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Geriatric emergency medicine: A survey of practicing emergency physicians
ORIGINAL CONTRIBUTION
geriatrics
Geriatric EmergencyMedicine: A Surveyof Practicing EmergencyPhysicians From the Department of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia;* the Arizona Center on Agingt and the
Robert M McNamara, MD, FACEP*S Elaine Rousseau, PhDt§ Arthur B Sanders, MD, FACEP~
Study objectives: To evaluate the current status of clinical, educational, social, ethical, and resource issues related to the care of the elderly among practitioners of emergency medicine. Design: A mailed survey instrument.
Department of Emergency
Setting: None.
Medicine,#: University of Arizona
Type of participants: Practicing emergency physicians randomly drawn from the membership list of the American College of Emergency Physicians.
of Medicine, Tucson; and the Societyfor Academic Emergency Medicine Geriatric Emergency Medicine Task Force, Lansing, Michigan.§ Receivedfor publication February 28, 1992. Accepted for publication March 12, 1992. Supported in part by a grant from the John A Hartford Foundation, New York.
Interventions: None Measurements and main results: A total of 971 surveys were mailed, with 433 useable surveys among the 485 (50%) respondents. The surveyed emergency physicians anticipated a major impact on emergency department patient flow and bed availability in the hospital and ICU as the population ages. For each of seven clinical presentations (abdominal pain, altered mental status, chest pain, dizziness/vertigo, fever without a source, headache, multisystem trauma), 45% or more of the emergency physicians have more difficulty in the management of older compared with younger patients. Most respondents reported that each of these presentations required more time and resources for older patients. The majority believed research, the availability of continuing medical education, and time spent during residency training regarding geriatric emergency medicine was inadequate. Conclusion: Practicing emergency physicians are uncomfortable with elderly patients, and this may reflect the inadequacies of training, research, and continuing education in geriatric emergency medicine. [McNamara RM, Rousseau E, Sanders AB: Geriatric emergency medicine: A survey of practicing emergency physicians. Ann Emerg MedJuly 1992;21:796-801 .]
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EMERGENCY PHYSICIAN SURVEY McNamara, Rousseau & Sanders
INTRODUCTION The nation's emergency care system must p r e p a r e itself for an increasing volume of geriatric patients. Emergency department visits have steadily increased in the past decade, rising from 81 million in 1980 to nearly 90 million in 1989.1, 2 Because the elderly use the ED with a frequency similar to 3,4 or higher thanS, 6 their proportionate numbers in the general community, the percentage of patients aged 65 years and older presenting to the ED can be expected to increase as the population ages. Current projections predict those aged 65 years and older will increase from 12.3% of the population in 1988 to 13% of the population by the year 2000. 7 By the year 2030, one in five Americans will be age 65 years or older, s This increased percentage of elderly patients will disproportionately stress the emergency health care network as compared with younger patients. Older patients more frequently use prchospital emergency medical services. 9 Once in the ED, this group has longer stays, undergoes more extensive testing, and has a much higher percentage of hospital admissioris.4,6 The impact of a growing n u m b e r of aged seems certain to stress a system that is already overburdened in many parts of the country.10 Despite this forthcoming crisis, to date there has been no assessment of how well practicing emergency physicians are p r e p a r e d to face this Challenge. The purpose of this survey was to evaluate the c u r r e n t status of clinical, educational, social, ethical, and resource issues related to the care of elderly patients among practitioners of emergency medicine. It is hoped the answers will direct future educational, research, and administrative tasks related to geriatric emergency care.
MATERIALS AND METHODS The survey instrument was designed and administered through the joint efforts of the Geriatric Emergency Characteristic Practice Type Clinical Academic Academic affiliate Administration
% 70 15 13 2
Table 1.
Characteristics of respondents" primary practice
Medicine Task Force of the Society for Academic Emergency Medicine and the Arizona Center on Aging at the College of Medicine, University of Arizona. I n p u t for the development of the questionnaire thus included emergency physicians, geriatricians, and a geriatric nurse. A computerized r a n d o m sample of 1,000 physicians was drawn from the membership list of the American College of Emergency Physicians. The questionnaire was mailed to these ACEP members with an explanatory cover letter. Nonrespondents were sent another questionnaire at threeweek intervals for up to three total mailings p e r person. To clarify the representativeness of the respondents, 30 nonrespondents were contacted by telephone and their answers compared with those responding to the mail survey. The nature of the respondents was assessed by requesting demographic information, training background, b o a r d certification status, p r i m a r y practice type, and setting including the hospital type, location, size, and n u m b e r of ED visits (Table 1). Specific areas addressed on the questionnaire included the level of difficulty emergency physicians h a d in obtaining information from various sources (Table 2) and the impact that increased numbers of the elderly would have on various areas of the hospital (Table 3). The physicians were asked whether the elderly were less, equal, or more difficult to manage with respect to seven clinical presentations (Table 4). F u r t h e r inquirie s were made regarding resources, time, and standards of care for the elderly with these complaints compared with younger patients (Table 5). Another m a j o r area of the questionnaire requested the physicians to rate on a Likert scale from 1 (very unimportant) to 6 (very important) the importance of several items grouped under the general headings of medical, social, ethical, and resource-related issues (Table 6). Several questions focused on educational issues. The respondents who completed emergency medicine residencies were asked to rate the time spent on geriatrics in their residency as insufficient, adequate, too much, or no opinion. This was followed by a similar question regarding the availTable 2.
