Lee A. Lindquist
Scott M. Dresden Editors
A Case-Based Approach to Improving Acute Care
Lee A. Lindquist • Scott M. Dresden Editors
A Case-Based Approach to Improving Acute Care
Lee A. Lindquist Northwestern University Feinberg School of Medicine Chicago, IL
Scott M. Dresden Northwestern University Feinberg School of Medicine Chicago, IL
ISBN 978-3-030-12414-4 (eBook)
© Springer Nature Switzerland AG 2019
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When an older adult enters the emergency department, it is everyone’s hope that the best clinical care will be provided. Whether you are an emergency department provider or you bring a beloved older relative or parent to the emergency department or you are a retired clinician seeking emergent care, we all want the best care for our older adult population. Caring optimally for older adults requires specific knowl- edge of geriatrics and aging. Each older adult that we see prepares us to take better care of the next older adult. With this premise, we sought to put together cases of older adult stories to help clinicians – and anyone else interested in improving the care of older adults – to learn from. Many of these cases arose from Geriatric Emergency Departments – from Northwestern Medicine in Chicago to VA Health Systems in Cleveland – where dedicated geriatrics training of the next generation of emergency department is occurring. It is at these top-rated academic geriatrics programs where health systems across the nation are sending their emergency department staff to participate in intensive geriatrics educa- tion with a goal to establish Geriatric Emergency Departments. Geriatric Emergency Departments are the next wave of treating older adults, and they start with health- care providers who understand the tenets of geriatrics. We hope that this book will help hone provider geriatrics skills and learn better what needs to be done in the emergency department.
We the authors and editors want to thank all of our fami- lies, friends, and supporters who assisted us with this book.
Whether it be from proofreading our work to watching our children while we work, we are truly thankful. We hope that in the future, when we ourselves become older adults, the best geriatrics care will be received no matter where the emer- gency happens.
Chicago, IL, USA Lee A. Lindquist Scott M. Dresden
1 Growing Older in the Emergency Department . . . . .1 Lee A. Lindquist and Paul A. Nelson
2 Components of an Effective Geriatric
Emergency Department . . . . . . . . . . . . . . . . . . . . . . . 11 Scott M. Dresden
3 Cognitive Impairment in the ED . . . . . . . . . . . . . . . . 39 Jill M. Huded and Todd I. Smith
4 Syncope in a Rural Emergency Department
Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Lucy Morse and Lee A. Lindquist
5 ER Referrals and Hospitalizations
from Post-acute and Long-Term Care Facilities. . . . 77 Fernanda Heitor
6 Can Home Visits Make a Difference
to Emergency Department Visits? “I will just
stop by his place on the way home: Who knew
it would be a journey?” . . . . . . . . . . . . . . . . . . . . . . . . 103 Dwayne Dobschuetz and Katherine O’Brien
7 Medication Errors in Aging Adults:
A Case-Based Approach to Medication
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Abbie Lyden and Katherine Allen
8 Pain, Opioid Use, and Palliative Care of Older
Adults in the Emergency Department . . . . . . . . . . . 139 William P. Burns
9 Acute Mental Status Changes and Over-the-Counter Medications in Older Adults. . . . . . . . . . . . . . . . . . . . 157 Katherine M. Hunold
10 Identifying Fall Risk in the Emergency
Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Chirley M. Rodriguez
11 Capacity, Advanced Planning, and Buying Time . . . 185 Hashim Q. Zaidi
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209
Katherine Allen, PharmD Department of Pharmacy, Department of Emergency Medicine, Northwestern Medicine, Chicago, IL, USA
William P. Burns, MD Department of Emergency Medicine, University of Wisconsin, Madison, WI, USA
Division of Palliative Care, Department of Medicine, University of Wisconsin, Madison, WI, USA
Dwayne Dobschuetz, APRN, MSN Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern Medicine Home Care Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Scott M. Dresden, MD, MS Department of Emergency Medicine, Northwestern Medicine, Center for Healthcare Studies, Buehler Center for Health Policy and Economics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Fernanda Heitor, MD Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Northwestern Medical Group, Chicago, IL, USA
Jill M. Huded, MD Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
Katherine M. Hunold, MD Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
Lee A. Lindquist, MD, MPH, MBA Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Abbie Lyden, PharmD, BCPS Northwestern Medicine, Department of Pharmacy, Department of Emergency Medicine, Department of Pharmacy Practice, Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
Lucy Morse, BS, MD Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Paul A. Nelson, B. Arch Chicago, IL, USA
Katherine O’Brien, MD Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern Medicine Home Care Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Chirley M. Rodriguez, MD Allegheny General Hospital, Pittsburgh, PA, USA
Todd I. Smith, MD, FACP, FHM Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
Hashim Q. Zaidi, MD Department of Emergency Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
in the Emergency Department
Lee A. Lindquist and Paul A. Nelson
It has been said that the only constant is change. And with more time, comes more change. When you bring your new car in for its first oil change, you are not expecting any surprises. When that same car comes into the shop after 200,000 miles, you might find out about some other areas of concern. The human body is no different. When a person over the age of 65 comes into the emergency department, that individual will – more than likely – have a complex health history. This is complicated further by the changes that occur over time throughout the aging process. From top to bottom (head to foot), this chapter will present some common changes that accompany aging and should be expected when seeing an older adult in the emergency department.
