Emergency medical care for the elderly

The Norwegian National Centre of Emergency Primary Health Care have been given the following assignment from the Norwegian Directorate of Health: To assess the emergency primary health care for the elderly population. The aim of the project is to increase the knowledge of emergency medical services for the elderly population and to point out areas where these can be improved.

Questions to be answered:

  1. How the elderly population use the emergency medical services today
  2. How the elderly and their dependents better can detect acute illness early and alert the right authority
  3. How the emergency care services better can detect acute sick or wounded conditions in the elderly population and ensure the right priority and treatment


We therefore investigated:

  1. Characteristics of the elderly's use of the emergency medicine services.
  2. Atypical presentation of acute illness and injury among the elderly.
  3. Identification of frailty in the emergency medicine services.


Method

Register data were used to explore how the elderly use emergency medical services today; the emergency number 113, emergency room and emergency center, GP, and immediate emergency admissions.

It has been reported in several international studies that older people who are in contact with an acute medical chain may have atypical disease presentation, but this knowledge has not been systematic collected before. A scoping review was therefore performed. This included 60 studies with > 1.2 million elderly patients in total. Atypical disease presentation means that typical symptoms of acute illness or injury may be less prominent or simply lacking.

In order to determine whether frailty is addressed in inquiries from the elderly to the emergency medicine chain, various sources were reviewed; current triage and decision support tools, relevant publications and reports. A search was also made in gray literature and communication with professionals. We finally examined potential scoring tools to identify frailty among acutely ill and injured seniors.

Results

The elderly account for a larger share of contacts with the whole emergency medicine chain than they make up of the total population. Compared with the middle-aged, the elderly make up a lower proportion of the population, but account for more immediate help admissions and contacts to 113. The elderly receive more frequent homevisits than the middle-aged, and the causes of contact are more often classified as general and unspecified.

1 in 3 elderly people with acute coronary syndrome presented without chest pain, 2 out of 5 elderly people with infection presented themselves without fever and 1 in 10 elderly people with acute abdomen presented themselves without abdominal pain. Instead, the elderly presented with nonspecific symptoms such as falls / difficulty walking, confusion, incontinence, fatigue / tiredness, malaise and loss of appetite. Studies that had examined the elderly with nonspecific symptoms and ailments found a wide range of conditions, from less serious to acute and life-threatening conditions. The consequences of atypical disease presentation were delays in diagnosis and treatment with poorer prognosis as a result.

The prevalence of frailty among acutely ill elderly people in Norway is unknown. Triage and decision support tools in use today do not help to distinguish between robust and frail older people. As of today, we do not have good enough tools to ensure that this patient group receives the right priorities and treatment.

Contact person: Isabel Sebjørnsen, iseb@norceresearch.no, 56107304

Project outcomes

  • Rapport nr.1-2021 Eldre i den akuttmedisinske kjeden
  • • Vi fant at 1 av 3 eldre med akutt koronarsyndrom presenterte seg uten brystsmerter, 2 av 5 eldre med infeksjon presenterte seg uten feber og 1 av 10 eldre med akutt abdomen presenterte seg uten magesmerter. I stedet presenterte de eldre seg med uspesifikke symptomer som fall/gangvansker, forvirring, inkontinens, utmattelse/tretthet, sykdomsfølelse, uvelhet og appetittløshet. Studier som hadde undersøkt eldre med uspesifikke symptomer og plager, fant et stort spekter av tilstander, fra mindre alvorlige til akutte og livstruende tilstander. Konsekvensene av atypisk sykdomspresentasjon var forsinkelser i diagnostikk og behandling med dårligere prognose som resultat.
  • • Vi fant at prevalensen av skrøpelighet blant akutt syke eldre i Norge er ukjent. Triage- og beslutningsstøtteverktøy i bruk i dag bidrar ikke med å skille mellom robuste og skrøpelige eldre. Per i dag har vi ikke gode nok verktøy for å sikre at denne pasientgruppen får rett prioritering og behandling.