ORIGINAL CONTRIBUTION
geriatrics
Geriatric EmergencyCare:An Annotated Bibliography From the Emergency Medicine Residency Program, Butterworth Hospital, Grand Rapids, Michigan; and the Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force, Lansing, Michigan. Received for publication February 28, 1992. Accepted for publication March 12, 1992. This study was supported in part by a grant from the John A Hartford Foundation, New York.
Jeffrey S Jones, MD, FACEP
This annotated bibliography provides selected references to journal articles addressing general issues of the care of elderly patients in the emergency department. The bibliography was compiled by the Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force. Because the literature pertinent to geriatrics has continued to grow rapidly, only key articles of general interest to the clinician and academician are included in the bibliography. Preference is given to recent publications; most references date from the past five years. The articles cited are primarily concerned with the delivery of emergency care to geriatric patients; economic, legal, ethical, and sociological topics receive limited coverage. Some articles were selected to highlight current controversies or changes in viewpoint. Aging physiology, atypical characteristics of illness, and disease processes have been addressed elsewhere (JAm GeriatrSoc 1989;37:894-910). [Jones JS: Geriatric emergency care: An annotated bibliography. Ann EmergMedJuly 1992;21:835-841 .] GENERAL Lowenstein SR, Crescenzi CA, Kern DC, et al: Care of the elderly in the emergency department. Ann EmergMed 1986;15:528-535. The authors prospectively studied the care provided to 234 elderly patients (65 years or older) and an equal number of nonelderly patients visiting the emergency department of an urban teaching hospital. Sociodemographic, treatment, cost, and outcome data were collected through ED record reviews and telephone follow-up. The elderly comprised 19% of the ED population and were often nonwhite (31%), Medicaid recipients (39%), living alone (41%), and multiply and chronically impaired. Among old-old patients (75 years or older), the most frequent reasons for visiting the ED (19%) were a self-care problem, a fall, or dehydration. Forty-five percent of old-old patients' visits were for true medical emergencies or urgencies. Compared with the nonelderly, the old-old more often were admitted (47% vs 18%), stayed a longer time in the ED (three hours versus 1.9 hours), and incurred a higher charge ($324 vs $208). The recidivism rate for nonelderly patients was only half as high (15%).
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BIBLIOGRAPHY ]ones
Ettinger WH, Casani JA, Coon PJ, et al: Patterns of use of the
coordinate medical treatment and social and psychiatric
emergency department by elderly patients. J Gerontol
services.
1987;42:638-642.
Baum SA, Rubenstein LZ: Old people in the emergency room: Age-related differences in emergency department use and care. J Am GeriatrSoc 1987;35:398-404.
The spectrum of illness and use patterns of 540 elderly patients (65 years or older) admitted to an ED were compared with an equal number of nonelderly patients. Elderly patients were more likely to have an emergent diagnosis, to arrive by ambulance, to be admitted to the hospital, and to have a medical (as opposed to a surgical) illness. The spectrum of diseases was different between the two groups. Elderly patients had a higher proportion of cardiac and pulmonary disease; nonelderly had more injuries and selflimited infectious disease. The proportion of psychiatric disease and social problems was low in both groups (about 5%). Elderly patients had a significantly lower proportion of n0nurgent diagnoses than the nonelderly patients. There is little evidence that elderly persons use the ED for primary self-care or social problems.
Eliastam M: Elderly patients in the emergency department. Ann EmergMed 1989;18:1222-1229. The population of the United States is aging, and the fastest growing group comprises those aged 85 years and older. This article reviews ED use by the elderly including physiologic changes, disease presentation, drug use, laboratory assessment, and treatment guidelines.
Barry PP, Crescenzi CA, Radovsky L, et al: Why elderly patients refuse hospitalization. JAm Geriatr Soc 1988;36:419-424. To identify important factors in the refusal of hospitalization by elderly patients, a study was conducted of 35 such "refusers" on the Home Medical Service of University Hospital and a comparison group of 70 patients who accepted hospitalization. The two groups were compared on the basis of demographic factors, health care factors, medical condition, and outcomes. Reasons for refusal were most commonly related to a negative perception of the health care system or a passive acceptance of death. Refusers were significantly less ill than acceptors and did not change in health or functional status at follow-up. The results suggest that refusal of hospitalization is most often related to interaction with the health care system and that less ill patients may have reasonable outcomes when treated at home.
Bassuk EL, Minden S, Apster R: Geriatric emergencies: Psychiatric or medical. Am J Psychiatry 1983;140:539-542. To determine how the elderly use the ED, the investigators compared emergency patients 65 years and older with younger patients in terms of demographics, clinical factors, patterns of ED use, and clinicians' responses. They found that, like younger patients, the elderly had scanty social supports but, unlike younger patients, came for care repeatedly with somatic complaints. Despite coexisting medical and psychiatric illnesses, these patients were generally managed by one service without consultation from the other. The authors, who found no differences in physicians' attitudes toward younger and older patients, emphasize the need to
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The authors prospectively abstracted ED records during a 22-day period in 1984 for demographic and medical variables. Older patients (ie, those 65 years of age or older) do not seem to be overusers of the ED for minor complaints; in fact, they tend to be more acutely ill on presentation than younger people. Older people were more likely to be hospitalized (46% vs 10%), to arrive by ambulance (35% vs 10%), and to have an identified source of primary care (95% vs 64%). Test-ordering patterns for specific complaints varied by patient age (eg, older patients had more ECGs performed for chest pain and fewer urinalyses for abdominal pain than younger patients). Therapy for specific complaints showed less age effect. Although generally more diagnostic tests were performed in older patients, the ED diagnosis tended to be more accurate for younger patients. These data indicate that the process of ED care may be substantially different for the elderly population and have implications for future planning and financing of medical care.
EDUCATION Jones J, Dougherty J, Cannon L, et al: A geriatrics curriculum for emergency medicine training programs. Ann EmergMed 1986;15:1275-1281. The authors present an integrated geriatric curriculum designed to operate within a three-year emergency medicine residency program. This curriculum identifies specific educational objectives for training in geriatric emergencies that can be summarized as follows: identify those impairments and functional disorders that often complicate diagnosis and therapy; acquire an understanding of how physiologic changes in aging affect normal laboratory and radiologic values; develop knowledge of drug side effects and interactions in this population; understand and treat the group of diseases peculiar to the elderly; recognize diseases and injuries that present a different clinical picture in old age; and differentiate and treat common psychosocial emergencies in the elderly. These educational objectives are further defined using a specific interlinked framework of didactic presentations, journal clubs, case conferences, therapeutic audits, formal rotations, and consultants. This format provides valuable educational experiences for the emergency medicine resident and may strengthen positive attitudes toward geriatric medicine.
Rahman A, Salend E, Liston M, et al: An educational program to improve geriatric emergency care. J EmergNurs 1989;15:313-317. This article describes a continuing education project designed to enhance knowledge and skill among emergency nurses and other ED personnel in assessing and meeting the needs of older patients. The project undertaken at the
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JoNes
UCLA Emergency Medicine Center demonstrated that not only is such education needed by ED staff, but it may provide the impetus for further efforts to improve care for older patients.
PREHOSPITAL 6erson LW, Skvarch MA: Emergency medical service utilization by the elderly. Ann Emerg Med 1982;11:610-612. The growing number of aged in the United States will continue to increase the demand for medical services, including emergency care. In a medium-sized city, 22% of 14,400 emergency medical services (EMS) responses were to patients older than 65 years. Of the elderly, those older than 75 years were more likely to call the EMS system than were those between 65 and 74 years old. Men used the service more often than women. Men were more likely to suffer a cardiac condition; women, an injury. Elderly patients were 1.7 times more likely to require paramedic-accompanied transportation to the hospital.
