Anna Giulia Cattaneo,DBSM
Emergencies occurring in old patients can represent a complex
clinical problem, expecially because of staff members specialized
in treating geriatric patients are frequently lacking in emergency
departments. In the elderly the acute disease is often superimposed
to other chronical conditions, simply linked to the aging
itself. In general, there is no need of technical equipments
different from those used in acute care of adult but jounger
subjects, but special skill and competence should be auspicated.
Other aspects of this problem are linked to the social and
mental conditions of older patients: they should only be supported
by inaffective relatives, unable to cohoperate at the best
with the care givers, or even absolutely alone, as a number
of aged individuals living at home. Aging potentially affects
all the steps of clinical care.
1. Anamnestic records and diagnostic problems.
The first medical act, at least in usual conditions, is an
accurate anamnestic record. This is often impossible or difficult
to obtain in the case of emergencies, and the diagnostic skill
of the staff can be the only support for a correct diagnosis.
If the patient is an older one, additional problems can arise.
In this eventuality, it is important to distinguish between
what is due to the acute problem and what was prehexisting.
An old subject suffering form a recent stroke, as an exemple,
can be unable of talking, but is its inability recent and
due to the stroke itself, or is it, at least in part, linked
to prehexisting conditions, like a dementia, Parkinson disease
and other similar ones? Solving this problem can be important
for diagnostical prediction, and when the patient lacks care
givers or relatives which can answer the question an extra
skilled diagnostical performance is required to the staff.
The problem can be hewever much more subtle. An aged unknown
person cames in the emergency room in confusional state, a
not infrequent occurrence in aging. He (or she) does not have
any people at the present which can give very important informations:
is the patients suffering from dementia, diabetes, dehydration,
or other conditions possibly linked to its present state?
Is he taking medication potentially motivating the confusion?
Is the elder addict to drugs or alchool? Is he victim of an
accident or perhaps of an abuse episode? Of course, every
question can be answered, with the help of time and diagnostic
procedures, but you have a very good occasion to train your
ability in early diagnosis.
Even when the elder claims more physical symptoms, diagnosis
can be difficult. Pain is often poorly reported by the aged,
and an acute infarct can be misdiagnosed. Moderate abdominal
pain can be the only indicator of a dramatically evolving
events, like the rupture of an aortic aneurisma, but can even
be the symptom of benign and minor conditions. Chronic prostatitis,
urogenital inflammations, and even more benign prostatic enlargement
are a frequent evenience in aging, but a serious consequence
of these often not threatening conditions is acute urinary
retention frequently, in which extreme pain not due to inflammation
can be experienced.
Emergencies in elderly people can presents with unusual symptomatology,
other than pain, or pathology itself can be unusual in younger
individuals. Good practice requires both knowledge of the
diseases most frequent in elderly, and of those unusual in
general population, but more common at older age.
Inspection requires attention to eventual signs of poor hygienic
and nutritional conditions. Ecchymoses can suggest falls,
abuse or aggressive behaviour, accident or spontaneous bleeding,
even from life threatening lesions.
Even when the most probable diagnosis has been reached, the
age of the patient does not ceases to ask the doctor for its
best. Drugs have a large number of side effects, some linked
to the aging condition itself, and the need for no delay cannot
support a not cautious medication. Side effects of the drug
of choice and pharmacological interactions with drugs recently
or chronically assumed by the patient must be carefully considered,
even when the previous medication sheduling is unknown.
Updated reviews on this argument appear frequently in the
international medical publications (Am J Emerg Med. 2006 Jul;24(4):468-78;
Emerg Med Clin North Am. 2006 May;24(2):449-65, viii).
The physical frailty of old persons enhances the risk of side
effects in the case of challenging treatments and manipulations.
Every invasive therapeutic measure performed in the aged can
be much more destructive than in younger organisms, as a consequence
of reduced tissue trophism, poor hygiene, nutrition or tissue
hydration. Every type of catheterism is associated with an
increased risk of hiatrogenic complications because of tissue
frailty and lack of elasticity, and fistulae, ruptures or
hemorrages may follow this kind of manipulations.
