Senior Emergency Rooms:Building a Care System for our
Senior Adult PatientsDebra Steveson, BSN
Objectives
• Describe the reasons for a senior emergency room
• Explain the special components of care in a senior emergency room
• Discuss the evidence on which the senior emergency room is based
• Discuss current issues with drug utilization in the elderly
• Relate information presented to a patient case
Last year was the first year the Baby Boomers hit the market. Are we prepared for this new adventure in healthcare? We have two choices at this juncture in the road: we can simply hang on and hope the ride is not too bumpy or we can help drive the process….
“The Little Boy and the Old Man” – Shel Silverstein
Said the little boy, "Sometimes I drop my spoon."Said the old man, "I do that too."
The little boy whispered, "I wet my pants."I do that too," laughed the little old man.
Said the little boy, "I often cry."The old man nodded, "So do I."
But worst of all," said the boy, "it seemsGrown-ups don't pay attention to me."
And he felt the warmth of a wrinkled old hand.I know what you mean," said the little old man.”
U.S. Department of Health & Human Services2011
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 20500%
5%
10%
15%
20%
25%
30%
Older Population by Age: 1900-2050 - Percent 60+, Percent 65+, and 85+
% 60+ % 65+ % 85+
Quick FactsExempla hospitals
• Lutheran Medical Center’s ED population - 21% are greater than 65 years of age
• St. Joseph’s ED population – 37% are 65 or older
• Good Samaritan Medical Center’s ED population – 29% are greater than 65 years of age
SENIOR ED PROJECT
EGSMC Primary Service Area (PSA) Statistics:• About 68,900 residents are age
65+, representing 9% of the population.
• Seniors in the PSA are estimated to generate 37,900 ED visits annually.*
• 65+ population is expected to grow 5% per year during the next five years, generating an additional 10,600 ED visits per year by 2017.*
• In five years, seniors will represent 12% of the total PSA population.
*Based on 550 ED visits per 1,000 population for residents age 65+ Source: Healthcare Cost and Utilization Project (HCUP) 2008 Nationwide Emergency Department sample (NEDS) for Community Hospitals
Slide 7
Primary Service Area (PSA) where 75% of EGSMC Inpatients Reside
Seniors Represent Nearly 40% of the Total Population Growth between 2012 and 2017
Slide 8
Age 0-1423%Age 65 +
39%
Age 45-6436%
Age 15-241%
Age 25-441%
Source: Truven/Claritas, 75% 2010 Total PSAPop EGSMC Total SA by Age & Race 2012-17 vMetro.xls
CONFIDENTIALFor Internal Use Only
Patients age 65+ Represent 29% of Total EGSMC Emergency Department Visits
Slide 9
EGSMC ED Volume by Age GroupNovember 2012 YTD (11 Months)
5%4%
10%
14%
22%
6% 5%
17%
10%
7%
0%
5%
10%
15%
20%
25%
30%
<18 18-24 25-44 45-64 65+
Age Group
To
tal E
D V
isit
s (I
P a
nd
OP
)
KP
Community
Source: Decision Support, Trendstar Data (note, total ED visit volume of 36,766 is low er than the Budget Comparison Report f igure by 2.6%)EGSMC ED Graphs.xls
CONFIDENTIALFor Internal Use Only
29%
The U.S. population of adults 65+ is projected to double by 2050
U.S
. Pop
ulati
on 6
5+ in
mill
ions
• The challenge: Older adults use the ED more than any other age group.
• True or False?– Older adults use the ED more appropriately than
any other age group.
11
Why a Senior ER?
• The challenge: Older adults use the ED more than any other age group.
• True or False? – Older adults use the ED more appropriately than
any other age group.
12
Why a Senior ER?
• How can these two statements both be true? Seniors visit the ED more because they are sicker than all other age groups.
• The solution - we need a better continuum of care to be able to take care of these patients.