L. A. Lindquist (*)
Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
P. A. Nelson Chicago, IL, USA
© Springer Nature Switzerland AG 2019 1 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_1
2 L. A. Lindquist and P. A. Nelson
A very common complaint to expect is “My hair is falling out.” After ruling out medical pathologic causes, such as hypothy- roidism, the conversation has to turn to “this may be normal.” Hair loss happens with time; not a big surprise, but why does it happen? Hair follicles spend more time in the latter parts of the cell cycle, telogen or resting phase, instead of the anagen or building phase, resulting in fewer new hairs being built and more older hairs falling out or becoming dormant . An inter- esting footnote is that hair also loses color and appears gray over time due to the loss and density of melanocytes, which are the cells that convey the color . This is also completely nor- mal and should be expected.
Another common complaint to expect is that of hearing loss. Hearing loss increases as people age. The prevalence of age- related hearing loss doubles with each decade of life, with two-thirds of older adults 70 years old and older with a clini- cally significant hearing loss, increasing to almost 90% of adults older than 80 years [3, 4]. Men are almost twice as likely to have hearing loss as females . When I begin to interview an older adult, I try to stand in front of them and use low-pitched tones. I do this because the higher-frequency tones are the first to be lost with age-related hearing loss. Hearing is even more difficult when there is background noise or multiple people nearby having discussions, like a typical emergency department. If the patient forgets their hearing aids, which can easily happen in an emergency, I will do what I call “flipping the stethoscope.” I will place my stethoscope into the ears of the patient and talk into the head or diaphragm. This way, the patient can hear you without needing to be screamed at by the examiner.
So why do older adults lose their hearing? Several changes occur over time in the ear:
Chapter 1. Growing Older in the Emergency Department 3
• The walls of the external ear canal become thinner.
• Thicker and longer hair follicles in the ear canal reach toward the tympanic membrane and do not sweep ceru-
men out as efficiently.
• Cerumen becomes drier, and both the number and activity
of cerumen glands decreases. This frequently translates into cerumen impactions, which can contribute to hearing loss .
Just as hearing decreases over time, so does vision. Specifically, there is decreased depth perception, contrast sensitivity, and acuity . So how does this translate in the emergency department? Writing instructions or printed material for older adult patients should have large font and high contrast (black and white) to make reading easier. Other changes to the eye include:
• Increase in visual threshold (the minimum amount of light needed to see an object) so rooms should be well lit
• Decrease in speed of light adaptation
• Increase in distance needed to focus near objects, due to
decrease in lens elasticity and ciliary muscle atrophy
• Decrease in number of photoreceptors
• Decrease in production of tears, so older adult patients
have drier eyes  Mouth
When people consider the oral health issues of an older adult, they might think of tooth loss, dental implants, and dentures. Tooth loss does occur with many older adult patients, so many people require softer food to eat in the emergency depart- ment. The mouth itself commonly becomes drier with age, as salivary glands experience fatty replacement and produce less saliva . To further complicate the dry mouth, many older
4 L. A. Lindquist and P. A. Nelson
adults take medications that cause dry mouth as a side effect. Together, this translates into providing foods that are moist and can be easily swallowed (e.g., mashed potatoes with gravy, applesauce). In addition, over the course of time:
• Dentition has increased thickness (and thus decreased pulp space).
• Dentition sensitivity has decreased.
• Smell and taste have decreased .
One of the main concerns/complaints of older adult patients is being constipated or not having regular bowel movements. Constipation becomes more common as people age for a number of reasons, such as medications, decreased mobility, and changes in diet. Yet the natural age-related changes of the GI tract unequivocally contribute. While the motility of the small intestine does not change with age, colon motility slows; meaning, it takes longer for stool to move through the colon. There are also decreased absorption rates of the GI tract. Older adults also tend to drink less water because their thirst mechanism diminishes, which causes the stool to become drier and harder. All of these factors result in hard, less frequent bowel movements which are the epitome of constipation concerns . While some older adult patients may hope for a daily bowel movement, we more commonly see them having one approximately every 3 days.
One Caveat with Constipation
It is imperative to ask older adults complaining of constipa- tion if they use any form of rectal suppository. Older adults who avidly use rectal suppositories are at risk of developing a “suppository plug”; the suppositories pile up in the rectum and may not melt sufficiently because of core body tempera- ture changes. As a result, the mass of unmelted suppositories
Chapter 1. Growing Older in the Emergency Department 5 can obstruct the rectum and cause constipation. This is usually
remedied by a digital rectal exam and manual dis-impaction.