6illick M, Steel K: Referral of patients from long-term to acutecare facilities. JAm GeriatrSoc 1983;31:74-78. Medical care available to residents of 100 nursing homes and 16 chronic-care hospitals was assessed by studying transfers of such persons to the ED of an acute-care hospital. Patient transfers were compared with 338 elderly patients from home (control group). Elevated temperature (38.9 C or higher) was found in 17.3% of nursing home patients and 30% of chronic-care hospital patients, compared with 1.8% of controls; mental status abnormalities were found in 66.1% of patients from nursing homes and in 90.9% of those from chronic-care hospitals, compared with 36.2% of controls. In addition, patients from chroniccare hospitals, but not those from nursing homes, often showed substantial abnormalities of blood pressure and pulse. The probability of admission to the hospital was the same for residents of nursing homes and persons living at home (44.0% and 43.2%, respectively) but was higher for persons from chronic-care facilities (81.3%). No evidence for "dumping" of patients was found. The study concludes that use of a hospital ED by nursing home patients is very similar to that by home residents, suggesting an inadequacy of on-site medical services, whereas that by chronic-care hospital patients is restricted to major illness, which is entirely appropriate.
TRAUMA DeMaria EJ, Kenney PR, Merriam MA, et al: Aggressive trauma care benefits the elderly. J Trauma1987;27:1200-1206. To evaluate factors that determine the long-term potential for recovery in this population, the authors studied 63 survivors of blunt trauma older than 65 years. The overall level of injury was moderate, with a mean Injury Severity Score of 15.8. Thirty-nine patients (62%) had two or more body regions injured. Surgery was required in half the patients,
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one third experienced complications, and nine (14%) required ventilatory support for five or more days. Only two patients did not live independently before trauma. Immediately after discharge, 21 patients (33%) were independent, 23 (37%) were dependent but living at home, and 19 (30%) required nursing home care. Nursing home patients were older, more severely injured, had more severe head and neck trauma, and required surgery more frequently after trauma than patients discharged directly home. Twelve of the 19 nursing home patients (63%) returned home 3.1 months after discharge, and 13 of the 23 dependent patients (57%) became independent. Overall, 38 patients (57%) returned to independent living after trauma. Aggressive support of the elderly trauma victim appears justified because few patients require permanent nursing home care and most return to independent living after trauma.
Fischer RP, Miles DL: The demographics of trauma in 1995. J Trauma1987;27:1233-1236. By 1995, population aging will decrease the size of the high-injury-risk age cohort (14 to 34 years) by 7 million (-8.2%). The reduction in the high-injury-risk cohort should reduce the overall volume of penetrating and blunt injury nationally despite a population increase of 21 million. However, the number of and the proportion of elderly victims of injury will increase, as there will be an additional 5.3 million (+18.5%) people aged 65 years or older. Yet payments based on Medicare diagnosis-related groups do not provide adequate reimbursement for any victims of injury, let alone the elderly. Moreover, Medicare and Medicaid reimbursements for the long-term care so frequently needed by the elderly victims of injury are inadequate. As our population ages, the adverse financial impact of these circumstances resultant from population aging will increasingly strain the financial resources of our trauma centers.
Spaite DW, Criss EA, Valenzuela TD, et al: 6eriatric injury: An analysis of prehospital demographics, mechanisms, and patterns. Ann Emerg Med 1990;19:1418-1421. The authors evaluated EMS system use, injury mechanisms, and prehospital assessments among elderly victims of trauma. Prehospital information was reviewed for injuries occurring in patients 70 years or older who were evaluated and treated by Tucson Fire Department paramedics during a 12-month period. A total of 1,154 cases occurred, which represented 30.3% of all 911 dispatches involving elderly patients. Injury mechanisms were fall (60.7%), motor vehicle accident (21.5%), fight (2.4%), accidental poisoning (2.3%), and choking (2.1%). The most frequent injuries determined by prehospital assessment were head or face (25.1%), upper extremity (17.2%), hip (14.5%), lower extremity (13.8%), back (9.8%), and chest or abdomen (5.0%). Suspected hip (P < .001) and pelvic (P < .005) injuries occurred more frequently during fails, whereas back injuries occurred most frequently in motor vehicle accidents (P < .001). Seventy-one fall victims (10.1%) had
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suspected medical causes of their fall. Twelve patients (1.0%) were in cardiac arrest. A knowledge of these injury patterns will be useful to emergency physicians and EMS administrators.
RESUSCITATION Wu AW, Rubin HR, Rosen M J: Are elderly people less responsive to intensive care? JAm Geriatr,Soc 1990;38:621-627. To determine if advanced ~ge is associated with increased mortality independent of severity of illness, Wu et al compared older and middle-aged patients admitted to a medical ICU. Charts of 130 patients aged 75 years or older and 135 patients aged 55 to 65 years were reviewed during a 30-month period. Hospital stay was slightly longer in the older group (37 vs 39 days). However, when logistic regression was used to adjust for APACHE IIM scores, whether the patient had a private attending physician, admitting diagnosis, or presence of cancer, older patients did not have a significantly greater risk of dying. When pulmonary artery catheterization was added to the model, it independently predicted mortality. APACHE IIM was an excellent predictor of mortality.
Tresch DD, Thakur RK, Hoffmann RG, et el: Should the elderly be resuscitated following out-of-hospital cardiac arrest? Am J Med 1989;86:145-150. Elderly and younger patients who were resuscitated suecessfully and hospitalized after out-of-hospital cardiac arrest were studied to determine if there was a significant difference in hospital course and long-term survival between the two groups. This retrospective study consisted of 214 consecutive patients, divided into two age groups: 112 elderly (older than 70 years) and 102 younger (younger than 70 years) patients. Before cardiac arrest, 47 of 112 (42%) elderly patients had a history of heart failure, compared with 19 of 102 (18%) younger patients, and were more commonly taking digitalis and diuretics. Younger patients, however, more often had an acute myocardial infarction at the time of the cardiac arrest (33% vs 16%). At the time of cardiac arrest, 83% of younger patients demonstrated ventricular fibrillation, compared with 71% of the elderly. In contrast, electromechanical dissociation was five times more common in the elderly patients. Although hospital deaths were more common in the elderly (71% vs 53%), the hospital stay of the elderly was not longer, the elderly did not have more residual neurologic impairments, and survival after hospital discharge (65%) was similar to that in younger patients.
Sachs GA, Miles SH, Levin RA: Limiting resuscitation: Emerging policy in the emergency medical system. Ann Intern Med 1991;114:151-154. Patients, families, and physicians frequently decide that a hospitalized patient will forego CPR and document this decision with a do-not-resuscitate (DNR) order. In community settings (eg, home, nursing home, hospice), these orders may conflict with paramedics' standing orders to provide CPR
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whenever it is medically indicated. The authors did a nationwide telephone survey of state offices for coordination of EMS to see how the states deal with this potential conflict. Eight states wereidentified that have specific policies enabling EMS personnel to accept DNR orders for patients being transported by ambulance. State officials identified administrative complexities and legal concerns as the primary barriers to enacting rehospitalization DNR policies. The study also identifies 21 local EMS systems that have developed policies for accepting orders to withhold life-sustaining treatment. Four types of policy models, characterized according to procedure for validating DNR orders and telephone accessing the EMS system; show that regulatory reform can address policy barriers in the absence of enabling legislation.
