Geriatric Patients and the Emergency Department - PowerPoint Presentation

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Geriatric Patients and the Emergency Department

# 3 in a 6 part series related to Geriatric Care and Emergency Medicine

Wasn’t she here last week?Frequent Flyers and other Vexing Tales of the Emergency Department

Optimizing Transitions from the Emergency Department: Transitions/Frequent flyers – Part 1Slide2

About This Webinar Series

Assessment of the Older Veteran

Cognitive Status in the Older VeteranOptimizing Transitions from the Emergency Department: Transitions/Frequent flyers – Part 1

Geriatric Medication Challenges

Pain Management Challenges

Optimizing Transitions from the Emergency Department: Transitions/Frequent flyers – Part 2

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Speakers

Alan Hirshberg, MD, MPH, FACEP is the Associate Chief of Staff at the Lebanon VA Medical Center, in Lebanon, PA. He is a residency trained Emergency Physician on the VHA Emergency Medicine Field Advisory Council and ACEP Emergency Medicine Clinical Practice Committee who regularly works with VHA facilities to assist them with challenges related to Emergency Medicine practice.

Carolyn K. Clevenger, DNP, GNP-BC is a Gerontological nurse practitioner whose research and clinical interests center around care of persons with dementia. She is Assistant Dean for MSN Education at the School of Nursing and Associate Program Director for the Atlanta VA Quality Scholars Program.

Dr

. Clevenger is the Principle Investigator of the HRSA-funded project to implement Interprofessional

Collaborative Practice for Primary Palliative Care. An initiative housed on six inpatient services or units at Emory

University Hospital. She serves on the Georgia Older Drivers’ Taskforce, a committee of the Governors Office of Highway Safety, and the Atlanta VAMC’s Dementia Committee.

Nicki Hastings,

MD, MHS

is a Geriatrician at the Durham VA Medical Center in Durham, NC. She is Director of the Durham Geriatrics PACT Clinic and an Investigator with the Durham Geriatrics Research and Education Center (GRECC) and Center for Health Services Research in Primary Care.

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Disclosures

No financial relationships or conflicts to disclose.

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Educational Objectives

Participants in this session will be able to: 

Recognize common factors associated with repeat visits to the ED among Veterans 65 and older;Describe the roles of the Emergency Department Team - physician, nurse, social worker, pharmacist, and psychologist - in caring for older Veterans’ with dementia in the ED setting

;

Discuss best practices for management and discharge planning for patients who are frequent fliers in the ED.

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The older patient (65+ years)

Account for 13-15% of all ED visits nationallyED visits of patients 65-74 years of age increased 34% from 1993-2003Older patients have higher rates of test use and longer ED stays than the general population

5x higher risk of ICU admission and 3.5 x the risk of hospitalization

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The older patient

May have difficulty communicating the nature of their needs to the Emergency Department (ED) staff and may also be unable to understand their treatment plans due to visual/auditory/cognitive impairment. Repeat ED visits can be a marker of ongoing care failure and should be reviewed

Discharge plans may require coordination through community agenciesThe older patient attempting suicide is at greater risk of completion of the actMay require admission

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Elders at Risk

HomelessnessMultiple co-morbid conditions – heart failure and headacheLow incomePsychiatric illness – anxiety, bipolar disorder, personality disorder, and schizophrenia

Prescription for opiod use8Slide9

Top conditions encountered

Neuropsychiatric – delirium, dementiaFalls – main cause of admission 15-30%Coronary disease – 20% c/o dyspnea or chest pain as principal complaints

Polypharmacy and adverse drug effects – 11% of ED visits for those older than 65 vs. 1-4% for those younger, 33% of adverse affects related to warfarin, insulin, and digoxin.Alcohol and Substance abuse – the children of the sixties are now elderly, etiology up to 14% of presentations related to associated delirium as well as withdrawal effects, associated mood disorder, or associated complications of use

Abdominal pain – up to 13% of older patients, mortality 6-8x higher than younger population

Infections – 4% main complaint of which 25% pneumonia, 22% urinary infection, and 18% sepsis/bacteremia

Social cause/functional decline – 9% of social admissions resulted from infectious,(24%) cardiovascular(14%), neurologic(9%), digestive(7%), pulmonary(5%) or other causes. 1-year mortality was up to 34%

Elder abuse/neglect – 10% rate of elderly abuse per national statistics9Slide10

The Special Case of Dementia

in the EDCarolyn K. Clevenger, DNP, GNP-BC

Associate Program Director, Atlanta VA Quality ScholarsAssistant Dean and Associate Professor, Emory Nursing

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“But all of our patients drive themselves here…”

26-40% of older ED patients have cognitive impairmentDementia (21.8%)Delirium (24%)

Delirium on top of dementia

Naughton BJ, Moran MB, Kadah H et al. Delirium and other cognitive impairment in older adults in an emergency department.