Level of problems in obtaining information regarding the elderly % of Responses
Practice Location Urban Suburban Rural
54 30 16
Hospital Type Community University Municipal/county
74 15 11
Hospital Beds More than 300 150 to 299 Fewer than 150
52 34 14
Yearly ED Visits More than 45,000 30 to 45,000 15to 30,000 Fewer tha n 15,000
46/797
I
32 29 31 9
Source
No Problems
Few Problems
Moderate Problems
Frequent Problems
47 19 9
30 36 35
14 41 56
Patient's physician 9 Transferring nursing home 4 Patient I
Table 3.
Anticipated impact of increasing numbers of elderly % of Responses Item Patient flew in the EB Availability of intensive care beds Availability of ward beds
No Impact
Minor Impact
I 2 5
24 23 38
Major Impact
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McNamara, Rousseau & Sanders
ability of continuing medical education (CME) in geriatric emergency medicine. Additionally, information was requested on the number of CME hours spent in the past year on four topics in emergency medicine including geriatric emergency medicine (Table 7). We also inquired about the adequacy of current research on geriatric emergency care. In an attempt to look at how well geriatric social issues are integrated into the El), we questioned the availability of child abuse and elder abuse protocols. Because the results are mainly descriptive, statistical analysis was limited to comparing telephone and mail respondents and the availability of child abuse and elder abuse protocols. Statistical testing included ~2 analysis and unpaired Student's t-test where appropriate. P < .05 was considered significant. RESULTS
Of the 1,000 computer-randomized names, 971 surveys were sent out. A total of 485 (50%) responses were obtained from the three mailings. Of these, 52 were eliminated from analysis for the following reasons: foreign respondent (25), not practicing emergency medicine (nine), residency director who participated in a parallel survey (six), student member (five), and returned mailings not acceptable for inclusion (seven). The results of the study reported below are from the remaining 433 respondents. The respondents were predominantly male (82%) with a mean age + SD of 39 + 8 years (range, 23 to 73 years). Most were board certified in emergency medicine (63%) and had trained in an emergency medicine residency (56%). Practice characteristics were well distributed (Table 1). The mean length of practice + SD was 8.9 + 5 years (range, 0 to 26 years). The surveyed emergency physicians reported a high level of communication problems with both patients and nursing home staff (Table 2). Information reporting from the elderly patient's physician~ although better, was still viewed as a moderate or frequent problem by 44% of those surveyed. Most practicing emergency physicians are anticipating that the aging of the population will have a major impact on patient flow and hospital bed availability, particularly in the ICUs (Table 3). Seven clinical presentations encountered in the elderly are shown (Table 4). The responses indicate that for each presentation, 45% or more of the emergency physicians have Table 4.
Reported level of difficulty managing older compared with younger adult patients
more difficulty in the management of older compared with younger patients. Each of these clinical situations is viewed as more consumptive of time and resources by most of those surveyed (Table 5). Some of these differences may be explained by the large percentages of physicians (Table 5) who believe better standards of care exist for these clinical presentations in younger patients. The respondents' opinions as to the level of importance of medical, social, ethical, and resource availability issues in the emergency care of geriatric patients are shown (Table 6). Possible responses ranged from 1 (indicating very unimportant) to 6 (indicating very important). All issues were considered somewhat important, but medical and ethical issues were considered relatively more important. For those trained in emergency medicine residencies. 53% felt insufficient time was spent on geriatric issues during their residency. This trend appears to continue in practice as the number of hours reported for CME in geriatric medicine is substantially lower than other major areas of emergency medicine (Table 7). This may be partially explained because 69% of the respondents believed insufficient CME was available in geriatric emergency medicine. Similarly, 71% of the respondents believed the amount of research in geriatric emergency care was inadequate at present. Elder abuse protocols (27%) were significantly less available than protocols for child abuse (75%) (P < .001). The 30 responses from the phone survey were generally similar to those of the mail respondents. Small but significant differences were noted in seven of the 17 items assessed in Table 6, but this was felt explainable by the difficulty in responding to a Likert scale item by telephone. The only other difference noted was a higher percentage of telephone respondents reporting the availability of elder abuse protocols. Given the relative lack of difference in responses between the mail and telephone respondents, the survey results may be generalized with some degree of confidence for describing practicing emergency physicians. DISCUSSION
The results of this study highlight several areas of concern and needed focus for the field of emergency medicine. There appear to be inadequate educational and research efforts Table 5.
