Are elderly patients undertriaged? Don’t miss life-threatening conditions

Comorbid and chronic conditions put patients at risk

If a 78-year-old woman came to your ED with lower abdominal pain and bloating, but had normal vital signs without chest pain, would you suspect a myocardial infarction (MI)?

When this patient was placed on a monitor, ED nurses at Carondelet St. Mary’s Hospital in Tucson, AZ, saw large ST-elevation in most leads, and point-of-care testing revealed positive myoglobin, creatine kinase, and troponin levels.

"The MI was of unknown time since she never had chest pain," says Mary G. Kelley, MS, ARNP, CEN, triage coordinator. "She also had an infracted bowel and died within the week from overwhelming sepsis."

At the same ED, a 94-year-old woman complained only of tiredness. "She looked great, without any complaint of chest pain and no history of any health problems," she recalls. "I was quite surprised when her heart rate during triage was 28." The patient was given a temporary pacemaker in the ED, admitted to the hospital, and subsequently discharged home without problems.

When triaging elderly patients, it is easier to miss common signs and symptoms of an acute problem, says Kelley. "Frequently, geriatric patients have many comorbid conditions that make it difficult to paint a picture," she says. "Also, elderly patients may have a problem over a long time, and their body compensates until it is unable to maintain homeostasis."

Older trauma patients are at high risk for being undertriaged, adds Linda J. Scheetz, EdD, APRN, BC, CEN, assistant professor at the College of Nursing at Rutgers, The State University of New Jersey in Newark. She points to a study showing that older patients were admitted to nontrauma centers more often than younger patients with comparable injuries. "This was possibly an inappropriate level of care given their injury severity," she says.1

Never assume that elderly patients have only minor injuries because they were taken to a nontrauma center ED, warns Scheetz. "Accurate triage in the ED according to accepted standards of practice is imperative," she says. She recommends using a five-level triage system for early identification of patients at risk for poor outcomes.

Older trauma patients often have a blunted physiologic response, so you may not see the typical "red flags" of hemodynamic instability, says Scheetz. This is due to a natural decline in immune system function associated with aging, and beta-blockers and angiotensin-converting enzyme (ACE) inhibitors may aggravate it, she explains. Additional factors that make accurate triage difficult include confusion, which may have been present before the traumatic event occurred, diminished hearing, a reluctance to admit pain, and a desire to avoid "burdening" ED staff, says Scheetz.

Even if injuries appear minor, perform thorough reassessments to check for delayed changes in physiologic status that indicate more serious injury, she advises.

Always obtain a clear history of an accident, fall, or motor vehicle crash, because this may raise your index of suspicion for internal injuries even if patients aren’t manifesting symptoms, says Kelley. She points to the example of a 78-year-old man who reported a headache after a fall, was given a computed tomography (CT) and discharged, but returned two days later with severe hip pain unable to walk. At this time, the patient’s wife informed ED nurses that he had fallen off the roof after drinking. "The patient had a hip fracture that was missed because the mechanism of injury was not fully explored," says Kelley.

To significantly improve assessment of geriatric patients, do the following:

  • Take into account age-related physiologic changes.

Here are age-related changes to consider when assessing vital signs:

— Geriatric patients are less likely to be tachycardic and tachypneic because of decreased maximum heart and respiratory rates, says Steven D. Glow, RN, MSN, FNP, adjunct assistant professor at the College of Nursing at Montana State University-Bozeman in Missoula.

— Hypovolemia in a patient with pre-existing hypertension can result in relative hypotension that falls within a "normal" blood pressure range, says Scheetz.

— Don’t assume that renal function is normal in a patient because urine output is good and blood urea nitrogen and creatinine are within normal limits, says Karen Hayes, PhD, ARNP, faculty at the School of Nursing at Wichita (KS) State University. "Because muscle mass declines with age, renal function can be impaired despite a serum creatinine level in the normal range," she explains. "When a creatinine level is even a little high, the renal function may be very marginal."

