Brian Dolan

Chapter Contents

Introduction

Older people constitute a growing proportion of attendances to the Emergency Department (ED). This chapter addresses the changing UK demographics, and the physiology of ageing, before considering the assessment of common acute older adult presentations, such as hypothermia, confusion and falls. The effects of polypharmacy and elder abuse will also be described and discussed.

In demographic terms, the UK has an ageing population. From 1971 to 2021 the number of people in the UK aged 65 and over is expected to increase by nearly 70 % from 7.3 million to 12.2 million (Office for National Statistics 2006), because average life expectancy in the UK has doubled in the last 200 years. By 2021, there will be more people over 80 than under the age of 5; over a quarter of the population will be over 60. The number of people aged over 65 years is escalating, with the fastest-growing group being those aged over 80 years. In England and Wales, the numbers in this age group increased by >1.2 million between 1981 and 2007 (from 1.5 to 2.7 million), from 2.8% to 4.5% of the population. It is suggested that by 2021 there are expected to be 601 000 people aged 90 and over (Office for National Statistics 2009).

More older people are likely to be admitted to hospital as the population ages; often this is via the ED as the gateway to hospital care. Older peoples’ health problems are also often complex clinically and managerially, thus time consuming and challenging for clinical staff (Bridges et al. 2005, Beynon et al. 2011).

Background

There is evidence from the UK, North America and Europe that people who live in areas of socio-economic deprivation have higher rates of emergency admissions, after adjusting for other risk factors. In the UK, admission rates are significantly correlated with measures of social deprivation (Majeed et al. 2000). Socio-demographic variables explain around 45 % of the variation in emergency admissions between GP practices, with deprivation more strongly linked to emergency than to elective admission (Duffy et al. 2002). Practices serving the most deprived populations have emergency admission rates that are around 60–90 % higher than those serving the least deprived populations (Purdy 2010, Purdy et al. 2011).

There have been concerns about the quality of care delivered to older people for many years. The Health Advisory Service 2000 (1998) identified eight major issues affecting the care of older people (Box 22.1). It was reported that older people waited longer in the ED than any other patient group (Association of Community Health Councils for England and Wales 2001); however, it was also acknowledged that older people present with more complex needs and take longer to process (Clark & Fitzgerald 1999). Meyer & Bridges (1998) found evidence of negative attitudes amongst nurses towards older people in the ED. Spilsbury et al. (1999) interviewed ED patients about their experiences. They reported concerns about lack of assessment, long waiting times, and staff not taking into account their sensory or physical problems while not giving consideration to their privacy, safety and comfort. They also stated that staff did not appear to understand their pre-admission circumstances. Meyer & Bridges (1998) concur, stating that ED nurses perceive their role as primarily providing biomedical care rather than nursing care. This prompted the Royal College of Nursing A&E Nursing Association to release a mission statement on the care of older people in the ED, which highlights the need to:

Higgins et al. (2007) describe the persistent negative attitudes of nurses towards older people in acute clinical settings and the National Service Framework for Older People creates a benchmark to underpin the care of older people (Department of Health 2001a). The aim of this document is to address their needs, by promoting knowledge-based practice and partnership working between those who use and those who provide a service (Department of Health 2001a). This highlights the need for emergency nurses to have expert understanding of the ageing process, specialist assessment whilst also developing practice through leadership, teaching and mentoring. Nikki et al. (2012) argue that more attention should also be paid to empathic encounters with family members, who will know the patient’s previous functional capacity and medication, which is decisive information when planning further care and thinking about the patient coping at home.

Physiology of ageing

There is no single unifying theory of ageing and it has recently been investigated as a complex, multifactorial process. Death and ageing are distinct entities, but ageing is associated with numerous gradual declines in physiological function that will inevitably lead to death. In broad terms there are two categories of theories to ageing (Maguire & Slater 2010). Ageing is genetically programmed and influenced by the environment, so the rate of ageing among people varies widely (Cheitlin 2003). Ageing is characterized by a general deterioration of bodily function. Although ageing is considered to be inevitable, the reality is that the rate of deterioration in organ function can be reduced by factors such as regular exercise and accelerated by habits such as cigarette smoking and heavy alcohol consumption. Indeed, there is considerable variability in individuals’ susceptibility to ageing. Table 22.1 outlines some of the organ and tissue changes associated with ageing, which will underpin patient assessment.

Assessment

An older person presenting to the ED requires a thorough physical, psychological and social assessment. Good communication is vital and the emergency nurse must have the ability to listen effectively. As older people’s hearing and vision may be impaired and their responses slow, it is important to give the patient time to express themselves freely. It is also important to remember that the history-taking process may take longer than the physical examination, and studies indicate that over 80 % of diagnoses are based on the interview alone (Epstein et al. 2003). Patients have previously expressed concerns about lack of assessment and information-giving (Considine et al. 2010). Older people can present with multiple pathologies and the presenting complaint may not be the only condition that needs to be considered.

The emergency nurse needs to elicit why the person has attended the ED. The assessment can begin with a general question that allows full freedom to respond; for example, ‘What brings you here?’ or ‘What can we do for you?’ After the patient answers, probe further by asking ‘Is there anything else?’ It is imperative to remember that patients may also have complex psychological and social causes and may have complicated feelings about themselves, their illnesses or potential treatments. To gain a thorough history, which fulfils the patient expectations, the interviewing technique must allow patients time to recount their own stories spontaneously (Bickley & Szilagyi 2003). An example of how to structure history taking is provided in Table 22.2.

When first meeting the patient, the nurse should introduce themselves, both as a courtesy and as an opportunity to establish a rapport. If the patient has walked into the department, the nurse should accompany the patient to the cubicle and observe features such as gait, balance and pace.

