Severity of the medical problem

Patients with signs or symptoms of severe illness should be transferred to hospital unless there are exceptional circumstances. Even with less severe presenting complaints, review in hospital might still be necessary for medical reasons. The elderly are less able to withstand blood loss following, for example, epistaxis or a laceration. They may have a myocardial infarction despite presenting with only minor or no chest pain. There may be only limited signs of peritonism despite significant intra-abdominal pathology. They are at higher risk of developing intracranial haemorrhage and neuropsychological sequelae following a minor head injury. It is best to be cautious and where there is suspicion of serious pathology the patient should be sent to hospital for medical assessment or arrangements made for an immediate visit by the patient’s GP. Research has shown that elderly patients with minor falls who dial 999 have a mortality rate of up to 5% at 28 days.

Cognitive status of the patient

The presence of cognitive impairment often renders the history and self-reported ability with activities of daily living unreliable. It is important for any community practitioner to be able to recognise cognitive impairment and, where possible, confirm history with a reliable witness. Impaired cognition in someone living alone might mean they are unable to look after themselves despite an illness being only minor.

Social circumstances

When the medical condition does not of itself indicate that hospital admission is required, the patient’s social circumstances may have a large bearing on whether they can remain at home. The availability of someone to provide food and hydration, give medication and call for help if their condition deteriorates is crucial for a person who has had a fall with soft tissue injury, has a chest infection or a minor head injury. If the patient is living alone, explore other sources of help such as family or friends. If such help is not available then it might be necessary to arrange emergency support from community rapid response teams.

A further complication is that the patient may be the main carer for someone else. If this is the case, social services should be contacted to arrange a sitting service or temporary respite placement until the carer is able to resume those duties. A review of social circumstances includes finding out if the patient has someone who could act as a carer or if they provide care for someone themselves.

Health and social care services

Across the UK there are a range of services under a variety of names with the primary purpose of supporting older patients at home or within supported settings outside hospital. Knowledge of the locally available services and how to contact them is crucial. Most services provided at home include care workers, nurses and therapists. A relatively new concept is that of ‘intensive case management’ – patients with high medical, nursing or social needs may have specialist teams already assigned to their care.

Subjective information – history

Not all patients in this age group are able to give a reliable history and thus it is essential to glean as much information as possible from carers. Details of general history taking are reviewed in Chapter 2. Specific elements of the history, including the social history and features highlighted in Box 8.2, will determine the need for further investigation or transfer.

Objective information – examination

Vital signs (Box 8.4) are, as always, important but may be altered by pre-existing morbidity. The GCS is the most obvious example where pre-existing confusion will make assessment of the verbal score difficult. Similarly, pulse and blood pressure may be altered by pre-existing medications such as β-blockers. Any concern about the vital signs or general appearance of the patient should trigger an immediate hospital assessment.

Box 8.4 Assessment of vital signs and general appearance

Vital signs

pulse

blood pressure

respiratory rate

oxygen saturations

temperature

GCS

General

does the patient appear unwell?

colour, rash, sweating

hydration, eyes, mouth

The next stage is a focused systems examination. A full examination is required but given the huge number of problems causing falls or confusion certain areas should be given additional emphasis. The examination described in Box 8.5 is aimed at patients with falls but most also applies to patients with confusion, including assessments of both physical and mental status.

Box 8.5 Examination and simple tests for older patients with immobility, falls or acute confusion

General appearance

Evidence of not coping at home

Parkinsonian features, e.g. rigidity, tremor

Depression

Thyroid status

Flushed, pyrexial

Cardiovascular

Pulse including peripheral pulses

Lying and standing blood pressure

Source of emboli – heart rhythm, murmurs and bruits

Neuromuscular system

Lateralising signs

Parkinson’s disease

Proximal muscle weakness

Gait – ‘Get up and Go’ test³

Abdomen

Masses and constipation

Infection

Chest auscultation

Urine dipstick

Mental test score

Hodkinson AMT⁴ (see Box 8.6)

Tests

12-lead ECG

BM stix

Urine dipstick

There are many tools available for the assessment of cognitive function. Each has limitations but they can give an indication of problems with cognition and can be used to follow progress. Box 8.6 shows the 10-question Hodkinson Abbreviated Mental Test score which combines brevity with validity. Questions have to be asked in the order shown and are given 1 mark for the correct answer or no mark. A score below 8 out of 10 implies cognitive impairment.

Tests

Examination of a 12-lead electrocardiograph (ECG) is important if there is concern about a silent myocardial infarction. However, it should be remembered that it can often be normal in someone with unstable or a new presentation of angina – these patients should be transferred to the Emergency Department for assessment. In someone who has lost consciousness without palpitations, chest pain, seizure or injury and has fully recovered, a normal 12-lead ECG means transfer to A&E is not routinely necessary.

