Introduction

Medical emergencies are common in older people and they may have difficulty accessing suitable health care once their GP practice is closed. They are less likely to use schemes such as NHS Direct than other parts of the population.¹ They or their carers are more likely to dial 999 if they have an urgent medical problem. The care of the elderly is an increasing proportion of work for GP out-of-hours services, ambulance services and Emergency Departments.

The acute medical problems of older people are often similar to those of younger adults but the presentation can be atypical or there can be a number of co-existing problems that make diagnosis difficult. Further difficulties occur in frailer, older adults who continue to manage at home despite the effects of increasing age and multiple medical problems. In these patients an apparently minor illness can lead to deterioration in a non-specific manner leading to immobility, a fall or acute confusion. The social circumstances and the availability of social support may be of greater importance than the management of the medical illness. Treatment at home is often the preferred and safest option. If a careful clinical and social assessment indicates that the primary problems require social support or nursing expertise, then clinicians must have the option of referring to community support schemes that are now more widely available.

However, major illnesses such as serious infections, heart disease and cancer can also present in a non-specific way. If the presence of one of these conditions is a possibility, then a planned short admission for investigation or early clinic review will be preferable to leaving the patient at home with subsequent admission in a worse condition at a later time.

The management of trauma and surgical emergencies is covered in other chapters. Discussion of single organ emergency problems in older adults such as myocardial infarction will be brief because they should be dealt with in a very similar way to their management in younger adults.

The main emphasis of this chapter is the assessment of physical state, mental state, medication and social circumstances in older adults presenting in a less specific manner such as with general deterioration, falls, confusion and minor injuries.

Community systems for the care of older people

The proper care of the older patient is one of the major priorities of many health systems. Some ‘full systems approaches’ are emerging but often they lack co-ordination and might only be available for limited times of the week. The bedrock of community care is Primary Care. In the future this will be augmented with support from General Practitioners with a Special Interest in Care of the Elderly or Community Care of the Elderly specialists (‘Community Geriatricians’) or intensive case management nurses. Acute events are common in this group and there needs to be a co-ordinated system to respond to emergency calls for help.

Figure 8.1 sets out the range of outcomes from community emergency assessment and shows the ideal system to respond to these emergencies. The community emergency medicine clinician carries out initial crisis support and a brief needs assessment. In significant numbers of older patients this will need to be backed up by either hospital or community services. The keys to success in such a system are excellent communication, mutual respect and clear referral pathways with common documentation systems.

Fig. 8.1 Range of outcomes from community emergency assessment and the ideal system to respond to these emergencies

Primary survey positive patients

The criteria for recognition of immediately life threatening problems are the same as for younger patients (Box 8.1). However the interpretation of vital signs may be more difficult and abnormalities need to be taken in context of pre-existing morbidity. A history from a reliable witness is essential. Previous neurological problems can make the GCS permanently <12. Similarly, the elderly are more prone to excessive bradycardia from cardiac medication but on the other hand, symptomatic heart block is common. Oxygen saturations should be interpreted in light of the known medical history and clinical setting.

Box 8.1 Vital signs indicating ‘primary survey positive patient’

A – potential airway compromise

unconscious patient/stridor/anaphylaxis/Hx of foreign body

B – severe distress

respiratory rate <10 or >29

oxygen sats <93% on air with no history of COPD

C – clinical signs of shock

pulse <50 or >120

systolic BP <90mmHg

D – GCS <12 (acute deterioration)

(acute stroke)

Primary survey positive patients should be transferred as soon as possible by paramedic ambulance to an A&E Department or an Emergency Admissions Unit depending on local protocols. The exception might be those patients with documented ‘end of life decisions’ such as Advanced Directives and clear, agreed treatment plans which might include ‘do not attempt resuscitation’ (DNAR) orders.

More than any other group of patients, the older adult might refuse transfer to hospital. If gentle coaxing has failed, carers and family can often be more persuasive. Sometimes it is necessary to consider whether the patient has the mental capacity to refuse transfer for assessment and treatment. In this situation it is possible to agree with family and carers that it is in the patient’s best interests to be taken to hospital, especially if they are suffering from serious life-threatening illness. Clear documentation of such decisions is essential in this situation.

Primary survey negative patients

In the elderly patient a greater emphasis must be given to factors other than the ‘medical problem’ alone. The variables to be considered are given in Box 8.2.

Box 8.2 Factors to consider when planning the management of acute events in older people

Severity of medical problem

Cognitive status of the patient

Social circumstances of the patient

Availability of community health and social care support