Author: Lisa Wolf, MS, RN, CEN, Amherst, Mass Section Editors: Andi L. Foley, RN, BSN, CEN, and Patricia Kunz Howard, RN, PhD, CEN Lisa Wolf, Pioneer Valley Chapter, is Clinical Assistant Professor of Nursing, University of Massachusetts, Amherst, Mass. For correspondence, write: Lisa Wolf, MS, RN, CEN, 110 Middle St, Hadley, MA 01035; E-mail: Noblewolf3@aol.com. J Emerg Nurs 2007;33:587-9. Available online 18 October 2007. 0099-1767/$32.00 Copyright n 2007 by the Emergency Nurses Association. doi: 10.1016/j.jen.2007.09.006 A 75-year-old woman presents to your triage booth. ‘‘Excuse me,’’ she says, ‘‘I’m feeling a little weak.’’ She tells you she has a history of hypertension, but cannot remember the medication she takes. In your triage room, her vital signs are as follows: blood pressure, 110/70 mm Hg; heart rate, 68; respiratory rate, approximated at 20; and temperature, 36.18 C (97 8 F). You assign her to an Emergency Severity Index level 3 (requiring resources, but currently stable), send her back to the waiting room, and move on to your next patient. Only later do you find out the patient is in septic shock, awaiting a bed in the ICU. The elderly population currently is 20% of most ED visit loads, 1 and this number will only continue to rise as ‘‘baby boomers’’ approach 60 years of age. Presentation in this population can be vague, and the rate of undertriage in the elderly is estimated at 55%. 2 A large component of this issue is atypical or vague presentation, where the chief complaint is ‘‘lethargy,’’ ‘‘fa- tigue,’’ or ‘‘not feeling myself.’’ Research suggests that health care professionals can be uncomfortable with this type of presentation and not pursue the complaint. 1 A Swiss study examined more than 11,000 patients presenting to emer- gency departments. 1 Of those patients, 9.3% were older than 65 years and designated ‘‘home care impossible,’’ a term that is roughly equivalent to ‘‘social admit’’ in the United States. All these patients were triaged into the lowest 2 categories (4 and 5 in Emergency Severity Index, or 3 and 4 in Canadian Triage and Acuity Scale), indicating ‘‘nonurgent’’ status. In fact, on closer examination, 51% of the ‘‘home care impossible’’ patients actually had a serious medical condition that required immediate attention, in- cluding myocardial infarction, sepsis, dissecting abdominal aortic aneurysm, glycemic emergencies, and stroke. 1 How Normal are ‘‘Normal Vital Signs’’? Effective Triage of the Older Patient TRIAGE DECISIONS December 2007 33:6 JOURNAL OF EMERGENCY NURSING 587