Responses to question comparing evaluation and management of older versus younger adult patients
% of Affirmative Responses
% of Responses Clinical Issue
Less Difficult
Abdominal pain Altered mental status Chest pain Dizziness/vertigo Feverwithout a source Headache Multisystem trauma
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1 10 12 4 14 7 3
Equal
More Difficult
21 " 31 43 32 41 46 25
78 59 45 64 45 47 72
ANNALS OF EMERGENCY MEDICINE
Clinical I s s u e Abdominal pain Altered mental status Chest pain Dizziness/vertigo Fever without a source Headache Multisystem trauma
Elderly More Elderly Require Time-Consuming More Resources 86
81
70 58 80 66 67 72
76 57 76 71, 64 71
BetterStandards of Care for Younger 43 44 31 40 29 37 40
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McNamara, Rousseau & Sanders
regarding geriatric emergency medicine. This may partially explain why most emergency physicians are less comfortable in the clinical evaluation and management of elderly patients as opposed to younger patients. The surveyed physicians seem aware of the crisis in health care resource use posed by the increasing number of elderly and view social and ethical issues as important in their practice. Medical issues regarding the elderly were assigned the highest importance by the surveyed physicians, and this concern was reflected in the r e p o r t e d higher level of difficulty with the various clinical presentations. Abdominal pain in the elderly was seen as more problematic than in younger patients by a large majority. Evidence supporting this is easily found in the literature. Fenyo, 11 in a Swedish study, reported that the diagnostic accuracy in the ED for elderly patients with abdominal pain was 70% to 80% and that the mortality doubled for those initially misdiagnosed in the ED. To illustrate the problems faced, this author mentioned the lack of characteristic pain migration in the elderly patient with appendicitis and that less than half of the elderly with perforated ulcers r e p o r t e d the sudden onset of pain. The diagnosis of appendicitis can be quite frustrating in the elderly, with one series reporting that only half of eventually proven appendicitis cases older than the age of 60 years carried that diagnosis as a possibility on admission. 12 Abdominal pain in the elderly carries a great significance in the ED as Scandinavian literature reveals that about one t h i r d will require surgery and a high percentage will need admission.ll, 13 The management of altered mental status in the elderly has been characterized by a high frequency of misdiagnosis. 14,15 Table 6. Assigned importance of issues in emergency care of geriatric patient by categories Mean Score*
SD
Medical issues Multiple medications and drug interactions 5.3 1.0 Altered disease presentation in the elderly 5.0 1.0 Altered physiologic response ofthe elderly 4.8 1.1 Inability to assess functional activities of the elderly 4.6 1.1 Social Issues Cost to society of caring for the elderly 4.8 1.4 inadequate access to care 4.2 1.3 Lack of primary care providers 4.2 1.3 Ability to pay for care 4.0 1.5 Elder abuse/neglect 4.0 1.2 Resources in ED Information transfer problems (nursing home, personal, physician, etc) 4.9 1.2 Social support for the elderly 4.7 1.1 Nursing support for the elderly 4.7 1.1 Emergency medical seryices 4.2 1.3 Ancillary services (taboratory, X-ray, etc) 4.0 1.3 Ethical Issues Resuscitation issues 5.1 1.2 Uncertainty regarding withholding/limitation of care (advance directives) 5.0 1.2 Adequate assessment of mental capacity 4.8 1.0 *Scale from 1to 6; larger numbersassociatedwith greaterlevelsof assignedimportance.
48/799
N 430 430 429 430 429 426 427 427 427
425 427 426 424 425 427 427 428
This is p a r t i c u l a r l y distressing given the likelihood that an acute mental status change may be the presenting feature of a serious medical condition. 14 Previously noted problems in the ED evaluation of such patients include inadequate histories, examinations, and l a b o r a t o r y testing. 16 Our survey reflects the increased difficulties encountered by emergency physicians in deahng with elderly patients presenting with an altered mental status. The survey noted a relatively lesser but still large percentage of emergency physicians reporting increased difficulty in managing and evaluating chest pain in older patients. Much of this may be related to increased prevalence of factors suggestive of myocardial infarction in elderly patients with chest pain. 17 This restricts admission specificity for older patients with chest pain. A deficiency of the survey may be that the question should have been posed as regarding myocardial infarction versus chest pain given the propensity of the elderly to present in an atypical fashion. 18,19 Dizziness and vertigo in the elderly has been described as "daunting to emergency physicians ''20 and represents a significant diagnostic problem. Fever in the elderly is generally a harbinger of serious problems, yet identifying a bacterial source is more difficult in these patients. 21-23 Recent developments of an index to evaluate the older patient with unexplained fever reflect the difficulties experienced in the ED with such cases.22, 23 Headache carries a much greater diagnostic significance in the elderly, with multiple potentially serious etiologies.24 The difficulties r e p o r t e d with elderly muhisystem t r a u m a in this survey are important to address, as trauma is the fifth leading cause of death in the elderly. 25,26 Elderly t r a u m a victims account for a disproportionate n u m b e r of t r a u m a related deaths, more frequently require admission, and currently consume one third of health care resources for trauma.25,27 P a r t i a l explanations for the high percentage of emergency physicians who r e p o r t e d clinical difficulties with the above issues are found in th e responses regarding education and research in geriatric emergency medicine in our survey. Inadequate training in an area will foster uncertainty and make clinical decision making more difficult. The fact that more than half of the emergency medicine residency graduates judged their training to have inadequately p r e p a r e d them on geriatric issues should be a m a j o r concern for residency educators. A geriatric curriculum for emergency
Topic
Trauma Emergency medical services Toxicology Geriatric emergency medicine
Mean Hours + SO
16.7+ 14.7
Table 7. Amount of reported continuing medical education in the past year
12.4 + 16.2 9.1 _+11.1 3.1 + 4.5
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medicine has been created, but currently there are no specific requirements for training in this area. 28 Practicing emergency physicians according to this survey have not remedied these deficiencies through CME, possibly because of the inadequate amount of available CME related to geriatric emergency care. Inadequacies of both geriatric emergency education and clinical standards are likely products of the lack of research conducted in this area. Ethical issues in emergency medicine are unique because of the difficulties of time constraints for decisions in the ED. 29 Current concerns over health care costs have raised the possibility of future rationing of health care resources by age. 3° If such practices are instituted, the ED may become a site of many difficult ethical decisions regarding the elderly. Social issues are a n a t u r a l occurrence in emergency medicine as the 24-hour availability of the modern ED has made it a major entry point for social problems. 31 The lack of elder abuse protocols in our survey may reflect an inadequate appreciation of the social needs of this population in the ED. Social issues received the lowest scores of importance among the physicians surveyed in our study but were still rated generally high. Failure to address social needs in the ED may result in unnecessary repeat visits. 15.32 Most of the previously discussed items can be adequately addressed by increased attention to geriatric issues among researchers, educators, and practitioners of emergency medicine. The resource-related problems pointed out in this survey, however, will require major efforts on a broader front, as they involve key issues related to health care costs. Those aged 65 years and older currently account for most hospital days, and this percentage is steadily increasing. 33 In the ED, elderly patients stay longer, use more resources, and are admitted at rates three to four times higher than younger patients.4-6 Hospitals and EDs are already overcrowded in many areas. 10 With the population aged 65 years and older increasing by 1,600 people per day, 3a the emergency care system will be seriously compromised in the near future unless concomitant expansion of health care resources occurs or access to limited resources is restricted. CONCLUSION
A survey conducted of practicing emergency physicians revealed that practicing emergency physicians are uncomfortable with elderly patients, and this may reflect the inadequacies of training, research, and CME in geriatric emergency medicine. Ethical and social concerns were considered important, and the aging of the population is anticipated to have major effects on the availability of resources in emergency medicine. REFERENCES 1. AlIA HospitalStatistics. Chicago, American Hospital Association,1981. 2.AHA HospitalStatistics. Chicago, American Hospital Association,1990.
