Older adults frequently present unique challenges in the emergency department. They often present with atypical symptoms that can mask underlying medical issues. Common problems seen include falls, delirium, adverse drug reactions, and functional decline. A thorough history, physical exam, and medication review are important to identify potential precipitating factors and make an accurate diagnosis. Not following best practices for geriatric assessments can lead to missed or delayed diagnoses that negatively impact outcomes.

1. Common pitfalls in
Geriatric Emergencies
Varalak Srinonprasert, MD.
Division of Geriatric Medicine
Siriraj Hospital

2. Older adults in ED
From a systematic review, compared
to younger persons; older adults
utilize ED at a higher rate
visit with greater level of urgency
longer stays in ED
more likely to be admitted or have
repeat ED visits
experience higher rates of adverse
health outcomes after discharge
Aminzadeh F, Ann Emer Med, 2002 : 39 : 238-47

3. Older adults in ED
Older people are referred to the ED
for medical reasons rather than injuries
Take longer to triage
Spend more time in the ED
Consume more resources which does not
always correspond to better diagnostic
accuracy (on the contrary, missed or
incorrect diagnoses are frequent)
Salvi F, Intern Emerg Med 2007:2;292–301

4. Older adults in ED
More frequently admitted
(30–50% vs. 10–20% of young/adults)
Undergo adverse health outcomes
after their discharge from the ED
Repeated ED visits (24% at 3 mo, 44% at 6 mo)
Hospitalization (24%)
functional decline (10–45% at 3 mo)
institutionalization and death (10% at 3 mo).
Salvi F, Intern Emerg Med 2007 2:292–301

5. After ED visits…
Risk factors for negative outcomes :
Age
Functional impairment
Recent hospitalization or ED use
Living alone
Lack of social support
Aminzadeh F, Ann Emer Med, 2002 : 39 : 238-47

6. What are the challenges
for those older clients??
Atypical presentations
Multiple co-morbidities
Impaired cognition/difficulty with
communication
Polypharmacy
Those make our life (works)
more challenging!!

7. Atypical presentation
Exhibit less symptoms and signs than
younger persons
Present with „Geriatric Giants‟
 Incontinence Immobility
 Intellectual impairment Inappetite
 Instability  Iatrogenesis

8. Atypical presentation
Exhibit less symptoms&signs
20-30% of elderly with severe infection
show no fever & leukocytosis
15-30% of elderly have no fever at ED
despite of having bacteremia
50% of older person with unstable
angina experience no chest pain

9. Atypical presentation
Present with „Geriatric Giants‟
Pt. present to ED without specific
complaint ( mainly declined function)
Had „ standard evaluation‟
Clinical history and complete physical exam,
laboratory tests (blood cell numeration,
glucose, Na, K, BUN,Cr),U/A and CXR
Rutschmanna, H. Swiss Med Wkly 2005 : 135;145-50

10. Atypical presentation
Acute medical conditions were
identified in 51%
infections, cardiovascular problems,
neurological, delirium, fractures
Considering final diagnosis : 26 %
was „undertriage‟
Rutschmanna, H. Swiss Med Wkly 2005 : 135;145-50

11. Atypical presentation
All would not be missed if
Triaging performed according to
guideline
Taking vital sign for all elderly
All was not missed because
Physicians follow guidance performing
„ Standard evaluation „
Rutschmanna, H. Swiss Med Wkly 2005 : 135;145-50

12. Common diagnoses in
older patients in ED: USA
Cardiovascular diseases 8.2%
Chest pain : 18.5%
Respiratory disorders 10.5%
dyspnea : 3.5%
GI disorders 6.1%
Nervous system disorders 3.0%
Ciccone A, Amer J Emer Med : 16;143-8

13. Common diagnoses in
older patients in ED: Asia
Chest infection/pneumonia 8.2%
Non-fracture head injury 7.2%
Heart failure 6.6%
Ischemic heart disease 6.2%
COPD 6.2%
Soft tissue injuries 6.0%
Fractures 6.0%
Lim H, Singapore Med J 1999; Vol 40(12): 742-44