Senior Emergency Room:A unit or a paradigm shift
• Physical changes of aging• Psychosocial needs• Co-morbidities
• Direct support -Certified Nurses Aid -Volunteers
• Consultative Services -Palliative/Hospice Care -Geropsychiatry/Behavioral Health -PT/OT -Clinical Pharmacy
• Care Coordination -Senior ER Care Coordinator through KP and Exempla -Community Based Referral and Care Coordination Services
How Is It Different?Clinical Modifications
The Case of Gertrude Current ED Paradigm
• 82 year old female via EMS from home after a trip and fall on throw rug. No head trauma. Denies LOC. Complains of right hip pain
• Medical history: diabetes, a-fib, coronary artery disease, depression, chronic low back pain
• Social history: lives alone, daughter is out-of-state• Meds: coumadin, metformin, metoprolol, aspirin,
simvastatin, fluoxetine, hydrocodone/acetaminophin
The Case of GertrudeCurrent ED Paradigm
• Roomed next to suicidal, intoxicated patient• Initial vitals stable, complains of 5/10 hip pain• Initial exam: anxious, trouble following directions,
right forearm skin tear, right hip contusion• Medicated with 4mg IV morphine• X-ray of hip negative for fracture• Continues to be agitated and anxious; medicated
with 1mg IV ativan• Physical therapy consulted for exam
The Case of GertrudeCurrent ED Paradigm
• Physical therapy notes patient is difficult to arouse and confused
• Head CT ordered, results negative for bleed• Return from CT, oxygen sats low, placed on oxygen• Incontinent of urine, straight cath for UA and culture• Admitted secondary to altered mental status and
hypoxia• Treated for catheter associated UTI• Discharged to SNF for rehab after 2-day inpatient stay
Senior Emergency Room Goal
• Transform care for our senior population in the ER in a manner that improves the quality, safety, and coordination of care by providing:
• Safe, quiet, comfortable and supportive care environment• Screening for early identification of seniors at risk• Education for patients and family• Coordination and mobilization of appropriate post
discharge resources• Effective transition back into the community• Provider of choice for our senior population
EGSMC Senior ER Screening
19
ED RN
Screening 65+
Braden
Morse Fall
Abuse questions
ISAR 3 or above KATZ
PHQ2 Positive Notify ED & PCP
Mini-Cog Positive Notify ED & PCP
PT/OT referral
CAM Positive Notify ED & PCP
ED RN ED RN
Current Process
Current Process
Current Process
Disorders of Cognition
• Depression - disorder of mood• Dementia - multiple cognitive deficits that include memory disturbance• Delirium - disturbance in consciousness and cognition that develops acutely
Depression
• Serious illness• Not part of aging• Affects 3-5% of people over 65 years of age• Most common cause of unexplained weight
loss• Can be observed and measured
Delirium
• Acquired syndrome with altered level of alertness, attention and perception.
• Develops over short period of time• Fluctuates over course of the day• Sleep/awake cycle disturbance• Psychomotor• Mental status
Confusion Assessment Method
• Most widely accepted diagnostic instrument1) acute onset and fluctuating course2) inattention3) disorganized thinking4) altered level of consciousness• Diagnosis of delirium by CAM requires
presence of numbers 1 and 2 and either 3 or 4
Dementia
• Development of memory problems AND at least one additional cognitive deficit
- Aphasia - Apraxia - Agnosia
Stages of Dementia• Early Stage -Appropriate social conversation, but longer pauses -Tendency to wander off topic -Trouble recalling names of people or places or things • Middle Stage - Difficulty finding words - May have difficulty following directions -Reading may still be preserved• Late Stage - Unable to complete activities of daily living, totally dependent - Very limited, if any, communication - Does not recognize self or others - Facial expression no longer change – flat affect
Mini Cog
• 3 minute instrument to screen for cognitive impairment in older adults.