3. Williams K: Who uses the accident service? Injury 1984;16:35-37.
4. Ettinger WH, Casani JA, Coon PJ, et al: Patterns of use ofthe emergency department by elderly patients. J Geronto11987;42:638-642. 5. Baurn SA, Rubenstein LZ: Old people in the emergency room: Age related differences in emergency department use and care. JAm Geriatr Sac 1987;35:398-404. 6. Lowenstein SR, Crescenzi CA, Kern DC, et al: Care of the elderly in the emergency department. Ann EmergMad 1986;15:528-535. 7. US Bureau of the Census: Statistical Abstract of the United States:1990,ed 110. Washington, DC, 1990. 8. Schick FL: Statistical Handbook on Aging Americans. Oryx Press, Phoenix, 1986. 9. Gerson LW, Skvarch L: Emergency medical service utilization by the elderly. Ann Emerg Med 1982;11:610-612. 10. Andrulis DP, Kellerman A, Hintz EA, et al: Emergency departments and crowding in United States teaching hospitals. Ann EmergMet 1991;20:980-986. 11. Fenyo G: Acute abdominal disease in the elderly. Experience from two series in Stockholm. Am J Surg 1982;143:751-754. 12. Horattas MC, Guyton DP, Wu D: A reappraisal of appendicitis in the elderly. Am J Surg 1990;160:291-293. 13. Janzon L, Ryden CI, Zederfelt B: Acute abdomen in the surgical emergency room. Acta Chir Scand1982;148:141-148. 14. Lipowski ZJ: Delirium in the elderly patient. N Engl J Med 1989;320:578-582. 15. Waxman HM, Carrer EA, Dubin W, et al: Geriatric psychiatry in the emergency department: Characteristics of geriatric and non-geriatric admissions. J Am Geriatr Sac 1982;30:427-432. 16. Waxman HM, Dubin W, Klein M, eta[: Geriatric psychiatry in the emergency department, II: Evaluation and treatment of geriatric and nongeriatric admissions. J Am Geriatr Sac 1984;32:343-349. 17. Solomon CG, Lee TH, Cook EF, et al: Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: The multicenter chest pain study experience. Am J Cardio11989;63:772-776. 18. Bayer A J, Chadha JS, Farag RR,et al: Changing presentation of myocardial infarction with increasing old age. J Am Geriatr Sac 1986;34:263-266. 19. Cocchi A, Franceschini G, Incalzi RA, et al: Clinico-pathological correlations in the diagnosis of acute myocardial infarction in the elderly. Age Ageing 1988;17:87-93. 20.Olsky M, Murray J: Dizziness and fainting in the elderly. Emerg IViedClin North Am 1990;8:295-307. 21. Bark SL, Smith JK: Infectious disease in the elderly. Mad Clin North Am 1983;67:273293. 22. Mellors JW, Horwitz RI, Harvey MR, et al: A simple index to identify occult bacterial infection in adults with acute unexplained fever. Arch Intern Med 1987;147:666-671. 23. Leibovici L, Cohen 0, Wysenbeek A J: Occult bacterial infection in adults with unexplained fever (validation of a diagnostic index). Arch Intern Med 1990;150:12701271, 24. Samiy AH: Clinical manifestations of disease in the elderly. Emerg Med Clin North Am 1990;8:333-344. 25. 0reskovich MR, Howard JD, Copass MK, et al: Geriatric trauma: Injury patterns and outcome. J Trauma 1984;24:565-569. 26. Martin RE, Teberian G: Multiple trauma and the elderly patient. EmergMed Clin North Am 1990;8:411-420. 27. Fife D, Barancik JI, Chatterjee BF: Northeastern Ohio Trauma Study: II. Injury rates by age, sex, and cause. Am J Pub@ Health 1984;74:473-478. 28. Jones J, Dougherty J, Cannon L, et al: A geriatrics curriculum for emergency medicine training programs. Ann Emerg Med 1986;15:1275-1281. 29. Adams J, Wolfson AB: Ethical issues in geriatric emergency medicine. Emerg Med Clin of North Am 1990;8:183-192. 30. Schneider EL, Buralnik JM: The aging of America (impact on health care costs). JAMA 1990;263:2335-2340. 31. McDonald AJ, Abrahams ST: Social emergencies in the elderly. EmergMet Clin North Am 1990;8:443-459.
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32. BassukEL, Minden S, Apsler R: Geriatric emergencies:Psychiatric or medical ? A m J PsFchiatry1983;140:539-542. 33. CampionEW, Barg A, May Mh Why acute-care hospitals must undertake long-term care. N Engl J Med 1983;308:71-75.
Address for reprints: Robert M McNamara, MD, FACEP,Department of Emergency Medicine, The Medical College of Pennsylvania,3300 Henry Avenue, Philadelphia, Pennsylvania 19129.
34. AMA Council on Scientific Affairs: Societal effects and other factors affecting healthcare for the elderly. Arch Intern Med 1990;150:1184-1189.
