**4. Most frequent pathologies in the elderly at the emergency department**

Next, emphasis will be placed on the most frequent pathologies in an emergency department and their differential characteristics in the elderly.

#### **4.1. Hypertension in the emergency room in the geriatric patient**

In the past, it was controversial to define the readings for normal blood pressure in the elderly and when to administer pharmacological treatment. Today, it is clear that the normal readings correspond to those of the adult population and that the benefit of administering pharmacological management is evident, even at very advanced ages. However, the latest studies (SPRINT, PURE) have put confusion regarding the goals. In the emergency department, it is important to differentiate between emergency and hypertensive emergencies, due to the implications in defining the speed and route of treatment.

• NT-proBNP levels are associated with short-term mortality in the elderly population treat-

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• Long-term mortality and morbidity are increased compared to younger patients, either with medical or intervention management. Heart failure, bleeding, and reinfarction rates

• In part, the poor results in the elderly are explained by the decrease in the use of treatments because of toxicity fear. The protocols must be applied strictly and not to discriminate the age. Consider the general state of health, life expectancy, functional status, and cognitive

• The intervention strategy has shown greater benefits in the elderly compared with

Although it is not clear whether advanced age is an independent risk factor for thromboembolism, elderly patients have a high incidence of risk factors for clot formation. Venous stasis, commonly caused by immobility, has been found to be the most common risk

• The diagnosis is notoriously difficult at all ages. In 70% of the cases in which the patient dies of a pulmonary embolism, there was no antemortem suspicion of the diagnosis.

• The rule in the elderly is that the pulmonary embolism occurs in a subtle and atypical way. Acute dyspnea, pleuritic chest pain, tachypnea, tachycardia, and hemoptysis are less fre-

• D-dimer decreases its utility with advancing age because the values rarely fall below the

• As aging is related to a decrease of the oxygen partial pressure and an increase in the alveolar-arterial gradient, gasometrical changes can be difficult to be interpreted in the

Neurovascular disease is the major cause of disability and death in the elderly. The aging brain is less resistant to physiological stress: the cerebral blood flow gradually decreases with age, the collateral circulation is diminished, the cerebrovascular barrier is less efficient, the cerebral self-regulation is altered, and the neuronal oxidative metabolism decreases. All this makes an ischemic event more pronounced, and the time threshold for effective interventions

**4.4. Geriatric patient with cerebrovascular disease in the emergency department**

are more frequent. However, the benefit of the treatment remains.

• Always provide the patient with cardiac and functional rehabilitation.

quent. Syncope and hemodynamic instability increase in frequency.

**4.3. Pulmonary thromboembolism in the elderly**

negative predictive threshold.

ed in emergency services.

status.

factor.

**Key points**

elderly.

lowers.

thrombolysis.

#### **Key points**


#### **4.2. Acute coronary syndromes in the elderly**

It is estimated that 60–65% of all heart attacks occur in people older than 65 years and 80% of the deaths due to this cause affect this population. They are one of the most frequent causes of emergency consultation, where more mistakes are committed, both in diagnosis and in the therapeutic decision-making.


#### **4.3. Pulmonary thromboembolism in the elderly**

Although it is not clear whether advanced age is an independent risk factor for thromboembolism, elderly patients have a high incidence of risk factors for clot formation. Venous stasis, commonly caused by immobility, has been found to be the most common risk factor.

#### **Key points**

correspond to those of the adult population and that the benefit of administering pharmacological management is evident, even at very advanced ages. However, the latest studies (SPRINT, PURE) have put confusion regarding the goals. In the emergency department, it is important to differentiate between emergency and hypertensive emergencies, due to the

• During the measurements, the patient must be in a controlled environment and in an appropriate position, with an adequate technique and the minimum possible stress.