Murphy DJ, Murray AMI Robinson BE, st al: Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989;111:199-205. Of 503 elderly patients, 112 (22%) survived initially, but only 19 (3.8%) survived to hospital discharge. The poorest outcomes were for patients with unwitnessed arrests (one of 116 survived), patients with terminal arrhythmias such as asystole and electromechanical dissociation (one of 237 survived), and patients with CPR lasting more than 15 minutes (one of 360 survived). Only two (0.8%) of 244 patients with out-of-hospital cardiopulmonary arrests left the hospital alive. Of 259 patients with in-hospital arrests, 17 (6.5%) survived to discharge. Most survivors had ventricular arrhythmias and were resuscitated within minutes. Initial survivors with either impaired consciousness or functional impairment after the arrest had significantly worse chances of survival than patients without these impairments. CPR is rarely effective for elderly patients with cardiopulmonary arrests that are out-of-hospital, unwitnessed, or associated with asystole or electromechanical dissociation.
PSYCHOSOCIAL AMA Council on Scientific Affairs: Societal effects and other factors affecting health care for the elderly. Arch Intern Med 1990;150:1184-1189. With advances in medical care, life expectancy of Americans has increased dramatically. The increase in the size of the elderly population has had a major impact on health care provision and will have an even greater impact on our health care system over the next several decades. Although today's medical students will spend nearly half their collective careers caring for the elderly, insufficient numbers of students show an interest in geriatrics. American society has become in many ways less traditional, and age is no longer seen as "a pathway to wisdom." Because we are now a more mobile society, extended families tend to scatter, and the elderly are frequently alone. We study the effects of our rapidly changing, youth-oriented society on health care for the elderly.
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Greenstein RA, Ness DE: Psychiatric emergencies in the elderly. Emerg Med C/in North Am 1990;8:429-441. To assess and treat elderly psychiatric patients properly, emergency personnel must be aware of the medical disorders associated with psychiatric illness and be prepared to initiate treatment quickly and appropriately. This article reviews the format for conducting a psychiatric history and mental status examination and discusses the most common emergency psychiatric disorders of the elderly and their management.
Council on Scientific Affairs: Elder abuse and neglect. JAMA 1987;257:966-971. Estimates of elder abuse approximate 10% of Americans older than 65 years of age; obtaining accurate incidence and prevalence figures is complicated by factors including denial by both the victim and perpetrator and minimization of complaints by health professionals. Broad agreement exists in categorizing elder abuse as physical, psychological, and financial and/or material, despite lack of uniformity in definitions. Systematic scientific investigation provides limited knowledge about the causes of elder abuse. Most experts, however, believe that family problems and conflict are a major precipitating factor. Preliminary hypotheses for elder abuse are extensively discussed. This report presents potential indicators of physical and psychological abuse, along with classification of elderly individuals at high risk, to assist the health professional in identification and prevention of elder abuse.
McDonald AJ, Abrahams ST: Social emergencies in the elderly. Emerg Med Clin North Am 1990;8:443-459. Elderly patients seek care from an ED for social problems as well as medical care. These problems are identified, and appropriate referral resources are described by the authors. Disposition problems, drug and alcohol abuse, and abuse of the elderly are key topics.
FUNCTIONAL ASSESSMENT Rowland K, Maitra AK, Richardson DA, et al: The discharge of elderly patients from an accident and emergency department: Functional changes and risk of readmission. AgeAging 1990;19:415-418. Four hundred fifty patients aged 75 years or older were followed up after discharge from an ED. Forty-three percent of all patients experienced some loss of functional independence. A small number (5.6%) were readmitted to the hospital within 14 days. This group was significantly less able to perform certain activities of daily living. Attention to functional assessment by ED staff may help to prevent readmission to the hospital of this frail elderly group of patients.
Denman SJ, Ettinger WH, Zarkin BA, et al: Short-term outcomes of elderly patients discharged from an emergency department. J Am Geriatr Soc 1989;37:937-943 To determine the short-term functional and medical outcomes and predictors of outcome after discharge from the
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ED, 100 elderly (65 years or older) and 100 uonelderly (younger than 65 years) patients were studied prospectively. There was no difference in patients' understanding of the diagnosis or in medication compliance. Elderly patients were more likely to keep scheduled follow-up appointments (87% vs 65%). Despite these similarities, the elderly had worse medical outcomes at three weeks; 67% of the elderly were better and 20% were worse. In contrast, 82% of the nonelderly were better and only 4% were worse. Functional impairments were more common in the elderly both at baseline and at three weeks. Independent predictors of poor medical outcome included age 65 years or older and functional impairment at baseline. Older patients with impaired functional status who are discharged from an ED should be targeted for close medical surveillance and ready access to health services.
Pinholt EM, Kroenke K, Hanley JF, et al: Functional assessment of the elderly: A comparison of standard instruments with clinical judgment. Arch Intern Med 1987;147:484-488. Using specific instruments and scales to measure mental status, nutritional state, visual acuity, gait, and activities of daffy living, Pinholt et al studied 79 medical inpatients aged 70 years or older. The patients' primary physicians and nurses were then interviewed and asked to rate their patients. The prevalence of functional impairment was high: 25 (32%) of the 79 patients were mentally impaired, 31 (39%) were malnourished, 18 (23%) were visually impaired, 31 (39%) had impaired gait, and 23 (29%) had problems with continence. Although clinicians recognized severe impairments, the sensitivity of their clinical judgment was poor in detecting moderate impairment in four categories: mental status sensitivity was 28% (five of 18); nutrition, 54% (14 of 26); vision, 27% (four of 15); and continence, 42% (five of 12). Comprehensive functional assessment instruments can detect these moderate impairments, which may be remediable through early intervention.
D I A G N O S T I C TESTING Kelso T: Laboratory values in the elderly: Are they different? Emerg Med Clin North Am 1990;8:241-254. Physiologic changes in the elderly can be expected to impair functions that usually are assessed by the performance of clinical laboratory tests. Biologic variability in this large, heterogeneous group is shown to be well established. Although some clinicians and clinical chemists have advocated the establishment of separate "reference ranges" for the elderly, satisfactory clear-cut ranges of acceptable limits in older patients have not been developed. Pertinent studies are reviewed and comparisons made, from which it is concluded that most laboratory values in older patients fall within the traditional "normal ranges" except for, in a few patients, acceptable elevations in serum alkaline phosphatase, blood urea nitrogen, glucose, or erythrocyte sedimentation rate.
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Loberant N, Rose C: Imaging considerations in the geriatric emergency department patient. EmergMed Clin North Am 1990;8:361-397. This article provides an overview of imaging modalities available to the emergency physician and a discussion of their applicability to common specific problems encountered in the geriatric population. In selected conditions, computed tomography, ultrasound, and radionuclide scanning have become primary modalities.
Jones J, Srodulski ZM, Romisher S: The aging electrocardiogram. Am J Emerg Med 1990;8:240-245. With advancing age, widespread histologic changes in the conduction system occur. These changes may alter several features of the ECG, including duration of the PR and QT intervals, orientation of the electric axis, duration and morphology of the aerial and ventricular complexes, and characteristics of the ventricular repolarization. With an awareness of atypical presentations and difficulties in ECG interpretation, emergency physicians may be able to improve the assessment and triage of elderly patients with acute coronary ischemia.