Kidneys and Fluid Balance
As mentioned above, older adults commonly experience a decreased perception of thirst. This lack of thirst places older adults at an increased risk of volume depletion. When an older adult enters the emergency department for syncope, dehydration should be part of the differential diagnosis . Offering or “pushing” fluids to older adults while they wait is also important, as most older adults will not feel thirsty or ask for a drink . From a fluid balance standpoint, the follow- ing also occur with age:
• Impaired response to serum osmolarity
• Decreased ability to concentrate urine following fluid
• Decreased baroreceptor sensitivity
• Decrease in total body water
• Increased ADH secretion and an increased ADH response
to osmoreceptor stimuli  With Respect to the Kidneys
Renal function decreases after age 40, and serum magnesium decreases by about 15% between the third and eighth decade [15, 16]. These changes in renal function result in a decreased renal excretion of drugs, which is why many medications should be renally dosed in older adults.
Cardiac murmurs are common in adults over 80 years old. Every patient over 80 who has a murmur does not need an echocardiogram. It is important to ask the patient how long
6 L. A. Lindquist and P. A. Nelson
they have had the murmur. For older adults, the S4 sound is normal and very common. Cardiac output does not change with age. However, the following changes do occur with the heart over time:
• Myocyte hypertrophy
• Increased left ventricular stiffness and wall thickness
• Decreased left ventricular compliance and diastolic filling
• Decreased ability to increase heart rate in response to
sympathetic stimulation 
From the pulmonary standpoint, the following changes
occur with age:
• Decreased chest wall compliance.
• Decreased diaphragmatic strength.
• Decreased FEV1 (5–30 ml/year in non-smokers, 60–70 ml/
year in smokers).
• A-a gradient increases with age, while Pa O2 decreases .
As we age, our skin thins out and becomes more fragile. The superficial blood vessels supplying blood to the skin also decrease and become more fragile. We see this occur when an older adult bumps their calves or arms and hematomas appear under the skin. Other skin changes that come with age are:
• Epithelial layers of skin flatten.
• Interdigitations between the dermis and epidermis are
• Turnover of epidermal cells is slower, which translates to
slower wound healing and increased susceptibility to
• Decreased ground substance and decreased subcutane-
• Collagen fibers lose elasticity .
Chapter 1. Growing Older in the Emergency Department 7
Decreased bone mass occurs with age and is a key reason why older adults are more prone to bone fractures. Height loss is very common among older adults and should be considered normal. The arches of the feet tend to diminish over time, which contributes to the appearance of height loss. The spine also appears to be shorter, sometimes pathologically from osteoporosis and compression fractures, but also as the nucleus pulposus gel between the vertebrate bones harden and become less gel-like. Further changes in bone occur over time due to:
• Decreased vitamin D calciferol (1, 25 (OH2) D) levels
• Decreased uptake of calcium by the gastrointestinal tract
• Decreased vitamin D synthesis by the skin, as older adults
spend more time indoors and have decreased exposure to sunlight 
Falls happen frequently as people grow older and often result in emergency department visits. Typically, falls are multifacto- rial, caused by extrinsic (e.g., polypharmacy), environmental (e.g., poor lighting, loose carpets), and most notably intrinsic factors (e.g., balance loss, muscle weakness). Older adults face decreased muscle mass, decreased proprioception/sensi- tivity, and increased sarcopenia (decreased type 2 muscle fibers), which can all contribute to an increased fall risk. From
a gait perspective, older adults experience:
• Decreased stride length
• Broad-based strides with small steps
• Decreased arm swings
• Increased flexion of hips and knees
Muscle loss increases as older adults spend more time being sedentary. The age-related muscle and gait changes, in
8 L. A. Lindquist and P. A. Nelson
addition to sitting more, contribute to the risk of falls. To improve muscle tone and gait, older adults should be referred to physical therapy to work on strengthening muscles and improving balance.
Special attention must be paid to older adult patients during their time in the emergency department. Naturally occurring, age-related issues can create additional problems that may not be usual concerns in an emergency room set- ting. Hearing loss, decreased vision, and reduced fluid intake are all common effects of the aging process that can make communicating with older adult patients more difficult. Hair loss, tooth loss, and constipation are common com- plaints that are likely to come up in the conversation. Normal age-related decrease of bone mass, muscle mass, and skin thickness are more issues that older adults deal with. And the effects of time and age on both the cardiopul- monary system and renal function can make the trip to the emergency department even more stressful for older adults. With this understanding in hand, patients over the age of 65 can be better served during any future emergency depart- ment visit.
1. Oh JW, Kloepper J, Langan EA, et al. A guide to studying human hair follicle cycling in vivo. J Invest Dermatol. 2016;136(1): 34–44.
2. Jo SK, Lee JY, Lee Y, Kim CD, Lee J-H, Lee YH. Three streams for the mechanism of hair graying.Ann Dermatol.2018;30(4):397– 401. https://doi.org/10.5021/ad.2018.30.4.397.
3. Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. Arch Intern Med. 2011;171:1851–3.
4. Lin FR, Thorpe R, Gordon-Salant S, Ferrucci L. Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci. 2011;66:582–90.
5. Chou R, Dana T, Bougatsos C, Fleming C, Beil T. Screening adults aged 50 years or older for hearing loss: a review of the evidence for the U.S. preventive services task force. Ann Intern Med. 2011;154(5):347–55.
