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Mary Dawood RNNurse Consultant in Emergency Care

Imperial College NHS Trust

Management of Emergency Care for frail older people

Mary Dawood Nurse Consultant

Imperial College NHS Trust

Definition of Frailty

• Increased vulnerability to insult or challenges resulting from impairments in multiple domains that compromise compensatory ability

Frailty Challenges

• Multiple interacting medical and social problems

• Impaired function• Altered pharmacokinetics and

pharmacodynamics• Polypharmacy• Atypical disease presentations

Context of the Emergency Department

• The Emergency Department is the most common point of access for frail elderly to the hospital

• Older people particularly those with dementia are heavy users of emergency services

• A poor ED experience can effect the entire hospital experience for the person both physically and mentally

• The ED is a very busy place which is frightening and much too fast for the older patient …..

Emergency Department Attendances 1987-2011

Emergency Data by Age Group

Where

• Try to find a quieter place (sometimes better to examine in short stay wards)

• Draw curtains/close doors to reduce visual distraction

• Keep lights on – less shadow the better • Don’t try to compete with loud noises, wait until they

are over before trying to communicate • Discourage loud chatting outside the cubicle• If you can find a second person will be easier, or

family member to stay in while examining.

Clear Signposting in the ED

• Signposting needs to be bold ,visible and multicue

• It should be at eye level as the older person can easily loose their balance if they have to crane their neck

Communication- What you need to know (in a short time)

• Used name (often different from given one)• What the person does/did – helps to connect / helps

with language recognition• Where the person is originally from – will help with

language• Family/ Carers – who’s key and the first names – talk

about ‘Margaret’, not ‘your daughter’ • What is the person’s home situation – who’s caring? • Who was with the person last?

Nursing Assessment

• In addition to routine recordings of vital signs the AMT4 may be useful in the initial assessment of cognition in elderly patients.

• Helps early recognition and documentation of cognitive impairment

• Age, • Date • Place (name of the

hospital or building),• Current year

Key Issues for People with Dementia in the ED

• Unsuitable environment – noise/activity • Fear / anxiety • Illness / pain will make cognition worse • Not good at waiting • Will often struggle to contextualise what is happening • Might react negatively to perceived threats• Will forget injury/incident/reason for admission • High risk of delirium • Will come as a package- family/carer (most people with a

diagnosis of dementia will have some level of care)

Communication - What the Person with Dementia Needs to know

• You might think it’s obvious who you are• No white coats• Poor vision • Poor hearing • Difficulty reading ID badges

Communicating Context • Every interaction should have: • Who you are (using the word Dr/Nurse)• Where you both are • Why the person is here • That the person is safe / you can be trusted• What’s about to happen (in the next minute) • Repeat it every time.

Delirium Alert

Pain Management

Poly-pharmacy

• Inappropriate prescribing is a common problem in older people

• Adverse drug events account for 6.5%of all admissions but more in older people leading significant morbidity and mortality

• Increased pharmacist support is recommended for the elderly with medication

Prioritise Medications

Be Alert

• High degree of vulnerability • Sometimes hard to separate unusual living

situations from abusive ones• Often involves financial abuse• Recurrent attendances need to be investigated • Easy to get it wrong

Safeguarding

• “No Secrets Policy” • All services should have

a nominated lead whilst accepting that safeguarding is everyone’s responsibility

Mental Health

• Depression is the commonest mental health problem in old age and is often undiagnosed

• The Geriatric Depression Score -5 is a useful screening tool for depression

Managing Challenging Behaviour

• It should be remembered that the elderly may react negatively to unfamiliar surroundings

• Unwell older people will not always be able to articulate the reasons for their distress and it is always important to establish whether pain, constipation, urinary retention or psychosis lie behind disturbed behaviour

• Medication should only be used where it is the safest and least restrictive way of managing behaviour, which is a serious risk to other patients, the staff or other people in the emergency setting, or to patients themselves.

• National guidance on rapid sedation can be found at: http://www.nice.org.uk/nicemedia/live/10964/29715/29715.pdf

Discharge Planning

• Early attention to discharge planning is essential as older people have complex needs

• They should only be discharged from hospital with adequate support and respect for their preferences

• Avoid discharging from the ED at night unless they are accompanied by family /carers

Major Incident Planning • Major incident plans and disaster preparedness plans

need to include explicit contingencies for the management of multiple casualties of frail older people

• Each area/region needs to have up to date lists of named key clinicians and social care personnel with contact numbers, who have specific responsibilities for older people in the event of a major incident

Hurricane Katrina • It is notable that of the

1,330 people known to have perished in Hurricane Katrina in New Orleans in 2005, 71% were over the age of 60 and 47% were older than 75 years and at least 68 people died in nursing homes.

Simple Recommendations to improve the Emergency Department Environment

• The assessment area for older people should be located in a quieter area of the department where observation is possible but noise, interruptions and over stimulation is minimised.

• Not be close to an exit. • Cubicle/rooms large enough to accommodate family

member/caregivers; • Food and drink should be readily available• Create an ambience consistent with the age of the patient eg older type

prints on the walls• Large Clock • Softer lighting to prevent glare • Suitable comfortable chairs• Non shiny /Non slip flooring• Trolleys with mattresses that are thicker to accommodate the frailty of

the older patient

Ideal vs Reality

Golden Rules for the ED • Privacy and dignity must be respected• Carers and/or family members should be involved if possible• Always consider pain as a cause of agitation/confusion • Two health care professionals need to be involved in

procedures one to monitor, comfort and distract, and the other to undertake the procedure;

• Intra and inter-hospital transfers of older people at night, should be minimised as it increases the risk of delirium

• Keep safeguarding in mind• Put a name bracelet on patient • Prioritise assessment if at all possible

Summary • The ED represents a key point in the health and social care

system where older people with health & social crises can be managed

• Create a “frailty friendly front door” if we get it right for the elderly it will be right for all

• Focus on the needs of the patient, respond to the needs• Think creatively – challenges are new, traditional

approaches will not be enough • Commissioning the right model relevant to the needs of the

local population

It is hoped that the Silver Book will be a valuable resource and be the Silver lining in the care of our frail older patients

Thank you for listening

Recommended reading !

Medical management of frailty: confessions of a gnostic

Kenneth Rockwood CAN MED ASSOC J 1997;157-1081-4