Updates in Geriatrics Christopher R. Carpenter, MD, FACEP, AGSF October 24, 2018
Disclosure of Relationships Deputy Editor-in-Chief Academic Emergency Medicine Editorial Board ACP Journal Club Journal of the American Geriatrics Society Past-Chair, ACEP Geriatric Section ACEP Clinical Policy Committee Speaker: BEEM and EM Abstracts No commercial relationships, including no Advisory boards/consulting/shareholder Officer or Board Member Speaker s Bureau Intellectual property/patents pending Other relationships
Objectives Appraise pertinent new literature & guidelines for ED care of geriatric patients Falls Altered mental status Weakness Review evidence-based approach for common geriatric presentations Examine the utilization and benefits of specialized geriatric EDs or geriatricization of all EDs
The Challenges
Clinics Geriatric Med 2013; 29: 31-47
Ideal World
Real World
ED Geriatric Admission Rates Across the World http://www.epijournal.com/articles/100/new-age-why-the-world-needs-geriatricemergency-medicine
Momentum Building
The Response
Proliferation of Geriatric EDs Academic Emergency Medicine 2014; 21: 337-346
GED Guidelines
GED Guidelines & Knowledge Translation Barriers
Sample Recommendations Medications Nurse & physician education should include medication management Falls evaluation should include polypharmacy (> 5 meds) screen Medication reconciliation with Pharmacy oversight should document high-risk meds
https://www.acep.org/geda/geda-home/index.html
Senior-Friendly ED
Is Delirium Relevant in ED? When not identified Time and resources wasted Misdiagnosis & malpractice risk Lost opportunity to prevent (some) ED returns and functional decline Present in 8%-10% of elderly in ED but 57%-85% of cases are missed Nagaraj et al Emerg Med Australas 2016; 28: 456-458 Han JH et al Acad Emerg Med 2014; 21: 937-940
Delirium Risk Factors Predisposing Cognitive impairment Sleep deprivation Oligoanalgesia Polypharmacy Immobility Visual impairment Hearing impairment Dehydration Precipitating Restraints Malnutrition Foley catheter Nagaraj et al Emerg Med Australas 2016; 28: 456-458
Han et al Ann Emerg Med 2013; 62: 457-465
Richmond Agitation Sedation Scale Han et al Acad Emerg Med 2015; 22: 878-882
Performance of Delirium Screens Tool Positive LR (95% CI) Negative LR (95% CI) CAM Infinite (Spec = 1.0) 0.14 CAM-ICU DTS+Brief CAM Brief CAM 51.3 (21.1 to 124.5) 19.5 (11.7 to 32.5) 16.3 (9.2 to 28.9) 0.28 (0.18 to 0.44) 0.19 (0.10 to 0.34) 0.19 (0.10 to 0.38) Han et al Acad Emerg Med 2014; 21: 180-187
Preventing Falls Kahn s Geriatric EM Textbook 2014, Chapter 32, p 343-350
Fall Risk Stratification Caveats Available studies assess risk of falls following an ED evaluation among community dwelling older adults. These instruments do NOT predict: Risk for falls that occur in the ED or hospital Risk for falls among nursing home patients
Post-ED Fall Risk Instruments Carpenter 2009 (N=261) Fall in last year Non-healing foot sore Cannot cut own toenails Self-reported depression Tiedemann 2013 (N=158) 2 falls in last year (2) 6 meds (1) Carpenter et al Acad Emerg Med 2014; 21: 1069-1082
Performance of ED Falls Screens Tool Carpenter Score >1 Carpenter Score >2 Tiedemann Score >0 Tidemann Score >1 Tidemann Score >2 Positive LR (95% CI) 2.40 (1.95-2.80) 1.30 (1.2-1.3) 1.48 (1.28-1.72) 2.00 (1.61-2.50) 3.76 (2.45-5.78) Negative LR (95% CI) 0.11 (0.06-0.20) 0 (0-0.14) 0.44 (0.30-0.64) 0.40 (0.28-0.57) 0.46 (0.34-0.64) No study has a very good positive LR. Carpenter et al Acad Emerg Med 2014; 21: 1069-1082
Age Ageing 2016; 16: 179 Over 600 elderly patients in ED after fall Randomized to de-prescribing of fall risk increasing meds vs. usual care* De-prescribing impossible in 40% and unsuccessful in another 35%, so % using FRID after 12-months 70% vs. 72% No effect on time to first fall * Not in ED
Foley Catheter Rosenberg et al Ann Emerg Med 2014; 63: e7-e25