Chapter 1. Growing Older in the Emergency Department 9
6. Anderson RG, Meyerhoff WL. Otologic manifestations of aging. Otolaryngol Clin N Am. 1982;15(2):353–70.
7. Ko F, Vitale S, Chou C-F, Cotch MF, Saaddine J, Friedman DS. Prevalence of nonrefractive visual impairment in US adults and associated risk factors, 1999–2002 and 2005–2008. JAMA J Am Med Assoc. 2012;308(22):2361–8. https://doi.org/10.1001/ jama.2012.85685.
8. Chou C-F, Cotch MF, Vitale S, et al. Age-related eye diseases and visual impairment among U.S. adults. Am J Prev Med. 2013;45(1):29–35. https://doi.org/10.1016/j.amepre.2013.02.018.
9. Razak PA, Richard KMJ, Thankachan RP, Hafiz KAA, Kumar KN, Sameer KM. Geriatric oral health: a review article. J Int Oral Health JIOH. 2014;6(6):110–6.
10. Schiffman SS. Taste and smell losses in normal aging and disease. JAMA. 1997;278:1357–62.
11. De Giorgio R, Ruggeri E, Stanghellini V, Eusebi LH, Bazzoli F, Chiarioni G. Chronic constipation in the elderly: a primer for the gastroenterologist. BMC Gastroenterol. 2015;15:130.
12. Warren JL, Bacon WE, Harris T, McBean AM, Foley DJ, Phillips C. The burden and outcomes associated with dehydration among US elderly, 1991. Am J Public Health. 1994;84(8):1265–9.
13. Mathey MF, Siebelink E, de Graff, et al. Flavour enhance- ment of food improves dietary intake and nutritional status of elderly nursing home residents. J Gerontol A Biol Sci Med Sci. 2001;56:M200–M2005.
14. Cowen LE, Hodak SP, Verbalis JG. Age-associated abnor- malities of water homeostasis. Endocrinol Metab Clin N Am. 2013;42(2):349–70. https://doi.org/10.1016/j.ecl.2013.02.005.
15. Chang F, O’Hare A, Miao Y, Steinman MA. Use of renally inappropriate medications in older veterans: a national study. J Am Geriatr Soc. 2015;63(11):2290–7. https://doi.org/10.1111/ jgs.13790.
16. Hanlon JT, Aspinall SL, Semla TP, et al. Consensus guidelines for oral dosing of primarily renally cleared medications in older adults. J Am Geriatr Soc. 2009;57(2):335–40. https://doi. org/10.1111/j.1532-5415.2008.02098.x.
17. Malavolta M, Caraceni D, Olivieri F, Antonicelli R. New challenges of geriatric cardiology: from clinical to preclinical research. J Geriatr Cardiol JGC. 2017;14(4):223–32. https://doi. org/10.11909/j.issn.1671-5411.2017.04.005.
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joint NHLBI/NIA workshop. J Gerontol Ser A Biol Med Sci.
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of an Effective Geriatric Emergency Department Scott M. Dresden
The world population is aging. By 2050 the population of elderly people – defined as age 60 and older by the World Health Organization (WHO) – is estimated to nearly double from 12% to 22% worldwide . To help address this older population’s health needs, the WHO recognizes that health sys- tems need to be better organized around older people’s needs and preferences, designed to enhance older people’s intrinsic capacity, and integrated across settings and care providers. Actions in this area needed to strengthen access to health care and people-centered and integrated health services.
One particular site of care which requires improvement to provide people-centered care and integrated health services for older adults is the emergency department (ED). For decades, researchers, clinicians, and policymakers have been lamenting the increasing and perceived inappropriate use of the ED [2, 3]. Despite multiple of attempts at decreasing ED
S. M. Dresden (*)
Department of Emergency Medicine, Northwestern Medicine, Center for Healthcare Studies, Buehler Center for Health Policy and Economics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
© Springer Nature Switzerland AG 2019 11 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_2
12 S. M. Dresden
use, visits to the ED continue to climb . Older adults use the ED more than any other age group, at a rate of nearly one visit per two people in the United States . In 2010, older adults had nearly 20 million ED visits in the United States, accounting for 15% of all ED visits . Once in the ED, older adults have longer stays, receive a greater number of diagnos- tic tests, are more likely to be hospitalized, and have higher charges than younger patients . Not only do these increas- ing visits by older adults put pressure on already overcrowded EDs, but they expose older adults to fragmented care and increased risk of adverse outcomes such as functional decline.
The role of the ED in the health-care system is changing at the same time the population is aging. EDs serve as a hub for prehospital emergency medical systems, an acute diagnostic and treatment center, a health-care safety net, and an always open portal for rapid inpatient admission . The US health- care system is increasingly reliant on the ED for outpatient acute care visits and hospitalizations. The ED is the most common site for acute care outpatient visits in the United States and accounts for over half of all inpatient hospitaliza- tions . The reasons for the increased role of the ED are likely multifactorial, particularly for older adults. Patients have come to rely on the ED as an accessible way to quickly alleviate symptoms, obtain advanced diagnostic procedures, seek reassurance, or initiate treatment. Additionally, access to outpatient care has become more difficult as availability of primary care clinicians and geriatricians has not kept up with the aging population. The growing volume of ED visits by older adults can be viewed as a failure of health-care systems, a problem in need of a solution, or an opportunity to provide accessible, integrated, people-centered care for older adults. The objective of this chapter and the rest of the book which follows is to describe and to demonstrate how an effective geriatric emergency department can reach this high ideal for acute care for older adults.