14. Common symptoms in
older patients visiting ED
Abnormalities of breathing 10.6%
Falls 9.6%
Musculoskeletal pain 8.2%
Cough 6.9%
Dizziness/Guidiness 5.6%
Lim H, Singapore Med J 1999; Vol 40(12):742-44

15. How about other
‘common problems’???
„No specific complaint‟ up to 20%
Delirium/acute confusion 10-30%
Adverse drug reactions 10-16%
Abnormalities of breathing 10.6%
Falls 9.6%
Musculoskeletal pain 8.2%

16. How about other
‘common problems’???
„No specific complaint‟ up to 20%
Delirium/acute confusion 10-30%
Adverse drug reactions 10-16%
Abnormalities of breathing 10.6%
Falls 9.6%
Musculoskeletal pain 8.2%

17. Delirium and cognitive
impairment
Delirium : an acute decline in
attention and cognition
Prevalence : 10-30% at ED
Higher rate of mortality
Increased health care costs
Up to 2/3 unrecognized

18. Delirium and cognitive
impairment
Approximately 25% of older patients
presented to ED having „ cognitive
impairment‟ ( delirium or dementia)
Creating difficulties communication
and management

19. Cognitive Impairment in
Older Patients Presented to ED
Gerson Naughton „95 Naughton „97
Impaired NA 8.5% 4.8%
consciousness
Delirium NA 9.6% 17%
Cog impaired NA 22% 38%
without delirium
Cognitively 40% 60% 40%
intact
Moderate Cog 34% NA NA
impaired
Mild Cog 26% NA NA
impaired

20. Unrecognized delirium
Impact on both short term and long
term outcomes
Mortality at 3 mo
31 % for unrecognized
12 % if physician noticed delirium
12 % for non-delirious older patients
Kakuma R, J Am Geriatr Soc 2003;51:443-50

21. Delirium (DSM-IV)
• Disturbance of consciousness with
inattention
• Change in cognition or perceptual
disturbance
• Acute onset and fluctuating course
• Resulted from medical conditions

22. Delirium : other features
• Disorientation
• Cognitive deficits
• Psychomotor agitation or retardation
• Perceptual disturbances
• Emotional lability
• Sleep-wake cycle reversal

23. Confusion Assessment
Method ( CAM)
A. Acute onset and fluctuating course
B. Inattention
C. Disorganized thinking
D. Altered level of consciousness :
hypoalert or hyperalert
Diagnosis of delirium :
A+B and C or D
Inouye SK, Ann Intern Med 113: 941,1990

24. Precipitating causes for delirium
Precipitating causes for delirium
D rugs
E nvironment
L ow oxygen
I nfections
R etention
I schemia
M etabolic
S ubdural hematoma
Salvi F, Intern Emerg Med 2007 2:292–301

25. Approach to older delirious
patients
History taking : particularly drugs
Thorough physical examination,
particularly neurological
Investigations
Recommended Optional
CBC, BUN, Cr, BS,  LFT
electrolyte  CXR
 U/A  ABG, EKG

26. Approach to older delirious
patients
How about CT brain ?
indicated if focal neurological
deficits present
a retrospective study revealed
15 % „ new changes‟
focal neurological deficits or decreased
level of consciousness
Naughton BJ, Acad Emerg Med 1997;4:1107-10.

27. A missed case
84 yo gentleman presented to ED
with paranoidal idea and aggressive
behavior, altered sleep-wake pattern
Any ideas ?

