Confusion Assessment Method

Approach to Geriatric Patients: Functional Assessment in the ED

In Medical Concepts by Rob Woods18 Comments

The wave of baby boomers is coming to an ED near you and it’s time to get prepared [1]. ED overcrowding does not seem to be going away anytime soon, and anything we can do to get these patients back to the community is better for everyone.

While not all 80 year olds have multiple medical problems (we have a spectrum bias based on what we see at work) it does not take many geriatric patients to add significantly to our already busy ED workload. The ED is a focal point for access to the health care system for all patients, particularly the elderly, so we need to prepare ourselves better for their needs. With this in mind, there is a movement towards developing a ‘Geriatric ED’ based on population trends and studies that found implementing geriatric friendly strategies successfully reduced the admission rate of geriatric patients [2].

Currently, few ED’s are lucky enough to have a Geriatric ED or even physicians with geriatric expertise within their group. However, excellent training is available online (see Geri-EM.com) that covers the major issues facing geriatric patients in the ED. Additionally, there are usually an excellent array of services for these patients in your community; you just need to know how to access them! It does not take much for certain geriatric patients to fall below the threshold of dependence, and by using the strategies outlined in this post we might be able to get them back to their home.

The Approach to Geriatric Patients in the ED

The overall approach to the geriatric patient must include the functional, social, cognitive, and medical domains [3].

a) Functional assessment

A functional assessment evaluates the patients ability to complete activities of daily living (ADLs) and instrumental ADLs (iADLS). ADLs are the things you do in the first 20 mins of your day (transferring, toileting, bathing, dressing, feeding, and continence) while iADLs are the things you learned to do when you left to go off to university (meals, housecleaning, meds, finances, driving/transport, shopping, phone/technology).

b) Social assessment:

A social assessment focuses on their supports in the community. A good way to assess this is to ask ”If something bad happened, who would you call?”

c) Cognitive assessment

A cognitive assessment includes screens for Delirium (CAM) & Dementia (mini-Cog). The mini-Cog can be done quickly and should be a vital sign for a Geriatric patient. If it is abnormal, it should prompt further assessment with a mini-mental exam.

Confusion Assessment Method

 

 

Mini-Cog

d) Medical assessment

The physical assessment is something that we already do pretty well. It quantifies the reason for their presentation: Why did they faint? What was injured when they fell? etc. We could probably do a better job of checking their medications for appropriateness and interactions, but realistically we often don’t have the time for this in the confines of an ED visit. A topic most certainly worthy of another Boring EM post!

Specific Scenarios

There are also some specific situations which we need to be aware of that require additional assessment in the geriatric patient:

a) Does your patient have impaired mobility?

Often geriatric patients can have impaired mobility after a minor injury or flare of arthritis. Consider performing a “Timed Up and Go” or TUG Test [4]. This test is performed as outlined below and gives you a sense of whether or not a patient requires a mobility aid. If they do, physical therapy (PT) can often see them in the ED and make the necessary arrangements. If they will be discharged and require help at home for a couple of days, an appointment with a community PT for follow-up and mobility aid teaching can often be set up for them at their residence. If larger concerns are identified the community PT can refer them for a Geriatric Assessment.

TUG test

 

b) Is your patient at risk for falls?

Effective decision tools have been developed by Carpenter and Tiedeman [5,6] to predict falls in the elderly. (Editor’s note: For some more #FOAMed on geriatric fall assessment, be sure to check out The SGEM Episode #89: Preventing Falling to Pieces where Dr. Milne reviews Dr. Carpenter’s latest meta-analysis on the topic with him as a guest!)

Carpenter [5]:

Carpenter fall assessment tool

Tiedeman [6]:

ED falls screening tool

If your patient screens positive for as a fall risk, community occupational therapy (OT) can go to their home and see what improvements can be made for reducing their risk (ie shower bars, bath seats, removal of throw rugs, etc.). If larger concerns are identified, community OT can refer them for a Geriatric Assessment.

c) Does your patient have complex geriatric issues?

Patients with multiple medications, dementia, fall risk, etc who do not require admission need referral for a geriatric assessment. Prior to consult, they can often send someone to their home to collect information and to collect their medical records. A full geriatric assessment might include assessment by OT, PT, social work, nursing, physician +/- geriatric psychiatry, pharmacy, recreational therapy, and a dietician.

d) Can future medical events be prevented?