The ED has the potential to be a site of accessible, inte- grated, and people-centered health services for older adults. This seems counterintuitive because of the many limitations
Chapter 2. Components of an Effective Geriatric… 13
of ED care. Care in the ED focuses on immediate problems and centers on rapid evaluation and stabilization. For older adults, the immediate problem is often the result of persis- tent, unmet, health-related needs, which may be related to impaired functional status, multi-morbidity, lack of social support, cognitive impairment, or depression [10–13]. These needs often go unaddressed, leaving older adults at increased risk for subsequent adverse events including repeat ED vis- its, hospitalization, nursing home admissions, or death after discharge from the ED [6, 10–12, 14, 15]. When clinicians fail to recognize health-related needs, a common management strategy of many ED physicians is to recommend hospital admission for multidisciplinary, ancillary services evaluation and treatment including physical therapy, occupational therapy, social work, pain management, and caregiver reas- surance and respite. These potentially preventable hospital- izations are costly and expose patients to risks such as delirium, falls, and nosocomial infections [16–20]. Many of these patients may be better cared for outside of the hospi- tal. In order to care for these patients safely in the outpa- tient setting, additional geriatric assessment and care coordination are needed prior to discharge from the ED. EDs often lack the resources and expertise necessary to provide geriatric assessment and care coordination services. However, the ED has enormous potential for improvement in this regard.
The ED has significant potential to improve person- centered care for older adults because it sits at a crossroads between inpatient and outpatient care . This unique set- ting provides opportunities to serve as a base for assessment, treatment, and care coordination for older adults with acute illnesses and injuries. In order to realize the potential for improvement in the acute care of older adults, policies, guide- lines, and accreditations have been developed to improve emergency care across the world [22–24]. One set of guide- lines which will serve as the basis for much of the discussion to follow are the Geriatric Emergency Department (GED) Guidelines published in 2014 and endorsed by the American
14 S. M. Dresden
College of Emergency Physicians, the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine .
Geriatric Emergency Department Multidisciplinary Team
Because of multiple competing priorities in the ED, it is not always feasible to train all emergency physicians, nurses, and other clinicians with specialty knowledge and skills necessary to effectively care for older adults in the ED. Instead, a mul- tidisciplinary team can provide complementary expertise to help address older adults’ unique special care needs such as cognitive impairment, falls, depression, functional impair- ment, depression, sensory impairment, and polypharmacy. In 2012, members of an international panel of geriatric emer- gency care endorsed ED staffing modifications for a GED . The panel had high levels of endorsement for the avail- ability of specialized nurses (85%), pharmacists (74%), social workers (88%), geriatric consultants (79%), and a designated professional, such as a transitional care nurse (TCN) to coor- dinate geriatric services (91%) [27, 28]. There were moderate levels of endorsement for the availability of physical therapy (59%) and occupational therapy (53%). The specific roles of these clinicians may vary by site, but their complementary skills can help to perform the varied assessments, modifica- tions, and care coordination described below.
Identifying Patients Who Benefit from Additional Services
In order for this multidisciplinary team to improve care for older adults, they must first identify patients who are at higher risk for poor outcomes. Not all older adults are at risk for geriatric syndromes. A 65-year-old man who works as an executive at a large corporation, has no medical problems,
Chapter 2. Components of an Effective Geriatric… 15
and is in the ED with a minor injury such as a laceration to his hand is unlikely to need additional assistance. Routine emergency care is warranted. Conversely, a 95-year-old woman with mild dementia who lives alone, has difficulty making it to her doctors’ appointments, and is in the emer- gency department after a fall down her stairs clearly needs additional assistance. In reality many patients fall in between these two scenarios, and identifying patients who will benefit from additional geriatric assessment and care coordination is often difficult but very important. In one Canadian study, approximately 30% of older adults in the ED had decline in functional status or death in the subsequent 4 months . An Australian study demonstrated that 22% of older adults were hospitalized without ED intervention . A multi-site American study had higher rates (35–44%) of hospitaliza- tions . With ED-based interventions, however, functional decline was decreased in the Canadian study, and hospital admissions were decreased in the Australian and American studies. These studies demonstrate the potential for ED-based intervention; however, the difficulty lies in identifying those older patients in the ED who are well enough to be dis- charged safely but have enough care needs to benefit from additional interventions. To help identify these patients who will most benefit from additional GED care, screening or care protocols should be developed.
