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Emergentology: The Geriatric Tsunami

Walker, Graham MD

doi: 10.1097/01.EEM.0000418681.95213.5a

Dr. Walkeris a fellow in simulation medicine in the Stanford/Kaiser Emergency Medicine Residency Program. He has been blogging since medical school, first at Over My Med Body, and now as the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm. (See FastLinks.)





“You always do a full history and a full physical on babies, infants, kids. You ask lots of questions of the parents,” he said.

He looks at me, and changes his tone, as if I'm now the dad. “Formula feeding? What kind of formula? Any changes in the formula? How much are you giving? How frequently? Is she taking it all? How much water are you using to dilute it?”

This is my introduction to Joel Berezow, MD, and how he approaches pediatric emergency medicine. Sitting in his little office outside Columbia's peds ED, he continues. “You guys order a bunch of lab tests and images over there in the adult ED. Kids are mostly healthy. You don't need labs or x-rays for most kids. You need a good history and a good physical exam for most kids; that's it.”

Which, if you ask me, is frequently the exact opposite of geriatric emergency medicine. It's all labs and x-rays. It's sometimes very little history. Very little exam. Infants can't give you history; they can't talk. But like Dr. Berezow said, most of the time they're going to be just fine (especially in the era of vaccinations).

The 90-year-old patient with altered mental status cannot give you history either, but he is not going to be just fine: he has a subdural, or hyponatremia, or delirium from a new medication, or a met to the brain, or dehydration, or an aphasia, or depression, or meningitis, or a good ol' UTI. Most of these things are beyond our ability to tease out by relying solely on a confused patient and a scrap of paper from the nursing home. So labs and studies it is.

Elderly people get workups because they probably have something. Take belly pain. An elderly person with a complaint of abdominal pain has a high risk of needing surgery (30–40% in one study, which seems a little high to me), a higher mortality from the disease he is brewing, and a higher mortality from the surgery itself. They also present more atypically, making the diagnosis less classic, tougher to make, and more morbid if not promptly diagnosed.

Which brings me to my question: what the hell are we going to do about the elderly? I'm certainly not trying to sound gerontophobic — let's be honest, I sometimes feel “the Weakest Generation” is an apt title for my peers and me — but I'm deeply concerned about the fact that we as a society — and a specialty — are doing so little to address the geriatric -tsunami that is on its way.

Right now, our 65+ population is around 13 percent. It will be up to 18 percent by 2025. Translation? Our population is only going to be sicker, more complicated, and more resource-intensive yet no one seems to be talking about it.

Of course, we discuss death squads, rationing, and Medicare spending projections, but no talking head or politician is looking 10 years down the line about how we might deal with our aging population. One in five Americans will be over 65 by 2030! I've read very little about developing systems or making societal changes to make day-to-day life better for our geriatric patients (and secondarily, for us in the trenches).

How many patients do you see who live alone? Or at the top of three flights of stairs? (Almost one of three elderly people live alone.) How many patients have no idea what medicines they take or develop a side effect from a new one? Forget medicine reconciliation; what is the patient physically taking? (One fantastic study found that 37 percent of patients on cholinergics were also receiving anticholinergics at the same time. Duh.)

How many elderly patients have access to healthy food or exercise to bolster their bodies if they fall ill or break a hip? How many patients have children — frequently the health care proxy — who live in another state?

Does anyone else suspect that a good number of the little old ladies with nonspecific complaints and negative repeated workups are probably lonely and depressed?

Silver linings are here and there but not nearly enough. Many of you have probably read about Mt. Sinai's (and others') “geri-ED,” a geriatric ED with nonslip floors, a skylight to help keep patients from developing delirium, and reading glasses. Hopefully these provide better care to geriatric patients while preventing iatrogenic morbidity, but they also only help the ED without influencing the hospital enough. We are comfortable managing undifferentiated patients, but other services will have to become more comfortable managing borderline, gray-zone patients without a clear diagnosis. (I can't think of a better way to break an ED than adding more complex patients.)

None of us has all the answers, but if you ask EPs what would help them take better care of patients, the answer isn't “more doctors.” (Not surprisingly, we're pretty good at remembering that ours is a team sport.) The responses go something like this:

  • Better education about geriatric emergency medicine.
  • 24/7 social work and case management.
  • Easier ability to observe patients in a clinical decision unit or holding area.
  • 24/7 physical therapy/occupational therapy.
  • 24/7 access to the doctor, nursing home, or family member who sent the patient to the ED.
  • 24/7 access to the code status/living will and health care proxy/durable power of attorney.
  • A crystal ball (if team players are #1, sarcasm is certainly a close second).

We emergency physicians are already geriatricians in some ways. Almost half of ED patients were 65 or older in 2007. We do a great job diagnosing, treating, and caring for our elderly patients. We worry about giving them narcotics or benzodiazepenes that may make them delirious, we try to navigate their narrow waters of risk and benefit, and we advocate for them when the consulting service is unimpressed by their normal white blood cell count.

But we need to advocate for them — and ourselves — in a broader sense, or I fear the next decades of our careers will only become more challenging and frustrating. Now that I think of it, zombies are all the rage today. If we had half as much pop culture interest in preparing for the zombie apocalypse as the elderly one, we'd be in pretty good shape.

Next month: The elderly apocalypse and some radical ideas on addressing it.

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The Silver Hour

What should EPs do for patients in last moments of life? Read Dr. Sheri Knepel's viewpoint on p. 3.

© 2012 Lippincott Williams & Wilkins, Inc.