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geriatrics
Geriatric EmergencyMedicine: A Surveyof Practicing EmergencyPhysicians From the Department of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia;* the Arizona Center on Agingt and the
Robert M McNamara, MD, FACEP*S Elaine Rousseau, PhDt§ Arthur B Sanders, MD, FACEP~
Study objectives: To evaluate the current status of clinical, educational, social, ethical, and resource issues related to the care of the elderly among practitioners of emergency medicine. Design: A mailed survey instrument.
Department of Emergency
Setting: None.
Medicine,#: University of Arizona
Type of participants: Practicing emergency physicians randomly drawn from the membership list of the American College of Emergency Physicians.
of Medicine, Tucson; and the Societyfor Academic Emergency Medicine Geriatric Emergency Medicine Task Force, Lansing, Michigan.§ Receivedfor publication February 28, 1992. Accepted for publication March 12, 1992. Supported in part by a grant from the John A Hartford Foundation, New York.
Interventions: None Measurements and main results: A total of 971 surveys were mailed, with 433 useable surveys among the 485 (50%) respondents. The surveyed emergency physicians anticipated a major impact on emergency department patient flow and bed availability in the hospital and ICU as the population ages. For each of seven clinical presentations (abdominal pain, altered mental status, chest pain, dizziness/vertigo, fever without a source, headache, multisystem trauma), 45% or more of the emergency physicians have more difficulty in the management of older compared with younger patients. Most respondents reported that each of these presentations required more time and resources for older patients. The majority believed research, the availability of continuing medical education, and time spent during residency training regarding geriatric emergency medicine was inadequate. Conclusion: Practicing emergency physicians are uncomfortable with elderly patients, and this may reflect the inadequacies of training, research, and continuing education in geriatric emergency medicine. [McNamara RM, Rousseau E, Sanders AB: Geriatric emergency medicine: A survey of practicing emergency physicians. Ann Emerg MedJuly 1992;21:796-801 .]
JULY 1992 2 1 : 7 ANNALS OF EMERGENCY MEDICINE
796/45
|
EMERGENCY PHYSICIAN SURVEY McNamara, Rousseau & Sanders
INTRODUCTION The nation's emergency care system must p r e p a r e itself for an increasing volume of geriatric patients. Emergency department visits have steadily increased in the past decade, rising from 81 million in 1980 to nearly 90 million in 1989.1, 2 Because the elderly use the ED with a frequency similar to 3,4 or higher thanS, 6 their proportionate numbers in the general community, the percentage of patients aged 65 years and older presenting to the ED can be expected to increase as the population ages. Current projections predict those aged 65 years and older will increase from 12.3% of the population in 1988 to 13% of the population by the year 2000. 7 By the year 2030, one in five Americans will be age 65 years or older, s This increased percentage of elderly patients will disproportionately stress the emergency health care network as compared with younger patients. Older patients more frequently use prchospital emergency medical services. 9 Once in the ED, this group has longer stays, undergoes more extensive testing, and has a much higher percentage of hospital admissioris.4,6 The impact of a growing n u m b e r of aged seems certain to stress a system that is already overburdened in many parts of the country.10 Despite this forthcoming crisis, to date there has been no assessment of how well practicing emergency physicians are p r e p a r e d to face this Challenge. The purpose of this survey was to evaluate the c u r r e n t status of clinical, educational, social, ethical, and resource issues related to the care of elderly patients among practitioners of emergency medicine. It is hoped the answers will direct future educational, research, and administrative tasks related to geriatric emergency care.
MATERIALS AND METHODS The survey instrument was designed and administered through the joint efforts of the Geriatric Emergency Characteristic Practice Type Clinical Academic Academic affiliate Administration
% 70 15 13 2
Table 1.
Characteristics of respondents" primary practice
Medicine Task Force of the Society for Academic Emergency Medicine and the Arizona Center on Aging at the College of Medicine, University of Arizona. I n p u t for the development of the questionnaire thus included emergency physicians, geriatricians, and a geriatric nurse. A computerized r a n d o m sample of 1,000 physicians was drawn from the membership list of the American College of Emergency Physicians. The questionnaire was mailed to these ACEP members with an explanatory cover letter. Nonrespondents were sent another questionnaire at threeweek intervals for up to three total mailings p e r person. To clarify the representativeness of the respondents, 30 nonrespondents were contacted by telephone and their answers compared with those responding to the mail survey. The nature of the respondents was assessed by requesting demographic information, training background, b o a r d certification status, p r i m a r y practice type, and setting including the hospital type, location, size, and n u m b e r of ED visits (Table 1). Specific areas addressed on the questionnaire included the level of difficulty emergency physicians h a d in obtaining information from various sources (Table 2) and the impact that increased numbers of the elderly would have on various areas of the hospital (Table 3). The physicians were asked whether the elderly were less, equal, or more difficult to manage with respect to seven clinical presentations (Table 4). F u r t h e r inquirie s were made regarding resources, time, and standards of care for the elderly with these complaints compared with younger patients (Table 5). Another m a j o r area of the questionnaire requested the physicians to rate on a Likert scale from 1 (very unimportant) to 6 (very important) the importance of several items grouped under the general headings of medical, social, ethical, and resource-related issues (Table 6). Several questions focused on educational issues. The respondents who completed emergency medicine residencies were asked to rate the time spent on geriatrics in their residency as insufficient, adequate, too much, or no opinion. This was followed by a similar question regarding the availTable 2.