• Always evaluate the underlying comorbidities that alter the prognosis of the current

• In a hypertensive emergency, the blood pressure readings should not be lowered abruptly,

• As an adequate physiological goal in elderly hypertensive patients, a pulse pressure be-

• In hypertensive emergencies use medication orally. It is a mistake to use the sublingual route because of its unpredictable effects and because the drugs were not designed for this route. In emergencies, use the intravenous way, and transfer the patient to an intermediate

• In the elderly, no drugs with adrenergic blocking effect such as clonidine or prazosin are the first choice, because of their excessive hypotensive effects and, in the case of clonidine,

It is estimated that 60–65% of all heart attacks occur in people older than 65 years and 80% of the deaths due to this cause affect this population. They are one of the most frequent causes of emergency consultation, where more mistakes are committed, both in diagnosis and in the

• Only 57% of those over 80 have chest pain. In octogenarians, the main presenting symptom is dyspnea. Syncope, dizziness, delirium, and falls are also frequent. This leads to frequent

• An elderly person is more likely to show a non-ST-segment elevation myocardial infarct (STEMI) than with an ST-segment elevation myocardial infarct (STEMI), given the phe-

• In relation to age, there are more incidences of tachyarrhythmias.

implications in defining the speed and route of treatment.

• Rule out pseudo-hypertension at very advanced ages.

as it generates more morbidity and mortality.

tween 50 and 60 mm Hg is recommended.

its sedative and anticholinergic effects.

**4.2. Acute coronary syndromes in the elderly**

**Key points**

90 Gerontology

decompensation.

or intensive care room.

therapeutic decision-making.

delays in diagnosis and treatment.

nomenon of ischemic preconditioning.

**Key points**


#### **4.4. Geriatric patient with cerebrovascular disease in the emergency department**

Neurovascular disease is the major cause of disability and death in the elderly. The aging brain is less resistant to physiological stress: the cerebral blood flow gradually decreases with age, the collateral circulation is diminished, the cerebrovascular barrier is less efficient, the cerebral self-regulation is altered, and the neuronal oxidative metabolism decreases. All this makes an ischemic event more pronounced, and the time threshold for effective interventions lowers.

#### **Key points**

• Twenty-one percent (21%) of elderly patients with cerebral ischemia have a normal physical examination.

• The only independent predictors of bacteremia in the elderly are the altered mental state (odds ratio [OR] 2.88; 95% CI 1.52–5.50), vomiting (OR 2.63; 95% CI 1.16–6.15), and the pres-

The Elderly in the Emergency Department http://dx.doi.org/10.5772/intechopen.75647 93

• The presence of a Barthel index less than 60, systolic blood pressure less than 90 mm Hg, and serum lactate >4 mmol/l are significantly associated with short-term mortality.

• Tendency to overdiagnosis due to high prevalence of asymptomatic bacteriuria. 52.2% of

• Do not attribute a septic picture in an elderly person to a urinary infection first, until care-

• Treating asymptomatic bacteriuria does not improve mortality but increases the side ef-

• The presence of symptoms is less clear in the elderly with cognitive impairment or the use of probes to stay in those who prevail atypical presentations (delirium, falls, functional

The incidence of community-acquired pneumonia (CAP) increases with age and is associated with high morbidity and mortality due to physiological changes associated with aging and a greater presence of chronic diseases. Pneumonia is the fifth cause of death in the United States among those over 65 years. It results in 600,000 hospitalizations and almost 60,000 deaths [16].

• There is an increased risk of pneumonia due to deglutition disorder, neurological disease, functional decline, malnutrition, use of sedatives, comorbidity, chronic neuropathies,

• *Streptococcus pneumoniae* remains, as in other ages, as the most frequent etiological agent. However, with aging the microorganisms colonize the oropharynx change, with an increase in Gram-negative and anaerobic germs; consequently, these increase as causal agents. The

• The diagnosis is complicated by the absence of classic symptoms, there is fever in only 26% of cases when compared with young people, and 44% have cough, fever, and dyspnea

ence of bands in the leucogram greater than 6% (OR 3.50; 95% CI 1.58–5.27).

**4.6. Urinary tract infection in the elderly in the context of emergencies**

fects of antibiotics and the rates of infection by resistant germs.

• The etiology is multimicrobial in 5–17% of patients.

urinary tract infections are misdiagnosed.

• If in doubt, focus on the blood picture or PCR.

smoking, heart failure, and institutionalization.

state of the denture also influences.

fully ruling out other causes.

**4.7. Pneumonia in the elderly**

**Key points**

decline, etc.).