Ann Emerg Med

. Jun 1995;25(6):751-755.11Slide12

Challenges

Long wait times for people with atypical presentations WanderingFast-paced environment Slow thinkersPoor historians

Transfer sheetsRecognition of impairment

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Agenda

Systematic Literature Review

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Study of Older ED PatientsSlide14

Dementia in the ED: Setting

ED in academic medical center28,500 visits annually

30% of visits made by persons over 65

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Dementia in the ED: Sample

ED patients 70+ years old

One or more visits to the ED over 6 monthsTwo approachesED VisitsIndividuals’ Patterns of ED Visits

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Dementia in the ED: Method

Retrospective chart reviewAge*, gender*, race*

Length of stay*Tests ordered*Disposition*

*

Based on NHAMCS (CDC, 2010)

Centers for Disease Control and Prevention, National Center for Health Statistics. National Hospital Ambulatory Care Survey (NHAMCS). In: US Department of Health and Human Services, editor.2010

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Dementia in the ED: Method

Study Additions

Evidence of cognitive impairment in ED, hospital or outpatient notes

Comorbidity

score (

Charlson)

Caregiver presence

Charlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP. The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients.

J Clin Epidemiol.

2008;61(12):1234-40.

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Dementia in the ED: Results

Average age79

y.o. with no dementia81 y.o. with dementia

Gender

59.3% female

Race59.9% white

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Dementia in the Atlanta ED: Results

Reasons for seeking care

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Dementia in the ED: Results

ED VisitsSampled 300 visits

199 by persons with no evidence of dementia101 by persons with documentation of dementia75 Recognized as such26 “Unrecognized”

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Dementia in the ED: Results

During each visitNo difference in number of

diagnostic tests by dementia statusMore testing if person with dementia was not recognized/not documented as suchLength of stay

(in ascending order)

Those without dementia

Those with recognized/documented dementia

Those with unrecognized/undocumented dementia

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Dementia in the ED: Results

DispositionAdmission to hospital (in ascending order)

Persons without dementiaPersons with recognized/documented dementia

Persons with unrecognized/undocumented dementia

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Dementia in the ED: Results

Pattern and Volume of ED Visits by IndividualsEach person with dementia made

twice as many ED visits Four

times as many if NO Caregiver present

Fewer days between visits (33

vs

41)

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Dementia in the ED: Results

Individuals’ PatternsPersons with dementia had more ED visits over the study period (1.63

vs 2.15)Selecting only

persons with 2+ visits

during the year, persons with dementia represent

38.3% of all visits39.9% of 7-day revisits

43.4% of 30-day revisits

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Dementia in the ED: Discussion

Longer stays and more testingHistory

Unclear about residential optionsPotential for missed or delayed diagnosisEvidenced by re-visits for similar complaints

Use of Observation status

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Dementia in the ED: Literature

What can the ED nursing staff DO?Assessment

CommunicationAdverse EventsPhysical EnvironmentEducation

Clevenger, C.K.,

Chu, T.A., Yang, Z. & Hepburn, K.W. (2012). Clinical Care of Persons with Dementia in the Emergency Department: a Review of the Literature and Agenda for Research.

Journal of the American Geriatrics Society

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Dementia in the ED: Literature

Assessment

Screen likely suspectsSix-item screenerMini-cog FAQ

St Louis University Memory Screen or Montreal Cognitive Assessment

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Screening tool for cognitive impairmentsensitivity 94%, specificity 86%

Six-Item Screener

Reproduced from Med Care, Callahan et al, The interviewer says the following: I would like to ask you some questions that ask you to use your memory. I am going to name 3 objects. Please wait until I say all 3 words and then repeat them. Remember what they are because I am going to ask you to name them again in a few minutes. Please repeat these words for me: apple, table, penny.

(Interviewer may repeat names 3 times if necessary, but repetition is not scored.)

Did patient correctly repeat all 3 words? Yes No

Orientation

Incorrect CorrectWhat year is this?

What month is this?

What is the day of the week?

MemoryWhat are the 3 objects I asked you to remember?

Apple

Table

Penny

A

score less than or equal to 4

(each correct answer counts as 1 point) corresponds

to a positive screen for cognitive impairment;

adapted from Callahan CM, Unverzagt FW,

Hui

SL, et al. Six-item screener to identify cognitive impairment among potential subjects for clinical research.

Med Care. 2002;40:771-781.

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Dementia in the ED: Literature

CommunicationNonverbal

Including touch, as appropriateEmotional truth

If repeating, exactly same as the first

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Dementia in the ED: Literature

Adverse Events (delirium, wandering, incontinence)Nonverbal cues and nursing judgment

Is the chief complaint likely to cause pain?Has the individual been in the ED for some time?

Anticipate and prevent dehydration

Make toilets visible

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Dementia in the ED: Literature

Physical Environment (A page from Senior ED’s)Natural light and quiet, glare-free floors

Clear signage for wayfindingProximity to nursing station

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Dementia in the ED: Literature

Education

Geriatric Emergency Nursing Education (GENE)Emergency Nurses Association & Hartford Institute for Geriatric Nursing

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Dementia in the ED: Summary

Early recognition is keyBuild in a standard measureSecondary history of present illnessCaregiver

Transferring facilityEducationAtypical presentationResidential care options for older adults

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Improving Post-ED Transitions for Older Patients

S. Nicole Hastings, M.D., M.H.S.

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Post-ED Transitions

The majority of older adults evaluated in the ED are not admitted to the hospital.

