Caring for Geriatric Patients in the
Emergency Department Setting
Part I: The Assessment of the Older Veteran
Ula Hwang, MD, MPH
Associate Professor of Emergency Medicine
Brookdale Department of Geriatrics and Palliative Medicine
Mount Sinai School of Medicine, New York NY
GRECC, James J. Peters VAMC, Bronx NY
Nannette Hoffman, MD
Associate Chief of Staff, Geriatrics and Extended Care
North Florida/South Georgia Veterans Healthcare System, Gainesville, FL
Vineesh Bhatnagar, MD
Associate Chief of Staff, Extended Care
VA New Jersey Healthcare System
1
The “Silver Tsunami”
2011 was first year the Baby Boomers entered the ≥65 age bracket.
That was just the beginning!
2
Typical Chronic Disease Management
Emergency Department/Hospital Admission
Functional Decline
Fall Risk 50%
Quality of
Life Declines
Patient Self –
Management,
Home Health Care,
Long Term Care
Adapted from PRHI Using Medical Homes to Reduce Readmissions
http://www.chqpr.org/downloads/UsingMedicalHomestoReduceReadmissions.pdf
3
Literature Suggests
1) An ED visit is a sentinel event and marks early
functional decline, leading to poor health outcomes,
higher health care utilization and higher cost of care.
2) Transitions of Care are key points wherein providers
have the ability to impact the trajectory of patients
and improve quality of care and decrease the cost of
care.
Friedmann PD, et.al. Am J Emerg Med 2001
Aminzadeh F, et.al. Ann Emerg Med 2002
Coleman EA, et.al. Med Care 2005
Hastings SN, et.al. Med Care 2008
4
Improved Care Transition Management
Emergency Room/Hospital Admission
Decrease Fall
Risk 50%
Improve Quality
of Life
Preventable
Admissions
SW Case Manager
Adapted from PRHI Using Medical Homes to Reduce Readmissions:
http://www.chqpr.org/downloads/UsingMedicalHomestoReduceReadmissions.pdf
http://www.chqpr.org/readmissions.html
5
Disconnect Between EDs
and Older Adults…
Space designed for ED priorities of rapid patient
evaluation and turnover, privacy forsaken for
maximal use of space, crowding of narrow beds,
shiny linoleum floors for quick cleanup…
6
• Paradigm shift of ED physical design and care (Pediatric ED)
• Geriatric ED Interventions (GEDIs)
– Structural modifications: lighting, flooring, hearing assist devices, clocks
– Process of care modifications: screening for cognitive impairment, adverse
health outcomes (e.g., ISAR, TRST, BRIGHT), nursing discharge coordinator
7
About This Webinar Series
Purpose:
• To build geriatric competencies in members of
the ED patient care team
• To enhance knowledge of unique and agespecific elements in caring for older Veterans
• Goal of reducing the frequency of unnecessary
return visits to the hospital
8
The Series
1. Assessment of the Older Veteran
2. Cognitive Status in the Older Veteran
3. Optimizing Transitions from the Emergency
Department: Transitions/Frequent flyers – Part 1
4. Geriatric Medication Challenges
5. Pain Management Challenges
6. Optimizing Transitions from the Emergency
Department: Transitions/Frequent flyers – Part 2
9
Geriatric Assessment and the Emergency Department (ED)
The goal is to provide a “geriatric context” as you evaluate seemingly “stable”
elderly ambulatory ED patients.
For the non acutely ill Geriatric patient:
The ED visit results from the straw breaking the camel’s back
10
For the Non-acutely Ill Elderly Patient:
• Ask yourself:
• Why is this patient here now?
• What should be on your radar?
11
Your ED Shift
• You have 3 patients with chest pain, one
patient with GI bleeding, one acutely
psychotic patient on one to one, one
intoxicated belligerent patient, and there’s a
doc on the phone from an outlying ED who
wants to transfer a patient to your ED.
12
In the Meantime:
• An eighty-two year old female with hypertension presents
with “dizziness” x one week but no syncope;
– Her medications are HCTZ 25 milligrams daily and Lisinopril 10
milligrams daily;
– Her vital signs show BP 125/78 HR 62 and mild orthostasis with change
in BP systolic of 15 mm Hg at one minute and little change in heart
rate;
– Her labs show a very mild pre-renal azotemia;
• Your diagnosis is mild orthostatic hypotension;
• You recommend the usual strategies: hydration, slow changes in position,
follow up with PCP to determine if BP medications should be adjusted.