If the patient needs to get undressed, they should do so themselves if they are able, as it is important for the patient to feel in control as much as possible. Offering the patient a seat while undressing will allow them to remove their clothes more easily. It also enables the nurse to assess the patient’s balance and ability to self-care. It is not essential for patients to remove all their clothing when getting undressed, and undergarments should only be removed if necessary. If the patient is wearing pyjamas or a nightdress on presentation, there is rarely a need to change into a hospital gown; however, the patient will usually require a full examination, and clothing should not inhibit this. The patient may require steps to climb onto the trolley where they are able.

Careful attention should be given to the condition of the patient’s skin; inspect the patient for old wounds, unhealed ulcers or bruises. The latter may give an indication of elder abuse (considered later in this chapter). An initial nutritional assessment should be completed.

Not all patients attending the ED require a full set of vital signs and the older person must be assessed individually. For many patients, vital signs will form an integral part of the patient assessment. Older people may have altered vital signs that are normal for them; however, it is imperative to establish their normal baseline. This can be gained from the patient or relative, the computer record system or the patient’s Single Assessment Process document (Department of Health 2001a). For example, the heart rate of an older person is likely to be slower, with arrhythmias being relatively common in otherwise asymptomatic patients. Similarly, the older person’s blood pressure is likely to be elevated, usually as a consequence of atherosclerosis. This predisposes the patient to the development of cardiovascular diseases, such as congestive cardiac failure, stroke, transient ischaemic attacks and dementia. If a normally hypertensive patient appears to have a normal blood pressure they may actually be hypotensive. Similarly, if the patient is prescribed and taking beta-blockers they will fail to have a tachycardic response to shock, so the emergency nurse must apply knowledge of pharmacology and altered physiology when analyzing vital signs.

A baseline temperature should be recorded. In older people, the temperature is usually recorded as 36.5°C or above, due to the reduction in basal metabolic rate. The patient’s respiration rate may be increased due to underlying conditions such as chronic obstructive pulmonary disease or asthma. Poor personal hygiene may reflect difficult socio-economic circumstances of the patient rather than an inability to cope, and the nurse should take this into account when assessing the patient. The patient’s pre-existing medical and drug history should be assessed and recorded during the assessment.

As with patients of all ages, the nurse needs to use language the patient will understand and provide frequent orienting information about the time, place and person, including explanations of equipment, procedures and routines. Older people may process information more slowly; the nurse should develop comfortable and natural ways of talking to the patient, bearing in mind normal deterioration in hearing and other special senses that are associated with ageing. Others involved in the care of the patient, such as relatives or ambulance crew, should be consulted about the patient’s condition. However, the patient’s view should be sought as much as possible, with others used to supplement the information provided by the patient.

Elder abuse

Elder abuse, although increasingly recognized as a violation of human rights, remains one of the most hidden forms of inter-family conflict within many societies (Podnieks et al. 2010, Naughton et al. 2012).

The prevalence of elder abuse in the UK is estimated to be 2.6 % (Biggs et al. 2009) although international studies range from 2.1 % in Ireland (Naughton 2011), to 9–11.4 % in the US (Lauman et al. 2009, Lowenstein et al. 2009), which raises several questions. Are the differences related to cultural/societal factors or study design factors or in the risk factors for elder abuse? Nurses should have a high index of suspicion when assessing older people, as with non-accidental injury in children. Clinicians must assess whether the mechanism is consistent with the injury or illness presented (Crouch 2003) as cognitive impairment limits older adults’ abilities to advocate for themselves and possibly heightens their risk for abuse (Ziminski et al. 2012). If emergency nurses know the red flags of abuse (Box 22.2), the right questions to ask (Boxes 22.3 and 22.4) and the appropriate action to take in cases of suspected abuse, they can make a critical difference to the welfare of an older person (Gray-Vickery 2005). As Phelan (2012) notes nurses in the ED should be cognizant of interviewing the older person on their own when collecting information, as he may be hugely compromised with the presence of a family member who may be the perpetrator. It is also useful to interview the accompanying relative separately to elicit the cause of attendance, which may deviate from the older person’s account. In the context of a relative refusing to leave, it should be noted and the older person should be facilitated to answer the questions rather than being dominated by the relative/other person. This is also why it is essential to build up rapport with the patient to enable to older person to disclose. If nurses suspect abuse, attention to detail when documenting is of paramount importance. Document the person’s account in their own words (Community and District Nursing Association 2003) and signs of abuse clearly, and consider the use of illustration through medical photography; this requires specialist consent and adherence to local protocols. Upon detection of abuse local guidelines and policies should be adhered to.

The questions act as a guide; enquiries must be made sensitively in a private and safe environment, allowing the person time to speak. It is important to find out what the person wants to happen.

Polypharmacy

The use of multiple medications (polypharmacy) is common among older people (Linton et al. 2007, Zarowitz 2011). This is caused by many factors, such as co-existing chronic conditions, use of more than one pharmacy, increase in the availability of over-the-counter medicines and multiple prescribing providers. Indeed, interviews carried out with multi-professionals reported that participants admitted that prescribing was sometimes inappropriate and prescribing for chronic diseases was poorly understood (Spinewine et al. 2005). A US study indicated that 23 % of women and 19 % of men take at least five prescription drugs (Kaufmann et al. 2002). These figures, however, do not take into account medication purchased over the counter.

The effects of polypharmacy may have precipitated the patient’s attendance at the ED. Falls and dehydration are common risk factors associated with multiple medications (Department of Health 2001b). Emergency nurses need to be aware of medicine-related features, which are known to be associated with problems in older people. These are:

Social and personal factors associated with medication-related problems are: