Weak Old Ladies

[brainfailure]

Advertisement - Members don't see this ad

OK. I'm rotating at a new place with A LOT more old people than I'm used to. What the heck do I do with all these 90+ ladies with generalized weakness but no other complaints? What's your guys' approach? I've been doing basic labs, EKGs, UAs. Sometimes I get lucky and the have a UTI or dehydration with a bump in their creatinine, but mostly a negative work up.

What to do?

 

[GeneralVeers]

OK. I'm rotating at a new place with A LOT more old people than I'm used to. What the heck do I do with all these 90+ ladies with generalized weakness but no other complaints? What's your guys' approach? I've been doing basic labs, EKGs, UAs. Sometimes I get lucky and the have a UTI or dehydration with a bump in their creatinine, but mostly a negative work up.

What to do?

Admit ----> Rehab ----> Nursing home

 

[tkim]

Admit ----> Rehab ----> Nursing home

Lather ----> Rinse ----> Repeat

 

[EM OR BUST]

OK. I'm rotating at a new place with A LOT more old people than I'm used to. What the heck do I do with all these 90+ ladies with generalized weakness but no other complaints? What's your guys' approach? I've been doing basic labs, EKGs, UAs. Sometimes I get lucky and the have a UTI or dehydration with a bump in their creatinine, but mostly a negative work up.

What to do?

Admit!

 

[C5toC9]

admit them and do what?

 

[The White Coat Investor]

I don't admit em, but I do a big "fishing expedition" type ED work-up. If I find something, I treat it. If I find something that needs admitting, I admit. If I find nothing, I send them home with PCP FU.

 

[GeneralVeers]

It's just too bad that the Soylent Green factory isn't an option.

 

[gutonc]

admit them and do what?

Move on to the next chart in the rack.

 

[shopsteward]

What the heck do I do with all these 90+ ladies with generalized weakness but no other complaints?

1) Check their feet. Seriously, bad feet = no exercise = generalized weakness.

2) Check they are not malnourished. Geriatrics are one of the few populations where underfeeding is likely to be an issue. (Overfeeding issues mostly resolve themselves before 90+)

3) Check whether there are physical therapy options to get the little old ladies moving. A little old lady in her early 90s with no physical illness and the right level of fitness can walk several miles without a problem, do all the routine housework and a fair amount of gardening - I have relatives and neighbours who have done or still do.

 

[Kubed]

... I've been doing basic labs, EKGs, UAs. ...

Ah, the gomergram.

 

[Winged Scapula]

It's just too bad that the Soylent Green factory isn't an option.

🤣

 

[SoCuteMD]

1) Check their feet. Seriously, bad feet = no exercise = generalized weakness.

2) Check they are not malnourished. Geriatrics are one of the few populations where underfeeding is likely to be an issue. (Overfeeding issues mostly resolve themselves before 90+)

3) Check whether there are physical therapy options to get the little old ladies moving. A little old lady in her early 90s with no physical illness and the right level of fitness can walk several miles without a problem, do all the routine housework and a fair amount of gardening - I have relatives and neighbours who have done or still do.

The above are not really "emergency department" issues.

I do a basic infection workup (CXR, UA/Cx) and then dispo home. I get care coordination involved if I can't find a reason to admit them but they clearly aren't functioning at home.

 

[shopsteward]

The above are not really "emergency department" issues.

I agree, but might not "feet, food, fitness" provide a possible answer to the question of "generalised weakness in an old person" once other diagnoses have been ruled out? If so, then might it not also indicate the appropriate forward management, such as discharge with recs for the PCP or even admission for malnutrition? (Presumably also if feet, food, fitness is the answer, then the patient shouldn't have been in the emergency department in the first place, but that doesn't provide a solution once they are already there.)

Would a decision on admission for malnutrition need to factor in the edibility of the hospital food?

It's also just possible that, in some cases, a little old lady of 90+ is still in full possession of her mind, and if reassured that there are no other medical issues and pointed in the direction of the solution, could take the appropriate action for herself.

 

[brainfailure]

Thanks for the responses guys.

For those that admit, what's your admission diagnosis? Do the hospitalists give you a hard time for admitting "generalized weakness"? Do you ever admit for r/o ACS without a history of chest pain/SOB (ie just complaining of generalized weakness)?

For those of you that don't admit, how much of a "fishing expedition" do you go on, partcularly for ACS?

Honestly, my former style was to do the fishing expedition (including just one EKG and enzymes) and if the basic stuff comes back negative and they can take care of themsleves or have a place where they will be taken care of I let 'em go. Then I worry I missed something.

 

[Arcan57]

You probably are missing something. Something made them feel run down and caused them to come into the ED, and its not always psych. Elderly ladies die of stuff all the time without having the decency to exhibit the symptoms the rest of us do. Which is why we tend to admit them for observation where we'd tell anyone else to take a hike. Counterbalancing that truth is that old ladies die all the time and unless you decided to piss off the family or actively murdered them, there isn't much medicolegal risk.

 

[WilcoWorld]

For those of you that don't admit, how much of a "fishing expedition" do you go on, partcularly for ACS?

Honestly, my former style was to do the fishing expedition (including just one EKG and enzymes) and if the basic stuff comes back negative and they can take care of themsleves or have a place where they will be taken care of I let 'em go. Then I worry I missed something.

