My medical school dean urged our class to “think not just about what interests you, but about who needs you.” Few patients I’ve encountered in healthcare have struck me as more in need than the frail elderly. As I’ve learned, the ED lies at the heart of the elder care ecosystem, a hub connecting seniors to resources, investigations, specialists, and acute care.
In this post, I’d like to share the Top Five things I’ve found interesting about geriatric emergency medicine, as well as some practical advice for learners.
1. Older adults come to the ED often, and are more unwell when they do.
In Ontario, persons over the age of 75 have the highest ED visit rate (73.1 per 100 of the population, compared to an average of 39.7).1 In 2015, adults aged 65 or better accounted for 22.4% of ED visits in Ontario.
And that proportion is rapidly growing. Between 2009 and 2015, the number of Ontario ED visits by older adults grew by 29.1%, whereas visits those aged 20 and 44 grew by just 8.5%.2 It’s also worth noting that, as of 2011, the median age of the baby boom generation was only around 55. Population ageing is poised to accelerate, and by 2031, the proportion of seniors may approach 23%, compared with 15% in 2011 (a relative increase of over 50%).3
Moreover, a striking 74.2% of Canadians over the age of 65 were triaged as urgent or emergent (CTAS 1-3). This figure rose to 81.4% among those aged 85 or older. And 20.8% of adults over 65 visiting the ED were admitted to hospital (28.2% among those 85 or older).1
2. ED visit is a critical opportunity to identify vulnerable older adults.
ED visits by older adults are “sentinel events” for morbidity and mortality.4,5 After an ED visit, 20% to 52% of seniors deteriorate functionally, including those not admitted to hospital.4 7.5% of a cohort of independent older adults visiting the ED accounted for 59.0% of all the cohort’s acute care encounters within 6 months.6 Identifying this subset of seniors “at high risk for adverse events, such as death, decline in physical function, rehospitalization, or institutionalization” before discharge is crucial.7
The 2013 Geriatric Emergency Department Guidelines recommend screening all geriatric patients for at-risk features using an instrument such as the Identification of Seniors at Risk (ISAR) tool (see Table 1).8,9
Table 1: Identification of Seniors At Risk (ISAR) Tool
Ask the patient each of these questions:
1. Before the injury or illness, did you need someone to help you on a regular basis?
2. Since the injury or illness, have you needed more help than usual?
3. Have you been hospitalized for one or more nights in the past six months?
4. In general, do you see well?
5. In general, do you have serious problems with your memory?
6. Do you take more than 3 medications daily?
A patient with a score of >1 positive responses is considered at high risk for adverse outcomes, and should be referred for expedited geriatric assessment.10
It’s important to note that the clinical benefit of such screening is controversial, and work is still needed to develop a tool using clinical decision rule methods and criteria.11
That having been said, the ISAR has modest accuracy in predicting ED return, emergency hospitalisation and mortality at 6 months, and may help inform discharge decisions.12 And diversion of older adults with positive ISAR screening to specialized geriatric assessment may reduce the risk of functional decline.10
Moreover, faced with the medical and psychosocial complexity with which many older patients present, it’s valuable to have a practical set of questions that can help assess function and structure your efforts to figure out which patients require special attention. Thus, it’s worth at least getting familiar with a tool like the ISAR to help identify vulnerable older adults, and learning how your institution screens for at-risk seniors.
3. Elder abuse is common, and every ED visit by a victim offers a chance to detect it.
Elder abuse includes physical, psychological, or sexual abuse; misappropriation of money or property; or neglect (the failure of a carer to meet the needs of a dependent old person).13
In one survey, 4% of Canadian older adults reported experiencing abuse.14 An Irish study of 2,311 family caregivers found that more than a third reported engaging in potentially harmful behaviours such as screaming, hitting, threatening abandonment, and withholding food.15
Since elder abuse victims are less likely to have regular follow-up with a family doctor, but go to the ED more often, it’s all the more important for ED providers to spot abuse.
Fortunately, EDs are ideal places to identify elder abuse.16
First, visits are unplanned, giving those responsible for the abuse less time to concoct stories and hide evidence of abuse.
Second, several different staff observe ED patients multiple times, providing many chances to spot abuse.
Finally, since half of older adults undergo imaging in the ED3, radiologists may be able to detect abuse evidence such as injuries inconsistent with the reported mechanism, co-occurrence of old and new injuries, and suspicious patterns.
As no screening tool is validated for ED use, experts emphasize the importance of being aware of and attentive to signs of abuse, and speaking to all team members. Also, be sure to learn about your institution’s processes for reporting suspected abuse, and don’t hesitate to voice concerns to your staff and colleagues.
Finally, it is important to understand that caring for a frail older adult can be physically, emotionally, and financially burdensome, and requires a great deal of skill and resilience – not to mention time away from work and other equally pressing responsibilities. The inability to provide for all of a person’s needs may be more a question of being overwhelmed than neglectful. It’s therefore important to maintain a compassionate rather than a judgmental attitude towards caregivers, and to use encounters with family and friends as opportunities to provide guidance, encouragement, and referral to additional supports.