ADVERSE DRUG R E A C T I O N S Montamat SC, Cusack BJ, Vestal RE: Management of drug therapy in the elderly. N Engl J Med 1989;321:303-309. Drug therapy in the elderly is complicated by many factors unique to this age group. Because it requires careful individualization, therapy should be based on the principles of pharmacokinetics. Multiple disease processes, environmental influences, and genetic variation often combine with the physiologic effects of aging to affect the distribution of drugs in this population. Also, misconceptions about the degree of compliance with drug therapy and the frequency of adverse drug reactions in the elderly should be recognized. With people surviving to older ages in increasing numbers and accounting for a major proportion of drug use, clinicians must be attentive to the goals and consequences of drug therapy in elderly patients.
Fox FJ, Auestad AE: Geriatric emergency clinical pharmacology. EmergMeal Clin North Am 1990;8:1221- 1239. The first part of this review article discusses the epidemiology of drug use and adverse drug effects in the elderly. The second part presents principles of geriatric therapeutics in the emergency department as well as guides to information sources.
Morrow D, Leirer V, Sheikh J: Adherence and medication instructions: Review and recommendations. JAm Geriatr Soc 1988;36:1147-1160. Prescription medication nonadherence among the elderly is a serious problem. Nonadherence is primarily caused by poor communication between health professionals and elderly patients. More specifically, nonadherence often reflects the inability of patients to understand and remember their
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medication instructions. Therefore, adherence can be increased by designing instructions that enable elders to easily construct a clear and simple mental model of how to take their medication. Inexpensive microcomputer-based hardware and software make it possible to provide elderly patients with effective instructions.
ETHICS Adams J, Wolfson AB: Ethical issues in geriatric emergency medicine. EmergMed Clin North Am 1990;8:183-192. Particularly in the care of the elderly, the emergency practitioner must be able to respond to ethical concerns in a manner that will provide the greatest benefit to patients and their families. Resuscitation-related concerns form only a highly visible part of a broad spectrum of ethical issues arising in the emergency care of the elderly. This article provides a framework for the recognition and analysis of many of these important ethical issues.
Jahnigen DW, Schrier RW: The doctor/patient relationship in geriatric care. Clin Geriatr Med 1986;2:457-464. Information derived from the relationship of the primary care physician with an older patient provides the best possible way to eliminate or minimize many ethical conflicts that arise in the care of the very old. The conscientious physician can seek information regarding the patient's personal value scheme and his or her expectations and use the breadth of available technology to best serve the patient. Many of the issues raised in this article are discussed in much greater detail in subsequent articles. The discussions of the issues they encompass are intended to inform and to stimulate. There is legitimate reason for optimism that, with education and thoughtful review, physicians will be able to improve the manner in which they care for older individuals.
Radecki SE, Kane RL, Solomon OH, et al: Are physicians sensitive to the special needs of older patients? JAm Geriatr Soc 1988;36:719-725. The sensitivity of primary care physicians to the health care needs of older patients was explored by means of an analysis of the use of diagnostic tests and therapeutic procedures during ambulatory visits. Survey data on a total of 28,265 visits to internists and family and general practitioners were studied to determine possible age-related differences in care. The study found that diagnostic testing falls off significantly for patients 75 years of age or older and that internists use substantially more tests for each age group than do family or general practitioners. The pattern of use of diagnostic tests in this secondary analysis does not address the issue of "appropriateness" but does suggest a pattern that makes little sense based on the known distribution of disease and functional disability in aging populations.
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BIBLIOGRAPHY Jones
Strange GR, Flynn RJ, Whitehall J: Ethical considerations in emergency department management of terminally ill patients. Ann EmergMed 1989;18:1085-1088.
Evans RW: Health care technology and the inevitability of resource allocation and rationing decisions. JAMA 1983;249:2047-2053, 2208-2219.
Case discussion of a 78-year-old man with a history of cancer of the lung who presented to the ED with nonspecific complaints. During the course of his workup, an acute lifethreatening problem was revealed. A panel from the University of Illinois AfFiliated Hospitals Emergency Medicine Residency diseuss the ethical issues involved in therapeutic and disposition decisions.
The scarcity in resource allocations to health care programs is explained in terms of the aging of the population, concomitant increase in chronic illness, and the cost of technologies of uncertain benefit that have evolved in response to these factors. Resource allocation decisions (cost-benefit and cost-effectiveness analyses) and criteria for rationing (eg, medical criteria, decision analysis, chance, first come-first served, merit) are discussed. The problem of relative scarcity by society is raised as a check on the felt urgency of the need for medical rationing. The societal fear of death, which supports the preoccupation with health care, has implications for the resolution of these conflicts.
Iserson KV: Getting advance directives to the public: A role for emergency medicine. Ann EmergMed 1991;20:692-696. Advance directives are designed to allow individuals to determine the course of their medical care in the event that they are no longer able to transmit the information to their physician. The US Supreme Court's recent Cruzan decision increased the importance of these legal instruments by declaring that "clear and convincing" evidence may be required by states to terminate life support in a patient unable to express his or her wishes about care. Only 9% of Americans have executed advance directives. Emergency physicians have the opportunity to assist their patients in advance by disseminating advance directives to those who have contact with the ED: patients, family members, friends, health care workers, EMS personnel, and police. A plan is suggested that includes education, the availability of advance directives, personnel available to help with completion of the documents, and immediate entry of the directive into a medical chart, if requested. This is in conformance with a recent policy adopted by the American College of Emergency Physicians.
ECONOMICS Schneider EL, Guralnik JM: The aging of America: Impact on health care costs. JAMA 1990;263:2335-2340. The rapid growth of the oldest age groups will have a major impact on future health care costs. The authors use current US Census Bureau projections for the growth of our oldest age groups to project future costs for Medicare, nursing homes, dementia, and hip fractures. Without major changes in the health of our older population, these health care costs will escalate enormously, in large part as a result of the projected growth of the "oldest old," those aged 85 years and older. Medicare costs for the oldest old may increase sixfold by the year 2040. It is unlikely that these projected increases in health care costs will be restrained solely by cost-containment strategies. Successful containment of these health care costs will be related to our ability to prevent and/or cure those age-dependent diseases and disorders that will produce the greatest needs for long-term care.
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RESEARCH Applegate WB, Curb JD: Designing and executing randomized clinical trials involving elderly persons. JAm Geriatr Soc 1990;38:943-950. This article focuses on methods and problems of conducting a randomized clinical trial involving older participants. Special attention must be paid to framing precise primary and secondary study hypotheses, adjusting for the potential confounding effects of comorbidity and disability, and analyzing multiple outcomes. When the sample or study cohort is chosen, there will be an inevitable trade-off between internal and external validity. Because elderly study cohorts are more prognostically heterogeneous, consideration should be given to enrolling an "at-risk" cohort and possibly to stratified randomization.
Dubler NN: Legal judgments and informed consent in geriatric research. J Am Geriatr Soc 1987;35:545-549. Maximizing personal preference and supporting residual autonomy should be the goal in assessing the capacity of elderly persons to provide legally effective informed consent. Many elderly persons of declining or diminished abilities retain the capacity to provide consent for certain protocols. When individual capability is clearly inadequate, the choice of possible alternative deciders is clouded in legal and ethical uncertainty.
Stanley B, Giudo J, Stanley M, et al: The elderly patient and informed consent: Empirical findings. JAMA 1984;252:1302-1306. This study looks at the capacity of geriatric patients to eonsent to research participation through the use of hypothetical cases. The elderly subjects had the same choices about the "reasonableness" of the risk:benefit ratio of the proposed study as did the younger subjects, but the elderly persons - - who were not cognitively impaired - - had poorer understanding of the consent information. Thus, special precautions may be warranted in the consent process and standards.
