Older Emergency Department (ED) patients are more likely to experience adverse health outcomes after their ED visit, independent of the severity of the disease that led to the ED visit. In this thesis, we explored two important features of geriatric emergency medicine: altered disease presentation and identification of vulnerable older ED patients.
The first part of the thesis of Agneta Calf shows that almost half of the older ED patients present with an atypical disease presentation and those patients had a longer hospital stay compared to those with a typical disease presentation. Furthermore, disease severity scores based on vital parameters are used for identification of patients at risk for deterioration, but lack diagnostic accuracy in older patients. In this thesis it is shown that addition of the geriatric parameter physical impairment to a disease severity score, is associated with clinical deterioration and therefore the presence of physical impairment should alert the clinician of the risk of clinical deterioration as well.
The second part of the thesis addresses identification of vulnerability and cognitive impairment in older ED patients. The identification of vulnerability is complex, but a dichotomous clinical judgement tool is a simple, feasible aid which can be used as a first step in the identification of vulnerable older ED patients. Finally, the diagnostic accuracy of screening instruments for cognitive impairment (both delirium and dementia) was examined. The 4 A’s Test showed to be the most useful instrument to rule out cognitive impairment, because of both methodological properties and its practicality for clinical use.