**Key points**


#### **4.5. Infections in the elderly at the emergency department**

The incidence of infectious processes in patients older than 75 years who attend the emergency services has increased significantly in the last 10 years (from 24.8% to 31.7%), as well as the severity of their clinical presentation and short-term mortality (30 days). This is explained by the summing effect of immunosenescence plus fragility [15].


#### **4.6. Urinary tract infection in the elderly in the context of emergencies**

#### **Key points**

**Key points**

92 Gerontology

cal examination.

prognosis.

**Key points**

tion of the protocols.

risk of intracranial bleeding.

• Tachycardia may not occur.

• Avoid all cost prostration or immobility.

**4.5. Infections in the elderly at the emergency department**

by the summing effect of immunosenescence plus fragility [15].

and decrease its usefulness to stratify the risk in this age group.

• In cases of bacteremia, it is more difficult to identify the source.

temperature or higher than 37.2 (sensitivity 83%).

infarction, valvular disease, and dyslipidemia.

• Twenty-one percent (21%) of elderly patients with cerebral ischemia have a normal physi-

• Always look for common risk factors: atrial fibrillation, carotid atherosclerosis, myocardial

• The approach by an interdisciplinary group is important to improve the functional

• Thrombolysis in cerebrovascular disease has shown full benefits up to the 75 years. In older patients there is evidence of benefit, coming from clinical trials with a small number of patients or case reports. Therefore, there is no contraindication for age. The key is to choose the patient properly, based on parameters of functionality, comorbidity, and strict applica-

• The use of ASA plus clopidogrel has not improved the final results, but it does increase the

The incidence of infectious processes in patients older than 75 years who attend the emergency services has increased significantly in the last 10 years (from 24.8% to 31.7%), as well as the severity of their clinical presentation and short-term mortality (30 days). This is explained

• The criteria of systemic response syndrome are not always present in the infected elderly

• The most accepted criterion for fever in the elderly is an increase of 1.2°C based on the basal

• Several studies have documented the absence of fever, as traditionally defined, in the presence of serious infections. The cut point of 38.2° centigrade loses sensitivity (40%).

• It is common that there is no leukocytosis in the elderly, as part of the infectious response. The cutoff point of the greatest sensitivity for infection is an absolute count of 14,000.

• The respiratory rate greater than 24 is conserved as part of the inflammatory response.

• Start the integral rehabilitation therapy early once the patient stabilizes.


#### **4.7. Pneumonia in the elderly**

The incidence of community-acquired pneumonia (CAP) increases with age and is associated with high morbidity and mortality due to physiological changes associated with aging and a greater presence of chronic diseases. Pneumonia is the fifth cause of death in the United States among those over 65 years. It results in 600,000 hospitalizations and almost 60,000 deaths [16].


due to clinical history. In institutionalized patients, alterations of the mental state are more frequent.

• Normotensions are synonymous with hypotension in patients with abdominal infection

The Elderly in the Emergency Department http://dx.doi.org/10.5772/intechopen.75647 95

• Prolonged presentation time, normothermia or hypothermia, and leukopenia are syn-

Emergency physicians frequently fail to identify and focus on psychiatric disorders, either as a primary reason for consultation or concomitant to the index disease, although they adversely

• It is essential, upon the appearance of new psychiatric symptoms in the elderly, to rule out organicity: infections, metabolic disorders, tumors of the central nervous system, reactions

• Depression is the most frequent psychiatric disorder in the elderly, with subsyndromal depression being the most common. It must be clarified that depression is not a natural

• The most common entities within the "late-onset psychosis" (older than 60 years) are as follows in order: dementias, delirium, affective disorders, schizophrenia, and schizophreni-

• Delirium: acute alteration of the state of consciousness, fluctuating, with difficulty to maintain the attention, alteration of the sleep-wake pattern, alteration of the perception. Always

• Dementia: cognitive disorder of long duration without alteration of the conscience. It con-

• In the agitated elderly patient, the use of mechanical restrictions produces greater complications.

