Caring for the Older Adult in the Emergency Department

Caring for the Older Adult in the Emergency

DepartmentVictor J. Scali DO, FACOEP-

Dist.Co-Director EM, EM/IM

ResidenciesDepartment of Emergency

MedicineAssistant Professor

UMDNJ/SOM

This Care of the Aging Medical Patient in the Emergency Room (CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the

New Jersey Institute for Successful Aging.This lecture series is supported by an educational

grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

Caring for the Older Adultin the Emergency Department

Question One

Which of the following medications can negate the lipid lowering effect of statin therapy in the elderly?(A) Aspirin(B) Ferrous sulfate(C) Interferon(D) Metoprolol(E) Phenytoin

Question Two

A Gait Timed Get-Up-And-Go Test between 10 and 20 seconds for an elderly patient who arrived ambulatory in the ED indicates:(A) Frailty(B) Independent living ability(C) Minimal fall risk(D) Mortality greater at one year(E) The need for motorized chair

Question Three

Which of the following DOES NOT predict repeat ED visits or hospitalizations when using the Triage Risk Screening Tool in the ED? (A) Difficulty walking or transferring

(B) ED use in previous 30 days (C) Five or more meds are taken (D) Living alone (E) Recent falls

The Perfect Storm

• Fragmented, overburdened U. S. healthcare system

» plus

• Rapid growth of elder population» plus

• Medicare system approaching bankruptcy

» plus

• Lack of geriatric emergency medicine training and research

Presentation Goals• Discuss an emergency medicine physician’s

informed approach to the geriatric patient

• Discuss the demographics of this population group

• Discuss quality care in the ED and strategies that will decrease hospital morbidity and mortality

• Discuss strategies to meet the future crisis in elder care

• Discuss effective ED transitions of care for geriatric patients

ED Patient Population Demographics

• Total ED visits = 130,000,000 in 2007

• Total hospital EDs = 4,500 –7% decrease in total EDs in

USA in 2008• Total uninsured patients =

47,000,000 in 2008

ED Patient Population Demographics

• 2003 ACEP/Robert Wood Johnson Foundation Survey of ED Physicians– 33% patients uninsured– 51% of EDs operating over normal

capacity on weekdays, 70% on weekends

– 97% felt uninsured patients used ED because of lack of access to primary care

– 93% stated uninsured patients had no access to meds for HPT/DM

– 93% stated patients can’t get follow-up specialty care for serious conditions

Institute of Medicine’s Report:

Hospital-Based Emergency Care: At The Breaking Point

(2006)“The emergency medicine system is highly fragmented, under funded, and overburdened.”– Overcrowding– Ambulance

diversion– Inadequate surge

capacity for disasters

Image Source: Microsoft Images

Geriatric Emergency Medicine Issues

• Where we are going?– 2006 IOM report addressed pre-hospital

and emergency pediatric care short falls

– Future effects of aging population on emergency care not addressed

– SAEM addressed the future in article on geriatric emergency medicine (Acad Emerg Med 2006;13(12):1345-1351.)

Demographics of Our Aging Population

• 2011: Baby Boomers start turning 65

• 2011: 13% of population age 65 (45 million people

• 2030: 20% of U.S. population age 65 (70 million people)- Fastest growing subset = >85

Demographics of Our Aging Population

• Differences between future >65 population and past:- Better educated- Less poverty- Fewer children- More ethnic/racial diversity

SAEM Report onGeriatric Emergency Medicine

Key Findings, Part 1• Pre-ED, EMS personnel lack training

in transporting older adults• Between 1993 and 2003, geriatric

patient visits to ED 26%• By 2030, geriatric patients will total

25% of ED visits

SAEM Report onGeriatric Emergency Medicine

Key Findings, Part 2• Older adults are:

– More vulnerable to disasters– More susceptible to infectious diseases– Less physiologic reserve– Drug therapy difficult

• Geriatric patients in ED require:– More time– More tests– More acute treatment– More frequent admissions– More ICU admits

