Currently, nearly one in two older adults will have an ED visit annually. Quality assessment and management of these patients, whether they are admitted to the hospital or discharged, can play a large role in determining the trajectory for the future care, function, and health care costsfor that patient. Unnecessary hospitalization for frail, older adults only accelerates functional decline.
The rapid pace of the ED is not a friendly environment for a frail, older person, nor is it a easy assessment to perform for the ED provider. In contrast to young adults, who usually present with one specific problem, older adults often present with multiple vague complaints.
The complexity of the assessment is magnified since they often have multiple comorbid medical problems such as congestive heart failure or dementia and can be on more than 10 medications. Compared to young adults, older adults are more likely to be hospitalized and use more staff time and resources. The ED diagnoses tend to be less accurate despite greater use of diagnostic tests and procedures. How can an ED provider perform a timely, effective assessment of older adults to identify any serious medical problems but avoid unnecessary hospitalization?
In 2014, the American College of Emergency Physicians (ACEP) published guidelines for optimal care of an older adult in the ED. Ideally it takes a team to care for a complex frail older adult. The three major areas for improvement are: (1 ) ED staffing and provider education, (2) Clinical processes of care, which includes the development of interdisciplinary teams, geriatric champions and leaders, and implementation of geriatric screens and protocols, and (3) Modification of the environment.
ED Geriatric Staffing and Education
Educating the staff on the unique needs of older adults is the foundation to creating a geriatric-friendly ED. ED staffing should include a Geriatric ED Medical Director and Nurse Manager. They should be actively involved in identifying needs for staff education and implementing geriatric-specific provider education.
Residency and continuing education should contain interdisciplinary content such as transitions of care and referral to community services, managing cognitive and behavioral disorders, and atypical presentation of disease. Up to one third of older adults with a significant acute medical problem may present to the ED with vague, nonspecific symptoms such as acute change in mental status, frequent falls, new weakness, or dizziness. These nonspecific symptoms may be their presenting symptoms for sepsis with no fever or leukocytosis, an acute abdomen with no peritoneal signs, or acute coronary syndrome (ACS). As high as 40% of patients over age 85 with ACS present without chest pain.
For other specific educational topics and details of staffing, refer to the ACEP guidelines that can be downloaded from the Geriatric-ED.com site. They recommend that besides specialized nursing (nurse coordinator and case manager), the ED have a social worker and ideally access to a pharmacist, physical therapy, occupational therapy, and a Geriatrician. In addition, The American Geriatric Society has a number of excellent educational resources2. Lastly, Geri-EM.com provides free online education for emergency providers.
Clinical Processes of Care
If a quick initial assessment rules out life-threatening, unstable conditions, clinical problems that are more common for the older adults need to be assessed to determine if they may be contributing to their acute problems, possibly impacting their outcome.
The ACEP Geriatric ED Guidelines suggested using the Identification of Seniors At-Risk Tool (ISAR) to identify all patients over the age of 65 who are high risk for functional decline. These patients are probably using their functional reserves just to get through their daily routines and could decompensate quickly with any additional medical problem. The ISAR has sixquestions such as; before this injury or acute illness did you need someone to help you on a regular basis?
More than one positive response is considered high-risk. Any patient who screens positive should receive additional screens for cognition, mobility, and polypharmacy. Patients admitted need timely referrals to case management and discharges from the ED require closer community follow-up with their PCP and community agency referrals, such as home health for a home safety assessment. Just as EDs have improved the efficiency and effectiveness for ACS and sepsis by implementing rapid screens and protocols, there is a unique set of screens and protocols that will improve timely effective care of those older adults identified as high risk.
High-risk older adults need to be screened for delirium and dementia. At least 17% of older adults in the ED have delirium and more than 50% of these cases are missed. Approximately 1 out of 3 older ED patients with delirium will die within six months. Two quick screening tests for delirium that have been validated in the ED are the Delirium Triage Screen (DTS) and the Brief Confusion Assessment Method (bCAM). Both of these tests can be accessed at www.eddelirium.org.
The DTS is most useful to rule out delirium and can be done in 10-20 seconds using some information that has already been gathered. It consists of establishing a Richmond Agitation-Sedation Scale (RASS), a very familiar ED tool, and if the patient scores anything other than a 0, which would be alert and normal, then a test of attention needs to be done. The DTS uses spelling “LUNCH” backwards as a test of attention. If the patient has more than one error on this test it is a positive screen for delirium and a bCAM needs done.
