Older Adults with Abdominal Pain Risk Mistriage, Inadequate Diagnostic Tests
Abdominal pain in older adults presenting to EDs is triaged as “emergent” acuity half as often as other similarly acute conditions, according to the authors of a recent analysis.1
Investigators compared adults age 65 years and older with a chief complaint of abdominal pain during 81,509 visits to 1,211 EDs from 2013 to 2017 to those who had no complaint of abdominal pain. Of adults age 65 years and older, 7% of the ED visits were for abdominal pain. These patients were less likely to be triaged to Emergency Severity Index level 2 (emergent) acuity.
However, abdominal pain patients were more likely to be admitted directly to the OR than older adults without abdominal pain. “Our finding does raise the concern that even within older adults, there may be under-recognition of the severity of abdominal pain at the time of triage, despite outcomes that are as bad or worse as non-abdominal pain chief complaints,” says Ari B. Friedman, MD, PhD, the study’s lead author and an assistant professor of emergency medicine at the University of Pennsylvania.
Friedman and colleagues wanted to know who receives effective testing, when clinicians use potentially ineffective or outdated testing (e.g., abdominal X-ray), and how many patients were screened for “curveballs” (e.g., ordering an ECG for the possibility the patient’s abdominal pain is caused by an inferior MI).
- One in six patients received an X-ray but not a CT or ultrasound. “While we can’t entirely rule out that some of these were chest X-rays looking for a pneumonia, most of them were probably abdominal plain films — X-rays. These have been shown to be misleading in a lot of cases,” Friedman explains.
- Most patients (60%) did not get an ECG. This is “a simple test that can help diagnose heart attacks, as well as arrythmias that can suggest the need for a CT angiogram to look for mesenteric ischemia, and also help avoid complications of nausea medicines,” Friedman reports.
- 40% of patients did not undergo CT or ultrasound imaging of their abdomen. “By contrast, 93% of 30-39-year-olds get an EKG for a chest pain chief complaint,” Friedman notes.
ED providers should not think of abdominal pain in older adults as “the same entity” as abdominal pain in younger patients. At the department level, Friedman says EDs should consider adding abdominal pain in older patients to the list of automatic ECG criteria.
“Review the patterns of prioritization of the CT scan to ensure that low-risk stroke and trauma patients aren’t unduly prioritized over older adults with abdominal pain,” Friedman advises.
Many changes related to aging can lead to “subtle presentations of insidious intra-abdominal pathology, leading to delay in diagnosis, missed diagnosis, and high morbidity and mortality,” says Bryan Baskin, DO, FACEP, quality improvement officer at the Cleveland Clinic Emergency Services Institute.
Exams can be less reliable without “classical” presentations due to less pain perception, febrile response, or muscular response to infection or inflammation.
“Of note, abdominal X-ray has limited utility in most cases to rule out insidious pathology. Abdominal X-rays in older adults have high positive predictive value but low negative predictive value and low sensitivity for most etiologies, including free air,” Baskin explains.
Thus, a “negative” abdominal X-ray is not as reassuring as it seems. Histories also might be unreliable due to cognitive changes. “Emergency medicine providers must keep a high index of suspicion for insidious etiology when seeing older patients with abdominal complaints,” Baskin concludes.
Elderly patients with abdominal pain represent a high-risk patient population, according to Chadd K. Kraus, DO, DrPH, FACEP, CPE, director of emergency medicine research and a practicing EP at Geisinger Emergency Medicine in Danville, PA.
One reason is these patients often present with multiple comorbid conditions, resulting in initial subtle or atypical symptoms. For example, patients might report just some mild nausea or vomiting, fever, or general malaise. Those might be the only clues to an intra-abdominal process, such as small bowel obstruction or infection.
“These subtle and nonclassic presentations can increase medico-legal risks because they frequently cause diagnostic errors or delays,” Kraus explains.
Failure to diagnose and treat a serious condition in an elderly patient in a timely manner can result in a malpractice claim, Kraus warns. Adding to the legal risks is the fact elderly patients with abdominal pain frequently present with conditions that require time-sensitive interventions.
Elderly patients also record high morbidity and mortality rates related to intra-abdominal processes. For EDs, “a broad diagnostic approach that considers worst-case scenarios can reduce the clinical and medico-legal risks in elderly patients with abdominal pain,” Kraus offers.
If the patient is to be discharged, clear and thorough return instructions are necessary. “Discussion with the patient, and documentation of a close follow-up plan within an established time frame, should be a part of the discharge for any elderly patient with abdominal pain,” Kraus says.
Discharged older patients with abdominal pain should be informed of new or worsening symptoms that warrant immediate return to the ED (including, but not limited to, symptoms such as fever, vomiting, or increasing pain).
“It is also important to document a clear, time-dependent follow-up — for example: ‘See your family doctor in the next 24-48 hours,’” Kraus recommends.
REFERENCE
- Friedman AB, Chen AT, Wu R, et al. Evaluation and disposition of older adults presenting to the emergency department with abdominal pain. J Am Geriatr Soc 2021; Oct 10. doi: 10.1111/jgs.17503. [Online ahead of print].
ED providers should not think of abdominal pain in older adults as the same as abdominal pain in younger patients. At the department level, consider adding abdominal pain in older patients to the list of automatic ECG criteria.
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