Healthcare For An Aging Population

Challenges• Surge in older adult population has long

been predicted, but:– U.S. healthcare system ill-prepared

• Size of healthcare workforce inadequate• Training/education in geriatric medicine inadequate

– Older Americans continue to consume more healthcare services than young adults

– Healthcare needs more complex– Medicare may be insolvent by the time all

baby boomers reach age 65 in year 2030

Solutions?The Domain Management Model

• DMM 1. Medical / Surgical Issues (The Body)– Biomedical model: Diseases and syndromes

• DMM 2. Mental Status, Emotions and Coping (The Mind)– Cognition, emotions, coping, spirituality

• DMM 3. Physical Function (Activities)– BADLs, IADLs, AADLs

• DMM 4. Living Environment (Surroundings)– Living arrangements, social, financialSiebens H. Acad Emerg Med 2005;12:162-

168.

Solutions?DMM & Identifying of Seniors at Risk

(ISAR) Questionnaire• DMM 1. Medical /Surgical Issues + ISAR

Questions– 6. Do you take more than three different medications

every day?– 3. Have you been hospitalized for one or more nights

during the past 6 months (excluding a stay in the Emergency Department)?

• DMM 2. Mental Status + ISAR Questions– 4. In general, do you see well?– 5. In general, do you have serious problems with your

memory?• DMM 3. Physical Function + ISAR Questions

– 1. Prior to this illness/injury, did you need help on a regular basis?

– 2. Because of the illness or injury that brought you to the Emergency Department, will you need more help than usual to take care of yourself ?

McCusker J, et al. J Am Geriatr Soc 1999;47:1229–1237.

Solutions?DMM and Triage Risk Screening Tool

(TRST)• DMM 1. Medical /Surgical Issues

– 1. Five or more medications?– 2. ED use in previous 30 days or

hospitalization in previous 90 days?• DMM 2. Mental Status

– 3. History or evidence of cognitive impairment (poor recall or not oriented)

• DMM 3. Physical Function– 4. Difficulty walking / transferring or recent

falls?• Other

– 5. Triage person’s professional appraisalMeldon SW, et al. Acad Emerg Med 2003;10(3):224-232.

Caveats of DMM Adaptation to ISAR & TRST

• ISAR– Identifies ED geriatric patients at risk

for adverse health and functional outcomes 6 months post-ED visit

– Predicts repeat visits to ED in 30 days or 3 times in 6 months• Sutton, et al. reported good test-retest reliability (Int J

Clin Pract 2008;62(12):1900-1909)

• TRST– Predicts repeat ED visits and

hospitalizations in 30 days and admissions to extended care facilities• TRST means of 2 or more: sensitivity 62%, specificity

57%

Question Three

Which of the following DOES NOT predict repeat ED visits or hospitalizations when using the Triage Risk Screening Tool in the ED ? (A) Difficulty walking or transferring

(B) ED use in previous 30 days (C) Five or more meds are taken (D) Living alone (E) Recent falls

Uniqueness of History Taking• Chief complaint• HPI• Sample history• ROS• Family history• Social history• Domicile• Degree of mental and physical

functionality at baseline• Family interview

Uniqueness of History Taking, Cont’d

• Family physician• Transfer sheets on ECF patients

woefully inadequate• Devices are disease markers:

pacemakers, AICD, Permcath• Time sensitive chief complaints

– Acute STEMI requiring emergent PCI– Stroke symptoms: Ischemic events and

TPA– Active GI bleeds vulnerable to shock– Abdominal pain: AAA, ischemic bowel,

perforated viscus

Caveats of ED History

• Identify Frailty– Anticipate impact

of hospitalization on cognition and function• Sun-downing in

past?– Screen ADLs for

functional decline – Screen for

cognitive decline


History: Functional Screening• Gait Timed Get Up and Go Test

(TGUG) on ambulatory patients– Instructions to patient:

• Rise from chair• Walk 10 feet• Turn around and walk back to the chair • Sit down

– Test results:• Normal <10 seconds• Frail <20 seconds• Needs PT >20 seconds

– Results correlate with falls risk, ECF placement, ADLs

History: Functional Screening• Activities of Daily

Living (ADLs)- Bathing- Dressing- Transfers- Toileting /

Continence- Self feeding

• Instrumental Activities of Daily Living (IADLs)- Uses phone- Travels- Shops- Cooks- Does housework- Manages money- Self administers meds

