Functional Assessment & Discharge Planning

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Principles of Care of the Older Patient

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In 1996 Dr Art Sanders published “Emergency Care of the elder person” — (Sanders, Beverly Cracom Publications, St. Louis, 1996). It develops 11 Principles of Care of the Older Emergency Department patient, a model for thinking about how older people are different from others.

Click on the principles below to learn more.

1. Presentations are frequently complex
  • Most younger people’s presentations can be reduced to a single problem – appendicitis, MI, poly-trauma – that the ED team can address and resolve. Older people’s presentations usually are multi-factorial with many interconnected issues ALL of which need to be addressed. For example, is it a simple infection? How do you choose the right antibiotic for a person on anti-coagulants with renal impairment and heart failure with significant fall risks and mild cognitive impairment who lives alone? And what sort of follow-up do they need?
2. Common diseases present atypically in older patients complex
  • Serious conditions — sepsis, ACS, stroke — can present without the typical symptoms but as weakness, confusion, falls, or functional decline. To learn more visit the module on Atypical Presentations.
3. The effects of co-morbid conditions can be confounding
  • Does intervening to manage one problem – treating a sprained ankle with NSAIDs and a splint, for example – have an effect on multiple other problems – renal impairment, hypertension, mobility problems. And is it really a sprained ankle or a recurrence of previous gout? Or a new flare of RA?
4. Polypharmacy is common and can be a factor in presentation, diagnosis, and management
  • Most older people in Canada take more than five medications. Many ED presentations are related to medication. To learn more visit the module on Medication Management.
5. Cognitive impairment is possible
  • Assessment of dementia (chronic brain failure) and delirium (acute brain failure) is important in the ED since they both have a significant effect on assessing the presenting complaint and on determining a safe discharge plan. To learn more visit the module on Cognitive Impairment.
6. Some diagnostic tests have different values
  • Emerg physicians need to keep in mind that “on paper” older people look different from younger people: WBCs and bacteria in urine can be normal; significantly elevated ESRs can be normal ; leukocytosis may not occur in sepsis; a “normal” creatinine may be consistent with chronic renal failure.
7. Decreased functional reserve is likely
  • With younger patients we can assume that their kidneys, brains, heart, and social lives are robust enough to tolerate even significant assaults. Aging is sometimes defined as the gradual decrease in functional reserve in ALL organ systems.
8. Social/community support may not be adequate and patients may rely on caregivers
  • Younger people are usually functionally independent and competent problem-solvers; older people with a new even minor problem may require support from others. It can be challenging to identify that support system since some safety nets have large holes in them.
9. Awareness of baseline functional status is essential in assessing new conditions
  • There is a wide range of “normal” in older patients. The tennis-playing 92-year-old yoga instructor/newspaper columnist can live next door to the house-bound 71-year-old with diabetes and early dementia. A conscious effort to establish what “normal” function for each individual older person will have an impact on diagnosis and discharge planning.
10. Health problems must be assessed in the context of need for psychosocial support
  • Younger people, with their medical and social resilience, face significant emotional and functional challenges when faced with a change in health status. Arranging for a durable discharge to the community for a frail older person after an Emerg visit will need to include some consideration of their psychosocial function.
11. The ED presentation is often a sentinel event: an opportunity to assess important factors in the person’s life
  • Many critical problems may not be recognized until the older person shows up in the ED. For example, a lack of end-of-life planning in someone with a steady progression of a terminal condition; inadequacy of care support in someone presenting with what looks like elder abuse; inability to access primary care because of mobility problems in someone whose medications have not been reviewed in several years; unrecognized dementia in a socially isolated person. You, the Emerg physician, may be the first person to assess these needs.
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