The early detection of the high-risk adult patient is essential to avoid new admissions and visits in the emergency room and to improve the level of physical and cognitive function. In

• The elderly has the highest rate of death by suicide compared to all age groups. • Fundamental: good clinical history and functional and neurological examination.

and who are chronically hypertensive.

**4.9. Psychiatric emergencies in the elderly**

and independently affect the prognosis [18].

• Investigate mistreatment of the elderly.

consequence of aging and must always be treated.

tributes to 16–23% of psychotic symptoms in aging.

**5. Forecast of the elderly in the emergency service**

**Key points**

to drugs, etc.

form disorders.

look for the triggering factor.

• Discard substance abuse.

onyms of severe intra-abdominal infections.


#### **4.8. Approach of abdominal pain in the elderly patient at the emergency department**

If in the young man, the acute abdomen becomes a diagnostic challenge, in the elderly it is a real mystery. It is frequent that a nonspecific pain and a soft abdomen without many signs conceal a true abdominal catastrophe. Total mortality for an elderly man who enters with abdominal pain complaint exceeds 10% [17].


#### **4.9. Psychiatric emergencies in the elderly**

Emergency physicians frequently fail to identify and focus on psychiatric disorders, either as a primary reason for consultation or concomitant to the index disease, although they adversely and independently affect the prognosis [18].

#### **Key points**

due to clinical history. In institutionalized patients, alterations of the mental state are more

• The CURB-65 is an index that has been validated adequately in the elderly and allows to

• To stratify the risk and possible complications in elderly patients with pneumonia who enter the emergency department, it is useful to classify them as fragile and non-fragile. • Lack of fever, absence of hypoxia, and altered mental state are associated with therapeutic

• Studies have shown a decrease in mortality in the elderly, related to the rapid administra-

• Pneumonia in institutionalized patients and pneumonia associated with health care are

• Patients with risk factors such as institutionalization in nursing homes, hospitalization for more than 2 days in the last 90 days, wound care in the last 30 days, high frequency of resistance to antibiotics in the community, infusion of home medications, dialysis, a member of the family with resistant germs and diseases, or immunosuppressive therapy should be covered for resistant germs (*Pseudomonas, Klebsiella, Acinetobacter*, and *Staphylococcus* resis-

• Remember the importance of vaccination against influenza and pneumococcus to the im-

If in the young man, the acute abdomen becomes a diagnostic challenge, in the elderly it is a real mystery. It is frequent that a nonspecific pain and a soft abdomen without many signs conceal a true abdominal catastrophe. Total mortality for an elderly man who enters with

• In the "surgical abdomen of the old man," the atypical presentation of the different entities

• The decrease of the myenteric receptors in the viscera modifies the perception of pain, making it diffuse and badly defined, with the absence of the so-called signs of peritoneal

• There is difficulty in the interrogation (dementia, basic pathology, loss of senses).

• The use of NSAIDs masks peritonitis and increases the risk of peptic ulcer.

**4.8. Approach of abdominal pain in the elderly patient at the emergency department**

related with higher comorbidity, poor functional status, and higher mortality.

decide the appropriate level of care to administer the treatment.

pact on mortality and hospitalizations in the ICU, respectively.

tion of the appropriate antibiotic treatment.

abdominal pain complaint exceeds 10% [17].

• Fever and leukocytosis are not constant.

irritation, which increases the false-negative rate.

frequent.

94 Gerontology

delay.

tant to methicillin).

**Key points**

is usual.


## **5. Forecast of the elderly in the emergency service**

The early detection of the high-risk adult patient is essential to avoid new admissions and visits in the emergency room and to improve the level of physical and cognitive function. In adults, prognostic assessment methods are based on the clinical characteristics of severity of the index event. But the older adult cannot be seen under the traditional biomedical gaze that the unifactorial analysis of patients tends to. The complexity of the disease in the elderly is preferable to approach it from a biopsychosocial approach through multidimensional analysis, which identifies how the demographic, clinical, psychological, functional, and social factors influence the acute disease in the elderly and alter its forecast [19]. At the emergency environment, we need brief, simple, and validated tools that help us detect problems in different areas. However, currently there are few prognostic indices used in clinical practice that include these variables typical of the elderly baseline condition.