• Advanced Activities of Daily Living- Still works- Volunteers - Does heavy housework- Recreation

Question Two

A Gait Timed Get-Up-And-Go Test between 10 and 20 seconds for an elderly patient who arrived ambulatory in the ED indicates:(A) Frailty(B) Independent living ability(C) Minimal fall risk(D) Mortality greater at one year(E) The need for motorized chair

Hospital Discharge Outcomes & Functional Decline

• At risk on admission, worse at discharge– Cognitive and functional impairment, pressure

ulcers, depression, low social activity • Pre- morbid risk for further

functional decline– Co-morbidities, age>80, sensory impairment,

frequent hospital admits, psychosocial issues• Outcomes of hospitalization

– More ECF placement, frequent readmissions, caregiver stress, increased mortality

– Higher expense and higher home service consumption

– Iatrogenic complications in 33% of patients

Physical Examination• Focused primary survey on

patients in extremis• When emergent patient stabilized,

more detailed examination should be done

• Caveats of the geriatric physical examination– Degree of personal hygiene– Evidence of incontinence– Decision making capacity– Signs of trauma, gait instability, or

elder abuse– Pressure sores, skin breakdown

Physical Examination

• Careful physical examination reveals positive findings– Fundoscopic changes – Bruits, pulsatile masses– Heart murmurs– Lungs: Rales, ronchi, wheeze– Peripheral edema, stasis changes– Skin changes: Ecchymosis– Surgical scars– Tattoos: Rads therapy– Indwelling devices present

Diagnostic Workup “Seek And Ye Shall Find”

• ED visits rarely limited to Accucheck, pulse ox, EKG, and vital signs

• Multiple co-morbidities tend to expand the differential diagnosis and workup– CT scans of head, neck, chest,

abdomen, pelvis, spine– MRI– Ultrasound Doppler

ED Treatment Tends To Be…• Complicated

– Multi-system involvement• Expensive

– Imaging: CT, MRI, Ultrasound/Doppler, Nuclear scans

• Invasive– Central line placement, intubation

• Dangerous– Anticoagulation, pressors, anti-arrythmic

agents, procedural sedation

Treatment success ultimately depends on pre-morbid level of conditioning and nutritional status

Drug Therapy in ED & During Hospitalization

• Identify risk of poly-pharmacy– Ziploc bag size

evaluation key!• Pint• Quart• Gallon• Shopping bag


• Identify adverse reactions to medications and toxicity as cause of ED visit– Digitalis in renal insufficiency– Aricept: Dehydration due to diarrhea– Vancomycin: Hearing loss– Lincosides, cephalosporins: c. diff. colitis– Quinolones: Seizures, tendon rupture– Chemotherapy: Leukopenia, anemia,

thrombocytopenia– Coumadin: Serious bleeding, GI, epistaxis, ICH– Herbal meds– Neuroleptic agents: QT prolongation,

arrhythmias– Benzodiazepines in Dementia patients:

Disinhibition– SSRI’s: Serotonin syndrome and agitation


• Know aging pharmacology when prescribing medications in ED– Medications that induce

cytochrome P450 may inactivate/negate therapy with other meds metabolized by this system• Example: phenytoin and

statin for cholesterol

Drug Therapy in the ED & Hospital

• Medications– Adverse drug events (ADE) = 11% of

ED visits– ADE = 12% of ED admissions– ADE’s cost U.S. healthcare system =

$76 billion annually– Average elder takes 4-8 meds

• Consumes 30% of all written prescriptions– Post hospitalization adds at least one

new med– EM physicians have limited knowledge

of aging physiology’s effect on meds prescribed

Question One

Which of the following medications can negate the lipid lowering effect of statin therapy in the elderly?(A) Aspirin(B) Ferrous sulfate(C) Interferon(D) Metoprolol(E) Phenytoin

Transitions of Care Begin in the ED

ED EVALUATION

Discharge Home

Home with RXHome with Services (PT, OT, VRN, Hospice)

Admit to Hospital

Discharge home

Sub-acute Rehab

ECF Placement

Adapted from CHAMP, Ideal Hospital D/C (Catherine DuBeau, MD). Used by permission.

