approach to the elderly patient in the ed - brown

Approach to the Elderly Patient in

the ED

Luna Ragsdale, MD, MPH

Geriatrics Emergency Medicine Fellow

July 6, 2007

OBJECTIVES

Recognize the need for a different approach to the geriatric emergency patient.

Review the principles of geriatrics emergency medicine.

Increase in Elderly Population (1920 to 2050)

ED Visits

From CDC. National Hospital Ambulatory Medical Care Survey: 2004 Emergency Department Summary. Advance Data from Vital and Health Statistics, 372: June 2006.

ED Use By Elderly Persons

1990 - 15% of ED visits by elderly

Admission to hospital - 5 times

32% admitted

ICU Admission - 5 times

7% admitted to ICU

Ambulance Service - 4 times

30% use ambulance

Comprehensive ED Care - 6 times

46% comprehensive care Ann Emerg Med 1992;21:819-824.

Patterns of ED Resource Use

Education

Lack of educational materials

69% of EP insufficient CME

53% lack of training in residency

40% of residency directors - training inadequate

Ann Emerg Med 1992;21:796-801

Ann Emerg Med 1992;21:825-829

Evaluation of Older Adults Compared to Younger Adults

McNamara RM, Rousseau E and Sanders AB. Geriatric emergency medicine: A survey of practicing emergency physicians. Ann Emerg Med. 1992; 21:796-801.

ED Environment

Uncomfortable for older persons

High volume, high stress

Anxious, worried patients

Little privacy

Limited ED provider time

Beds, lighting, noise

Modifications can make a difference

Attitudes and Ageism

Negative View of Aging

language

frail, disabled elderly

nursing home patients

distorted view of elderly persons

Aging - deterioration to be avoided and feared

Attitudes and Ageism

Aging - stage of life

Active, productive, heterogeneous

Misperceptions falls, incontinence, confusion

thrombolytics

Geriatric Emergency Care Model

Principles of Geriatrics Emergency Medicine

1. The patient’s presentation is frequently complex.

2. Common diseases present atypically in this age group.

3. The confounding effects of co-morbid diseases must be considered.

4. Polypharmacy is common and may be a factor in presentation, diagnosis, and management.

5. Recognition of the possibility for cognitive impairment is important.

6. Some diagnostic tests may have different normal values.

Principles of Geriatrics Emergency Medicine

7. The likelihood of decreased functional reserve must be anticipated.

8. Social support systems may not be adequate, and patients may need to rely on caregivers.

9. A knowledge of baseline functional status is essential for evaluating new complaints.

10. Health problems must be evaluated for associated psychosocial adjustment.

11. The emergency department encounter is an opportunity to assess important conditions in the patient’s personal life.

1. The patient’s presentation is frequently

complex

2. Common diseases present atypically in this age group

3. The confounding effects of co-morbid diseases must be

considered

4. Polypharmacy is common and may be a factor in

presentation, diagnosis, and management

5. Recognition of the possibility for cognitive impairment is important

ED Mental Status Exam

High incident of impairment

Delirium/Dementia missed in ED

Reliability of history

Symptom of medical emergency

Reversible causes

Confusion Assessment Method Worksheet

I. ACUTE ONSET OR FLUCTUATING COURSE

Is there evidence of an acute change in mental status from the patient’s baseline? OR Did the (abnormal) behavior fluctuate during the day (i.e., tend to come and go or increase and decrease in severity)? NO YES II.INATTENTION Did the patient have difficulty focusing attention (e.g.,

being easily distractible or having difficulty keeping track of what was being said)? NO YES

III. DISORGANIZED THINKING

Was the patient’s thinking disorganized

or incoherent (e.g., rambling or irrelevant

conversation, unclear or illogical flow of

ideas, or unpredictable switching from

subject to subject)? No Yes

IV. ALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate the patient’s level of

consciousness? ____ Alert (normal) ____ Vigilant (hyperalert) ____ Lethargic (drowsy, easily aroused) ____ Stupor (difficult to arouse) ____ Coma (unarousable) Do any checks appear in this box? No Yes From Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion:

the confusion assessment method-a new method for detection of delirium. Ann Intern Med 1990;113:941-948

Six Item Screener

I am going to name three items. Please wait until I say all the items and then repeat them. Remember them because I will ask you to name them in a few minutes.

Repeat these words:

APPLE – TABLE – PENNY

May repeat 3 times if necessary

Six Item Screener Did the patient correctly repeat

all three words: Yes or No

What year is this? _____1 point

What month is this? _____1 point

What is the day of the week? _____1 point

What are the three objects I asked you to remember?

Apple _____1 point

Table _____1 point

Penny _____1 point

_____(6)

Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, and Hendrie HC. Six item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care. Sep 2002; 40:771-81.

6. Some diagnostic tests may have different normal

values

Labs Unchanged* Hemoglobin and Hematocrit WBC Platelet count Electrolytes (sodium,

potassium, chloride, bicarbonate)

BUN Liver function tests

(transaminases, bilirubin, prothrombin time)

TSH Calcium Phosphorus * Aging changes do not occur in these

parameters; abnormal values should prompt further evaluation.

Common Abnormal Labs† ESR Creatinine Alkaline phosphatase UA Glucose Albumin D dimer †Includes normal aging and other

age-related changes.

7. The likelihood of decreased functional reserve must be anticipated

8. Social support systems may not be adequate, and patients may need to rely on caregivers

9. A knowledge of baseline functional status is essential

for evaluating new complaints

10. Health problems must be evaluated for associated psychosocial adjustment

11. The ED encounter is an opportunity to assess important conditions in the patient’s personal life

In addition…

Not all elderly are the same

Heterogenous and diverse group

Physiologic rather than biologic age should guide care

Physiology of Aging

Normal aging is benign

Associated with decline of body reserve

Usually does not causes problems until disease occurs

Recommendations

Sit down and talk to the patient and/or family

Call the nursing home/assisted living home/pcp/family for baseline function if patient unable to provide

Avoid foley use if possible

Do not treat asymptomatic pyuria

Take Home Points

Elderly patients possess unique pathophysiologic and clinical concerns that require special management principles.

Optimal emergency care of elderly patients requires a more comprehensive model of care that takes into account the patient’s biological, functional, cognitive and social support status in assessing and discharge planning.

Remember to screen for delirium in mental status change (CAM) and cognitive impairment in all elder patients (SIS).

Elders are funny and resourceful…

Questions?

Available Resources

http://geriatricweb.sc.edu/subbrowse.cfm Reuben D, Herr K, Pacala J, et al. Geriatrics at

Your Fingertips 2005 Edition. Published by AGA. Text version and donwloadable PDA version available at www.geriatricsatyourfingertips.org

Portal of Geriatric Online Education www.pogoe.com

Meldon SW, Ma JO, Woolard R. Geriatric Emergency Medicine; 2005, The McGraw-Hill Companies, Inc.