Prevention is the future of the geriatric ED. Tools are being developed to identify seniors who are at risk (the ISAR questionnaire [7]) and determine appropriate interventions (SEISAR [8]):

ISAR questionnaire

A score of 2 or higher on the ISAR questionnaire suggests need for intervention and prompts further assessment with the SEISAR (Systemic Evaluation & Intervention for SRs at Risk) Tool [8] to see which interventions would be of benefit.

The SEISAR Tool

As these assessments are quite in depth, they would require more than just a home care coordinator. Dedicated individuals are needed for these types of geriatric assessment. I suspect that resources for these types of services will increasingly be made available as our population continues to age.

Conclusion

The ED’s geriatric population is going to continue to increase. This population has unique needs that historically, have not been well addressed in the ED. This post outlined a basic approach for the assessment of geriatric patients and some common scenarios that emergency physicians should be prepared to address with evidence-based resources. Emergency medicine trainees and attendings that familiarize themselves with these resources will be better prepared to address the unique needs of our geriatric patients.

Edited / Reviewed by Brent Thoma (@Brent_Thoma)

References

  1. Foot, D. K., & Stoffman, D. (1997). Boom bust and echo: how to profit from the coming demographic shift (1st Edition). Saint Anthony Messenger Press and Franciscan.
  2. Keyes, D. C., Singal, B., Kropf, C. W., & Fisk, A. (2014). Impact of a new senior emergency department on emergency department recidivism, rate of hospital admission, and hospital length of stay. Annals of emergency medicine, 63(5), 517-524.
  3. Retrieved from Geri-EM.com September 8th, 2014.
  4. Bohannon, R. W. (2006). Reference Values for the Timed Up and Go Test: A Descriptive Meta‐Analysis. Journal of geriatric physical therapy, 29(2), 64-68.
  5. Carpenter, C. R., Scheatzle, M. D., D’Antonio, J. A., Ricci, P. T., & Coben, J. H. (2009). Identification of fall risk factors in older adult emergency department patients. Academic emergency medicine, 16(3), 211-219.
  6. Tiedemann, A., Sherrington, C., Orr, T., Hallen, J., Lewis, D., Kelly, A., … & Close, J. C. (2012). Identifying older people at high risk of future falls: development and validation of a screening tool for use in emergency departments. Emergency medicine journal, emermed-2012.
  7. Dendukuri, N., McCusker, J., & Belzile, E. (2004). The identification of seniors at risk screening tool: further evidence of concurrent and predictive validity.Journal of the American Geriatrics Society, 52(2), 290-296.
  8. Retrieved from http://stmarysresearch.ca/en/publications_and_tools/clinical_tools/isar-seisar December 28, 2014
Rob Woods
Rob is an emergency physician and trauma team leader in Saskatoon, Saskatchewan. He founded the Royal College emergency medicine residency program at the University of Saskatchewan and currently serves as Program Director.
Rob Woods
- 2 weeks ago
  • Eve Purdy

    Dr. Woods, amazing summary! I find myself struggling to figure out why I am worried about discharge in older patients and this gives some really nice tangible things to look for to explain my hesitance!

    Just to be a pain, we don’t have any great evidence to support interventions to reduce injuries from falls (including OT intervention at home) and I imagine if we screen for fall risk in the ED many patients will come up +ve. Should we be identifying a large number of at risk patients and spending money on interventions that unfortunately don’t seem to make a difference in terms of downstream outcomes? Maybe if we identify a high enough risk population they will have an effect, I just don’t know. Perhaps that is the next step of ED falls research?

    • Rob Woods

      Thanks Eve. I think your last statement is correct. This is where we need to go next. For now, our part of the solution is to quantify the scope of the problem. We can do this by identifying at risk patients in the ED.

    • Don Melady

      Eve — It’s important to
      remember that “lack of great evidence” is not the same as
      “knowing that interventions don’t make a difference.” Your last
      sentence is absolutely true — that we need more research about ED-based care
      of older patients. Currently we “know” very little. What
      screening tools work? What are we screening for? What interventions
      make a difference? And what is the outcome we are looking at? ED
      research tends to focus on blunt objective system-level markers (mortality? —
      for geriatric patients it’s 100%; return to ED? — maybe for a sick and
      declining older person, that is a good thing; increased costs? maybe spending
      more money to more completely assess older people will SAVE costs downstream.)
      Geriatric-friendly research needs to use outcomes that are relevant to
      the patient.