Level of problems in obtaining information regarding the elderly % of Responses
Practice Location Urban Suburban Rural
54 30 16
Hospital Type Community University Municipal/county
74 15 11
Hospital Beds More than 300 150 to 299 Fewer than 150
52 34 14
Yearly ED Visits More than 45,000 30 to 45,000 15to 30,000 Fewer tha n 15,000
46/797
I
32 29 31 9
Source
No Problems
Few Problems
Moderate Problems
Frequent Problems
47 19 9
30 36 35
14 41 56
Patient's physician 9 Transferring nursing home 4 Patient I
Table 3.
Anticipated impact of increasing numbers of elderly % of Responses Item Patient flew in the EB Availability of intensive care beds Availability of ward beds
No Impact
Minor Impact
I 2 5
24 23 38
Major Impact
ANNALS OF EMER6ENCY MEDICINE 21:7
75 75 57
JULY 1992
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McNamara, Rousseau & Sanders
ability of continuing medical education (CME) in geriatric emergency medicine. Additionally, information was requested on the number of CME hours spent in the past year on four topics in emergency medicine including geriatric emergency medicine (Table 7). We also inquired about the adequacy of current research on geriatric emergency care. In an attempt to look at how well geriatric social issues are integrated into the El), we questioned the availability of child abuse and elder abuse protocols. Because the results are mainly descriptive, statistical analysis was limited to comparing telephone and mail respondents and the availability of child abuse and elder abuse protocols. Statistical testing included ~2 analysis and unpaired Student's t-test where appropriate. P < .05 was considered significant. RESULTS
Of the 1,000 computer-randomized names, 971 surveys were sent out. A total of 485 (50%) responses were obtained from the three mailings. Of these, 52 were eliminated from analysis for the following reasons: foreign respondent (25), not practicing emergency medicine (nine), residency director who participated in a parallel survey (six), student member (five), and returned mailings not acceptable for inclusion (seven). The results of the study reported below are from the remaining 433 respondents. The respondents were predominantly male (82%) with a mean age + SD of 39 + 8 years (range, 23 to 73 years). Most were board certified in emergency medicine (63%) and had trained in an emergency medicine residency (56%). Practice characteristics were well distributed (Table 1). The mean length of practice + SD was 8.9 + 5 years (range, 0 to 26 years). The surveyed emergency physicians reported a high level of communication problems with both patients and nursing home staff (Table 2). Information reporting from the elderly patient's physician~ although better, was still viewed as a moderate or frequent problem by 44% of those surveyed. Most practicing emergency physicians are anticipating that the aging of the population will have a major impact on patient flow and hospital bed availability, particularly in the ICUs (Table 3). Seven clinical presentations encountered in the elderly are shown (Table 4). The responses indicate that for each presentation, 45% or more of the emergency physicians have Table 4.
Reported level of difficulty managing older compared with younger adult patients
more difficulty in the management of older compared with younger patients. Each of these clinical situations is viewed as more consumptive of time and resources by most of those surveyed (Table 5). Some of these differences may be explained by the large percentages of physicians (Table 5) who believe better standards of care exist for these clinical presentations in younger patients. The respondents' opinions as to the level of importance of medical, social, ethical, and resource availability issues in the emergency care of geriatric patients are shown (Table 6). Possible responses ranged from 1 (indicating very unimportant) to 6 (indicating very important). All issues were considered somewhat important, but medical and ethical issues were considered relatively more important. For those trained in emergency medicine residencies. 53% felt insufficient time was spent on geriatric issues during their residency. This trend appears to continue in practice as the number of hours reported for CME in geriatric medicine is substantially lower than other major areas of emergency medicine (Table 7). This may be partially explained because 69% of the respondents believed insufficient CME was available in geriatric emergency medicine. Similarly, 71% of the respondents believed the amount of research in geriatric emergency care was inadequate at present. Elder abuse protocols (27%) were significantly less available than protocols for child abuse (75%) (P < .001). The 30 responses from the phone survey were generally similar to those of the mail respondents. Small but significant differences were noted in seven of the 17 items assessed in Table 6, but this was felt explainable by the difficulty in responding to a Likert scale item by telephone. The only other difference noted was a higher percentage of telephone respondents reporting the availability of elder abuse protocols. Given the relative lack of difference in responses between the mail and telephone respondents, the survey results may be generalized with some degree of confidence for describing practicing emergency physicians. DISCUSSION
The results of this study highlight several areas of concern and needed focus for the field of emergency medicine. There appear to be inadequate educational and research efforts Table 5.