Transitions of Care Begin in the ED

ED EVALUATION

Discharge Home

Home with RXHome with Services (PT, OT, VRN, Hospice)

Admit to Hospital

Discharge home

Sub-acute Rehab

ECF Placement

Adapted from CHAMP, Ideal Hospital D/C (Catherine DuBeau, MD). Used by permission.

Observation Medicine

Appropriate ED DischargeBefore discharging an elderly patient home from the ED, ask:• Is ADL baseline stable or can ADL

independence be recovered easily at home?

• Are there sufficient/willing caregivers available to assist transition?

• Are meals and medication(s) supervision available, if needed?– Has medication list been reconciled?

• Is the home a safe environment and disability friendly?

• Is primary medical care available for follow-up?

• Are any home services (PT, OT, VRN) needed?

Adapted from CHAMP, Ideal Hospital D/C (Catherine DuBeau, MD)

Post-ED Disposition Transitionsof Care

• ED visit now Day 1 of hospitalization!• Admitted elders most often require

higher level of care (PCU, CCU, ICU)• Hospital course protracted &

complicated• Elders admitted with serious illness

often require higher levels of care than baseline on discharge– Inevitable cognitive and functional

decline

Consider Hazards of Hospitalization in Your ED

Disposition• Delirium: Disturbance of consciousness

and attention– Assess risk of delirium during anticipated

hospitalization• Deconditioning

– Serious consequence of bed rest, so mobilize early

• Depression– Underdiagnosed in elders, so screen for it

• Dementia– Undiagnosed in geriatric ED admission – Decision making capacity– Hypoactive delirium in ECF patients

misdiagnosed as depression

Hazards of Hospitalization, Cont’d

• Fall risk?• Foley catheter placement

– Avoid placing for nursing convenience – Placed in ED only for CBI, urinary retention,

therapeutic diuresis, and to monitor output in shock states

– Remove as soon as possible• Wound Care

– Document pressure-induced wounds and staging present on admission

– Inform admitting physician of need to address– Prevention is the best treatment

Ethical & Social Challenges For ED Transitions of Care

• ED = key venue for realistic end-of-life planning

• Refocus families on loved one’s lack of:– Quality of life– Suffering– Impossible recovery

• DNR/DNI/DNH• Palliative care• Hospice• Social workers and case managers

Initiating Higher Level Transitions of Care in the ED:

Pain Management• Use numeric pain

scales when possible• Recognize pain in

dementia patients• Use opiates and non-

opiates properly• Manage opiate side

effects– Nausea– Pruritis– HypotensionImage Source: PhotoDisc® Health & Medicine


Palliative Care• Discuss prognosis & care plan with

family• Emphasize palliative care for patients

with advanced disease• Clarify existing Advance Directives &

discuss DNR



Palliative Care

• Avoid repetitive diagnostics / invasive treatment when risks & discomfort outweigh benefit

• Treat non-pain symptoms• Cardiac arrest survivors


The Future of Emergency Care for Geriatric Patients:

Recommendations

• EMT’s: 110 hour course with anatomy, physiology, airway, splinting, transport, c-spine precautions, etc.

• Paramedics: EMT training + advanced skills (ETT, defibrillation, medications)

• Pediatric focus: 4% of patients, vulnerable, EMSC driving force for education

• No specific geriatrics training, but 100-167/1000 use rate

Pre- Hospital Care


Recommendations• GEMS (Geriatric Education for

EMS)– Developed by AGS & EMT Training

Coordinators Council– Available to states

• Safe, high quality care only assured through:– Education– Equipment changes– Procedural changes

Pre- Hospital Care

• Geriatric patients more vulnerable in both natural and man-made disasters– Hurricane Katrina

• 70% of dead > age 60– 2004 Indian Ocean Tsunami


RecommendationsDisaster Planning

• Vulnerability of elders– Social isolation– Impaired mobility– Economic constraints– Special needs: Oxygen, HD, nebulizers,

wheel chairs, complex meds– Functional dependency

• Lack of proper shelters• Hospital admission reimbursement


RecommendationsDisaster Planning

“What we’ve got here… is failure to communicate!”