28. A missed case
84 yo gentleman presented to ED
with paranoidal idea and aggressive
behavior.
onset : over 2 days
Underlying disease : HT, BPH
Medications : Felodipine, Cardura
Recently „ catching a cold „ received „
cold remedies‟ , not eating so well
Lab : essentially normal
CT brain : unremarkable

29. A missed case
Medication review : Norgesic,
Actifed
Complete resolution after ceasing
medication and adequate IV
replacement

30. Delirium in older persons
Delirium is an emergency medical
condition
Delirium is a treatable condition
Delirium in elderly represents an
intrinsically multifactorial syndrome
Any patient with acute confusion or
mental deterioration should be consider
to be delirious until another diagnosis is
found

31. Falls
35% of older persons present to Trauma
emergency room
10 % in combined ED
Leading cause of death from accident in
older persons
Cause of falls identified in 94% of older
fallers
Appropriate intervention could reduce
future hospitalization

32. Causes of falls identified
31.2%
Weakness, generalized
27.3%
Environmental hazard
15.6%
Orthostatic hypotension
5.2%
Acute illness
3.9%
Gait or balance disorder
3.9%
Drug effect
3.9%
Weakness, focal
2.6%
Poor vision
1.3%
Drug reaction
5.2%
Unknown
Rubenstein LZ.Ann Intern Med 1990;113:308

33. How to evaluate older fallers
Evaluate falls-related injuries
Identify potential causes
detail history for the incident
identify intrinsic risk factors : thorough
physical examination including gait
assessment when feasible
appropriate investigations : CBC, BUN,
Cr, electrolyte, BS might be helpful

34. Adverse drug reactions (ADRs)
10-16% of ED visits in elderly caused by
ADRs
Patients older than 65 years are prescribed
a mean of 6 medications
Only 42% able to remember all drugs they
are taking
12-16% having problem understanding
prescriptions, especially when new and
multiple
Salvi F, et al. Intern Emerg Med 2007 ;2: 292-301
Rudolph J,et al. Arch Intern Med. 2008;168:508-513

35. Adverse drug reactions (ADRs)
ADRs increases with age

36. Another missed case
A 67 yo lady complains of „feeling dizzy‟ in her head,
unsteady, nausea and vomiting for 4 days. She developed
headache without fever for 2 days. Neuro exam :
unremarkable.
Medical BG : DM, HT, Dyslipidemia, Osteoporosis.
She had come to ED 3 visits over the last 3 days. Her blood
sugar has been below 200 mg/dl. Her blood pressure has
been mildly elevated.
She had a CT brain performed at her second visit with
unremarkable result.

37. Drug use in elderly
Another missed case
A 67 yo lady complains of „feeling dizzy‟ in her head
Medication review was performed :
Plendil 2.5 mg Co-aprovel 150 mg Amaryl 2 mg
ASA 81 mg Metformin 2000mg α-D3 0.25mg
CaCO3 1000 mg Simvastatin 10 mg Lesec 40 mg
Motilium 1*3 Merislon 24 mg Cinrizine 75 mg

38. Drug use in elderly
Another missed case
A 67 yo lady complains of „feeling dizzy‟ in her head
Medication review was performed :
Felodipine 2.5 mg Irbesartan+HCTZ Glimepiride 2 mg
150 mg/12.5mg
ASA 81 mg Metformin 2000mg α-D3 0.25mg
CaCO3 1000 mg Simvastatin 10 mg Omeprazole 40 mg
Motilium 1*3 Betahistine 24 mg Cinnarizine 75 mg
What next???

39. Another missed case Drug use in
elderly
Serum electrolyte came back
110 4.1
74 26
NSS infusion was administered and Co-approvel was
ceased. Her serum sodium returned back to normal
with in 3 days with complete resolution of her
symptoms.

40. Adverse drug reactions (ADRs)
10-16% of ED visits in elderly caused by
ADRs
Only half of those received correct
diagnosis
On the contrary, nearly 50% , another new
drug was prescribed without considering
ADRs
No routine drug review was undertaken
Salvi F, et al. Intern Emerg Med 2007 ;2: 292-301

41. “It is a good remedy sometimes to do nothing”
- Hippocrates (circa: a long, long time ago)
“It is a good remedy sometimes…
….to take some remedies away..”

42. Take home message
Give some more time to older persons
presented to ED, most of them do
really unwell when they come to ED
Appropriate history and thorough
physical examination would be
suitable
„ Basic investigations‟ would be quite
helpful
Don‟t forget : medication review
“ Drugs could cause illnesses!!!”

43. Thank you for
your attention
Questions?