Geriatric UTI Asymptomatic bacteruria is common and not associated with adverse outcomes Antibiotics (in asymptomatic bacteruria) risks >> benefits ED vague complaints often prompt UA not testing and/or not treating is a paradigm shift Crnich et al JAGS 2017; 65: 1661-1663
UTI Diagnostics in Elderly Meta-analysis of four ED studies Only females History and physical exam not accurate LR+ range 0.8 2.2 LR- range 0.7 1.0 UA helpful Nitrite positive LR+ range 7.5 24.5 Leukocyte esterase negative LR- 0.2 Meister et al Acad Emerg Med 2013; 20: 631-645
2008 2011
GED Guidelines CRITICISMS AND CONCERNS
Criticisms Partitioning of the ED Pediatric Oncologic Trauma Stroke Emergency Department Cardiac Geriatric Issues of: Cost/efficiency Need for general expertise among ED MDs Response: In most cases not partitioning, but developing a local expertise/protocols Pediatrics all EDs are capable of handling pediatrics; some specialize Heart centers/stroke centers quality of care
Criticisms Evidence Base There is no evidence that any of this improves patient outcomes Responses: Partially correct Geri ED guidelines extrapolated from other settings and current basis Most similar endeavors have lacked evidence early on - pediatric EDs, trauma systems, etc. Geri EDs are already here
Clinics Geriatric Medicine 2013; 29: 31-47
J Am Geriatr Soc 2014; 62: 1781-1785 Northwestern University, 2013 Emergency Medicine nurses with extra geriatric training GEDI nurses reduced ED admissions by 15%
J Am Geriatr Soc 2018; 66: 459-466 Three US ED s 2013-2015 Transitional care nurse reduce 30 day re-admissions
J Am Geriatr Soc 2018; 66: 452-458 2000 patients randomized over 3-years Trained nurse, scripted phone follow-up within 3-days of ED discharge
Criticisms Know it Alls We are all geriatric ED docs... Response: About process of care as much as anything The Geri ED provides protocols, resources, ancillary staff, etc. Ex: ED obs units work because of the provision of resources and protocols plus some additional expertise Impetus for additional education and research to improve care
Current ED Screening Practice Western J Emerg Med 2011; 12: 489-495
NEXT STEPS
GED Boot Camp: (potential) Keys to Success The faculty worked with the implementation team before and after the Boot Camp
http://geri-em.com/
https://geriatric-ed.com/
https://gempodcast.com/
Recap/Conclusions The silver tsunami is an international phenomenon with emerging innovations accelerated by international collaboration An expanding array of free resources exist for pre-hospital, nursing, ED, and post-ed settings Geriatric ED accreditation may be coming to you Effective geriatric care requires a village and wise choices
Questions? Contact Information E-mail: carpenterc@wustl.edu http://tinyurl.com/carpenter2017 Twitter1 @GeriatricEDNews Twitter2 @SAEMEBM
GEM Choosing Wisely #1 Don t use antipsychotics as first choice to treat behavioral & psychological symptoms of dementia
GEM Choosing Wisely #2 Don t prescribe a medication without conducting a drug regimen review
GEM Choosing Wisely #3 Don t use physical restraints to manage behavioral symptoms of hospitalized older adults with delirium
GEM Choosing Wisely #4 Perform a targeted history & physical examination for those who present with fall to identify the etiology and extent of injury
GEM Choosing Wisely #5 Avoid placing indwelling catheters in the ED for urine output monitoring in stable patients who can void, or for patient or staff convenience
GEM Choosing Wisely #6 Don t recommend a percutaneous feeding tube (PEG) in patients with advanced dementia; instead offer oral feeding
GEM Choosing Wisely #7 In patients with confusion, perform a brief screen for delirium & dementia
GEM Choosing Wisely #8 Don t use antimicrobials to treat bacteruria in older adults unless specific urinary symptoms
GEM Choosing Wisely #9 Don t delay engaging palliative care
GEM Choosing Wisely #10 Engage social work early in the patient s visit to identify and address social and logistical needs.