• When the patient leaves the ED, unbeknownst to you, while driving she is
involved in an MVA and after a lengthy hospitalization dies. Two years
later you are named in a lawsuit because the patient was actually
demented and should not have been driving. You are being sued because
you failed to accurately diagnose her “condition in the ED”.
13
14
Five Things
•
•
•
•
•
Cognitive Impairment/Dementia
Medications
Falls
Abuse/Neglect
Acute Illness Presentation
15
ED Sees the Societal Symptom of Lack of
Access to Aging Resources: Granny Dumping
• “The positive tail light sign. They roll them in the door and all I
see is the tail lights vanishing in the distance.”
• “The `packed-suitcase-syndrome.' When they show up with all
of granny's belongings in one or two suitcases and they say,
`Put her in the hospital and take care of her. We can't take
care of her any more.' "
• “The most common manifestation of the problem is family
members who leave a relative with a host of suggested
ailments.”
16
“Granny Dumping”
• Usually a confluence of dementia “effects”
(behavioral and sleep disturbance/caregiver
burnout) and gait disturbance results in the
elderly being dropped off in the ED driveway.
• Usually no acute illness; the “placement
problem” who doesn’t meet “interqual”
standards.
17
Cognitive Impairment
• Mild Cognitive Impairment (MCI): not dementia-can do
ADLs minimal memory and intellectual deficits, may
have IADL deficits; minimal or subtle gait disturbance.
Likely you won’t pick this up on an ER visit. Family
attributes it to “he’s getting older”.
• Dementia overt memory, intellectual and ADL deficits
usually associated with gait problems and sometimes
behavioral manifestations (inertia to
agitation/aggression)-no longer independent in IADL ;
20% over age 80 and 50% over age 84.
• Delirium acute deterioration of cognition over baseline
deficits, latter often unrecognized.
18
Cognitive Impairment
• Short test 3/3 objects at 5 minutes and Clock.
Can’t do one it’s mild cognitive impairment to
dementia, can’t do two it’s definite dementia.
Can’t do clock, should the patient be driving?
• Delirium versus moderate dementia: if no
history or context may be difficult to know the
difference. Usually you can find some history
or context to help you.
19
Yes You Can Ask About Guns Even
in Florida
• Dementia with behavioral disturbance
• If physical aggression, must admit
• Before discharging a demented patient from
the ED, it would be prudent to:
– Ask about Guns
– Ask about Driving
20
Cognitive Impairment/Dementia:
• The “socially appropriate” patient-confabulate to save
face.
• The person with the patient does all the talking.
• The patient can’t name his or her medications, only
knows them by “the little red capsule I take at bedtime.”
• “Non compliant” label usually means cognitive
impairment.
• The patient who actually can’t read, can they read the
writing on their medication bottle? (Ask how far did you
go in school?).
21
Walking as Described by an ED Doc:
• “When does an ED doc ever watch a pt try to
walk??? Unless the pt is running for the
bathroom.”
22
Gait and Falls:
Gait Observation Starting from Seated is an Excellent
Neurological Exam Surrogate
• History: Acute versus Chronic Falls and Gait Problems.
• Look at Meds (we’ll get to that).
• Check Orthostasis, HR responses typically blunted in older
folks.
• Simple observations are telling: the patient that is always in
the wheelchair; getting up from supine to sitting patient
struggles; getting up from a chair-must use hands and arms
for support; walking speed slow and shuffling and standing on
one foot. (most folks over 80 years can’t do this well if at all).
• In an elderly individual if there is appreciable chronic gait
disturbance there is inevitably accompanying dementia.
23
Fall Pearls
• If patient can’t weight bear, the hip is
fractured until proven otherwise regardless of
the plain radiograph findings; thigh or knee
pain is a hip fracture until proven otherwise.
• The normal head CT and the non focal
neurological exam after striking the head is a
misnomer. Delayed subdurals are more
common and missed.