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geriatrics
Geriatric EmergencyCare:An Annotated Bibliography From the Emergency Medicine Residency Program, Butterworth Hospital, Grand Rapids, Michigan; and the Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force, Lansing, Michigan. Received for publication February 28, 1992. Accepted for publication March 12, 1992. This study was supported in part by a grant from the John A Hartford Foundation, New York.
Jeffrey S Jones, MD, FACEP
This annotated bibliography provides selected references to journal articles addressing general issues of the care of elderly patients in the emergency department. The bibliography was compiled by the Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force. Because the literature pertinent to geriatrics has continued to grow rapidly, only key articles of general interest to the clinician and academician are included in the bibliography. Preference is given to recent publications; most references date from the past five years. The articles cited are primarily concerned with the delivery of emergency care to geriatric patients; economic, legal, ethical, and sociological topics receive limited coverage. Some articles were selected to highlight current controversies or changes in viewpoint. Aging physiology, atypical characteristics of illness, and disease processes have been addressed elsewhere (JAm GeriatrSoc 1989;37:894-910). [Jones JS: Geriatric emergency care: An annotated bibliography. Ann EmergMedJuly 1992;21:835-841 .] GENERAL Lowenstein SR, Crescenzi CA, Kern DC, et al: Care of the elderly in the emergency department. Ann EmergMed 1986;15:528-535. The authors prospectively studied the care provided to 234 elderly patients (65 years or older) and an equal number of nonelderly patients visiting the emergency department of an urban teaching hospital. Sociodemographic, treatment, cost, and outcome data were collected through ED record reviews and telephone follow-up. The elderly comprised 19% of the ED population and were often nonwhite (31%), Medicaid recipients (39%), living alone (41%), and multiply and chronically impaired. Among old-old patients (75 years or older), the most frequent reasons for visiting the ED (19%) were a self-care problem, a fall, or dehydration. Forty-five percent of old-old patients' visits were for true medical emergencies or urgencies. Compared with the nonelderly, the old-old more often were admitted (47% vs 18%), stayed a longer time in the ED (three hours versus 1.9 hours), and incurred a higher charge ($324 vs $208). The recidivism rate for nonelderly patients was only half as high (15%).
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BIBLIOGRAPHY ]ones
Ettinger WH, Casani JA, Coon PJ, et al: Patterns of use of the
coordinate medical treatment and social and psychiatric
emergency department by elderly patients. J Gerontol
services.
1987;42:638-642.
Baum SA, Rubenstein LZ: Old people in the emergency room: Age-related differences in emergency department use and care. J Am GeriatrSoc 1987;35:398-404.
The spectrum of illness and use patterns of 540 elderly patients (65 years or older) admitted to an ED were compared with an equal number of nonelderly patients. Elderly patients were more likely to have an emergent diagnosis, to arrive by ambulance, to be admitted to the hospital, and to have a medical (as opposed to a surgical) illness. The spectrum of diseases was different between the two groups. Elderly patients had a higher proportion of cardiac and pulmonary disease; nonelderly had more injuries and selflimited infectious disease. The proportion of psychiatric disease and social problems was low in both groups (about 5%). Elderly patients had a significantly lower proportion of n0nurgent diagnoses than the nonelderly patients. There is little evidence that elderly persons use the ED for primary self-care or social problems.
Eliastam M: Elderly patients in the emergency department. Ann EmergMed 1989;18:1222-1229. The population of the United States is aging, and the fastest growing group comprises those aged 85 years and older. This article reviews ED use by the elderly including physiologic changes, disease presentation, drug use, laboratory assessment, and treatment guidelines.
Barry PP, Crescenzi CA, Radovsky L, et al: Why elderly patients refuse hospitalization. JAm Geriatr Soc 1988;36:419-424. To identify important factors in the refusal of hospitalization by elderly patients, a study was conducted of 35 such "refusers" on the Home Medical Service of University Hospital and a comparison group of 70 patients who accepted hospitalization. The two groups were compared on the basis of demographic factors, health care factors, medical condition, and outcomes. Reasons for refusal were most commonly related to a negative perception of the health care system or a passive acceptance of death. Refusers were significantly less ill than acceptors and did not change in health or functional status at follow-up. The results suggest that refusal of hospitalization is most often related to interaction with the health care system and that less ill patients may have reasonable outcomes when treated at home.
Bassuk EL, Minden S, Apster R: Geriatric emergencies: Psychiatric or medical. Am J Psychiatry 1983;140:539-542. To determine how the elderly use the ED, the investigators compared emergency patients 65 years and older with younger patients in terms of demographics, clinical factors, patterns of ED use, and clinicians' responses. They found that, like younger patients, the elderly had scanty social supports but, unlike younger patients, came for care repeatedly with somatic complaints. Despite coexisting medical and psychiatric illnesses, these patients were generally managed by one service without consultation from the other. The authors, who found no differences in physicians' attitudes toward younger and older patients, emphasize the need to
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The authors prospectively abstracted ED records during a 22-day period in 1984 for demographic and medical variables. Older patients (ie, those 65 years of age or older) do not seem to be overusers of the ED for minor complaints; in fact, they tend to be more acutely ill on presentation than younger people. Older people were more likely to be hospitalized (46% vs 10%), to arrive by ambulance (35% vs 10%), and to have an identified source of primary care (95% vs 64%). Test-ordering patterns for specific complaints varied by patient age (eg, older patients had more ECGs performed for chest pain and fewer urinalyses for abdominal pain than younger patients). Therapy for specific complaints showed less age effect. Although generally more diagnostic tests were performed in older patients, the ED diagnosis tended to be more accurate for younger patients. These data indicate that the process of ED care may be substantially different for the elderly population and have implications for future planning and financing of medical care.
EDUCATION Jones J, Dougherty J, Cannon L, et al: A geriatrics curriculum for emergency medicine training programs. Ann EmergMed 1986;15:1275-1281. The authors present an integrated geriatric curriculum designed to operate within a three-year emergency medicine residency program. This curriculum identifies specific educational objectives for training in geriatric emergencies that can be summarized as follows: identify those impairments and functional disorders that often complicate diagnosis and therapy; acquire an understanding of how physiologic changes in aging affect normal laboratory and radiologic values; develop knowledge of drug side effects and interactions in this population; understand and treat the group of diseases peculiar to the elderly; recognize diseases and injuries that present a different clinical picture in old age; and differentiate and treat common psychosocial emergencies in the elderly. These educational objectives are further defined using a specific interlinked framework of didactic presentations, journal clubs, case conferences, therapeutic audits, formal rotations, and consultants. This format provides valuable educational experiences for the emergency medicine resident and may strengthen positive attitudes toward geriatric medicine.
Rahman A, Salend E, Liston M, et al: An educational program to improve geriatric emergency care. J EmergNurs 1989;15:313-317. This article describes a continuing education project designed to enhance knowledge and skill among emergency nurses and other ED personnel in assessing and meeting the needs of older patients. The project undertaken at the
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JoNes
UCLA Emergency Medicine Center demonstrated that not only is such education needed by ED staff, but it may provide the impetus for further efforts to improve care for older patients.
PREHOSPITAL 6erson LW, Skvarch MA: Emergency medical service utilization by the elderly. Ann Emerg Med 1982;11:610-612. The growing number of aged in the United States will continue to increase the demand for medical services, including emergency care. In a medium-sized city, 22% of 14,400 emergency medical services (EMS) responses were to patients older than 65 years. Of the elderly, those older than 75 years were more likely to call the EMS system than were those between 65 and 74 years old. Men used the service more often than women. Men were more likely to suffer a cardiac condition; women, an injury. Elderly patients were 1.7 times more likely to require paramedic-accompanied transportation to the hospital.
