Emergency Geriatrics. Essentials in Caring for Older Patients CCFP(EM) FCFP
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1 Emergency Geriatrics 101 Essentials in Caring for Older Patients Don Melady BA MD MScCH(c) Don Melady BA MD MScCH(c) CCFP(EM) FCFP
2 Ten Things I know about Old People in the ED
3 Learning Objectives At the end of this session you will be able to: Identify three ED-friendly screening tools for delirium, dementia, and functional decline; Identify three strategies for managing behavioural disturbances in the older patient; List the five most problematic drug classes in the elderly and List the five most problematic drug classes in the elderly and how to safely use them.
4 1. Care of the Elderly is FUN! Dr. Strangelove Or How I Learned to Stop Worrying and Love the Bomb
5 1. Care of the Elderly is FUN! Work at the top of your license! Galen Hippocrates Osler House
6 2. Delirium looks different when you are Old
7 2. Delirium looks different when you are Old 70% of acute mental status change in older patients is: HYPOACTIVE! Withdrawn Quiet Reserved Just not herself
8 2. Delirium looks different when you are Old The most helpful question you can ask: What has changed? Or Better still use some standardized approach
9 2. Delirium looks different when you are Old CAM (Confusion Assessment Method)
10 2. Delirium looks different when you are Old CAM (Confusion Assessment Method) The value of a standardized evidence-based validated-in-the-ed approach: MUST! Feature 1: Acute onset & fluctuating course Feature 2: Inattention ONE Or BOTH Feature 3: Disorganized thinking Feature 4: Altered level of awareness (Sharon Inouye, 1990)
11 3. Dementia changes ED Management Don t assume that what you see is what you get
12 3. Dementia changes ED Management Loss of short term memory; PLUS one of: Aphasia Agnosia Apraxia Loss of executive functioning
13 3. Dementia changes ED Management Mini-Cog (<45 seconds) Register three items Draw a clock face with hands at 10 past 2 Recall the three items
14 3. Dementia changes ED Management Mini-Cog Scoring 1 point for each recalled word after the Clock Draw Test (CDT) Possible Score: indicates positive screen for dementia. 1 or 2 with an abnormal CDT indicates positive screen for dementia. 1 or 2 with a normal CDT indicates negative screen for g dementia. 3 indicates negative screen for dementia.
15 4. Cognitive Impairment and Functional Decline are not normal
16 4. Cognitive Impairment and Functional Decline are not normal Functional Assessment Do you need any assistance on a day-to-day basis? How do you get to and from your doctor s? Does anyone come in to help you with things? OR
17 4. Cognitive Impairment and Functional Decline are not normal Use A Tool!!!
18 4. Cognitive Impairment and Functional Decline are not normal Identification of Seniors at Risk (ISAR) Tool (McCusker et al., 1999) 2 = Predicts Functional Decline, Recidivism, Institutionalization
19 4. Cognitive Impairment and Functional Decline are not normal Failure to cope is not a diagnosis Acute Functional Decline (NYD) is a diagnosis
20 3 screening tools? For Delirium? CAM For Dementia? Mini Cog For Functional impairment? ISAR
21 5. Tethers are bad!
22 5. Tethers are bad!
23 5. Tethers are bad!
24 5. Tethers are bad!
25 5. Tethers are bad!
26 5. Tethers are bad!
27 5. Tethers are bad!
28 5. Tethers are bad!
29 5. Tethers are bad! Be pro-active about avoiding restraints in any form -- and get people moving.
30 6. Eating, Drinking, and Walking are Good! Being hungry, thirsty, and immobile are bad!
31 6. Eating, Drinking, and Walking are Good!
32 7. Care of the Elderly is a Team Sport Do you have a Geriatric Team?