For detailed summaries on abuse risk factors, history-taking, and physical exam signs, I recommend Rosen’s outstanding chapter on elder abuse and neglect.17
4. Don’t call it “failure to cope”.
When describing an older adult with increasing difficulty caring for him- or herself, or an unexplained decrease in activity, common terms like ‘weak and dizzy’ or ‘the dwindles’ are unhelpful and misleading.18 And whatever you do, don’t call it “failure to cope” or “acopia,” which British Geriatrics Society President Emeritus Dr. David Oliver warns is an admission that you “have no training in dealing with frailty and no understanding that functional impairment usually comes with treatable diagnoses.”.19
Moreover, the term “failure” is pejorative and can lead one to overlook the real problem: the inability of a patient’s often exceptional effort and skill to overcome a weakening support structure, care system failures, abuse and/or ill health. Sensitivity to language is a small but good step towards eradicating the ageism prevalent in healthcare.20
Acute functional decline – a syndrome characterized by “a sudden change in ability to function at baseline,” which is always a symptom of an underlying medical problem – is a better term because it emphasizes the three key elements of the syndrome: a sudden (over days) decline compared to baseline (specific to the patient’s circumstances) in functioning (not just health or cognition). This means it’s essential to understand all three of these components in the context of a patient’s daily life. Good collateral from family, primary care doctors, and/or a nursing home is indispensable.
Finally, as Dr. Oliver’s comment underscores, a referral for “failure to cope” doesn’t really supply enough information to guide medical management. Admitting and consulting services – including busy internal medicine residents taking referrals overnight – may appreciate the use of the more structured and formal diagnosis of “acute functional decline.”
5. Take altered mental status as seriously in the old as you would in the young.
Many unwell seniors present with behavioural or cognitive changes, either as a chief complaint or in conjunction with physical symptoms.21 Significant cognitive impairment is wrongly assumed to be part of normal ageing, and we frequently confuse chronic processes such as dementia with acute conditions like psychosis and delirium.
Regardless of age, altered mental status (AMS) can be a symptom of life-threatening illnesses, and needs to be approached in a structured way. A retrospective cohort study of US Medicare recipients with a mean age of 69 who died within 7 days of being discharged from the ED found that, of the 20 most common discharge diagnoses (including chest pain, syncope and abdominal pain), AMS conferred the highest relative risk of death. The authors of that study concluded that “[t]here is a particular clinical ‘signature’ of discharge diagnoses from emergency departments linked to short term deaths, especially syndromic diagnoses not involving pain, like altered mental status, dyspnea, and malaise and fatigue.”22
AMS is addressed well in numerous sources, including chapters in both Rosen’s and Tintinalli’s 23,24 and in a great module by Clerkship Directors in Emergency Medicine.25 AEIOU TIPS is a popular mnemonic that supplies a good differential for AMS (see Table 2).
|Table 2. The AEIOU TIPS Mnemonic for Causes of Altered Mental Status
Insulin (hypo- or hyperglycemia)
This post was copyedited by Michael Bravo (@bravbro).
Interests and Insights in Geriatric Medicine
Thom has done a great job at extracting some insightful points about older people in the ED – demographics, functional assessment, abuse, attitudes, and forms of cognitive impairment – which can start to change the way we approach an increasingly large number of patients we see. We all went into EM because of the fast pace; the one-on-one; the excitement of resuscitation; the thrill of changing an outcome an intervention or procedure. However as we get more deeply into the business, we realize that most of our time is spent with slow moving, slow talking older people with multiple problems, multiple care providers (both professional and personal), and a complex web of psycho-social, cognitive, and functional impairments. I’m pleased that a young physician (still in medical school) has started to identify key learning points that apply to many older ED patients – especially since residency programmes, for the most part, are woefully devoid of focussed training about the group of patients you’ll spend most of your career with!
The field of Geriatric Emergency Medicine has expanded rapidly in the past ten years as physicians and health care systems finally noticed that the job was starting to be “all about the old people.” (Those of us in the field joke about the tsunami we watched coming for 65 years!) I would urge trainees to be as proactive as possible in supplementing their education to enhance skills in the complex challenging and fascinating area of Geriatric EM – and not to just learn it through trial-and-error, as most of us did over the first 15 years of our careers! High-yield opportunities would be an elective in any of Geriatric Medicine, Geriatric Psychiatry, Palliative Medicine, or some sort of home-based primary care. It may seem like an odd choice for an EM resident – but I suspect the skills knowledge and attitudes you enhance will yield greater benefits than further refining your ultrasound-guided procedural skills or reviewing one more time resuscitation pharm/phys! Take a look at one of five North American fellowships in Geriatric Emergency Medicine (Cornell, Hopkins, UNC, UC Davis, Toronto – follow https://geriemfellow.blog to share Dr. Brousseau’s learning). Or if you only have six hours, complete the modules on www.geri-EM.com
Fasten your seat belts: it’s going to be a wild geri ride!