When superficial scares must be cured, alternative repair
techniques (skin transplant, as an exemple) should be appropriate
even in the case of minor lesions: the risk of infections
and bleeding increases with the longer time required for skin
Falls and fractures are so frequent that can be considered
a special topic of the care of the aged person, requiring
a multidisciplinar approach, with the need of radiological,
medical, neurological, orthopedic and rehabilitative diagnostics
4. Some acute conditions frequently presenting unusual features
in the elderly.
This last point is not planned, of course, to be a complete
discussion of the argument, but only to recall some occurrencies
choiced from the most recent reports appeared in medical literature.
Age is the most important single risk factor associated with
stroke, and this last is probably the most important cause
of long-term disability in the industrialized world. However,
other modifiable risk factors are recognized possibly influencing
the prognosis. The scheduling and effectiveness of treatment
are greatly influenced by the gap between the event and the
request of medical help, but this kind of data are frequently
undereported in the case of elderly patients.
Acute respiratory failure in the elderly is an important
topic, but studies evaluating prognostic factors (mortality
or long-term outcomes) have been considered lacking (Fagon
JY, Crit Care. 2006;10(3):R82).
Acute psychiatric disorders, agitation and aggressive behaviour,
confusion, amnesia, can be common in the older, and require
an accurate diagnosis, as focused in a recent review on the
argument (Emerg Med Clin North Am. 2006 May;24(2):467-90,
viii). A wide class of drugs used to control agitation shows
weak evidence for antiaggressive effects, atypical antipsychotics
seem to be superior to others. The intramuscular formulation
provides a powerfull mean of treating for emergency care.
In the case of elderly patients with dementia, however, they
are considered unsafe (J Clin Psychiatry. 2006;67, 1013-24
and Suppl 10:22-31). Seizures are another evenience which
can be frequent in the elderly, not to be confused with agitation,
stupor or confusional conditions.
Fever must be correctly diagnosed; acute toxicity of neuroleptics
is one possibility between others.
Myocardial ischemia and infarct can present unusual features,
the recently defined transient left ventricular apical balooning
being a most elusive one (WMJ. 2006 May;105(3):49-54).
Spontaneous internal hemorrages and bleeding must be carefully
considered, and surgical treatment never considered an obsolete
or desperate measure at any age, even in the very old patient.
Bleeding can occurs from varices, expecially in hepatic cirrhosis,
and ileal varices can occur, in addition to more traditional
localizations (J Nippon Med Sch. 2006 Aug;73(4):221-5).
Aortic sclerosis can be the source of aneurismatic ruptures,
which can be poorly symptomatic even if seriously life threatening.
An unusual case of retropharyngeal hemorrage presenting with
cough, dysphagia, dyspnea, and cervical ecchymosis in an octuagenary
male patient has been reported by Miller et al. (S D Med.
2006 Jul;59(7):295-7, 299).
Monitoring vital parameters during stressfull manipulations
permits a safer procedure, with early detection of both gradual
deleterious trends of pre-existing conditions and acute emergencies
occurring during the treatment. Monitoring has been proposed
as auspicable for elderly persons even during dental care
(Int Dent J. 2006 Apr;56(2):102-8).
In summary, it seems to be auspicable that in the emergency
departments several staff members should be expecially trained
in treating the frail aged patient. In addition, it should
be of great help a programmed intervention focused on social
prevention of neglect and abuse of old persons living alone.
Better connection between nursing homes or residential care
givers and hospitals, and continuity of care after the emergency,
actively involving general practitioners, nurses and nursing
home staff, should be obtained with the help of special training
Anna Giulia Cattaneo, DBSM, Università
dell'Insubria, Via J-H Dunant,3 - 2100 Varese
|Gli editoriali più recenti