24
Abuse-Neglect
• Unexplained injuries
– Minimal trauma fractures in isolation may not be a
sign of abuse due to disuse osteoporosis
•
•
•
•
•
•
•
Pressure Ulcers; skin irritations, redness, rashes;
Malnutrition
Clinical findings of medication non- compliance;
Poorly groomed/poor hygiene
Clothing smells of urine
Nails dirty not trimmed
Lots of skin tears
25
Who is getting the Social Security or
Pension Check? Early SW involvement.
26
Medications
• There is going to be an entire session on this.
– Look for common offenders.
– Cognitively impaired patients: no telling what they
are taking and when, what’s old, what’s new, what
their neighbor has and what’s in the medicine
cabinet from three prior hospitalizations. Meds
likewise can impact cognitive impairment.
– Also we in “health-care” mess up.
27
AVOID TAKING AT NIGHT
AT BEDTIME
28
Common Problematic Medication Scenarios:
•
ACEI + Diuretics with orthostasis, azotemia;
•
Too much “blood thinning” ASA + anticoagulant + clopidogrel + LWMH and no PPI gastric
protection;
•
Septra DS BID; not adjusting for declining GFR when prescribing meds;
•
Terazosin at night with hypotension at 10 AM;
•
Hypoglycemia: too much of a good thing: too much insulin, use glipizide instead of glyburide
due to declining GFR in elderly;
•
Delirium–hallucinations from “sleepers” hypnotics;
•
Using anti-psychotics for sleep;
•
Benadryl and Tricyclic Antidepressants-strong anticholinergic effects (confusion, urinary
retention, constipation and orthostasis);
•
Too much lipid lowering –rhabdomyolysis;
•
Too much AV node suppression with calcium channel blocker, Digoxin, beta blocker, look at
the EKG ?sinus brady 1st degree AV block, a BBB or IVC delay;
–
•
Theophylline for complete heart block if patient refuse pacemaker;
Urinary Retention from opioids, muscle relaxants, calcium channel blockers, anti-cholinergics
or combination of these (don’t use oxybutinin unless you know the PVR especially in a male
or a diabetic).
29
Elderly Present With Acute Illness in a Blunted Fashion:
Requires More Imaging and More Vigilance
•
Less prominent temperature elevations; often on medications that blunt febrile
response (NSAIDs, Acetaminophen);
•
Less neutrophil stress response to infection;
•
Cognitive impairment results in vague history;
•
Less active so they don’t complain of dyspnea (watch their respiratory effort and
rate) but are very deconditioned so is “DOE” just deconditioning versus COPD, CHF,
etc. (likely lots of occult sleep apnea too with pulmonary hypertension);
•
Muted heart rate responses to hypovolemic stress;
•
Pain blunted and non -specific; no guarding, muted peritoneal signs; delayed
appendicitis presentation;
•
Drop in Hct w/o GI bleeding on anticoagulants and vague groin/abdominal pain:
think retroperitoneal bleed; if a fall think of ruptured spleen;
•
Herald pain of Zoster-is it dermatomal?
•
If agitated is the bladder full? Agitation may be pain;
•
If patient won’t weight bear, think fracture.
30
In Closing
• The Advance Directive should be the “sixth
vital sign.
• If air travel were like health care:
http://www.youtube.com/watch?v=5J67xJKpB6c&fea
ture=youtube_gdata_player
Thank you for listening
31
Vineesh Bhatnagar, MD
ACOS, Extended Care
VA New Jersey Health Care System
32
•
•
•
Principles of Geriatric Assessment
Communication Strategies
Geriatric screening tools in the ED for:
a)
b)
c)
d)
•
Cognition Assessment
Depression Assessment
Functional Assessment
Mobility and Gait Assessment
Social Assessment
33
•
Introduce yourself
•
Face the patient directly
•
Sit at eye level
•
Speak slowly and Rephrase as necessary
•
Ask open-ended questions:
“What would you like me to do for you?”
"How would you describe your life at home?"
"Can you tell me what your typical day at home is like.”
34
To determine a patient’s
•
Medical status
•
Functional status
•
Psychosocial situation
• That would help in developing a comprehensive
treatment plan and ensure safe discharge
planning.
35
Activities of Daily Living
(ADL)
Instrument al Activity of
Daily Living (IADL)
Transfers
*Handling House
Finances
*Bathing
*Housekeeping
*Toileting
Laundry
Grooming
Preparing meals
Feeding
Self Administer
Medications
Continence
Using the telephone
*Driving
*Shopping
36
•
A ‘significant change’ in the ADL or IADL activities within a
‘short interval of time’ could be the single most important
clinical finding.