33 7. Care of the Elderly is a Team Sport ED Geriatric Mental Health Protocol ED Nurse Outreach Teams Liaison with Home-Based Primary Care Providers Home-Care Case Managers in the ED (or easy access) Specialized Geriatric Emerg Nurses An Emerg-aware OT/PT/SW team Geriatric pharmacy consultation Physical plant modifications and supplies
34 8. It s easier than you think to keep someone out of Hospital
35 8. It s easier than you think to keep someone out of Hospital There is no such thing as crisis placement to long-term care.
36 9. Some Drugs Cause Problems. Some Drugs Solve Problems.
37 9. Some Drugs Cause Problems. Some Drugs Solve Problems. Beers Criteria for Potentially Inappropriate Medication in Older Adults JAGS, 2012; 60 (4) Canadian Consensus on Inappropriate Prescribing Practices McLeod, Huang, Tamblyn, CMAJ, 1997; 156 (3)
38 9. Some Drugs Cause Problems. Some Drugs Solve Problems. Bad drugs! Anti-coagulants: Warfarin, ASA, clopidogrel Hypo-glycemics: Insulin and OHGs Anti-cholinergics/Anti-histamines histamines Benzodiazepines: short- and long-acting NSAIDs: especially indomethacin and ketorolac but all non-cox2s Budnitz et al. Medication use leading to emergency department visits for adverse drug events in older adults. Annals of Internal Medicine 2007; 147 (11):
39 9. Some Drugs Cause Problems. Some Drugs Solve Problems. Good Drugs!!! Hydromorphone Not renally cleared Potent Easily dosed Widely available Haloperidol Not anti-cholinergic Potent Easily dosed Widely available
40 10. Go Low. Go Slow. But Go! Pharmaco-dynamics: Lower physiologic thresholds for all organ systems Small doses have much bigger effects even in healthy older patients Remember! You can put more in, but you can t take it out!
41 Conclusion At the end of this session are you able to: Identify three ED-friendly screening tools for delirium, dementia, and functional decline; Identify three strategies for managing behavioural disturbances in the older patient; List the five most problematic drug classes in the elderly and List the five most problematic drug classes in the elderly and how to safely use them.
42 Questions
43 Thanks! The model patient: Rosabel Levitt! The Geriatric team at Mount Sinai Hospital ED
44 References Delirium (1) Lewis L et al. Unrecognized delirium in ED geriatric patients. Am J Emerg Med 1995;13(2): (2) Hustey FM, et al. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 2003;41(5): (3) Kakuma R, et al. Delirium in Older Emergency Department Patients Discharged Home: Effect on Survival. Geriatrics 2003;51(4): (4) Wong CL, et al. Does this patient have delirium?: value of bedside instruments. JAMA 2010 Aug 18;304(7): (5) Wilber S. Altered Mental Status in Older Emergency Department Patients. Emergency medicine clinics of North America 2006;24(2):
45 References ISAR CAM McCusker J, et al., Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 1999 Oct;47(10): Inouye K, et al., Clarifying Confusion: The Confusion Assessment Method, A New Method for the Detection of Delirium. Annals of Internal Medicine 1990;113(12): Wong CL, et al., Does this patient have delirium?: value of bedside instruments. JAMA 2010 Aug 18;304(7): Mini Cog Wilber ST, et al., An Evaluation of Two Screening Tools for Cognitive Impairment in Older Emergency Department Patients. Acad Emerg Med 2005;12(7):
46 References Medication Management 1) Budnitz D, et al Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007; 147(11): ) Fick D et al. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012;60(4): ) Hafner JW, et al. Adverse drug events in emergency department patients. Ann Emerg Med 2002 Mar; 39(3): ) Heard K et al. Inappropriate prescribing in elderly ED patients. Am J Emerg Med 2008 Mar;26(3): ) Hustey FM, et al. Inappropriate prescribing in an older ED population. Am J Emerg Med 2007 Sep;25(7): ) Nixdorff N et al. Potentially ti inappropriate i medications and adverse drug effects in elders in the ED. Am J Emerg Med 2008 Jul;26(6): ) Zed PJ, et al. Incidence, severity and preventability of medication-related visits to the emergency department: a prospective e study. CMAJ 2008 June;178(12):
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