Caring for Geriatric Patients in the Emergency Department Setting Part I: The Assessment of the Older Veteran

1. Caring for Geriatric Patients in the Emergency Department Setting Part I: The Assessment of the Older Veteran Ula Hwang, MD, MPH Associate Professor of Emergency Medicine Brookdale Department of Geriatrics and Palliative Medicine Mount Sinai School of Medicine, New York NY GRECC, James J. Peters VAMC, Bronx NY Nannette Hoffman, MD Associate Chief of Staff, Geriatrics and Extended Care North Florida/South Georgia Veterans Healthcare System, Gainesville, FL VineeshBhatnagar, MD Associate Chief of Staff, Extended CareVA New Jersey Healthcare System

2. The “Silver Tsunami” 2011 was first year the Baby Boomers entered the ≥65 age bracket. That was just the beginning!

3. Typical Chronic Disease Management Emergency Department/Hospital Admission Functional Decline Fall Risk 50% Quality of Life Declines Patient Self –Management, Home Health Care, Long Term Care Adapted from PRHI Using Medical Homes to Reduce Readmissions http://www.chqpr.org/downloads/UsingMedicalHomestoReduceReadmissions.pdf

4. Literature Suggests • An ED visit is a sentinel event and marks early functional decline, leading to poor health outcomes, higher health care utilization and higher cost of care. • Transitions of Care are key points wherein providers have the ability to impact the trajectory of patients and improve quality of care and decrease the cost of care. Friedmann PD, et.al. Am J Emerg Med 2001 Aminzadeh F, et.al. Ann Emerg Med 2002 Coleman EA, et.al. Med Care 2005 Hastings SN, et.al. Med Care 2008

5. Improved Care Transition Management Emergency Room/Hospital Admission Decrease Fall Risk 50% Improve Quality of Life Preventable Admissions SW Case Manager Adapted from PRHI Using Medical Homes to Reduce Readmissions: http://www.chqpr.org/downloads/UsingMedicalHomestoReduceReadmissions.pdfhttp://www.chqpr.org/readmissions.html

6. Disconnect Between EDs and Older Adults… Space designed for ED priorities of rapid patient evaluation and turnover, privacy forsaken for maximal use of space, crowding of narrow beds, shiny linoleum floors for quick cleanup…

7. Paradigm shift of ED physical design and care (Pediatric ED) • Geriatric ED Interventions (GEDIs) • Structural modifications: lighting, flooring, hearing assist devices, clocks • Process of care modifications: screening for cognitive impairment, adverse health outcomes (e.g., ISAR, TRST, BRIGHT), nursing discharge coordinator

8. About This Webinar Series Purpose: • To build geriatric competencies in members of the ED patient care team • To enhance knowledge of unique and age-specific elements in caring for older Veterans • Goal of reducing the frequency of unnecessary return visits to the hospital

9. The Series • Assessment of the Older Veteran • Cognitive Status in the Older Veteran • Optimizing 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

10. For the non acutely ill Geriatric patient: The ED visit results from the straw breaking the camel’s back Geriatric Assessment and the Emergency Department (ED)The goal is to provide a “geriatric context” as you evaluate seemingly “stable” elderly ambulatory ED patients.

11. For the Non-acutely Ill Elderly Patient: • Ask yourself: • Why is this patient here now? • What should be on your radar?

12. Your ED Shift • You have 3 patients with chest pain, one patient with GI bleeding, one acutely psychotic patient on one to one, one intoxicated belligerent patient, and there’s a doc on the phone from an outlying ED who wants to transfer a patient to your ED.

13. In the Meantime: • An eighty-two year old female with hypertension presents with “dizziness” x one week but no syncope; • Her medications are HCTZ 25 milligrams daily and Lisinopril 10 milligrams daily; • Her vital signs show BP 125/78 HR 62 and mild orthostasis with change in BP systolic of 15 mm Hg at one minute and little change in heart rate; • Her labs show a very mild pre-renal azotemia; • Your diagnosis is mild orthostatic hypotension; • You recommend the usual strategies: hydration, slow changes in position, follow up with PCP to determine if BP medications should be adjusted. • When the patient leaves the ED, unbeknownst to you, while driving she is involved in an MVA and after a lengthy hospitalization dies. Two years later you are named in a lawsuit because the patient was actually demented and should not have been driving. You are being sued because you failed to accurately diagnose her “condition in the ED”.

15. Five Things • Cognitive Impairment/Dementia • Medications • Falls • Abuse/Neglect • Acute Illness Presentation

16. ED Sees the Societal Symptom of Lack of Access to Aging Resources: Granny Dumping • “The positive tail light sign. They roll them in the door and all I see is the tail lights vanishing in the distance.” • “The `packed-suitcase-syndrome.' When they show up with all of granny's belongings in one or two suitcases and they say, `Put her in the hospital and take care of her. We can't take care of her any more.' " • “The most common manifestation of the problem is family members who leave a relative with a host of suggested ailments.”