•
ADL impairment is a strong predictor of clinical outcomes
like nursing home placement, frequent emergency room
visits, and death among older adults.
•
Temporary or permanent loss of ADL or IADL activities
determines a safe discharge plan from the ED/institutional
setting.
For example:
Loss of IADLs requires HHA,meal service, ADHC assistance in a home setting
Loss of 1-2 ADLs would need Assisted Living Facility level of supervision
Loss of >2 ADLs would need Nursing Home level of supervision.
37
•
The subject is encouraged to wear regular footwear and to use any customary
walking aid.
•
No physical assistance is given during the test.
•
Have the subject walk through the test once before being timed to become familiar
with the test.
•
To test the patient, give the following instructions:
–
Rise from the chair
–
Walk to the line on the floor (10 feet)
–
Turn
–
Return to the chair
–
Sit down again
Normal: completes task in < 10 seconds. – can be independently mobile
Intermediate score: 11-20 seconds.
- needs assistive device for mobility
Abnormal: completes task in >20 seconds - high risk for falls and needs supervision
38
Mini Cog Test
3 Object Recall=0
Cognitive
Dysfunction
3 Object Recall= 1-2
Clock Drawing
Test Abnormal
Clock Drawing
Test= Normal
3 Object Recall=3
Normal Cognition
39
Please Note: The choice of 3 objects should be unrelated (eg.
paper, pencil, erasure – will skew the test results)
•
Mini Cog is nearly as good a screening test as Folstein’s Mini
Mental Status Exam (MMSE) or St. Louis University Mental State
(SLUMS) test.
•
The test is 73% sensitive and 76% specific
•
The test results are less affected by confounding factors like
education level, ethnicity, language and socio-economic
•
Mini Cog takes about half as much time to perform than MMSE or
SLUMS test (about 3 mins)
•
If the test is abnormal, SLUMS or MMSE testing would be indicated
40
Patient Health Questionnaire (PHQ-2)
Answers “Yes” to either:
“Do you often feel down or depressed?”
“Have you lost interest in doing things?”
PHQ-2 is 100% sensitive and 77% specific.
It has 93% negative predictive value but only 38% positive predictive
value.
PHQ-2 can rule out but not diagnose depression (akin to D-dimer test
for PE)
Further
validation of Depression would require a Geriatric Depression
Scale (15 questions) tool
41
•
Ethnic, spiritual and cultural background
•
Availability of a reliable support system
•
Caregiver burden
•
Socio-economic condition
•
Home safety assessments
•
Elder abuse
•
Advance directives
42
Scope
Rapid Screening Test
Cognitive
function
(3 mins)
Mini Cog Test + Clock Drawing Test (if needed)
Depression
(PHQ-2 )
(1 min)
Answers “Yes” to either:
“Do you often feel down or depressed?”
“Have you lost interest in doing things?”
Delirium
(1 min)
Confusion Assessment Method (CAM)
-Acute onset
-Fluctuation
-Inattention
-Altered level of consciousness
43
Scope
Rapid Screening Test
Functional
status
(1 minute)
Answers “Yes” to one or more :
Do you need help to:
a) do light housework?
b) take a bath or shower?
c) manage the household finances?
d) shop?
Mobility
Gait
Balance
Fall Risk
(1 minute)
Timed “GET UP AND GO TEST”
44
•
The focus of a geriatric evaluation is on functional assessment.
•
Not all screening tools are applicable to every geriatric patient.
The decision should be based on the clinical judgment.
•
ED requires an interdisciplinary approach (physician, nursing
and social work) for time efficient assessment of the older
adult.
•
Most of the geriatric screening tools, do not need a physician’s
involvement. This way the burden of geriatric assessment can
be shared amongst the interdisciplinary team.
45
With an exponential increase in U.S. population in the
age 65 yrs and above bracket, geriatricians are
recognizing the need for a less cumbersome
assessment tool than the existing Comprehensive
Geriatric Assessment (CGA) tool.
A head to head prospective trial is underway to
compare CGA with a proposed Mini Geriatric
Assessment (MIGA) tool on the parameters of time
involvement, accuracy and clinical outcomes. The trial
is scheduled to complete in 2014.
46