• Detects people with mild cognitive impairment, too mild to meet diagnostic criteria for dementia.– A 3 item recall test for memory– And a simply scored Clock-drawing test (CDT)
• Normal clock drawing- the patient places the correct time and the clock appears grossly normal
Mini Cog
• If patient answers incorrectly, do not correct the response, if the patient asks if the answer was correct, something like, “ that was pretty close” is sufficient.
• Do not provide any clues or hints to the correct answer
• Do not allow family or friends to provide hints.• What were the 3 words I asked you to
remember? The order of the words do not matter.
Mini Cog Scoring
• Number of correct items recalled____.• If 3 then negative screen. STOP• If number of correct items recalled is 1-2• Is Clock Drawing Test abnormal? -no then screen is negative - yes with an abnormal Clock Drawing then the screen is positive
Notify ED physician
Case Review• 68-yr-old female presents to ED, referred by residential
assisted living facility. - was in the dining room of the facility wearing only a bed
sheet, claiming that she was the Virgin Mary and that somebody had kidnapped baby Jesus.
- In the ambulance on the way to the ED, patient abruptly fell asleep and when she woke up didn’t know who or where she was.
- has history of mild dementia and depression.• How would you go about differentiating dementia/delirium/depression? • How would you communicate and care for this patient?• What would you communicate to the attending physician?
Greatest Issues to aging• Loosing Family Members, Friends, • Loss Of Mobility• Loss Of Drivers License • Boomers Caring For Parents• Parents In Nursing Homes• Decrease In Reimbursement • Family Changes• Retirement• Widowhood• Declining Physical Reserves • Changes In Income • Shrinking Social World For Some
Benefits of aging
• Peace Comes With Age– Just being able to feel at peace with myself and the world.
Staying healthy is a good way to ensure a good quality of life for the long term.
• Retirement• Time • Discounts • Grandchildren• Financial Stability? • Lack Of Urgency (not bladder related!)
Normal changes of aging
• Vision• Hearing• Smell and Taste• Touch• Communication
Vision
• Macular Degeneration• Cataracts• Glaucoma• Diabetic Retinopathy• Hemianopsia
Myths of aging
• Old people are sick and disabled• Most are in nursing homes• Senility comes with old age• Old people are unhappy• Old people get very tranquil or very cranky• No interest in sex and can’t have it anyway• Few satisfactions in old age• By age 70 psychological growth is complete
Biases
• Bias in Providing Preventive Care– Older adults are often excluded from disease screening
tests. As a result, diseases are diagnosed when they have reached their later stages, therefore treatment becomes expensive.
– Part Of Their Social History. • Dr.’s Are For Sickness• Lack Of Funding
• Bias From Lack Of Geriatric Training• Gap In Primary Care Availability • Medical Intervention• Training For Nursing
Different approach to senior adults
• Triage interview• Assessment - slower response to questions - listen to entire answer - more history, medications, and allergies - seek treatment later
Assessment and Interventions
• A – I - different approach - different challenges - safety considerations• M – O• Atypical presentations• Therapies that could aggravate
Special considerations
• Pain• Skin care• Sexuality• Abuse
Skin Care in the Senior Adult
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Abuse in the Senior Adult population
• True or False
• The majority of maltreatment of seniors occur in SNF.• Sexual and physical abuse are the most common.• Colorado does not have mandatory reporting of senior abuse.• Interview of the abused senior should never occur apart from
the caregiver.
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Medication considerations
• Beers criteria - Identifies medications and drug classes that are potentially inappropriate based on best available studies. - Lists medications that exacerbate common disease states in the elderly - Lists medications that increase delirium and altered mental status - Reports medications that have been statistically associated with falls.
Beware of Drug-Drug Interactions
• Chance of DDI nearly 100% with 8 or more drugs1
• Almost 50% of community-dwelling geriatric patients had at least one DDI2
• DDI can result in ADR or suboptimal dosing• >80% of computerized DDI alerts ignored3
1Sloan RW. Drug Interactions. Am Fam Physician 1983; 27:229-38.
