Managing the Elderly Emergency Department Patient

Summary of Managing the Elderly Emergency Department Patient

Annals of Emergency Medicine, Volume 73, no. 3 : March 2019

Christina L. Shenvi, MD, PhD; Timothy F. Platts-Mills, MD, MSc*

*Corresponding Author. E-

Head CT

We routinely obtain head CTs for older patients with head trauma, even in the absence of loss of consciousness, but will consider avoiding imaging if the patient has a minor mechanism of injury, has no headache or neurologic symptoms, is not receiving anticoagulants, can return rapidly if they develop symptoms, and understands the risk of not receiving a head CT. 

C-Spine

In the context of a research study, the National Emergency X-Radiography Utilization Study criteria had a sensitivity of 100% (95% confidence interval 97% to 100%) for identifying clinically significant cervical spine injuries.31 These criteria have been externally validated in older fall patients.32 We think the criteria can be applied to older adults but that patients with baseline cognitive impairment should be considered to have an “altered level of consciousness” and thus not meet criteria for avoiding imaging.

Rib Fracture

Rib fractures are also common and morbid in older adults. The probability of developing pneumonia increases with each rib fracture, with reported rates of 30% in older adults with 3 to 4 rib fractures and 50% with 6 or more fractures.34 Given the low sensitivity of chest radiograph (<50%)35 and the risks of respiratory failure and pneumonia, chest CT should be considered in patients with a negative radiograph result but in whom rib fractures are suspected according to chest wall tenderness, tachypnea, hypoxia, or splinting.  Admission should be considered for older patients with rib fractures to provide analgesia, monitoring of respiratory function, and pulmonary therapy.

Hip Fracture

X-rays are 98% sensitive.

In patients with hip fractures, ED ultrasonographically guided femoral nerve block should be considered. When followed by a continuous fascia iliaca block, this approach is associated with reduced opioid use, improved postoperative pain, and improved functional outcomes at 6 weeks.39 39. Morrison RS, Dickman E, Hwang U, et al. Regional nerve blocks improve pain and functional outcomes in hip fracture: a randomized controlled trial. J Am Geriatr Soc. 2016;64:2433-2439.

Adverse Drug Reactions Medications

Polypharmacy, most commonly defined as receiving 5 or more medications, is a major risk factor for adverse drug reactions.48,49 Classes of medications that frequently result in ED visits for adverse drug reactions include anticoagulants, antibiotics, diabetes agents, and analgesics

For patients with adverse drug reactions who do not require hospitalization, emergency providers should strongly consider stopping the offending medication. Tapering may be necessary with antidepressants, antihypertensives, and benzodiazepines. Patient-specific deprescribing, which is a process to reduce medication burden, has been shown to reduce mortality,52, Deprescribing algorithms can be found at http://www.deprescribing.org.

Goals of Care

Ask about activities of daily living, ask about advanced directives and POLST forms, ask about goals of care.  UpToDate has the ReMAP stepwise approach.