Transcript Emergency Department Approach To The Geriatric Patient

Caring for the Older Adult in
the Emergency Department
Victor J. Scali DO, FACOEP-Dist.
Co-Director EM, EM/IM Residencies
Department of Emergency Medicine
Assistant Professor
UMDNJ/SOM
Caring for the Older Adult
in the Emergency Department
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.
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:
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Better educated
Less poverty
Fewer children
More ethnic/racial diversity
SAEM Report on
Geriatric 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 on
Geriatric Emergency Medicine
Key Findings, Part 2
• Older adults are:
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More vulnerable to disasters
More susceptible to infectious diseases
Less physiologic reserve
Drug therapy difficult
• Geriatric patients in ED require:
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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, financial
Siebens 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 appraisal
Meldon 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):19001909)
• 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
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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
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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
Image Source: Microsoft Images
History: Functional Screening
• Gait Timed Get Up and Go Test (TGUG) on
ambulatory patients
– Instructions to patient:
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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)
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Bathing
Dressing
Transfers
Toileting / Continence
Self feeding
• Instrumental Activities of
Daily Living (IADLs)
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Uses phone
Travels
Shops
Cooks
Does housework
Manages money
Self administers meds
• Advanced Activities of Daily Living
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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
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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
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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 premorbid level of conditioning and nutritional status
Drug Therapy in ED & During
Hospitalization
• Identify risk of polypharmacy
– Ziploc bag size
evaluation key!
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Pint
Quart
Gallon
Shopping bag
Drug Therapy in ED & During
Hospitalization
• Identify adverse reactions to medications and toxicity as
cause of ED visit
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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
Drug Therapy in ED & During
Hospitalization
• 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
Admit to Hospital
Discharge home
ECF Placement
Sub-acute Rehab
Home with RX
Home with Services
(PT, OT, VRN, Hospice)
Adapted from CHAMP, Ideal Hospital D/C (Catherine DuBeau, MD). Used by permission.
Transitions of Care Begin in the ED
ED EVALUATION
Discharge Home
Observation Medicine
Admit to Hospital
Discharge home
ECF Placement
Sub-acute Rehab
Home with RX
Home with Services
(PT, OT, VRN, Hospice)
Adapted from CHAMP, Ideal Hospital D/C (Catherine DuBeau, MD). Used by permission.
Appropriate ED Discharge
Before 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 Transitions
of 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
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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
Image Source: PhotoDisc® Health & Medicine
– Nausea
– Pruritis
– Hypotension
Initiating Higher Level Transitions of
Care in the ED: Palliative Care
• Discuss prognosis & care plan with family
• Emphasize palliative care for patients with
advanced disease
• Clarify existing Advance Directives & discuss
DNR
Image Source: Microsoft Images
Initiating Higher Level Transitions of
Care in the ED: Palliative Care
Image Source: Microsoft Images
• 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
Pre- Hospital Care
• 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
The Future of Emergency Care for
Geriatric Patients: Recommendations
Pre- Hospital Care
• 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
The Future of Emergency Care for
Geriatric Patients: Recommendations
Disaster Planning
• Geriatric patients more vulnerable in both
natural and man-made disasters
– Hurricane Katrina
• 70% of dead > age 60
– 2004 Indian Ocean Tsunami
The Future of Emergency Care for
Geriatric Patients: Recommendations
Disaster Planning
• Vulnerability of elders
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Social isolation
Impaired mobility
Economic constraints
Special needs: Oxygen, HD, nebulizers, wheel chairs,
complex meds
– Functional dependency
• Lack of proper shelters
• Hospital admission reimbursement
The Future of Emergency Care for
Geriatric Patients: Recommendations
“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
The Future of Emergency Care for
Geriatric Patients: 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
The Future of Emergency Care for
Geriatric Patients: 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
The Future of Emergency Care for
Geriatric Patients: 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
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:
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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 welltrained professionals like you who can create
change in the U.S. Healthcare System
References
1.
2.
3.
4.
Institute of Medicine of the National Academies. Hospital-Based Emergency
Care: At the Breaking Point. Washington, DC: The National Academy of
Sciences, 2007.
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.
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.
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.
References
5.
6.
7.
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.
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.
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.