The GED guidelines recommend that all older adults be screened for “high-risk features” and those at risk are referred to inpatient or outpatient services to help improve overall health and functional outcomes. Possible screening tests include the Identification of Seniors at Risk (ISAR) score  or the triage risk screening tool (TRST) . Though these tools have not been shown to have good prognostic accuracy, they can help ED teams focus their efforts and identify patients with modifiable risk factors such as polypharmacy or functional dependence. Instead of relying on a screening test to identify patients who may benefit from GED care, ED-wide protocols on priority geriatric conditions such as falls or polypharmacy may
16 S. M. Dresden
allow the clinicians to use clinical gestalt to help assist in identifying patients who would benefit from GED care. Alternatively, if resources allow, all patients above an age cutoff could be automatically identified as needing GED care. This approach was used in the Australian DEED II study which used an age cutoff of 75 and demonstrated bet- ter maintenance of physical and mental function for 6 months after an ED visit .
Assessments, Interventions, and Care Coordination
Once appropriate patients are identified. Validated assess- ments should be performed to identify common geriatric syndromes. The protocol for performing these assessments may vary by hospital. Some EDs have used a dedicated pro- fessional called a transitional care nurse (TCN) to conduct assessments and care coordination. TCNs are ED nurses or nurse practitioners with dedicated education and training in geriatrics . They have dedicated shifts where they are not responsible for primary ED care but are available as an extra resource in the ED for older adults. They perform a battery of assessments and conduct care coordination measures such as consulting other members of the multidisciplinary GED team, primary care physicians, inpatient or outpatient clinicians, and other members of the patient’s care team. The TCN model was developed to address the unique and chal- lenging clinical environment of the ED. It is a fast-paced, sometimes chaotic environment with frequent interruptions and sees a wide variety of patients from the worried well to the critically ill. The TCN model capitalizes on the experience of ED nurses who are comfortable and thrive in this environ- ment and provides them with the expertise, to identify and address geriatric-specific needs that frequently go unnoticed or unaddressed in typical EDs. Though they are still relatively new, TCN programs have been shown to decrease hospital- izations for up to 30 days after an ED visit .
Chapter 2. Components of an Effective Geriatric… 17
Other models of geriatric assessment in the ED include the geriatrics consult model or the multidisciplinary availability model. The geriatrics consult model uses the best experts in geriatrics in the hospital, geriatricians, to perform comprehen- sive geriatric assessment in the ED . However, many hospi- tals do not have geriatrics consult services available, and those that do are often stretched thin already . This model depends on strong relationships between the geriatric service and the ED and relies on hospital departments outside of the ED to provide personnel and sustainability. Additionally, the time pressures of the ED may limit the practicality of this model for many EDs as ED length of stay is increasingly scrutinized.
The multidisciplinary availability model creates services which are available to the ED, such as pharmacy, social work, and physical therapy, but it depends on the primary ED team to identify the most appropriate clinician to assist with evalu- ation. This model may be best used for patients with easily identifiable geriatric syndromes, such as falls. For example, physical therapists may be available to perform assessments on older adults in the ED after a fall . This model requires more active screening and involvement of the primary ED team to identify the appropriate clinicians to assist with patient needs than the TCN model or the geriatrics consult model. It is likely most appropriate for focused, easily identi- fiable geriatric syndromes, but complex and subtle cases may be missed by the primary ED team if there are no compre- hensive education and protocols detailing appropriate use of assessments for geriatric syndromes.
Regardless of which model is used, it is important to iden- tify which patients are at risk for negative outcomes. Assessments generally focus on geriatric syndromes which are commonly found in the ED, present a high risk of poor outcome, and may be actionable. Commonly identified risks include medication risk, falls, functional decline, delirium, dementia, elder abuse, and palliative care needs. They should be considered for inclusion in GED care protocols.
18 S. M. Dresden
Adverse drug events (ADEs) are common and problematic for older adults; they may be reduced by more accurate medi- cation lists, better patient-clinician communication, and better understanding of potentially inappropriate medications. From 2004 to 2014, ED visits by older adults with ADEs increased from to 200,000 to 450,000 ED visits in the United States annually [36, 37]. Many of these ADEs are preventable . Common preventable causes of ADEs are use of inappropri- ate drugs, ignoring clinical or laboratory results, inadequate monitoring, inappropriate dose or frequency, and inadequate patient education and patient non-compliance .
Polypharmacy, generally defined as taking six or more medi- cations, is common among older adults and is associated with adverse health outcomes . Less than half of patients are familiar with their medications or have a medication list with them, and discrepancies in medication lists are common [41–43]. This presents the possibility of inaccurate information for pre- scribers, which may lead to unknown drug-drug interactions when starting patients on new medications in the ED. Because of the potential dangers of ADEs for older adults, particularly those with polypharmacy, patients who are found to have polyphar- macy likely will benefit from formal medication reconciliation.
Medication reconciliation can be performed by a pharma- cist, TCN, physician, or nurse. It is important to have clear expectations as to who will be performing which tasks regard- ing medication reconciliation to prevent skipped or redun- dant steps. According to the Joint Commission, medication reconciliation is the process of comparing a patient’s medica- tion orders to all of the medications that the patient has been taking . This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, ser- vice, practitioner, or level of care. This process comprises five steps: (1) develop a list of current medications, (2) develop a
Chapter 2. Components of an Effective Geriatric… 19
list of medications to be prescribed, (3) compare the medica- tions on the two lists, (4) make clinical decisions based on the comparison, and (5) communicate the new list to appropriate caregivers and to the patient.