      I think I don’t agree with
      the (vaguely ageist) assumption that “many patients will screen +ve”
      (in fact the majority of older patients do not have major fall risk factors).
      And even if it were true, surely we would never claim that because a
      person is loaded with CAD risk factors we shouldn’t attempt risk stratification
      or proceed with further testing and intervention!

      Don Melady @geri_em

      • Eve Purdy

        Thanks Dr. Melady for adding your expertise!

        I didn’t mean to be ageist and regret that my comment came across that way. Thanks for pointing it out and I will be more careful with my words. I had in mind patients being assessed for a fall (which we know is a high risk factor for future falls) in my suggestion that many would be at high risk.

        I think the trouble I have with screening in this instance is that it conflicts with some of the epidemiology principles I have learned (don’t screen unless you have an intervention) and what I have seen in the falls literature (lack of reduction in injuries from fall reduction interventions). Having said that, the questions make sense and don’t really serve as a “screen” so much as they add to the entire clinical picture. As Dr. Woods nicely explained these types of questions help ED docs characterize the problem and be a part of the solution, something I hope to be a part of!

      • I think I interpret Eve’s comments very differently than you Dr. Melady. I think Eve is right to suggest for learners, screening for something that you can’t do something about can feel very frustrating…

        And so, for the attendings / chiefs (or attendings-to-be & chiefs-to-be) remember that it is important to also make sure to advocate for all patients who need our attention – and particularly the geriatric patient population. We MUST ask these questions and screen, and we MUST put in place systems of care that can deal with the cases that are flagged.

        It’s about making sure we meet the need. If we take a temperature, we have to be willing to go the mile to diagnose and treat the source of the sepsis… 😀

        T

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  • Don Melady

    Rob — Thanks for the excellent compression of all the highlights of Geriatric EM! If all Emerg docs followed your tips on the next shift, two things would happen:

    1. old people would get much better care;

    2. Emerg docs would enjoy that shift a lot more.

    Older people are the core population of EM — getting excellent at caring for them makes the job a lot more fun!

    Don Melady

    http://geri-em.com

    • Rob Woods

      Thanks Don! Geri-EM was a starting point for my talk.

  • Michelle Gibson

    Here I go again commenting on an ED blog – I feel like a rebel geriatrician. 🙂

    I love this. Those of us who do geriatrics day in, day out (by choice even!) struggle with the incredible heterogeneity of our patient population. It’s not that this is not an issue elsewhere, but it always seems magnified, and it’s made even more interesting by the frequent lack of any studies that include “real” geriatric patients with multi-morbidity, frailty, and other fun things to measure.

    My non-scientific gut feeling is that what research has been done so far suffers due to not being able to delve into difficult to measure patient characteristics- why do some patients benefit from OT assessments and others don’t? (In my experience, some patients do … but I know the data is unclear as to who those people are.) My patients are beautifully complex people, and it is always a guess as to who will take suggestions and who won’t. Just take the number of patients who tell me they didn’t fall – they just slipped/sat down unexpectedly/took a break from standing/settled to the floor/felt like lying down suddenly. 🙂

    I don’t have answers, but I do feel strongly that knowing which patients have significant issues with ADLs, cognition, gait, general frailty has got to be a necessary but insufficient first step. I hope research backs me up! However it’s hard to argue that not knowing that a patient has cognitive impairment has got to be a problem when providing prescriptions, discharge prescriptions, and follow-up appointments. This is frequently magnified in the ED.

    I will agree though that the more we know about caring for our older patients, the more fun it is. Of course, I have a significant bias, so take that as you will.

    • Thanks for chiming in as always. Multidisciplinary learning via blogs is a huge win for us all! You are not a rebel, you are a pioneer!

      (btw, any time you wanna write. We’ve hosted Ross Morton in the blog, and he’s a NEPHROLOGIST… so we’d love to have you! We’ve also had a dermatologist… and we’re hoping to get an allergist too!)

    • Eve Purdy

      Thanks for commenting! We love when non ED folks join the conversation 🙂

      I often feel like taking a break from standing. Maybe I’ll try settling to the floor some time!

