Geriatric Emergencies

This is a pathway for adults aged 65 and older. Use your local age cutoff where it differs. Aging shrinks physiologic reserve. Expect less cardiac output in reserve, a blunted response to hypovolemia, slower renal drug clearance and altered drug sensitivity. Frailty and comorbidity matter more than age alone. The Clinical Frailty Scale is a 9-point global rating of fitness and frailty. It shows how much deterioration a patient can absorb.

• Common causes: infection (pneumonia, urinary, skin), dehydration, medication adverse effects, falls with or without injury, acute coronary syndrome, stroke, hypoglycemia, and bowel obstruction.
• Clinical course: A small change from baseline can turn into shock or respiratory failure over hours. Atypical presentation is common. The first complaint is often confusion, weakness, falls, poor intake or a change in function rather than a classic symptom.
• Baseline first: Compare every finding with the patient's own normal. That covers mental status, gait, blood pressure, heart rate and oxygen need. Get that normal from family, caregivers, facility records and the medication list.

Presentations

• Typical: The syndrome you'd expect, with the usual signs. Chest pain, dyspnea, focal weakness, fever with cough.
• Atypical: New confusion or drowsiness, falls, anorexia, weakness, urinary incontinence or functional decline. Few localizing signs to point you anywhere.
• Severe: Hypotension, altered mentation, hypoxia or hypothermia. Sometimes the blood pressure sits near normal if the patient takes a beta-blocker or another rate-controlling drug.

Red Flags

• New confusion or drowsiness compared with baseline (use the Confusion Assessment Method, below).
• Any head strike in a patient on an anticoagulant or antiplatelet, even with a normal exam.
• Shock index (heart rate divided by systolic BP) of about 0.8 or higher, or SBP well below baseline. Beta-blockers and baseline hypertension blunt the heart rate's climb. Read the trend, not only the number.
• Blood glucose below 70 mg/dL with any change in mental status.
• SpO₂ below target or new oxygen requirement; respiratory rate 22 or higher.

• Delirium vs dementia: Delirium comes on acutely, fluctuates and brings inattention. Dementia is gradual and doesn't fluctuate. Treat new delirium as an emergency until you've found a cause.
• Hypoglycemia: Confusion, weakness or falls in a patient on insulin or a sulfonylurea. Check glucose first. Sulfonylurea and long-acting insulin lows can come back after correction.
• Stroke vs hypoglycemia: A focal deficit that doesn't correct with glucose is a stroke until proven otherwise. See Acute Ischemic Stroke.
• Sepsis vs medication effect: New confusion with fever, tachycardia or a raised lactate points to infection. Sedation or an anticholinergic load can cause delirium on its own. Don't assume it's only the drug.
• Shock vs baseline hypotension: A low pressure that is normal for this patient isn't shock. Compare it with the baseline and the perfusion signs.

1. Scene safety and mechanism: for a fall, ask about the height, the head strike and what the patient was doing before the fall.
2. Baseline: ask family or the facility for the normal mental status, mobility and medications, and bring the medication list or bottles.
3. Spinal precautions: use spinal motion restriction per local protocol when the mechanism or exam requires it.
4. Glucose and oxygen: check glucose; give oxygen to the SpO₂ target in local protocol.
5. Positioning and warmth: keep the patient warm and prevent falls. Do not leave a confused patient unattended.
6. Early notification: tell the receiving team about the baseline, the anticoagulant and the fall.

Doses vary by protocol; follow local protocols and medical direction.

• IV or IO access and monitoring (Paramedic/RN/CCT): establish access, continuous monitoring, and a 12-lead ECG when ischemia is possible. See IO Access.
• Hypoglycemia (Paramedic/RN/CCT): dextrose 10 g IV (100 mL of D10) or glucagon 1 mg IM when no IV access. See Dextrose and Glucagon. Oral glucose 15 g if the patient can swallow safely. See Oral Glucose. Sulfonylurea and long-acting insulin lows often come back for hours. Do not release after a single correction. Transport or observe, and recheck glucose. Expect glucagon to be less effective when glycogen stores are poor (malnourished or fasting patients).
• Opioid-related depression: naloxone titrated to breathing and ventilation, per protocol. See Naloxone.
• Agitated delirium (Paramedic/RN/CCT): Treat the cause first. Then reach for non-drug measures: reorientation, a familiar person, lighting, a quiet space. Haloperidol is an option only when agitation endangers the patient or staff. The adult dose is 2 to 5 mg IM. Frail or debilitated older adults get a lower dose, per protocol and medical direction. See Haloperidol. Get a 12-lead ECG and QTc before dosing when feasible, and correct potassium and magnesium. Avoid stacking sedatives.
• Shock (Paramedic/RN/CCT): Give fluid in boluses and reassess after each one for lung findings, then add a vasopressor per protocol. Fluid volume depends on the protocol. The Surviving Sepsis Campaign 2021 guideline suggests about 30 mL/kg in the first 3 hours for sepsis-induced hypoperfusion, and it is a weak recommendation. Older adults with heart failure or renal disease need smaller boluses, with a reassessment after each. See Norepinephrine and Lactated Ringer's.
• Pain: Titrate analgesia to effect and to breathing. Acetaminophen comes first where it is enough. In older adults, opioids need reduced doses and a lower frequency. Avoid NSAIDs in patients on anticoagulants or with renal disease or heart failure. Watch for oversedation, falls and delirium.