6illick M, Steel K: Referral of patients from long-term to acutecare facilities. JAm GeriatrSoc 1983;31:74-78. Medical care available to residents of 100 nursing homes and 16 chronic-care hospitals was assessed by studying transfers of such persons to the ED of an acute-care hospital. Patient transfers were compared with 338 elderly patients from home (control group). Elevated temperature (38.9 C or higher) was found in 17.3% of nursing home patients and 30% of chronic-care hospital patients, compared with 1.8% of controls; mental status abnormalities were found in 66.1% of patients from nursing homes and in 90.9% of those from chronic-care hospitals, compared with 36.2% of controls. In addition, patients from chroniccare hospitals, but not those from nursing homes, often showed substantial abnormalities of blood pressure and pulse. The probability of admission to the hospital was the same for residents of nursing homes and persons living at home (44.0% and 43.2%, respectively) but was higher for persons from chronic-care facilities (81.3%). No evidence for "dumping" of patients was found. The study concludes that use of a hospital ED by nursing home patients is very similar to that by home residents, suggesting an inadequacy of on-site medical services, whereas that by chronic-care hospital patients is restricted to major illness, which is entirely appropriate.
TRAUMA DeMaria EJ, Kenney PR, Merriam MA, et al: Aggressive trauma care benefits the elderly. J Trauma1987;27:1200-1206. To evaluate factors that determine the long-term potential for recovery in this population, the authors studied 63 survivors of blunt trauma older than 65 years. The overall level of injury was moderate, with a mean Injury Severity Score of 15.8. Thirty-nine patients (62%) had two or more body regions injured. Surgery was required in half the patients,
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one third experienced complications, and nine (14%) required ventilatory support for five or more days. Only two patients did not live independently before trauma. Immediately after discharge, 21 patients (33%) were independent, 23 (37%) were dependent but living at home, and 19 (30%) required nursing home care. Nursing home patients were older, more severely injured, had more severe head and neck trauma, and required surgery more frequently after trauma than patients discharged directly home. Twelve of the 19 nursing home patients (63%) returned home 3.1 months after discharge, and 13 of the 23 dependent patients (57%) became independent. Overall, 38 patients (57%) returned to independent living after trauma. Aggressive support of the elderly trauma victim appears justified because few patients require permanent nursing home care and most return to independent living after trauma.
Fischer RP, Miles DL: The demographics of trauma in 1995. J Trauma1987;27:1233-1236. By 1995, population aging will decrease the size of the high-injury-risk age cohort (14 to 34 years) by 7 million (-8.2%). The reduction in the high-injury-risk cohort should reduce the overall volume of penetrating and blunt injury nationally despite a population increase of 21 million. However, the number of and the proportion of elderly victims of injury will increase, as there will be an additional 5.3 million (+18.5%) people aged 65 years or older. Yet payments based on Medicare diagnosis-related groups do not provide adequate reimbursement for any victims of injury, let alone the elderly. Moreover, Medicare and Medicaid reimbursements for the long-term care so frequently needed by the elderly victims of injury are inadequate. As our population ages, the adverse financial impact of these circumstances resultant from population aging will increasingly strain the financial resources of our trauma centers.
Spaite DW, Criss EA, Valenzuela TD, et al: 6eriatric injury: An analysis of prehospital demographics, mechanisms, and patterns. Ann Emerg Med 1990;19:1418-1421. The authors evaluated EMS system use, injury mechanisms, and prehospital assessments among elderly victims of trauma. Prehospital information was reviewed for injuries occurring in patients 70 years or older who were evaluated and treated by Tucson Fire Department paramedics during a 12-month period. A total of 1,154 cases occurred, which represented 30.3% of all 911 dispatches involving elderly patients. Injury mechanisms were fall (60.7%), motor vehicle accident (21.5%), fight (2.4%), accidental poisoning (2.3%), and choking (2.1%). The most frequent injuries determined by prehospital assessment were head or face (25.1%), upper extremity (17.2%), hip (14.5%), lower extremity (13.8%), back (9.8%), and chest or abdomen (5.0%). Suspected hip (P < .001) and pelvic (P < .005) injuries occurred more frequently during fails, whereas back injuries occurred most frequently in motor vehicle accidents (P < .001). Seventy-one fall victims (10.1%) had
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suspected medical causes of their fall. Twelve patients (1.0%) were in cardiac arrest. A knowledge of these injury patterns will be useful to emergency physicians and EMS administrators.
RESUSCITATION Wu AW, Rubin HR, Rosen M J: Are elderly people less responsive to intensive care? JAm Geriatr,Soc 1990;38:621-627. To determine if advanced ~ge is associated with increased mortality independent of severity of illness, Wu et al compared older and middle-aged patients admitted to a medical ICU. Charts of 130 patients aged 75 years or older and 135 patients aged 55 to 65 years were reviewed during a 30-month period. Hospital stay was slightly longer in the older group (37 vs 39 days). However, when logistic regression was used to adjust for APACHE IIM scores, whether the patient had a private attending physician, admitting diagnosis, or presence of cancer, older patients did not have a significantly greater risk of dying. When pulmonary artery catheterization was added to the model, it independently predicted mortality. APACHE IIM was an excellent predictor of mortality.
Tresch DD, Thakur RK, Hoffmann RG, et el: Should the elderly be resuscitated following out-of-hospital cardiac arrest? Am J Med 1989;86:145-150. Elderly and younger patients who were resuscitated suecessfully and hospitalized after out-of-hospital cardiac arrest were studied to determine if there was a significant difference in hospital course and long-term survival between the two groups. This retrospective study consisted of 214 consecutive patients, divided into two age groups: 112 elderly (older than 70 years) and 102 younger (younger than 70 years) patients. Before cardiac arrest, 47 of 112 (42%) elderly patients had a history of heart failure, compared with 19 of 102 (18%) younger patients, and were more commonly taking digitalis and diuretics. Younger patients, however, more often had an acute myocardial infarction at the time of the cardiac arrest (33% vs 16%). At the time of cardiac arrest, 83% of younger patients demonstrated ventricular fibrillation, compared with 71% of the elderly. In contrast, electromechanical dissociation was five times more common in the elderly patients. Although hospital deaths were more common in the elderly (71% vs 53%), the hospital stay of the elderly was not longer, the elderly did not have more residual neurologic impairments, and survival after hospital discharge (65%) was similar to that in younger patients.
Sachs GA, Miles SH, Levin RA: Limiting resuscitation: Emerging policy in the emergency medical system. Ann Intern Med 1991;114:151-154. Patients, families, and physicians frequently decide that a hospitalized patient will forego CPR and document this decision with a do-not-resuscitate (DNR) order. In community settings (eg, home, nursing home, hospice), these orders may conflict with paramedics' standing orders to provide CPR
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whenever it is medically indicated. The authors did a nationwide telephone survey of state offices for coordination of EMS to see how the states deal with this potential conflict. Eight states wereidentified that have specific policies enabling EMS personnel to accept DNR orders for patients being transported by ambulance. State officials identified administrative complexities and legal concerns as the primary barriers to enacting rehospitalization DNR policies. The study also identifies 21 local EMS systems that have developed policies for accepting orders to withhold life-sustaining treatment. Four types of policy models, characterized according to procedure for validating DNR orders and telephone accessing the EMS system; show that regulatory reform can address policy barriers in the absence of enabling legislation.
