The Elderly Patient

1
The Elderly Patient

• Tintinallis Chapter 307

2
Introduction

• more time-consuming, more difficult to evaluate,
  and use more resources than do younger adult
  patients
• physiology of aging results in altered disease
  presentations, altered pharmacodynamics, and
  decreased functional reserve, as well as social
  problems

3
Epidemiology

• Elderly population is growing
• 12 percent of the population was 65 years of age
  or older in 1990, whereas 20 percent of the
  population will be 65 years of age or older by
  the year 2030
• In 1995, almost 16 percent of ED visits were made
  by patients age 65 years and older, and 46
  percent were admitted to the hospital

4
Principles of Geriatrics

• 1. The patient's presentation is frequently
  complex.
• 2. Common diseases present atypically in this age
  group.
• 3. The confounding effects of comorbid diseases
  must be considered.
• 4. Polypharmacy is common and may be a factor in
  presentation, diagnosis, and management.
• 5. Recognition of the possibility for cognitive
  impairment is important.

5
Principles of Geriatrics

• 6. Some diagnostic tests may have different
  normal values.
• 7. The likelihood of decreased functional
  reserve must be anticipated.
• 8. Social support systems may not be adequate,
  and patients may need to rely on caregivers.
• 9. A knowledge of baseline functional status is
  essential for evaluating new complaints.
• 10. Health problems must be evaluated for
  associated psychosocial adjustment.
• 11. The emergency department encounter is an
  opportunity to assess important conditions in a
  patient's personal life.

6
Physiologic Changes

• patients are asymptomatic until they are stressed
  or reach a critical threshold
• resting cardiac output decreases at approximately
  1 percent per year after age 30 years
• Chronologic and physiologic age, however, may
  vary considerably

7
Specific Issues

• Altered Mental Status
• 30 to 40 percent will meet the criteria for
  either delirium or cognitive dysfunction, and
  often unsuspected by the physician
• 3 item recall is a good screening test
• Functional Decline
• Change in a patient's ability to perform tasks of
  independent living and is not a part of normal
  aging
• Acute functional decline needs to be evaluated as
  a medical emergency

8
Trauma

• Trauma
• 20 percent of trauma patients are 65 years of age
  or older, older patients represent 28 percent of
  trauma deaths
• Falls are the most common mechanism of injury for
  older persons, followed by motor vehicle crashes
  and pedestrian accidents
• blood pressure and pulse, often remain within
  normal limits until the patient deteriorates
  acutely
• many as 50 percent of older patients admitted to
  the hospital after a fall die within 1 year

9
Infection

• changes in the immune system with age are
  responsible for the increased susceptibility to
  infection in the elderly
• atypical disease presentations of sepsis
• Hypothermia may be evident instead of fever
• most common sites of infection include the lungs,
  urinary tract, abdomen, and skin

10
Dispostion

• elderly patients in the ED are more likely to
  require hospital admission for their illness or
  injury than are younger patients
• elderly patient's family, friends, and social
  support system should be informed and involved
  before the patient leaves the ED