Fear the geriatric abdominal pain

I still remember my very first EMS call. Adrenaline coursed through my veins as we thundered lights and sirens through the streets. Bouncing around in the back of the unit, my imagination ran wild with what we were about to encounter.

The call was much more routine than the nightmare I had cooked up inside my head.

Shortly after arriving, we approached the patient’s apartment, only to be greeted at the door by a pleasant woman in her 80s. She had called 911 because she had “felt a bit off,” had some vague epigastric discomfort and had been vomiting. We delivered her uneventfully to the hospital, a blue emesis bag clutched in one hand, her purse in the other.

A few hours and a couple 911 calls later, we returned to the ED to drop off another patient. Chatting with some of the nurses, we found out the women we had transported during my first call had died.

I was shocked. She had seemed fine just a few hours before. I learned my first real lesson in medicine that day. Never trust a geriatric patient with abdominal pain!

I also learned that even the most well-appearing patients can harbor serious underlying pathologies. This is especially true among our geriatric patients (those over 65) and abdominal pain is one of the deadliest complaints they can present with.

What may be masking symptoms in geriatric patients

It wasn’t until I started training as an emergency physician that I began to understand how dangerous a geriatric abdominal pain complaint truly is. The simple fact is, half of these patient will end up being admitted to the hospital and roughly 20% will go on to need surgery [1]. Most terrifying of all is that studies reveal the mortality rate to be between 5-10% for geriatric patients who present to the emergency department for abdominal pain [1,2]. This is a chief complaint that is not to be trifled with.

There are many potential reasons why this complaint can be so dangerous. Geriatric patients have increased incidences of cancer, higher rates of bowel obstructions and they often have multiple comorbidities. Geriatric patients also have reduced physiologic reserves to survive an operation/or acute illness, they have weakened immune systems and are often on multiple medications that may mask symptoms or blunt the body’s compensatory mechanisms.

These patients also have pathologies that are rarely seen in younger populations, including vascular phenomenon, such as mesenteric ischemia or abdominal aortic aneurysms.

Geriatric patients may also take longer to develop pain from their complaints or may not develop pain at all. They may present with other signs and symptoms, such as isolated fever or only nausea and vomiting. Geriatric patients can also manifest thoracic complaints with isolated abdominal pain.

One study of geriatric patients with unstable angina found 8% had a chief complaint of epigastric pain instead of chest pain we would anticipate [3]. Not only can cardiac ischemia present as isolated abdominal pain, that same study found almost half of geriatric patients with unstable angina did not have any chest pain at all. The study did find that 40% of the patients had nausea and 11% had vomiting^[3].

Both nausea and vomiting may be inappropriately mischaracterized to an abdominal process or written off all together and an ECG may not be obtained. Geriatric patients are also often on multiple medications, such as opioids that may mask pain, or beta blockers that may artificially normalize vital signs. Cognitive function may also play a role (e.g., for a patient with dementia who is unable to provide an accurate history). Clearly, there are many factors that come into play that can complicate abdominal pain in this population.

How to care for elderly patients with abdominal pain

So how can EMS providers best help these patients? Besides the top notch care you are already providing in the field, advocating for these patients when they get triaged in the ED may help them to get dispositioned more appropriately. Knowing that the elderly patient with abdominal pain that you transport to the ED has up to a 1/10 chance of dying based solely off their presenting complaint should always be in the back of your mind.

Even after a short transport, you will know more about the patient then the team at triage who may only have time to ask a handful of questions. These patients frequently get sent to the waiting room when they may be the sickest patient in the ED.

If you have concerns about a patient at all, advocating in triage could be the difference between a patient getting seen in 30 minutes or in 3 hours. If a patient was having severe pain and you treated them with IV analgesics, communicating the level of discomfort to the receiving facility prior to pain medication may help to paint a picture of the potential seriousness of the complaint.

Mentioning medications that may minimize patients’ vitals (e.g., the patient is on a beta blocker) is another way to advocate for them.

Have a low threshold to obtain an ECG on these patients to look for signs of cardiac ischemia. It may also be prudent to transport these patients to hospitals with surgical or inpatient capabilities. If the patient ends up decompensating, they will more than likely need a surgeon. The chance the patient will get admitted is roughly a coin flip. These patients may not be appropriate for your local free-standing ED.

Ultimately the most important thing you can do is simply recognize the significance of an elderly patient who calls 911 for abdominal pain. These patients are often sicker than they appear. Obtaining a solid history, maintaining a low threshold to obtain an ECG and advocating for these patients at the hospital may just save a life.

References

1. Lewis, M., et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2005;60(8):1071-1076. doi: 10.1093/gerona/60.8.1071
2. Fenyo G. Acute abdominal disease in the elderly: experience from two series in Stockholm. Am J Surg. 1982;143(6):751–754. doi: 10.1016/0002-9610(82)90052-6
3. Canto J., et, al. Atypical presentations among Medicare beneficiaries with unstable angina pectoris. Am J Cardiol 2002;90: 248–253. 10.1016/S0002-9149(02)02463-3