Responses to question comparing evaluation and management of older versus younger adult patients
% of Affirmative Responses
% of Responses Clinical Issue
Less Difficult
Abdominal pain Altered mental status Chest pain Dizziness/vertigo Feverwithout a source Headache Multisystem trauma
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1 10 12 4 14 7 3
Equal
More Difficult
21 " 31 43 32 41 46 25
78 59 45 64 45 47 72
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Clinical I s s u e Abdominal pain Altered mental status Chest pain Dizziness/vertigo Fever without a source Headache Multisystem trauma
Elderly More Elderly Require Time-Consuming More Resources 86
81
70 58 80 66 67 72
76 57 76 71, 64 71
BetterStandards of Care for Younger 43 44 31 40 29 37 40
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regarding geriatric emergency medicine. This may partially explain why most emergency physicians are less comfortable in the clinical evaluation and management of elderly patients as opposed to younger patients. The surveyed physicians seem aware of the crisis in health care resource use posed by the increasing number of elderly and view social and ethical issues as important in their practice. Medical issues regarding the elderly were assigned the highest importance by the surveyed physicians, and this concern was reflected in the r e p o r t e d higher level of difficulty with the various clinical presentations. Abdominal pain in the elderly was seen as more problematic than in younger patients by a large majority. Evidence supporting this is easily found in the literature. Fenyo, 11 in a Swedish study, reported that the diagnostic accuracy in the ED for elderly patients with abdominal pain was 70% to 80% and that the mortality doubled for those initially misdiagnosed in the ED. To illustrate the problems faced, this author mentioned the lack of characteristic pain migration in the elderly patient with appendicitis and that less than half of the elderly with perforated ulcers r e p o r t e d the sudden onset of pain. The diagnosis of appendicitis can be quite frustrating in the elderly, with one series reporting that only half of eventually proven appendicitis cases older than the age of 60 years carried that diagnosis as a possibility on admission. 12 Abdominal pain in the elderly carries a great significance in the ED as Scandinavian literature reveals that about one t h i r d will require surgery and a high percentage will need admission.ll, 13 The management of altered mental status in the elderly has been characterized by a high frequency of misdiagnosis. 14,15 Table 6. Assigned importance of issues in emergency care of geriatric patient by categories Mean Score*
SD
Medical issues Multiple medications and drug interactions 5.3 1.0 Altered disease presentation in the elderly 5.0 1.0 Altered physiologic response ofthe elderly 4.8 1.1 Inability to assess functional activities of the elderly 4.6 1.1 Social Issues Cost to society of caring for the elderly 4.8 1.4 inadequate access to care 4.2 1.3 Lack of primary care providers 4.2 1.3 Ability to pay for care 4.0 1.5 Elder abuse/neglect 4.0 1.2 Resources in ED Information transfer problems (nursing home, personal, physician, etc) 4.9 1.2 Social support for the elderly 4.7 1.1 Nursing support for the elderly 4.7 1.1 Emergency medical seryices 4.2 1.3 Ancillary services (taboratory, X-ray, etc) 4.0 1.3 Ethical Issues Resuscitation issues 5.1 1.2 Uncertainty regarding withholding/limitation of care (advance directives) 5.0 1.2 Adequate assessment of mental capacity 4.8 1.0 *Scale from 1to 6; larger numbersassociatedwith greaterlevelsof assignedimportance.
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N 430 430 429 430 429 426 427 427 427
425 427 426 424 425 427 427 428
This is p a r t i c u l a r l y distressing given the likelihood that an acute mental status change may be the presenting feature of a serious medical condition. 14 Previously noted problems in the ED evaluation of such patients include inadequate histories, examinations, and l a b o r a t o r y testing. 16 Our survey reflects the increased difficulties encountered by emergency physicians in deahng with elderly patients presenting with an altered mental status. The survey noted a relatively lesser but still large percentage of emergency physicians reporting increased difficulty in managing and evaluating chest pain in older patients. Much of this may be related to increased prevalence of factors suggestive of myocardial infarction in elderly patients with chest pain. 17 This restricts admission specificity for older patients with chest pain. A deficiency of the survey may be that the question should have been posed as regarding myocardial infarction versus chest pain given the propensity of the elderly to present in an atypical fashion. 18,19 Dizziness and vertigo in the elderly has been described as "daunting to emergency physicians ''20 and represents a significant diagnostic problem. Fever in the elderly is generally a harbinger of serious problems, yet identifying a bacterial source is more difficult in these patients. 21-23 Recent developments of an index to evaluate the older patient with unexplained fever reflect the difficulties experienced in the ED with such cases.22, 23 Headache carries a much greater diagnostic significance in the elderly, with multiple potentially serious etiologies.24 The difficulties r e p o r t e d with elderly muhisystem t r a u m a in this survey are important to address, as trauma is the fifth leading cause of death in the elderly. 25,26 Elderly t r a u m a victims account for a disproportionate n u m b e r of t r a u m a related deaths, more frequently require admission, and currently consume one third of health care resources for trauma.25,27 P a r t i a l explanations for the high percentage of emergency physicians who r e p o r t e d clinical difficulties with the above issues are found in th e responses regarding education and research in geriatric emergency medicine in our survey. Inadequate training in an area will foster uncertainty and make clinical decision making more difficult. The fact that more than half of the emergency medicine residency graduates judged their training to have inadequately p r e p a r e d them on geriatric issues should be a m a j o r concern for residency educators. A geriatric curriculum for emergency
Topic
Trauma Emergency medical services Toxicology Geriatric emergency medicine
Mean Hours + SO
16.7+ 14.7
Table 7. Amount of reported continuing medical education in the past year
12.4 + 16.2 9.1 _+11.1 3.1 + 4.5
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medicine has been created, but currently there are no specific requirements for training in this area. 28 Practicing emergency physicians according to this survey have not remedied these deficiencies through CME, possibly because of the inadequate amount of available CME related to geriatric emergency care. Inadequacies of both geriatric emergency education and clinical standards are likely products of the lack of research conducted in this area. Ethical issues in emergency medicine are unique because of the difficulties of time constraints for decisions in the ED. 29 Current concerns over health care costs have raised the possibility of future rationing of health care resources by age. 3° If such practices are instituted, the ED may become a site of many difficult ethical decisions regarding the elderly. Social issues are a n a t u r a l occurrence in emergency medicine as the 24-hour availability of the modern ED has made it a major entry point for social problems. 31 The lack of elder abuse protocols in our survey may reflect an inadequate appreciation of the social needs of this population in the ED. Social issues received the lowest scores of importance among the physicians surveyed in our study but were still rated generally high. Failure to address social needs in the ED may result in unnecessary repeat visits. 15.32 Most of the previously discussed items can be adequately addressed by increased attention to geriatric issues among researchers, educators, and practitioners of emergency medicine. The resource-related problems pointed out in this survey, however, will require major efforts on a broader front, as they involve key issues related to health care costs. Those aged 65 years and older currently account for most hospital days, and this percentage is steadily increasing. 33 In the ED, elderly patients stay longer, use more resources, and are admitted at rates three to four times higher than younger patients.4-6 Hospitals and EDs are already overcrowded in many areas. 10 With the population aged 65 years and older increasing by 1,600 people per day, 3a the emergency care system will be seriously compromised in the near future unless concomitant expansion of health care resources occurs or access to limited resources is restricted. CONCLUSION
A survey conducted of practicing emergency physicians revealed that practicing emergency physicians are uncomfortable with elderly patients, and this may reflect the inadequacies of training, research, and CME in geriatric emergency medicine. Ethical and social concerns were considered important, and the aging of the population is anticipated to have major effects on the availability of resources in emergency medicine. REFERENCES 1. AlIA HospitalStatistics. Chicago, American Hospital Association,1981. 2.AHA HospitalStatistics. Chicago, American Hospital Association,1990.