17. “Granny Dumping” • Usually a confluence of dementia “effects” (behavioral and sleep disturbance/caregiver burnout) and gait disturbance results in the elderly being dropped off in the ED driveway. • Usually no acute illness; the “placement problem” who doesn’t meet “interqual” standards.

18. Cognitive Impairment • Mild Cognitive Impairment (MCI): not dementia-can do ADLs minimal memory and intellectual deficits, may have IADL deficits; minimal or subtle gait disturbance. Likely you won’t pick this up on an ER visit. Family attributes it to “he’s getting older”. • Dementia overt memory, intellectual and ADL deficits usually associated with gait problems and sometimes behavioral manifestations (inertia to agitation/aggression)-no longer independent in IADL ; 20% over age 80 and 50% over age 84. • Delirium acute deterioration of cognition over baseline deficits, latter often unrecognized.

19. Cognitive Impairment • Short test 3/3 objects at 5 minutes and Clock. Can’t do one it’s mild cognitive impairment to dementia, can’t do two it’s definite dementia. Can’t do clock, should the patient be driving? • Delirium versus moderate dementia: if no history or context may be difficult to know the difference. Usually you can find some history or context to help you.

20. Yes You Can Ask About Guns Even in Florida • Dementia with behavioral disturbance • If physical aggression, must admit • Before discharging a demented patient from the ED, it would be prudent to: • Ask about Guns • Ask about Driving

21. Cognitive Impairment/Dementia: • The “socially appropriate” patient-confabulate to save face. • The person with the patient does all the talking. • The patient can’t name his or her medications, only knows them by “the little red capsule I take at bedtime.” • “Non compliant” label usually means cognitive impairment. • The patient who actually can’t read, can they read the writing on their medication bottle? (Ask how far did you go in school?).

22. Walking as Described by an ED Doc: • “When does an ED doc ever watch a pt try to walk??? Unless the pt is running for the bathroom.”

23. Gait and Falls: Gait Observation Starting from Seated is an Excellent Neurological Exam Surrogate • History: Acute versus Chronic Falls and Gait Problems. • Look at Meds (we’ll get to that). • Check Orthostasis, HR responses typically blunted in older folks. • Simple observations are telling: the patient that is always in the wheelchair; getting up from supine to sitting patient struggles; getting up from a chair-must use hands and arms for support; walking speed slow and shuffling and standing on one foot. (most folks over 80 years can’t do this well if at all). • In an elderly individual if there is appreciable chronic gait disturbance there is inevitably accompanying dementia.

24. Fall Pearls • If patient can’t weight bear, the hip is fractured until proven otherwise regardless of the plain radiograph findings; thigh or knee pain is a hip fracture until proven otherwise. • The normal head CT and the non focal neurological exam after striking the head is a misnomer. Delayed subdurals are more common and missed.

25. Abuse-Neglect • Unexplained injuries • Minimal trauma fractures in isolation may not be a sign of abuse due to disuse osteoporosis • Pressure Ulcers; skin irritations, redness, rashes; • Malnutrition • Clinical findings of medication non- compliance; • Poorly groomed/poor hygiene • Clothing smells of urine • Nails dirty not trimmed • Lots of skin tears

26. Who is getting the Social Security or Pension Check? Early SW involvement.

27. Medications • There is going to be an entire session on this. • Look for common offenders. • Cognitively impaired patients: no telling what they are taking and when, what’s old, what’s new, what their neighbor has and what’s in the medicine cabinet from three prior hospitalizations. Meds likewise can impact cognitive impairment. • Also we in “health-care” mess up.

28. AVOID TAKING AT NIGHT AT BEDTIME

29. Common Problematic Medication Scenarios: • ACEI + Diuretics with orthostasis, azotemia; • Too much “blood thinning” ASA + anticoagulant + clopidogrel + LWMH and no PPI gastric protection; • Septra DS BID; not adjusting for declining GFR when prescribing meds; • Terazosin at night with hypotension at 10 AM; • Hypoglycemia: too much of a good thing: too much insulin, use glipizide instead of glyburide due to declining GFR in elderly; • Delirium–hallucinations from “sleepers” hypnotics; • Using anti-psychotics for sleep; • Benadryl and Tricyclic Antidepressants-strong anticholinergic effects (confusion, urinary retention, constipation and orthostasis); • Too much lipid lowering –rhabdomyolysis; • Too much AV node suppression with calcium channel blocker, Digoxin, beta blocker, look at the EKG ?sinus brady 1st degree AV block, a BBB or IVC delay; • Theophylline for complete heart block if patient refuse pacemaker; • Urinary Retention from opioids, muscle relaxants, calcium channel blockers, anti-cholinergics or combination of these (don’t use oxybutinin unless you know the PVR especially in a male or a diabetic).