The bCAM is the best test to rule in delirium and is 78% sensitive and 97% specific if administered by a nonphysician. This test has four features:
1. Altered mental status or fluctuating course
3. Altered level of consciousness
4. Disorganized thinking
The test of attention for this is to have the patient say the months of the year backwards and it is positive if > 1 error. Both 1 and 2 and either 3 or 4 need to be positive to confirm delirium. The cause of delirium is usually multifactorial, often related to any acute medical problems, such as sepsis, but in a frail older adult it may be complicated by less life-threatening things such as dehydration, polypharmacy, fecal impaction, or urinary retention. Many of these patients may have an undiagnosed dementia, which makes them more vulnerable to delirium with any acute illness.
One of the most accurate dementia screening tools validated in the ED is the Short Blessed Test.
Another very quick screening test for dementia is the Mini-cog3. This involves giving the patient three words to remember, then distracting them and having them draw a clock. Give them a time to record that requires the hands of the clock to be in two different quadrants with a time such as 2:35 or 4:55. People with early dementia have difficulty abstracting to determine where that second hand goes. Any test done for dementia in a patient with active delirium will need to be repeated at a later date when the patient is back to baseline.
The Family Questionnaire is another useful tool. An informant familiar with the patient is asked six questions to help determine if they may have had an undiagnosed dementia prior to their current illness. More than 50% of people with dementia have not been formally diagnosed or informed of their diagnosis.
Those older adults who screen positive on the ISAR should be asked if they have had a fall in the last year and screened for safe mobility. A Timed Get Up and Go (TUG) can gather a lot of information and be done in < 1 minute for those able to participate. The patient should be observed getting up from a chair, walking ten feet, and returning to sit down. This is an ideal test to quickly assess strength, stability, and gait. Those patients who take longer than 15 seconds are at an increased fall risk. Ideally this is done with their usual gait aid. Things that often get missed on an ED fall evaluation are orthostatic BP and an assessment of vision. Just having the patient read something in regular print can be a quick screen. Older adults develop visual deficits so gradually that they often don’t complain about it. Older adults are more vulnerable to polypharmacy and adverse drug reactions due to multiple comorbidities and reduced physiologic reserves. 40% of patients > age 65 take five to nine medications daily. There is a 50-60% chance of a drug-to-drug interaction when taking this many medications. Medication reconciliation can be difficult and time-consuming in an older adult and could be streamlined with a pharmacist as part of the ED team.
Any new symptom needs to be considered as a possible drug reaction. Many drug side effects are not well-known or recognized, such as a patient who presents with falls due to bradycardia from their cholinesterase inhibitor donepezil. Another example is a patient with diabetes type 2 with neuropathy and renal insufficiency who presents to the ED with increased confusion because of failure of their PCP to adjust duloxetine and gabapentin for renal function. The Beers Criteria, which is a comprehensive review of high-risk medications in older adults, was just updated in 2019.
Emergency Department Environment
Details outlining ED environment change can be found in the ACEP Geriatric ED Guidelines. Many of these recommendations will benefit patients of all ages. Things that address comfort most include extra thick/soft gurney mattresses, warming blankets, and exam chairs/recliners that can facilitate and provide safer transfers. Use separate enclosed rooms when possible to help noise reduction. Having soft music available can decrease noise and have a calming effect. Have at least two seats per room for family. Have wheel-chair accessible toilets with raised toilet seats, bedside commodes, and walkers available. For improved vision, enhance lighting using natural light where possible. Light-colored walls with matte sheen and light flooring with a low-glare finish are recommended. Signs with large print and large face clocks in each room are valuable additions.
The most helpful sensory addition is investing in pocket talkers for patients with poor hearing. These can work even for some of those people who have refused to wear their own hearing aids. One very sturdy brand is Williams Sound PKT D1 EH Pocketalker Ultra Duo Pack Amplifier with Single Mini Earbud and Folding Headphone. This can be ordered at Amazon.com.
Implementing some of these geriatric principles into ED processes should help address the complexity of the acute care of the older adult. The ultimate goal is to improve the quality and satisfaction with care for the patient, family, and providers. Incorporating team-based care and system-level changes takes time, but there are simple things that providers can implement immediately and become the geriatric champions.
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