I do an H&P and a similar battery; ecg, enzymes, UA, CXR, chemistry. I'd guess that about 60% of the time I find something worth treating, and it doesn't always require admission. If I find nothing and the patient feels well enough to go home, I arrange for PCP follow up as quickly as I can manage. If the ECG has a concerning abnormality I'll observe or admit for ACS.

I should also say that I'm much more liberal with my CT imaging in nonagenarians.

 

[quinsy]

For those that admit, what's your admission diagnosis? Do the hospitalists give you a hard time for admitting "generalized weakness"? Do you ever admit for r/o ACS without a history of chest pain/SOB (ie just complaining of generalized weakness)?

The admission diagnosis on paper is "weakness". When I call the hospitalist, I tell them straight up, "Mrs. X is this frail, weak, little old lady and even though her labs, EKG, CXR, and UA are normal, she can't walk more than 10 feet without falling over. She lives alone and she is not safe at home. This is a social admission until she can find placement."

Hospitalists generally understand this sort of thing because they admit it all the time. Sometimes the LOLs of this world are just not safe at home, and it's your job not to send them there unattended if they are not safe, even though some tragedies that might befall them could be merciful in your mind, you don't want to be that guy who sent Grandma home the night before she died, and if she just falls and gets incapacitated alone on the floor and goes into rhabdo in puddles of her own excrement over a several days timespan etc etc., it's not actually a very good way to die.

 

[chimichanga]

...she can't walk more than 10 feet without falling over. She lives alone and she is not safe at home. This is a social admission until she can find placement...

The ED group here diagnoses them w/ "ambulatory dysfunction"

they all get H/H or placed after the "admission"

 

[SoCuteMD]

I saw a weak older gentleman today.

Crit - 18.

When he told me about his black stools and I mentioned that it sounded like he might have an ulcer he said, "Oh, is that why my stomach's been bothering me this week?"

The man was not a complainer, and that's understating it!

 

[VienneseWaltz]

For those that admit, what's your admission diagnosis?

When I was a resident, I had an attending who would use "advanced senescence." 🙄

 

[leorl]

HA advanced senescence. I like that. WOL (weak old lady) = cardiac admit r/o acs here. If it's really not cardiac, then it's a failure to thrive admit. Unless they say something specific like "I have no air conditioning and I want to stay here awhile."

 

[xaelia]

"Adult Failure to Thrive"

 

[GeneralVeers]

I hate "failure to thrive" as a diagnosis. It somehow implies that old people should be growing and improving. In reality everything is downhill after 30. To expect an 80-year old with dementia to "thrive" is to delude oneself.

 

[quinsy]

To expect an 80-year old with dementia to "thrive" is to delude oneself.

Maybe our New England elderly are more vivacious than yours are... I've seen even 90 year olds who are thriving! I saw a 90-something year old come in a few weeks back with the complaint "I think I pulled a muscle in yoga class" (!). We were dying to ask if it was "downward dog" position or what...

Another 90-something came in with blood all over his lacerated face due to a trip and fall while gardening, and became very irritated that I didn't fix it up fast enough for him "don't you know, I have a date tonight! I'm going out on the town! I've got to get home and freshen up!"

 

[GeneralVeers]

Maybe our New England elderly are more vivacious than yours are... I've seen even 90 year olds who are thriving! I saw a 90-something year old come in a few weeks back with the complaint "I think I pulled a muscle in yoga class" (!). We were dying to ask if it was "downward dog" position or what...

Another 90-something came in with blood all over his lacerated face due to a trip and fall while gardening, and became very irritated that I didn't fix it up fast enough for him "don't you know, I have a date tonight! I'm going out on the town! I've got to get home and freshen up!"

"Thriving" is not the same as "status quo". With good genetics and healthy living you can more or less maintain the status quo for some time. However the trend over time is ALWAYS downwards. No one expects those 90-year olds to age backwards and "thrive" unless they are Benjamin Button.

 

[quinsy]

"Thriving" is not the same as "status quo".

Having a lively social life with intermittent yoga class does not seem like the status quo for 90 year olds. If you take thriving only to mean improvement over time, then perhaps, but I believe the definition is broader and includes the ideas of prospering and being vigorous. Therefore I would posit that at any age it is possible to either thrive or fail to thrive. 🙂

 

[GeneralVeers]

Having a lively social life with intermittent yoga class does not seem like the status quo for 90 year olds. If you take thriving only to mean improvement over time, then perhaps, but I believe the definition is broader and includes the ideas of prospering and being vigorous. Therefore I would posit that at any age it is possible to either thrive or fail to thrive. 🙂

So you believe that the 80-year old demented patients with a G-tube and bedsores has a chance to "thrive"?

 

[quinsy]

So you believe that the 80-year old demented patients with a G-tube and bedsores has a chance to "thrive"?

No, those would be the ones in the 'failing' category.

 

[EMS5]

Not a doctor by any rate, but little old lady calls plague us just as much, so I thought I'd drop my .02 in the bucket...

More times than not, the dispatch is uber-vague. Usually "sick subject" or "subject fallen". If I stuck my toes to the line as far as protocol, most of these are justifiable ALS workups especially considering their histories.

More often, I keep it BLS and just get vitals and nasal O2 and let you guys start addressing which chronic issue is most likely causing today's trip to the local ED.