• Head injury on an anticoagulant or antiplatelet: Get a head CT per local protocol, even when the exam is normal. Reversal agents (prothrombin complex concentrate, vitamin K, idarucizumab or andexanet alfa per the anticoagulant and local protocol) target the anticoagulant. See Anticoagulant Reversal, Prothrombin Complex Concentrate and Vitamin K. Tranexamic acid is a separate decision for TBI or hemorrhage inside its time window. See Tranexamic Acid. The ACEP 2023 mild TBI clinical policy addresses whether discharge is safe after a single normal CT in these patients. Follow local policy on observation and repeat imaging. Bleeding can grow after a normal first scan. Give return precautions and confirm a responsible adult at home.
• Fall with injury: Run the trauma assessment per the trauma assessment page. Look for hip fracture, rib fracture and occult bleeding. Don't rely on a normal blood pressure. After a long lie on the floor, check CK, potassium and renal function for rhabdomyolysis.
• Syncope or a fall without a clear cause: 12-lead ECG, orthostatic vitals where safe, and a medication review for arrhythmia, bradycardia or hypotension.
• Hypothermia: Check core temperature. Older adults may not shiver, so warm them gently and reassess.
• Infection: Early antibiotics and fluids per the Sepsis and Septic Shock pathway. Sepsis-3 defines sepsis as organ dysfunction from a dysregulated host response to infection.
• Delirium workup: review medications, check glucose, sodium and oxygen, and look for infection and retention. Stop the offending drug when it is safe.
• Escalation: ICU or step-down admission for shock, respiratory failure or failure to clear delirium. Use the Hemorrhagic Shock pathway when bleeding is suspected.

• Destination: Go to the nearest appropriate hospital per local triage criteria. Older adults are often undertriaged. Lower the bar for a trauma center when a fall with injury, an anticoagulant or frailty raises concern. Follow the 2021 National Guideline for the Field Triage of Injured Patients and local criteria.
• Prenotify: send the baseline mental status, the medication and anticoagulant list, the fall mechanism and the vitals trend.
• In transit: monitor mental status, glucose, SpO₂ and blood pressure trend. Reassess each contact, and document the baseline comparison.
• Handoff: include the last medication doses, anticoagulant and time of last dose, any fall or head strike, and the family contact.
• Equipment: pad pressure points, use fall-prevention measures, keep the patient warm, and have suction ready for aspiration risk.

• Pediatrics: adult pathway. For children use weight-based dosing and pediatric vital signs.
• Pregnancy: Not this pathway. For pregnancy-related emergencies, see Preeclampsia and Eclampsia.
• Older Adults: Many drugs clear more slowly in older adults, so the half-life runs longer. For example, the propranolol page notes that older adults clear it more slowly. Start low and titrate to effect.
• Polypharmacy and Beers criteria: The AGS Beers Criteria (2023) lists drugs to avoid or use with caution in older adults. The high-risk classes for delirium, falls and hypoglycemia are benzodiazepines, Z-drugs, antipsychotics, anticholinergics, opioids combined with benzodiazepines, and sulfonylureas. Before you add any sedative, review the full medication list. Avoid new anticholinergics or benzodiazepines where a non-drug or lower-risk option exists. Tell the receiving team which drugs were given.
• Renal Impairment: Reduced clearance changes drug dosing. Check the medication page for the renal adjustment before you give any drug.
• Patients on Anticoagulants: Any head strike, bleeding or fall calls for an anticoagulant review. See Anticoagulant Reversal.
• Patients on Beta-Blockers: Heart rate may not climb in shock. Hypoglycemia can show up without its typical adrenergic signs. See Metoprolol and Propranolol.
• Dementia: The baseline is the patient's normal. Any change from it is delirium until shown otherwise.
• Elder abuse and neglect: Watch for unexplained injuries, a history that doesn't fit the injury, a delay in seeking care, or a caregiver who is reluctant to answer. Report per local mandatory reporting law and protocol.
• Goals of care: ask about the patient's stated wishes, a health care proxy and any advance directive. Follow local protocols on code status and on transport decisions.

• Error: Trusting a normal heart rate. Beta-blockers and other rate-controlling drugs can blunt tachycardia. Check mental status, perfusion and baseline.
• Error: Taking a normal exam or a refusal as clearance for a head strike in someone on an anticoagulant. Apply the local head-injury protocol. Record the anticoagulant and last dose, and hand off the fall.
• Error: Calling confusion dementia or a behavioral problem. Screen for delirium with CAM. Check glucose, oxygen, infection and medications first.
• Error: Giving haloperidol for agitation with no QTc check, before non-drug measures, or to a patient with Parkinson disease or dementia with Lewy bodies. The FDA boxed warning covers older adults with dementia-related psychosis. IV use is off-label.
• Error: Stacking sedatives for agitation. Each added drug raises the risk of respiratory depression and falls. Reassess before the next dose.
• Error: Giving a standard adult dose and forgetting reduced clearance. Start low, titrate to effect and check the medication page.
• Error: Missing an elder abuse or neglect pattern. Document the history as the patient gives it. Report per local law.