3. Williams K: Who uses the accident service? Injury 1984;16:35-37.
4. Ettinger WH, Casani JA, Coon PJ, et al: Patterns of use ofthe emergency department by elderly patients. J Geronto11987;42:638-642. 5. Baurn SA, Rubenstein LZ: Old people in the emergency room: Age related differences in emergency department use and care. JAm Geriatr Sac 1987;35:398-404. 6. Lowenstein SR, Crescenzi CA, Kern DC, et al: Care of the elderly in the emergency department. Ann EmergMad 1986;15:528-535. 7. US Bureau of the Census: Statistical Abstract of the United States:1990,ed 110. Washington, DC, 1990. 8. Schick FL: Statistical Handbook on Aging Americans. Oryx Press, Phoenix, 1986. 9. Gerson LW, Skvarch L: Emergency medical service utilization by the elderly. Ann Emerg Med 1982;11:610-612. 10. Andrulis DP, Kellerman A, Hintz EA, et al: Emergency departments and crowding in United States teaching hospitals. Ann EmergMet 1991;20:980-986. 11. Fenyo G: Acute abdominal disease in the elderly. Experience from two series in Stockholm. Am J Surg 1982;143:751-754. 12. Horattas MC, Guyton DP, Wu D: A reappraisal of appendicitis in the elderly. Am J Surg 1990;160:291-293. 13. Janzon L, Ryden CI, Zederfelt B: Acute abdomen in the surgical emergency room. Acta Chir Scand1982;148:141-148. 14. Lipowski ZJ: Delirium in the elderly patient. N Engl J Med 1989;320:578-582. 15. Waxman HM, Carrer EA, Dubin W, et al: Geriatric psychiatry in the emergency department: Characteristics of geriatric and non-geriatric admissions. J Am Geriatr Sac 1982;30:427-432. 16. Waxman HM, Dubin W, Klein M, eta[: Geriatric psychiatry in the emergency department, II: Evaluation and treatment of geriatric and nongeriatric admissions. J Am Geriatr Sac 1984;32:343-349. 17. Solomon CG, Lee TH, Cook EF, et al: Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: The multicenter chest pain study experience. Am J Cardio11989;63:772-776. 18. Bayer A J, Chadha JS, Farag RR,et al: Changing presentation of myocardial infarction with increasing old age. J Am Geriatr Sac 1986;34:263-266. 19. Cocchi A, Franceschini G, Incalzi RA, et al: Clinico-pathological correlations in the diagnosis of acute myocardial infarction in the elderly. Age Ageing 1988;17:87-93. 20.Olsky M, Murray J: Dizziness and fainting in the elderly. Emerg IViedClin North Am 1990;8:295-307. 21. Bark SL, Smith JK: Infectious disease in the elderly. Mad Clin North Am 1983;67:273293. 22. Mellors JW, Horwitz RI, Harvey MR, et al: A simple index to identify occult bacterial infection in adults with acute unexplained fever. Arch Intern Med 1987;147:666-671. 23. Leibovici L, Cohen 0, Wysenbeek A J: Occult bacterial infection in adults with unexplained fever (validation of a diagnostic index). Arch Intern Med 1990;150:12701271, 24. Samiy AH: Clinical manifestations of disease in the elderly. Emerg Med Clin North Am 1990;8:333-344. 25. 0reskovich MR, Howard JD, Copass MK, et al: Geriatric trauma: Injury patterns and outcome. J Trauma 1984;24:565-569. 26. Martin RE, Teberian G: Multiple trauma and the elderly patient. EmergMed Clin North Am 1990;8:411-420. 27. Fife D, Barancik JI, Chatterjee BF: Northeastern Ohio Trauma Study: II. Injury rates by age, sex, and cause. Am J Pub@ Health 1984;74:473-478. 28. Jones J, Dougherty J, Cannon L, et al: A geriatrics curriculum for emergency medicine training programs. Ann Emerg Med 1986;15:1275-1281. 29. Adams J, Wolfson AB: Ethical issues in geriatric emergency medicine. Emerg Med Clin of North Am 1990;8:183-192. 30. Schneider EL, Buralnik JM: The aging of America (impact on health care costs). JAMA 1990;263:2335-2340. 31. McDonald AJ, Abrahams ST: Social emergencies in the elderly. EmergMet Clin North Am 1990;8:443-459.
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32. BassukEL, Minden S, Apsler R: Geriatric emergencies:Psychiatric or medical ? A m J PsFchiatry1983;140:539-542. 33. CampionEW, Barg A, May Mh Why acute-care hospitals must undertake long-term care. N Engl J Med 1983;308:71-75.
Address for reprints: Robert M McNamara, MD, FACEP,Department of Emergency Medicine, The Medical College of Pennsylvania,3300 Henry Avenue, Philadelphia, Pennsylvania 19129.
34. AMA Council on Scientific Affairs: Societal effects and other factors affecting healthcare for the elderly. Arch Intern Med 1990;150:1184-1189.
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