— If a patient still is awake after head trauma, this doesn’t mean you can rule out a large subdural hematoma, says Hayes. The elderly are at more risk for this because of the stretched cerebral veins caused from brain atrophy, so you must monitor closely for any changes in mental status, Hayes explains.

"If subtle signs of mental status changed are missed in the ED, the subdural may grow to press on vital brain structures causing serious brain damage," she says. "This is particularly dangerous if the patient is discharged."

— Aggressively treat a low hematocrit in patients with significant cardiac and/or pulmonary dysfunction, says Hayes.

"Elders who compensate for poor cardiac or respiratory function with increased hematocrit will decompensate quickly when they enter a blood loss state," she says. "The ED nurse must recognize the potential for danger and monitor closely until the blood loss can be stopped or blood replaced."

Most elderly patients take blood thinners, such as aspirin to prevent strokes or maintain patency after angioplasty, notes Linda Whitt, RN, BSN, CEN, ED nurse at Bon Secours DePaul Medical Center in Norfolk, VA. "Some are on more potent thinners like [warfarin] or [clopidogrel], so they are much more likely to bleed from injuries, specifically to their heads."

— Elderly patients with chest trauma may have rib fractures and/or pulmonary contusion even if this isn’t initially apparent on X-ray, says Hayes. "Because the chest wall may be frail in an elder, rib fractures and resulting pulmonary contusion may occur with minimal trauma," she says. "If missed, respiratory difficulties may ensue."

  • Allow patients to explain what brought them to the ED.

You will get more information by listening carefully than by firing a bunch of questions at the patient, Kelley advises. For instance, if a patient tells you that his groin pain came on suddenly and is not radiating into the flank, this could mean the difference between a diagnosis of abdominal aortic aneurysm vs. a kidney stone, she says.

  • Ask "what is different today?"

Ask family members "what are you seeing now that is different from this patient’s normal behavior, such as level of functioning, mental status, or speech?" or ask the patient, "What is different about how you feel now compared to your normal state of health?" suggests Glow.

These questions can help you determine if altered mental status such as memory loss, confusion, and altered gait are normal for the patient or signs of altered electrolytes or altered glucose, says Glow.

If a patient’s complaint is an acute exacerbation of a chronic problem, ask what occurred recently that caused the condition to worsen, advises Glow. For example, many patients with chronic obstructive pulmonary disease are always short of breath, but knowing that the client had a sudden change in sputum color might point to pneumonia as the cause of increased dyspnea, Glow explains.

Without this information, the patient’s condition may be difficult to assess correctly, says Glow. "Stroke symptoms such as slurred speech, weakness, or facial droop are treated very differently if they have been present for an hour vs. several years," he adds.

Reference

1. Scheetz LJ. Trauma center versus nontrauma center admissions in adult trauma victims by age and gender. Prehosp Emerg Care 2004 Jul-Sep; 8:268-272.

Sources

For more information on assessment of elderly patients, contact:

  • Steven D. Glow, RN, MSN, FNP, Adjunct Assistant Professor, College of Nursing, Montana State University-Bozeman, Missoula Campus, 32 Campus Drive, No. 7416, Missoula, MT 59812-7416. Telephone: (406) 243-2536. Fax: (406) 243-5745. E-mail: sglow@montana.edu.
  • Karen Hayes, PhD, ARNP, Faculty, School of Nursing, Wichita State University, 1845 Fairmount, Wichita, KS 67260. Telephone: (316) 978-5721. E-mail: karen.hayes@wichita.edu.
  • Mary G. Kelley, MS, ARNP, CEN, Triage Coordinator, Emergency Department, Carondelet St. Mary’s Hospital, 1601 W. St. Mary’s Road, Tucson, AZ 85745. Telephone: (520) 872-2422. E-mail: mkelley@carondelet.org.
  • Linda J. Scheetz, EdD, APRN, BC, CEN, Assistant Professor, College of Nursing, Rutgers, The State University of New Jersey, Ackerson Hall, 180 University Ave., Newark, NJ 07102-1814. Telephone: (973) 353-5326, ext. 537. Fax: (973) 353-1277. E-mail: lscheetz@andromeda.rutgers.edu.