approach to the elderly patient in the ed - brown
TRANSCRIPT
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.