In addition to polypharmacy, older adults are more sus- ceptible to ADEs from individual medications. Physiologic, pharmacodynamic, and pharmacokinetic changes with age impact the therapeutic window for medications for older adults and make older adults more susceptible to ADEs . To address increased susceptibility to ADEs, the American Geriatrics Society publishes the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults . The Beers Criteria present a set list of medications that can be easily and rapidly applied when making clinical decisions. Common potentially inappropriate medications used in the ED include anticholinergics, anticoagulants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDs). The 2015 Beers Criteria are divided into several sections, which include lists of (1) potential inappropriate medications to avoid for many or most older adults, (2) medications for older adults with specific diseases or syndromes to avoid, and (3) medications to be used with caution. Published data have found an association between the use of medications on the Beers list and adverse outcomes including higher costs, increased ED visits, hospitalizations, and death [47, 48].
As part of a medication screen in a GED, medications which appear on the Beers Criteria should be flagged. The risks of the flagged medication should be considered against the possible benefits, and a conversation about possible deprescribing should commence between the ED team and the patient’s outpatient medical care team. It may not be possible to avoid all high-risk medications. Continuity with inpatient and outpatient clinicians is essential. In addition to flagging outpatient medications, clinicians in the GED should feel empowered to discuss potentially inappropriate use of medications in the ED and upon discharge from the ED. Common potentially inappropriate medications used in the ED include anticholinergics, anticoagulants, benzodiaz-
20 S. M. Dresden
epines, and nonsteroidal anti-inflammatory drugs (NSAIDs). If these medications are ordered or prescribed, discussion about the risks, benefits, and alternatives should be had between the ordering team and the GED team.
The CDC estimates that more than one out of four adults 65 years and older fall each year, and 2.8 million of these older adults are treated in the ED for fall-related injuries . Identification of risk factors for falls in older adults can have important implications on patients’ long-term quality of life . Sometimes these risk factors are apparent and related to the chief complaint. But often they are subtler and may even be actively concealed by the patient.
In order to identify patients who would most benefit from fall risk interventions, screening tests for geriatric ED patients at risk of falling have been developed. The Carpenter score and the Tiedemann score were each developed in older adult ED patients [51, 52]. Of the two scores, the Carpenter score appears to be most effective in identifying patients who are at low risk for fall in the next 6 months. Both are included in a later chapter in this book.
In addition to the Carpenter and Tiedemann screens, the CDC developed the Stopping Elderly Accidents, Deaths & Injuries (STEADI) program. STEADI uses a 12-item screen- ing test to identify patients at risk of falling. This test takes approximately 15 min to administer  and combines the approach of risk factor assessment with functional assess- ment. Few ED studies have assessed predictors of future falls or interventions to reduce fall risk, and the existing studies show poor prognostic accuracy for the 6 months following an ED visit . If a patient is high risk by the screening, a func- tional assessment is recommended. Potential functional assessments include the Timed Up and Go (TUG) test, the 30-s chair stand test, and the four-stage balance test. Patients who are at high risk for falls by screening, functional assess-
Chapter 2. Components of an Effective Geriatric… 21
ment, or both should be referred to physical therapy for fur- ther evaluation and rehabilitation. Ideally, this referral can be initiated in the ED. However, depending on local resources and individual safety concerns, it may need to happen in the inpatient or outpatient settings.
Functional decline is defined as “a decrement in physical func- tion, cognitive function, or both” . It is one of the most common and serious clinical problems for older adults and is often measured by a reduction in ability to perform self-care activities of daily living (ADLs) [56, 57]. Functional decline has major impacts on patients’ ability to live independently in the community. Screening for functional decline in the ED is important as dependence on one or more ADLs at the time of an ED visit is associated with increased risk of nursing home placement over the next year . Additionally, functional decline is associated with increased mortality, increased need for rehabilitation and home care services, and greater health- care expenditures. ADLs as defined by Katz et al. include bathing, dressing, toileting, transferring, continence, and feed- ing. Patients who require supervision, direction, personal assistance, or total care are considered dependent for that ADL. Identifying functional decline can prompt a social work consult who may be able to assist with home care resources or nursing home placement if necessary .
Delirium, an acute decline in attention and cognition, is a common problem for older adults in the ED, occurring in approximately 10% of older adults in the ED and 14–56% of hospitalized older adults [60–62]. Though in the past, delirium has been minimized as an expected part of aging, it is a seri- ous form of organ (brain) dysfunction and can accurately be
22 S. M. Dresden
called “acute brain failure” . ED patients with delirium are over 2.5 times more likely to die in the next 6 months as those who don’t have delirium . Delirium is also associ- ated with poor patient and hospital outcomes including last- ing functional decline, nursing home placement, extended hospital length of stay, increased need for restraints, and added staffing . Fortunately, detection of delirium in the ED dramatically decreases the risk of death at 6 months and 18 months after an ED visit .