validated. Several authors have proposed to stratify the risk of the geriatric patient in the emergency department based on a model of comprehensive geriatric assessment, adapted to

The Elderly in the Emergency Department http://dx.doi.org/10.5772/intechopen.75647 97

The frail senior is the one who has his homeostatic reserves to the limit, with a high probability of suffering a deleterious outcome. The detection of this patient is fundamental in the emergency services, since in this scenario it is where there is more risk of entering the cascade of functional decline and dependence. It is interesting how the acute disease acts as a trigger, unmasking the frailty picture. Studies have shown how frail senior people in the emergency room have higher rates of hospitalization, functional deterioration, readmissions, and short-term mortality, when compared with non-frail elderly. For the screening of frail elderly people in the emergency department, the ISAR, TRST, deficit accumulation index (DAI), and comprehensive geriatric assessment are recommended in selected patients defined as high risk. Identifying frail elderly allows designing a special care plan, which has shown a decrease in the number of admissions in residence at 30 days, an increase in patient satisfaction, less functional deterioration, fewer readmissions, and without increasing costs. No impact on

It is common to observe how some interventions are systematically denied to the elderly, arguing as the only reason age. This produces gross errors, since chronological age alone does not provide enough information to make the best decision. They are the multidimensional parameters that include basal functionality, comorbidities, and emotional-cognitive and social support, which together reflect biological aging and support the relevance or not

The diagnostic approach and the therapeutic approach of the elderly, in the emergency department, should be framed in a deep knowledge of their physiological alterations, a careful anamnesis, and therapeutic prudence. Because of the diminished homeostatic reserve of

this service [21].

**7. Decision-making**

of the proposed treatment [23].

**8. Conclusion**

**Conflict of interest**

**6. The frail senior in the emergency room**

mortality or institutionalization has been demonstrated [22].

the elderly, the time to establish adequate treatment is shorter.

I declare not having any conflict of interest in the elaboration of this paper.

Having clear prognostic variables to help the quick detection of the patient at high risk of this outcome helps to decide which patients should be considered for aggressive interventions, treatments with curative purposes, support treatments, or treatments only for palliative purposes.

Currently, there are models of structured triage in the emergency services, being the most prominent: the Australian model (Australasian Triage Scale (ATS)), the Canadian scale of triage and gravity for emergency services (Canadian Emergency Department Triage and Acuity Scale (CTAS), the Manchester Triage System (MTS), the Emergency Severity Index (ESI), and the Andorran model of triage (Model Andorra of Triage (MAT)); however, these are not suitable for use in elderly patients.

When referring to the young and adult population, there are known instruments that try to predict the short-term prognosis of critical hospitalized patients, such as the APACHE III used in the intensive care units (ICU); the SUPPORT, to establish the 6-month prognosis of hospitalized patients both inside and outside the ICU; and more recently the short version of the EORTC QLQ-30 for use in palliative care. The drawback of these evaluations is that they overestimate age a priori as an element of risk, without considering that there are also "robust" elderly or with successful aging, in which the chronological age alone does not weigh as a negative factor.

The scales "Identification of Seniors at Risk" (ISAR) and the "Triage Risk Screening Tool" (TRST) have been published for use in the elderly, which allow assessing the risk of complications at release of the service and classifying the degree of fragility [20].

The prognosis of the diseases in geriatric patients is frequently influenced by the basal health condition of the elderly, which is determined by the nutritional status, the mental state, and the functional capacity (level of independence for the activities of daily life), variables that are not contemplated in the scales of habitual use in adults. In this sense, it has been shown that the deterioration of each of these areas can be an independent factor of mortality in the elderly.

The multidimensional geriatric assessment is an evaluation carried out by an interdisciplinary team to identify the problems and establish a care plan to improve the functionality and quality of life of the geriatric patient. It offers an integral and holistic view of the elderly adult patient, in which the clinical condition is evaluated, but psychological, functional, and social evaluation is also included. In fact, having knowledge of the instruments used in daily practice in geriatric care is extremely useful. Different scales and protocols are used and duly validated. Several authors have proposed to stratify the risk of the geriatric patient in the emergency department based on a model of comprehensive geriatric assessment, adapted to this service [21].