30. Elderly Present With Acute Illness in a Blunted Fashion: Requires More Imaging and More Vigilance • Less prominent temperature elevations; often on medications that blunt febrile response (NSAIDs, Acetaminophen); • Less neutrophil stress response to infection; • Cognitive impairment results in vague history; • Less active so they don’t complain of dyspnea (watch their respiratory effort and rate) but are very deconditioned so is “DOE” just deconditioning versus COPD, CHF, etc. (likely lots of occult sleep apnea too with pulmonary hypertension); • Muted heart rate responses to hypovolemic stress; • Pain blunted and non -specific; no guarding, muted peritoneal signs; delayed appendicitis presentation; • Drop in Hct w/o GI bleeding on anticoagulants and vague groin/abdominal pain: think retroperitoneal bleed; if a fall think of ruptured spleen; • Herald pain of Zoster-is it dermatomal? • If agitated is the bladder full? Agitation may be pain; • If patient won’t weight bear, think fracture.

31. In Closing • The Advance Directive should be the “sixth vital sign. •  If air travel were like health care: http://www.youtube.com/watch?v=5J67xJKpB6c&feature=youtube_gdata_player Thank you for listening

32. The Assessment Of The Older Veteran in the Emergency room setting Vineesh Bhatnagar, MD ACOS, Extended Care VA New Jersey Health Care System

33. TOPICS COVERED • Principles of Geriatric Assessment • Communication Strategies • Geriatric screening tools in the ED for: • Cognition Assessment • Depression Assessment • Functional Assessment • Mobility and Gait Assessment • Social Assessment

34. COMMUNICATION STRATEGIES: • Introduce yourself • Face the patient directly • Sit at eye level • Speak slowly and Rephrase as necessary • Ask open-ended questions: “What would you like me to do for you?” "How would you describe your life at home?" "Can you tell me what your typical day at home is like.”

35. GOALS OF GERIATRIC ASSESSMENT IN ED SETTING • Medical status • Functional status • Psychosocial situation To determine a patient’s • That would help in developing a comprehensive treatment plan and ensure safe discharge planning.

36. FUNCTIONAL ASSESSMENT

37. FUNCTIONAL ASSESSMENT • A ‘significant change’ in the ADL or IADL activities within a ‘short interval of time’ could be the single most important clinical finding. • ADL impairment is a strong predictor of clinical outcomes like nursing home placement, frequent emergency room visits, and death among older adults. • Temporary or permanent loss of ADL or IADL activities determines a safe discharge plan from the ED/institutional setting. For example: Loss of IADLs requires HHA,mealservice, ADHC assistance in a home setting Loss of 1-2 ADLs would need Assisted Living Facility level of supervision Loss of >2 ADLs would need Nursing Home level of supervision.

38. TIMED GET UP AND GO TEST (TUG) • The subject is encouraged to wear regular footwear and to use any customary walking aid. • No physical assistance is given during the test. • Have the subject walk through the test once before being timed to become familiar with the test. • To test the patient, give the following instructions: • Rise from the chair • Walk to the line on the floor (10 feet) • Turn • Return to the chair • Sit down again Normal: completes task in < 10 seconds. – can be independently mobile Intermediate score: 11-20 seconds. - needs assistive device for mobility Abnormal: completes task in >20 seconds - high risk for falls and needs supervision

39. COGNITION SCREENING

40. MINI COG TEST Please Note: The choice of 3 objects should be unrelated (eg. paper, pencil, erasure – will skew the test results) • Mini Cog is nearly as good a screening test as Folstein’s Mini Mental Status Exam (MMSE) or St. Louis University Mental State (SLUMS) test. • The test is 73% sensitive and 76% specific • The test results are less affected by confounding factors like education level, ethnicity, language and socio-economic • Mini Cog takes about half as much time to perform than MMSE or SLUMS test (about 3 mins) • If the test is abnormal, SLUMS or MMSEtesting would be indicated

41. DEPRESSION SCREENING Patient Health Questionnaire (PHQ-2) Answers “Yes” to either: “Do you often feel down or depressed?” “Have you lost interest in doing things?” PHQ-2 is 100% sensitive and 77% specific. It has 93% negative predictive value but only 38% positive predictive value. PHQ-2 can rule out but not diagnose depression (akin to D-dimer test for PE) Further validation of Depression would require a Geriatric Depression Scale (15 questions) tool

42. SOCIAL ASSESSMENT • Ethnic, spiritual and cultural background • Availability of a reliable support system • Caregiver burden • Socio-economic condition • Home safety assessments • Elder abuse • Advance directives

43. STRATEGIES FOR RAPID SCREENING

44. STRATEGIES FOR RAPID SCREENING

45. SUMMARY • The focus of a geriatric evaluation is on functional assessment. • Not all screening tools are applicable to every geriatric patient. The decision should be based on the clinical judgment. • ED requires an interdisciplinary approach (physician, nursing and social work) for time efficient assessment of the older adult. • Most of the geriatric screening tools, do not need a physician’s involvement. This way the burden of geriatric assessment can be shared amongst the interdisciplinary team.

46. RESEARCH TRIAL With an exponential increase in U.S. population in the age 65 yrs and above bracket, geriatricians are recognizing the need for a less cumbersome assessment tool than the existing Comprehensive Geriatric Assessment (CGA) tool. A head to head prospective trial is underway to compare CGA with a proposed Mini Geriatric Assessment (MIGA) tool on the parameters of time involvement, accuracy and clinical outcomes. The trial is scheduled to complete in 2014.