitivity 37%, specificity 98%, and total correct classification 88% for the model, corresponding percentages of 41%, 97%, and 86% for the ISS).

  Morris et al performed a case-control study of the effect of pre-existing conditions on trauma mortality. ¹³⁶ They evaluated 3074 trauma deaths and 9868 matched controls (injury survivors) identified by the use of computerized hospital discharge data from California. They studied patients of all ages and found the presence of pre-existing conditions to increase with age. Pre-existing conditions associated with mortality included cirrhosis(OR = 4.6), congenital coagulopathy (OR = 3.2), chronic obstructive pulmonary disease (OR = 1.8), ischemic heart disease (OR = 1.8), and diabetes mellitus (OR = 1.2).

  Other factors associated with mortality in studies include early intubation, ¹³⁹ hypotension, ^127,132,133 TS, ^133,140,141 ISS, ^140,141 closed head injury, ^127,132,139 base deficit ≤ — 6, ¹⁴² sepsis, ¹³² cardiopulmonary complications, ¹³⁸ bradycardia, prior MI, and history of chronic renal insufficiency. ¹³²

  Accurate prediction of mortality is important for a number of reasons. First, it may provide information to help patients and surrogate decision makers decide on their desired level of care. Second, it allows for comparison between sites for quality-assurance purposes. Third, it may help tailor patient care, by predicting patients who require more aggressive trauma care. Currently, there is no validated, accurate way of predicting mortality in older patients. This is likely due to the multifactorial nature of mortality in older trauma patients.

Scalea et al retrospectively analyzed older blunt multiple trauma patients treated at their level 1 trauma center. ¹⁴⁵ The authors describe their experience with 60 patients in 1985 aged 65 and over with diffuse multiple trauma who were stable after initial resuscitation. The overall mortality was 44%; factors that were found to predict mortality were pedestrian-motor vehicle accident, diffuse trauma, initial systolic blood pressure less than 130 mm Hg, systemic acidosis, multiple fractures, and head injuries. The authors did not describe the method used to determine these risk factors or indicate whether they were found to be statistically significant predictors of mortality. The mortality was 85% in the group with any risk factor, and 63% of deaths were in the late post-injury period, commonly from multiple-organ failure.

  In 1986 the authors performed invasive monitoring on any patient who had any of the risk factors noted above. Fifteen patients were treated with invasive monitoring; the mortality rate was 93%. The average time to invasive monitoring was 5.5 hours from arrival in the intensive care unit. Because of the low survival rate, after 1986 the authors began a protocol that involved early invasive monitoring. The mortality after this was initiated was 47% (P < .001 compared with 1986). The average time to invasive monitoring was 2.2 hours. The groups did not differ in number of injuries, percentage requiring operation, or percentage of patients who died without significant injuries.

  The authors suggest that early invasive monitoring of older patients at risk of mortality from multiple-organ failure may improve survival. Given the use of historical controls and the limited comparative information between the groups, it cannot be determined whether the improved survival was due to early invasive monitoring or some other factor.

  McKinley et al developed a standardized protocol for resuscitation of trauma patients at risk for post-injury multiple-organ failure. ¹⁴⁶ They performed an inception cohort study of patients resuscitated by this protocol, comparing patients aged 65 and older with those under age 65. Patients who had (1) specific injuries (flail chest, two or more abdominal organ injuries, major vascular injury, complex pelvic fracture, or two or more long-bone fractures), (2) base deficit of 6 mEq/L or more, and (3) need for transfusion of six units or more of packed red blood cells, or patients aged 65 and older who have any two of the above criteria, were resuscitated by this protocol; patients with severe brain injury were excluded. The protocol involved resuscitation guided by pulmonary artery catheter using a combination of fluids, blood, inotropics, and vasopressors, with a goal of an oxygen delivery index (DO2I) of at least 600 mL/min*m2.

  Over 19 months, 54 patients under age 65 and 12 patients aged 65 or over were resuscitated by this protocol. Older patients' cardiac index and DO2I were significantly lower in the older group than in the younger group at the start of resuscitation. Eighty-three percent of older patients required inotropic support with dobutamine, versus 31% of younger patients (P < .05); 25% of older patients and 19% of younger patients required vasopressors (P = NS). Fifty percent of older patients and 19% of younger patients developed multiple-organ failure. Survival at 7 days was similar between groups (92% older and 94% younger), but 30-day survival was significantly less in the older group (42%) than in the younger group (89%) (P < .05 for both comparisons).

EmergMed 28 (Level B): Valid and accurate ways to predict outcomes in older trauma patients must be developed on the basis of cohort or case-control studies that can identify risk factors for bad outcomes.

EmergMed 30 (Level B): Exploratory studies are needed to identify new noninvasive ways of determining which older trauma patients might benefit from invasive monitoring and aggressive resuscitation.

EmergMed 31 (Level A): To determine whether early invasive monitoring and aggressive resuscitation of high-risk older trauma patients result in improved outcomes, large-scale, randomized controlled trials should be performed, and outcomes that include not only short-term mortality but also long-term mortality and function should be used (see also Key Research Questions in Geriatric Emergency Medicine, next).

EmergMed KQ1: Can alterations in the process of emergency department care, such as those found to be beneficial elsewhere (ie, geriatric specialty inpatient units), improve the outcomes of older emergency department patients?

Hypothesis-generating studies include the following: evaluation of the micro-environment of the ED to determine the characteristics (eg, communication, physical environment) that affect outcomes in elderly patients, development of brief instruments to detect cognitive and functional impairment in older ED patients, and generation of interventions (educationalmodels, protocols, computer support systems) to improve physician documentation and medication prescribing.

Hypothesis-testing studies include the study of specific elements of care (ie, improved environment, communication, recognition of delirium, linkage with geriatric teams) on outcomes in older ED patients. This should lead to a controlled study of the effects of a multifaceted approach to geriatric ED care on patient outcomes.

EmergMed KQ2: What diagnostic and therapeutic interventions can improve outcomes in older emergency department patients with high-risk common complaints, such as abdominal pain and acute coronary syndromes?

Hypothesis-generating studies include prospective, longitudinal studies of outcomes, evaluation of predictors of adverse outcomes, and evaluation of varied diagnostic approaches to older ED patients with the high-risk common conditions.

Hypothesis-testing studies would be based on the results of the hypothesis-generating studies and would include controlled trials of methods for improving outcomes for older ED patients with the high-risk common conditions.

EmergMed KQ3: In older blunt multiple trauma patients, does early invasive monitoring and aggressive resuscitation result in improved outcomes?

Hypothesis-generating studies include the development and validation of sensitive and accurate methods to predict which patients are at risk for multiple-organ failure and death after blunt trauma, and the study of noninvasive methods of determining who may benefit from invasive monitoring and aggressive resuscitation.

Hypothesis-testing studies involve evaluating whether early invasive monitoring and aggressive resuscitation of high-risk older trauma patients results in improved outcomes and comparing the effect of different techniques of aggressive resuscitation on outcomes. These studies should consist of large-scale randomized controlled trials, using outcomes that include not only short-term mortality but also long-term mortality and function.

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