  • Danica K

    Haha! “iADLs are the things you learned to do when you left to go off to university (meals, housecleaning, meds, finances, driving/transport, shopping, phone/technology).”

    Well done article. Geriatric patients can be challenging if there are multiple co-morbidities and may require a large time commitment in a busy ED. I also find caregiver burnout is often a presenting issue, where suddenly you’ve multiplied your patients. Good care requires meeting the needs of everyone to the best of your ability.

    Eve, where have you found that falls prevention efforts have proven ineffective? Everything I’ve read has shown they are. This CIHI report is the only thing I could find indicating minimal reduction in rate of falls, but a reduction in the percentage of falls causing injury.

    http://www.accreditation.ca/sites/default/files/falls-joint-report-2014-en.pdf

  • Matt McIsaac

    Brent- Disqus likes to delete my posts before I post them 🙁

    Rob- great article. Geri in the ED is tough. I regularly feel I am not giving optimal care. May of the tools above are better used proactively, but we end up using them in a reactive sense, often as somebody is in the throes of a negative health situation. I often find it quite difficult to access geriatric consultation in the emerg, at least in Saskatoon. This often leads to consultation to IM, often with gnashing of teeth, understandably so. This also often leads to a poor Dx along the lines of ‘failure to cope’, as though someone who lived to 90 at home with 7 meds on board and a few MIs can’t cope. Things are only going to get worse as the boomer generation ages, and as our society shows a chilling lack of will to address elder care. Care homes are in short order and inundated, families don’t want elders at home, and it’s not just the boomers who will be crashing the gates, but also a new wave of obese inactive patients suffering ‘geriatric’ states at a much younger age with yet more difficult care demands. While this might seem a great business opportunity to some, to the emerg dr in me, it’s bloody frightening. Your article couldn’t be more pertinent. A few questions:

    1. The info above is great- are these work sheets available in the Stoon emerg rooms? If not, perhaps a simple toolkit could be created to help guide the busy Emerg dr. and help with good documentation. (?resident project)
    2. Is the emerg the best place for this care? Would a geri-ED/urgent centre be desirable or even feasible?
    3. How do you deal with caregiver burnout when the geriatric patient is actually good to go home? I miss the ability I had in many rural settings to simply do a quick respite weekend (often half the staff were relatives of the patient, so easy!)

    Thanks again for a great article.

    Slainte

    -Matt

    • Don Melady

      Matt — thanks for great comments! Especially about the idiocy of the term “failure to cope”! I’m less pessimistic about the future: EM has always been great about addressing the social reality around us. A wave of older patients is coming our way and it can’t be “business as usual.” It’s time to stop “cursing the darkness” and to start lighting some candles. There are now lots of free-standing “Geriatric EDs” in the US — connected to the main ED but similar to the Peds area where “things are different”. See the ACEP Guidelines document: http://www.acep.org/geriEDguidelines/ With some of my American colleagues we have created a GeriED Bootcamp to teach departments how to make themselves more senior-friendly. We’d be happy to bring it to a health care system near you! I don’t see the free-standing option as appropriate for Canada, but every ED should be as senior-friendly as possible. Sith some support, from among others James Stempien in Sask, I just got funded to develop a GeriED website to support hospitals to geriatricize their EDs.

    • Rob Woods

      Thank Matt. Sorry for the tardiness in reply.

      1. Nadim Lalani and Floyd Besserer created a template for a Geri-EM chart, and it was put to a design challenge on ALiEM:

      http://www.aliem.com/design-challenge-an-aliem-fellows-project/

      2. No it’s not, but they’re gonna keep coming, so we need to be ready.

      3. I have no great solutions from our limited role in the ED, other than to be empathetic to the situation.

      Cheers,

  • gary

    We use problem specific charts generated after triage in our 70K+ ED in Sudbury. All charts are age/gender specific (making over 500 different charts). Relevant charts all have ADL’s and iADL’s and specific charts such as DEMENTIA MEMORY PROBLEMS and ALTERED MENTAL STATE also contain a 2 step delirium screen (delirium triage screen – sensitive plus bCAM – specific). Very easy to use at point of care. If interested contact off line. [email protected]

    • Rob Woods

      Thanks Gary. That sounds like a great set of tools!

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