NSAIDS and the elderly• Congestive Heart Failure:
– 10-fold increased risk of CHF exacerbation requiring hospitalization in elderly
• Chronic Kidney Disease:– Most nephrologists recommend avoiding NSAIDs when CrCl <60
ml/min (Stage 3 CKD)• GI Bleed:
– ↑bleeding risk: • Age>60• Concurrent anticoagulants• Prior ulcer or hemorrhage• Concurrent steroids
• ↑ bleeding risk correlates with↑duration of use!
Renal considerations
• Morphine• Methadone• Digoxin• Bactrim• Ciprofloxacin• Levofloxacin• Nitrofurantoin• Acyclovir• Famciclovir• Colchicine
• Gabapentin• Metoclopramide• Glyburide• Enoxaparin (Lovenox)• Fondaparinux (Arixtra)• Metformin• Thiazide diuretics• NSAIDs• Spironolactione• Bisphosphonates (ie.
Alendronate)
Pain management in the elderly
• Increased risk of adverse effects due to increased sensitivity to opioids– Sedation, confusion, delirium, constipation, pruritus,
nausea• Recommendations:
– “Start low, go slow”– Manage fears, expectations– Avoid long-acting opioids unless chronic pain in opioid-tolerant patient– Treat “incident” pain with short-acting agents– Use only ONE agent– Prescribe laxatives (senna, bisacodyl)– NEVER use meperidine (Demerol)
Drugs and Delirium in the Elderly• Anticholinergics (oxybutynin)
• TCAs (amitriptyline)
• Antipsychotics • Antihistamines (Tylenol PM)
• H2 blockers• Opioids (MS Contin)
• Digoxin (dose > 0.25mg/d)
• Antihypertensives (hypotension)
• Alcohol• Benzodiazepines (diazepam)
• Antiparkinsonian drugs• Antibiotics• Corticosteroids
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Combining these drugs can have additive / synergistic effects!
Drugs and Falls in the Elderly
• Anticholinergics (oxybutynin, amitriptyline)
– Visual changes, sedation• Anticonvulsants
– Ataxia, sedation• Alcohol, aminoglycosides, loop diuretics, high-dose ASA
– Vestibular dysfunction (balance/posture)• Benzodiazepines (diazepam), antihistamines (Tylenol PM), opioids
(MS Contin)
– Cerebral impairment - leading to instability and sedation
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Medication List for 80 year old • Diazepam 5mg Q8H
prn• Metformin 1,000mg
BID• Lisinopril 10mg QD• Metoprolol 50mg BID• Warfarin 2mg QD• Simvastatin 40mg QHS• Oxybutynin 5mg Q8H
• Amitriptyline 75mg QHS
• MS Contin 15mg Q8H• Tylenol PM QHS• Alendronate 70mg
QOW• Calcium + VitD BID• Digoxin 0.25mg QD
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Suggestions for management
• Discontinue Tylenol PM, consider trazodone 25mg QHS as needed
• Taper diazepam – start with reducing to 5mg Q12H• Decrease digoxin to 0.125 mg daily• Adjust HTN medications (HR / BP low – orthostatic risk)• Discontinue Metformin, consider low-dose Glipizide• Change MS Contin to fentanyl 12.5 mcg Q72H and add Senna• Add oxycodone IR 5 mg Q6H prn for knee pain• Change amitriptyline to nortriptyline and decrease dose to
20mg QHS
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How do we keep up?
Point-of-care medication list including:– Herbals and Supplements– Over-the-counter Medications– “As Needed” Medications– Date/time of last dose taken– Vaccination History– Drug/food Allergies
Sometimes it may be necessary to contact SNFs, Nursing homes, outpatient pharmacies, or family members if patient has altered mental status or does not know what is being taken
References
• ENA• AARP www.aarp.org • Administration on Aging - www.aoa.gov • Independent Sector - www.independentsector.org • National Council on Aging (NCOA) - www.ncoa.org • Senior Corps - www.seniorcorps.org
Questions?
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