Diagnosis of older adults with dyspnea is particularly challenging in the ED setting for many reasons. “Some ED decision tools, and also chest X-rays, aren’t quite as accurate in older patients as they are in younger patients,” says Katherine Hunold Buck, MD, an assistant professor of emergency medicine at the Ohio State University Wexner Medical Center.
Older adults might present with atypical symptoms, such as “just not feeling right.” Some experience a decreased sensation of dyspnea itself, so they do not even report feeling short of breath when they present to the ED. Older patients also may present with various comorbid conditions that are causing shortness of breath, such as congestive heart failure or COPD. “This leads to misdiagnosis, or diagnostic uncertainty,” Buck says.
If older patients with dyspnea are misdiagnosed, higher admission rates, longer stays, mortality, or rehospitalization within one year all are possible outcomes. “We really wanted to look at this group in particular. There is a potential for high reward for the ED,” Buck says.
Buck and colleagues enrolled 81 ED patients age 65 years or older who presented with dyspnea.1 The ED attending physician diagnosed pneumonia in 16 patients, COPD in 12 patients, and heart failure in 30 patients. “Based on expert review of the patient record and subsequent tests, we calculated under- and overdiagnosis rates for these diagnoses,” Buck explains.
The EPs’ diagnosis was correct in 89.9% of pneumonia diagnoses, 91.1% of the COPD diagnoses, and 73.4% of heart failure diagnoses. “We need tools that can help improve ED diagnostic accuracy,” Buck offers.
Certain tests that would give more information to complete the diagnostic picture are not available in the ED, such as bronchoalveolar lavage. Blood culture results also are unavailable. “On the inpatient side, we can watch the patient over time and see how the disease progresses,” Buck notes.
In contrast, ED providers are seeing a snapshot in time of the illness. Thus, it is not always possible to make the diagnosis in the ED. Buck says diagnostic uncertainty needs to be communicated, whether to the patients or family at discharge, or to inpatient providers (if the patient is admitted), or to outpatient providers who may follow up with the patient. “We need to be sure that we are clear that we haven’t definitively ruled out certain conditions,” Buck stresses.
In verbal handoffs and in the ED chart, EPs must be clear on this point. The differential diagnosis should be accompanied by medical decision-making that explains the diagnoses the EP believes are definitively ruled in or out, says Buck, as well as diagnoses about which information is lacking. “That way, the assumption is not that we have ruled something out when we are unsure,” Buck explains. “This may help prevent diagnostic momentum and early closure.”
- Hunold KM, Schwaderer AL, Exline M, et al. Diagnosing dyspneic older adult emergency department patients: A pilot study. Acad Emerg Med 2020; Nov 28. doi: 10.1111/acem.14183. [Online ahead of print].