Murphy DJ, Murray AMI Robinson BE, st al: Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989;111:199-205. Of 503 elderly patients, 112 (22%) survived initially, but only 19 (3.8%) survived to hospital discharge. The poorest outcomes were for patients with unwitnessed arrests (one of 116 survived), patients with terminal arrhythmias such as asystole and electromechanical dissociation (one of 237 survived), and patients with CPR lasting more than 15 minutes (one of 360 survived). Only two (0.8%) of 244 patients with out-of-hospital cardiopulmonary arrests left the hospital alive. Of 259 patients with in-hospital arrests, 17 (6.5%) survived to discharge. Most survivors had ventricular arrhythmias and were resuscitated within minutes. Initial survivors with either impaired consciousness or functional impairment after the arrest had significantly worse chances of survival than patients without these impairments. CPR is rarely effective for elderly patients with cardiopulmonary arrests that are out-of-hospital, unwitnessed, or associated with asystole or electromechanical dissociation.
PSYCHOSOCIAL AMA Council on Scientific Affairs: Societal effects and other factors affecting health care for the elderly. Arch Intern Med 1990;150:1184-1189. With advances in medical care, life expectancy of Americans has increased dramatically. The increase in the size of the elderly population has had a major impact on health care provision and will have an even greater impact on our health care system over the next several decades. Although today's medical students will spend nearly half their collective careers caring for the elderly, insufficient numbers of students show an interest in geriatrics. American society has become in many ways less traditional, and age is no longer seen as "a pathway to wisdom." Because we are now a more mobile society, extended families tend to scatter, and the elderly are frequently alone. We study the effects of our rapidly changing, youth-oriented society on health care for the elderly.
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Greenstein RA, Ness DE: Psychiatric emergencies in the elderly. Emerg Med C/in North Am 1990;8:429-441. To assess and treat elderly psychiatric patients properly, emergency personnel must be aware of the medical disorders associated with psychiatric illness and be prepared to initiate treatment quickly and appropriately. This article reviews the format for conducting a psychiatric history and mental status examination and discusses the most common emergency psychiatric disorders of the elderly and their management.
Council on Scientific Affairs: Elder abuse and neglect. JAMA 1987;257:966-971. Estimates of elder abuse approximate 10% of Americans older than 65 years of age; obtaining accurate incidence and prevalence figures is complicated by factors including denial by both the victim and perpetrator and minimization of complaints by health professionals. Broad agreement exists in categorizing elder abuse as physical, psychological, and financial and/or material, despite lack of uniformity in definitions. Systematic scientific investigation provides limited knowledge about the causes of elder abuse. Most experts, however, believe that family problems and conflict are a major precipitating factor. Preliminary hypotheses for elder abuse are extensively discussed. This report presents potential indicators of physical and psychological abuse, along with classification of elderly individuals at high risk, to assist the health professional in identification and prevention of elder abuse.
McDonald AJ, Abrahams ST: Social emergencies in the elderly. Emerg Med Clin North Am 1990;8:443-459. Elderly patients seek care from an ED for social problems as well as medical care. These problems are identified, and appropriate referral resources are described by the authors. Disposition problems, drug and alcohol abuse, and abuse of the elderly are key topics.
FUNCTIONAL ASSESSMENT Rowland K, Maitra AK, Richardson DA, et al: The discharge of elderly patients from an accident and emergency department: Functional changes and risk of readmission. AgeAging 1990;19:415-418. Four hundred fifty patients aged 75 years or older were followed up after discharge from an ED. Forty-three percent of all patients experienced some loss of functional independence. A small number (5.6%) were readmitted to the hospital within 14 days. This group was significantly less able to perform certain activities of daily living. Attention to functional assessment by ED staff may help to prevent readmission to the hospital of this frail elderly group of patients.
Denman SJ, Ettinger WH, Zarkin BA, et al: Short-term outcomes of elderly patients discharged from an emergency department. J Am Geriatr Soc 1989;37:937-943 To determine the short-term functional and medical outcomes and predictors of outcome after discharge from the
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ED, 100 elderly (65 years or older) and 100 uonelderly (younger than 65 years) patients were studied prospectively. There was no difference in patients' understanding of the diagnosis or in medication compliance. Elderly patients were more likely to keep scheduled follow-up appointments (87% vs 65%). Despite these similarities, the elderly had worse medical outcomes at three weeks; 67% of the elderly were better and 20% were worse. In contrast, 82% of the nonelderly were better and only 4% were worse. Functional impairments were more common in the elderly both at baseline and at three weeks. Independent predictors of poor medical outcome included age 65 years or older and functional impairment at baseline. Older patients with impaired functional status who are discharged from an ED should be targeted for close medical surveillance and ready access to health services.
Pinholt EM, Kroenke K, Hanley JF, et al: Functional assessment of the elderly: A comparison of standard instruments with clinical judgment. Arch Intern Med 1987;147:484-488. Using specific instruments and scales to measure mental status, nutritional state, visual acuity, gait, and activities of daffy living, Pinholt et al studied 79 medical inpatients aged 70 years or older. The patients' primary physicians and nurses were then interviewed and asked to rate their patients. The prevalence of functional impairment was high: 25 (32%) of the 79 patients were mentally impaired, 31 (39%) were malnourished, 18 (23%) were visually impaired, 31 (39%) had impaired gait, and 23 (29%) had problems with continence. Although clinicians recognized severe impairments, the sensitivity of their clinical judgment was poor in detecting moderate impairment in four categories: mental status sensitivity was 28% (five of 18); nutrition, 54% (14 of 26); vision, 27% (four of 15); and continence, 42% (five of 12). Comprehensive functional assessment instruments can detect these moderate impairments, which may be remediable through early intervention.
D I A G N O S T I C TESTING Kelso T: Laboratory values in the elderly: Are they different? Emerg Med Clin North Am 1990;8:241-254. Physiologic changes in the elderly can be expected to impair functions that usually are assessed by the performance of clinical laboratory tests. Biologic variability in this large, heterogeneous group is shown to be well established. Although some clinicians and clinical chemists have advocated the establishment of separate "reference ranges" for the elderly, satisfactory clear-cut ranges of acceptable limits in older patients have not been developed. Pertinent studies are reviewed and comparisons made, from which it is concluded that most laboratory values in older patients fall within the traditional "normal ranges" except for, in a few patients, acceptable elevations in serum alkaline phosphatase, blood urea nitrogen, glucose, or erythrocyte sedimentation rate.
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Loberant N, Rose C: Imaging considerations in the geriatric emergency department patient. EmergMed Clin North Am 1990;8:361-397. This article provides an overview of imaging modalities available to the emergency physician and a discussion of their applicability to common specific problems encountered in the geriatric population. In selected conditions, computed tomography, ultrasound, and radionuclide scanning have become primary modalities.
Jones J, Srodulski ZM, Romisher S: The aging electrocardiogram. Am J Emerg Med 1990;8:240-245. With advancing age, widespread histologic changes in the conduction system occur. These changes may alter several features of the ECG, including duration of the PR and QT intervals, orientation of the electric axis, duration and morphology of the aerial and ventricular complexes, and characteristics of the ventricular repolarization. With an awareness of atypical presentations and difficulties in ECG interpretation, emergency physicians may be able to improve the assessment and triage of elderly patients with acute coronary ischemia.