In VAMC EDs, ~75% of older patients are treated and releasedOutpatient ED visits are increasingly intensive.

In VAMC EDs, 45-65% of patients are prescribed at least one new medication;

25% told to change or stop a baseline medication

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Frequent Users

Frequent Flyers, Super UsersUse ED on multiple occasions; account for a disproportionally high number of ED visitsMajority are not elderly, but some are

Frequent users are sicker (physical and mental), challenging life circumstances36Slide37

Obstacles to Safe and Effective Transitions

The medication mazeCommunication hurdlesThe follow-up leap of faith

Scratching the surface37Slide38

The Medication Maze

New medications and dosage changes

Common ED discharge drugs (e.g. NSAIDs, opioid analgesics, antibiotics) are often risky for older patients

Medication Reconciliation Across Transitions

Different

prescribers

Multiple medications and chronic conditions

Over the

counter drugs

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Communication hurdles

Between providersDirect communication between ED and PCP rare- not always possible; not always necessary17% of VA PCPs always/almost always promptly notified of ED visits

Between providers and patients and their families

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Follow Up Leap of Faith

Primary CarePoor patient understanding of whether it’s needed, and if so, how soonInefficiencies if providers unaware of needsSpecialty Referrals

Patient’s role, timing

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Scratching the Surface

Substance abuseDepressionHousing or food insecurityElder abuseCaregiver stress

Poorly controlled chronic diseases

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Improving ED Transitions

Get collateral history of medication use, if possible, esp OTCDrug-drug, drug-disease interactions,

renally doseEducate about possible side effects, and what to do if they occur

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Improving ED Transitions

Enhanced communication between providers Synchronous vs Asynchronous

PCP notification of ED visits: necessary but not sufficientFocus on quality of content and action items for PCP

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Improving ED Transitions

Enhanced communication with patients and familiesStandardized content of discharge instructions

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Improving ED Transitions

Enhanced communication with patients and familiesScreening for communication barriers such as hearing and cognitive impairmentIncluding companions/family members in discharge discussions

Communication methods such as the “teach back”, asking patients or surrogates to repeat key information in their own wordsPrinted materials – attention to font size and literacy level

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Follow-up Care

Plan for how outstanding tests and appointments to be completed

Expectations for when/how they will be contactedExplicit discussion regarding resolution of sx/warning signs

Updated telephone

contacts

, for patient and/or caregiver

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Scratch below the surface

AskSubstance abuseDepression

Housing or food insecurityElder abuseCaregiver stressPoorly controlled chronic diseasesEngage other team members

Communicate concerns findings to PCP and patient; direct referrals when appropriate

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Thanks for your Attention!

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Bibliography

“Review: Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriatness, and Consequences of Unmet Health Care Needs,” Anrea

Gruneir, Mara J. Silver and Paula A. Rochon, Med Care Res Rev

2011 68:131

http://mcr.sagepub.com/content/682/131

“Older Patients in the Emergency Department: A Review,” Nikolaos Samaras, Thierry Chevalley

, Dimitrios Samaras, and Gabriel Gold, Annals of Emergency Medicine, September 2010, 56:3,261-269. “Older Adults in the Emergency Department: A Systematic Review of Patterns of Use, Adverse Outcomes, and Effectiveness of Interventions,”

Faranak

Aminzadeh, William Dalziel,

Annals of Emergency Medicine

, March 2002;39:3,238-247.

“How Frequent Emergency Department Use by US Veterans Can Inform Good Public Policy,” Jesse Pines,

Annals of Emergency Medicine

, 2013, pending publication.

The Merck Manual, Hospital Care and the Elderly: Provision of Care to the Elderly: Merck Manual Professional,

http://www.merckmanuals.com/professional/geriatrics/provision_of_care_to_the_elderly/hospital_care_and_the_elderly.html

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Bibliography

Survey: Many Elderly Are in the Dark at ED Discharge, http://www.acep.org/content.aspx?id=46032 “What Patients Really Want From Health Care,” Allan

Detsky, JAMA, Dec 14, 2011;Vol306, #22, p2500-2501.“Health Services Use of Older Veterans Treated and Released from Veterans Affairs Medical Center Emergency Departments.” Hastings SN et al.

J Am

Geriatr

Soc 2013; 61:1515-1521.“Quality of Pharmacotherapy and Outcomes for Among Older Veterans Discharged from the Emergency Department.” Hastings et al. J Am

Geriatr Soc 2008; 56 (5):875-880.“The evolution of changes in primary care delivery underlying the Veterans Health Administrations’s

quality

transformation”.Yano

EM et al. Am J Public Health 2007;97:2151-2159.“Older Veterans and Emergency Department Discharge Information.” Hastings SN et al.

BMJ

Qual

Saf

2012 Oct;21:835-842.

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Questions/Comments

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