Elderly Fall
Answer: D
The elderly represent 12 to 24% if all ED visits; they present more frequently and with higher morbidity than younger patients. They have up to a 5-fold higher risk for admission and 5-fold higher admission rate to the ICU. This ever-increasing population is made more challenging by multiple comorbidities and the atypical presentation of serious illness in this age range.
Collateral information from family or caregivers is important to consider. Although he has no chief complaint, it is important to screen this man for delirium. Up to one quarter elderly patients present to the ED with delirium, dementia, or both. It is sometimes difficult to differentiate the two, as up to 50% of those who present with delirium have underlying dementia. Observational studies have shown that delirium in the ED is diagnosed with a high specificity (98 to 100%), but with an unacceptably low sensitivity (16 to 35%).
The Confusion Assessment Method (CAM) is a rapid bedside screening tool validated in the ED with 86% sensitivity and 100% specificity. Inouye et al (Ann Intern Med, 1990) proposed the following:
To diagnose delirium in the acute setting, patient should have both (1) and (2) and either (3) or (4):
1. Is there evidence of an acute change in mental status from the patient’s baseline?
2a. Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
2b. Did the behavior fluctuate during the interview, that is, tend to come and go, or increase and decrease in severity?
3. Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
4. Overall, how would you rate this patient’s level of consciousness?
● alert (normal)
● vigilant (hyperalert)
● lethargic (drowsy, easily aroused)
● stupor (difficult to arouse)
● coma (unarousable)
(feature shown by any answer other than “alert”)
A fall may be the only presenting complaint for an infectious etiology; classic signs such as fever and tachycardia are often absent (A). In addition, cardiac presentations in this age group are non-specific or cryptic. Other non-obvious causes of falls are sepsis, medication toxicity, acute abdominal pathology, and elder abuse.
Up to 6% of falls will result in fractures; hip fractures are the most common to be missed on plain radiographs. Comorbidities make this population especially vulnerable to complications; the mortality rate at 1 year after a hip fracture is 25% (B).
Even a trivial fall can result in a subdural hematoma. The subdural may be present for weeks to months before symptoms emerge, and the trauma may be so minor that it is not recalled in up to 50% of cases. (C)
Polypharmacy and adverse drug affects constitute 11% of ED visits in the elderly (older patients average 4.2 medications at any given time). A study done recently with the National Electronic Injury Surveillance System showed that three medication classes caused 48% of all ED visits for adverse reaction: oral anticoagulant or antiplatelet agents (warfarin, aspirin, clopidogrel); antidiabetic agents (insulin, metformin, glyburide, glypizide); and agents with a narrow therapeutic window (digixin, phenytoin). Changes in dosing as well as the natural changes in drug metabolism with aging should prompt the clinician to review the medication history of any elderly patient who presents to the ED (D).
From the 2013 ABEM LLSA Reading List:
Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. 2010;56(3):261-269.