• Improve coordination & communication between Extended Care Facilities (ECFs) and ED– 25% of ECF residents transported to ED

annually– ECF residents present with different

illnesses than community dwellers– 66% of ECF residents are cognitively

impaired


Recommendations

• Improve coordination & communication between Extended Care Facilities (ECFs) & ED– 10% of patients transported without

transfer sheets– 90% of patients lack important

information on transfer paperwork – EDs reciprocate with lack of discharge

instructions– Healthcare costs increase with poorly

executed transports– Poor execution of transitions of care put

patient safety at risk


Recommendations

• Alternatives to hospitalization needed– Observation Status in hospital now an

alternative • ED decision to admit may be

patient’s death knell• Cochrane Review “Hospital at

Home”– Home treatment better than

hospitalization• Lower rates of depression & ECF

admissions• Better family and patient satisfaction


Recommendations

• CMS requirement: 3 day inpatient hospital stay required to qualify for Medicare skilled nursing facility coverage– Move appropriate patients from ED to

Rehab– Delaying rehab with useless admission

may be harmful


Recommendations

Planning for Geriatric Patients: Training,

Equipment, and Policies• EP workforce poorly trained in geriatric-

focused care• EPs see geriatric patients at their worst• Current ED treatment model based on

1962 American College of Surgeons Committee on Trauma principles:– Rapid treatment of emergent and urgent

needs only– Counter intuitive to complex problems of

elderly patients• Result: system grinds to a halt and

frustration of staff occurs

Photograph by Don Frazier. Used by permission.

My Hero, Super Geri…“Banana” George Blair

• Surprise! This 90+ year old water skier’s favorite color is yellow!

• Favorite fruit? Left to your imagination!

• Learned to:– Water ski at age 40– Barefoot water ski at 46– Snowboard at 75– Race cars at 81– Skydive at 82– Bull ride at 85

Photograph by Don Frazier. Used by permission.

More Amazing Seniors…• Mae LaBorde

– Screen Actors Guild Card at age 95• Yvonne Dowlen

– Competitive ice skating in “Over 56” league at age 82

• Harry Bernstein– Authored The Invisible Wall at age 93,

published when he was 96, also wrote The Dream

• Herb Schon– Cycled cross country in 47 days at age

75

The Perfect Storm

• Fragmented, overburdened U.S. healthcare system

• Rapid growth of elder population• Medicare system solvency in

question• Lack of geriatric training and

research

Can We Avoid The Perfect Storm?

Through education and research… with well-trained professionals like you who can create change in the

U.S. Healthcare System

References1. Institute of Medicine of the National Academies.

Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academy of Sciences, 2007.

2. Wilber ST, Gerson LW, Terrell KM, Carpenter CR, Shah MN, Heard K, Hwang U. Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of Emergency Care in the U.S. Health System. Acad Emerg Med 2006;13(12):1345-1351.

3. Siebens H. The Domain Management Model—a tool for teaching and management of older adults in emergency departments. Acad Emerg Med 2005;12:162-168.

4. McCusker J, Bellavance F, Cardin S et al. Detection of older people at increased risk of adverse health outcomes after an emergency visit: The ISAR screening tool. J Am Geriatr Soc 1999;47:1229–1237.

References5. Meldon SW, Mion LC, Palmer RM, et al. A brief risk-

stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med 2003;10(3):224-232.

6. Sutton M, Grimmer-Somers K, Jeffries L. Screening tools to identify hospitalised elderly patients at risk of functional decline: A systematic review. Int J Clin Pract 2008;62(12):1900-1909.

7. Shepperd S, Doll H, Broad J, et al. Hospital at home early discharge. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000356. DOI: 10.1002/14651858.CD000356.pub3.

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Caring for the Older Adult in the Emergency Department

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