ADVERSE DRUG R E A C T I O N S Montamat SC, Cusack BJ, Vestal RE: Management of drug therapy in the elderly. N Engl J Med 1989;321:303-309. Drug therapy in the elderly is complicated by many factors unique to this age group. Because it requires careful individualization, therapy should be based on the principles of pharmacokinetics. Multiple disease processes, environmental influences, and genetic variation often combine with the physiologic effects of aging to affect the distribution of drugs in this population. Also, misconceptions about the degree of compliance with drug therapy and the frequency of adverse drug reactions in the elderly should be recognized. With people surviving to older ages in increasing numbers and accounting for a major proportion of drug use, clinicians must be attentive to the goals and consequences of drug therapy in elderly patients.
Fox FJ, Auestad AE: Geriatric emergency clinical pharmacology. EmergMeal Clin North Am 1990;8:1221- 1239. The first part of this review article discusses the epidemiology of drug use and adverse drug effects in the elderly. The second part presents principles of geriatric therapeutics in the emergency department as well as guides to information sources.
Morrow D, Leirer V, Sheikh J: Adherence and medication instructions: Review and recommendations. JAm Geriatr Soc 1988;36:1147-1160. Prescription medication nonadherence among the elderly is a serious problem. Nonadherence is primarily caused by poor communication between health professionals and elderly patients. More specifically, nonadherence often reflects the inability of patients to understand and remember their
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medication instructions. Therefore, adherence can be increased by designing instructions that enable elders to easily construct a clear and simple mental model of how to take their medication. Inexpensive microcomputer-based hardware and software make it possible to provide elderly patients with effective instructions.
ETHICS Adams J, Wolfson AB: Ethical issues in geriatric emergency medicine. EmergMed Clin North Am 1990;8:183-192. Particularly in the care of the elderly, the emergency practitioner must be able to respond to ethical concerns in a manner that will provide the greatest benefit to patients and their families. Resuscitation-related concerns form only a highly visible part of a broad spectrum of ethical issues arising in the emergency care of the elderly. This article provides a framework for the recognition and analysis of many of these important ethical issues.
Jahnigen DW, Schrier RW: The doctor/patient relationship in geriatric care. Clin Geriatr Med 1986;2:457-464. Information derived from the relationship of the primary care physician with an older patient provides the best possible way to eliminate or minimize many ethical conflicts that arise in the care of the very old. The conscientious physician can seek information regarding the patient's personal value scheme and his or her expectations and use the breadth of available technology to best serve the patient. Many of the issues raised in this article are discussed in much greater detail in subsequent articles. The discussions of the issues they encompass are intended to inform and to stimulate. There is legitimate reason for optimism that, with education and thoughtful review, physicians will be able to improve the manner in which they care for older individuals.
Radecki SE, Kane RL, Solomon OH, et al: Are physicians sensitive to the special needs of older patients? JAm Geriatr Soc 1988;36:719-725. The sensitivity of primary care physicians to the health care needs of older patients was explored by means of an analysis of the use of diagnostic tests and therapeutic procedures during ambulatory visits. Survey data on a total of 28,265 visits to internists and family and general practitioners were studied to determine possible age-related differences in care. The study found that diagnostic testing falls off significantly for patients 75 years of age or older and that internists use substantially more tests for each age group than do family or general practitioners. The pattern of use of diagnostic tests in this secondary analysis does not address the issue of "appropriateness" but does suggest a pattern that makes little sense based on the known distribution of disease and functional disability in aging populations.
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BIBLIOGRAPHY Jones
Strange GR, Flynn RJ, Whitehall J: Ethical considerations in emergency department management of terminally ill patients. Ann EmergMed 1989;18:1085-1088.
Evans RW: Health care technology and the inevitability of resource allocation and rationing decisions. JAMA 1983;249:2047-2053, 2208-2219.
Case discussion of a 78-year-old man with a history of cancer of the lung who presented to the ED with nonspecific complaints. During the course of his workup, an acute lifethreatening problem was revealed. A panel from the University of Illinois AfFiliated Hospitals Emergency Medicine Residency diseuss the ethical issues involved in therapeutic and disposition decisions.
The scarcity in resource allocations to health care programs is explained in terms of the aging of the population, concomitant increase in chronic illness, and the cost of technologies of uncertain benefit that have evolved in response to these factors. Resource allocation decisions (cost-benefit and cost-effectiveness analyses) and criteria for rationing (eg, medical criteria, decision analysis, chance, first come-first served, merit) are discussed. The problem of relative scarcity by society is raised as a check on the felt urgency of the need for medical rationing. The societal fear of death, which supports the preoccupation with health care, has implications for the resolution of these conflicts.
Iserson KV: Getting advance directives to the public: A role for emergency medicine. Ann EmergMed 1991;20:692-696. Advance directives are designed to allow individuals to determine the course of their medical care in the event that they are no longer able to transmit the information to their physician. The US Supreme Court's recent Cruzan decision increased the importance of these legal instruments by declaring that "clear and convincing" evidence may be required by states to terminate life support in a patient unable to express his or her wishes about care. Only 9% of Americans have executed advance directives. Emergency physicians have the opportunity to assist their patients in advance by disseminating advance directives to those who have contact with the ED: patients, family members, friends, health care workers, EMS personnel, and police. A plan is suggested that includes education, the availability of advance directives, personnel available to help with completion of the documents, and immediate entry of the directive into a medical chart, if requested. This is in conformance with a recent policy adopted by the American College of Emergency Physicians.
ECONOMICS Schneider EL, Guralnik JM: The aging of America: Impact on health care costs. JAMA 1990;263:2335-2340. The rapid growth of the oldest age groups will have a major impact on future health care costs. The authors use current US Census Bureau projections for the growth of our oldest age groups to project future costs for Medicare, nursing homes, dementia, and hip fractures. Without major changes in the health of our older population, these health care costs will escalate enormously, in large part as a result of the projected growth of the "oldest old," those aged 85 years and older. Medicare costs for the oldest old may increase sixfold by the year 2040. It is unlikely that these projected increases in health care costs will be restrained solely by cost-containment strategies. Successful containment of these health care costs will be related to our ability to prevent and/or cure those age-dependent diseases and disorders that will produce the greatest needs for long-term care.
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RESEARCH Applegate WB, Curb JD: Designing and executing randomized clinical trials involving elderly persons. JAm Geriatr Soc 1990;38:943-950. This article focuses on methods and problems of conducting a randomized clinical trial involving older participants. Special attention must be paid to framing precise primary and secondary study hypotheses, adjusting for the potential confounding effects of comorbidity and disability, and analyzing multiple outcomes. When the sample or study cohort is chosen, there will be an inevitable trade-off between internal and external validity. Because elderly study cohorts are more prognostically heterogeneous, consideration should be given to enrolling an "at-risk" cohort and possibly to stratified randomization.
Dubler NN: Legal judgments and informed consent in geriatric research. J Am Geriatr Soc 1987;35:545-549. Maximizing personal preference and supporting residual autonomy should be the goal in assessing the capacity of elderly persons to provide legally effective informed consent. Many elderly persons of declining or diminished abilities retain the capacity to provide consent for certain protocols. When individual capability is clearly inadequate, the choice of possible alternative deciders is clouded in legal and ethical uncertainty.
Stanley B, Giudo J, Stanley M, et al: The elderly patient and informed consent: Empirical findings. JAMA 1984;252:1302-1306. This study looks at the capacity of geriatric patients to eonsent to research participation through the use of hypothetical cases. The elderly subjects had the same choices about the "reasonableness" of the risk:benefit ratio of the proposed study as did the younger subjects, but the elderly persons - - who were not cognitively impaired - - had poorer understanding of the consent information. Thus, special precautions may be warranted in the consent process and standards.
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