Blood glucose measurement should be routine in anyone with a history of diabetes or presenting with increasing confusion or blackouts.

Urine dipstick testing should be performed for anyone with symptoms of a urinary tract infection, such as the recent onset of confusion or signs of sepsis. Urinary tract infections affect a significant proportion of older adults.

Management plan

Older adults prefer to be treated at home and where possible this should be facilitated. Removal to unfamiliar environments can precipitate distress and confusion and lead to a further deterioration in the patient’s clinical condition and a further loss of independence. Transfer to hospital must therefore be reserved for those cases where further investigations are likely to be of benefit or where an adequate standard of care cannot be provided in the home. Competent elderly patients must be fully involved in making decisions about their care plan and any interventions must always be subject to their fully informed consent. Different management strategies are now discussed.

Treat and leave/review

Details of treatment of specific minor injuries are described in Chapter 13. Patients with minor illness can be treated at home if adequate support is available. However, it should be ensured that the patient and their carers clearly understand when and how to seek further advice or help if their condition does not improve or deteriorates. If patients do not require further referral their GP must still be informed of the ‘emergency’ episode and they can then decide when to review the patient.

Examples of treat and leave patients include those with chronic balance and gait problems despite support from the falls service, those with an obvious minor infection suitable for treatment with oral antibiotics, or those with soft tissue injury but no bony tenderness and requiring only simple analgesia.

Treat and refer

Many emergency calls reveal increased social care or community nursing needs. The occurrence of a previously un-investigated, non-specific presentation of illness in an older person also highlights the need for referral for a specialist assessment that can be started in Primary Care. Most health communities now have care pathways for dealing with patients presenting in a variety of ways – for example, following a fall. Those involved in emergency care must know how to access these pathways of care and how to obtain rapid response nursing and social care.

Another example suitable for treat and refer might be a patient who has fallen with a brief loss of consciousness or short period of palpitations. If they have recovered and have a normal 12-lead ECG they may be suitable to be left at home but referred for urgent review in a hospital or community clinic. An abnormal 12-lead ECG in the patient with loss of consciousness would, however, require hospital assessment.

Another reason for referral to hospital would be for X-rays to exclude fracture. Referral pathways should be established to enable the community emergency practitioner to directly refer patients for an appropriate X-ray with varying urgency. X-ray of what might be a minor fracture may be deferred if pain can be controlled with simple analgesics to avoid an admission in the middle of the night. However, if the patient is unable to care for themselves or the suspected fracture is associated with significant pain or neurovascular problems, an X-ray may be required in a shorter time-scale. Self-mobilising patients with suspected bony injuries to the upper limbs will rarely require transfer by emergency ambulance and alternative forms of transport should be considered.

Treat and transfer

There are several groups of patients in this category. Some have worrying symptoms, as in Box 8.7. Others are less ill but lack suitable support at home or appropriate services to support the patient at home cannot be organised. If a bed in an Intermediate Care facility cannot be arranged, these patients will need to be taken to hospital. Finally, there are those who cannot be properly assessed at home and who need to be brought to the Emergency Department for this to be done.

Box 8.7 Worrying features making hospital referral more likely

Falls

Recurrent blackouts

Altered behaviour before or after a fall

Associated symptoms, e.g.

– ischaemic chest pain requiring repeat ECG or cardiac enzymes

– ‘dizziness’ with a postural BP drop or with vertigo

New drowsiness

Inability to bear weight or use arms due to pain

Hip pain

Confusion

Acute onset

Recent medication changes

New symptoms such as personality change or focal weakness

Recent head injury

Behaviour likely to lead to harm for self or others

When transfer is required, the community emergency practitioner can make an important contribution to the work of the ambulance service by recommending the most appropriate form of transport for patients requiring admission. For example, a patient requiring no care other than assistance to get to the vehicle will not require a paramedic staffed emergency ambulance, and can be safely cared for by staff with more limited training, thus preserving scarce resources for those patients most likely to benefit from them.

Other factors to consider

Any clinician seeing an older person in their home has the opportunity to assess the level of care that person is receiving and whether they are being subject to abuse. The pattern of injury seen in physical abuse is often similar to those sustained during a fall but if the patient denies a fall the possibility of elder abuse should be considered. It should also be remembered that psychological, financial and sexual abuse plus abuse through neglect can all lead to physical and mental decline resulting in an emergency assessment. If elder abuse is suspected, social services should be informed. Please visit www.elderabuse.org.uk for more information and advice.