Delirium is not a normal consequence of aging; rather it is an acute brain failure. It is common, occurring in 10% of geri- atric ED patients, and is a major threat to their quality of life . Delirium is associated with higher death rates, pro- longed hospitalization, increased health-care costs, and accel- erated long-term functional and cognitive impairment [65, 67–69]. The effects of delirium are most severe when delirium is undetected . Therefore, it is concerning that delirium is frequently missed by emergency physicians (EPs) in 57–83% of cases .
Though commonly thought of in the hyperactive or agi- tated form which is characterized by increased psychomotor activity, anxiety, and agitation, delirium can also be hypoac- tive (quiet) or mixed . Hypoactive delirium is character- ized by decreased psychomotor activity and has the appearance of depression and sedation. This subtype is most often missed by physicians and can be difficult to identify without a delirium assessment because of its subtle presen- tation . A patient with mixed-type delirium exhibits fluctuating levels of psychomotor activity over a period of time.
It is important to have a consistent protocol to screen geri- atric patients in the ED so that hypoactive and mixed delir- ium is not missed. The Delirium Triage Screen (DTS), brief Confusion Assessment Method (bCAM), and the DTS fol- lowed by the bCAM all are quick assessments and with good sensitivity and specificity for identifying delirium . The DTS is the highly sensitive, and the bCAM is highly spe- cific. Combining the DTS with the bCAM if the DTS is posi- tive provides high sensitivity and specificity (Fig. 2.1). After identifying delirium, it is important to begin to look for its
0 or 1 error
ED-DTS Negative No Delirium
Components of an Effective Geriatric… 23 Step 1: Delirium Triage Screen
Rule-out Screen: Highly Sensitive
Altered Level of Consciousness RASS
DTS Positive Confirm with bCAM
“Can you spell the word ‘LUNCH’ backwards?”
Step 2: Brief Confusion Assessment Method
Confirmation: Highly Specific
Feature 1 – Altered Mental Status or Fluctuating Course
> 1 errors
0 or 1 errors
bCAM Negative No Delirium
bCAM Negative No Delirium
bCAM POSITIVE DELIRIUM PRESENT
bCAM Negative No Delirium
Feature 2 – Inattention
“Can you name the months backwards from December to July?”
Feature 3 – Altered Level of Consciousness? RASS
Feature 4 – Disorganized Thinking
1) Will a stone float on water?
2) Are there fish in the sea?
3) Does one pound weigh more than two
4) Can you use a hammer to pound a nail?
Command: “Hold up this many fingers” (Hold up two fingers). “Now do the same thing with the other hand” (Do not demonstrate).
Figure 2.1 Delirium triage screen followed by brief confusion assessment method. (Han et al. . Reproduced with permission)
24 S. M. Dresden
cause. Oftentimes, the evaluation and treatment of delirium require hospitalization.
Common causes of delirium that should be evaluated for include:
• Infections – most commonly urinary tract infections (UTI) or pneumonia.
• Anticholinergic medications.
• Any new medication, especially if multiple medications
have been recently added.
• Electrolyte imbalances.
• Alcohol/drug use or withdrawal.
• New focal neurologic findings should guide an evaluation
for stroke syndromes.
Of the 20 million ED visits each year by older adults, between 20% and 40% of those were by persons with dementia, who use the ED at a higher rate than persons of similar age with- out dementia . Many ED-based cognitive impairment and general adverse outcome screening tools have been devel- oped [75–77]. The accepted criterion standard (“gold stan- dard”) is the Mini-Mental State Exam (MMSE) where a cutoff score <23 out of 30 has been widely accepted as an indication of cognitive dysfunction. However, the MMSE takes time and is not practical as an ED cognitive screen, with studies suggesting its implementation would miss 70% of patients .
More appropriate for the ED, the Short Blessed Test (SBT) is a six-item screening test that takes <10 min to administer and is graded from 0 to 12 (normal 0–4; question- able 5–9; impaired 10–12) and has high sensitivity and speci- ficity . The Ottawa 3DY (O3DY) is a four-item screen where one or more errors indicate impairment and has a
Chapter 2. Components of an Effective Geriatric… 25
sensitivity of 95% . Other cognitive screens such as the Brief Alzheimer’s Screen and the Montreal Cognitive Assessment (MoCA) have both been suggested as potential ED cognitive screens, but neither have been validated in large ED patient populations.
Ottawa 3DY screen for cognitive impairment :
• What is the day?
• What is the date?
• What year is it?
• Spell “world” backward.
Once dementia is identified in the ED, coordinating care becomes extremely important. Because care for patients with dementia overlaps geriatrics and neurology, resources in any given area may differ. Additionally, specialized clinics such as the Alzheimer’s Disease Research Centers funded by the National Institute on Aging often require definitive imaging and cerebrospinal fluid analysis prior to a clinic visit. It is not necessary nor practical for these tests to be performed in the ED, so oftentimes coordination with the patient’s primary care physician for definitive testing is necessary.
Elder abuse is defined as “Intentional actions that cause harm or a serious risk of harm to a vulnerable elder by a caregiver or person who stands in a trust relationship with the elder, or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” Each year approxi- mately 4% of all older adults (approximately 1.2 million older adults) are known to be abused or neglected in the United States . This number is likely a gross underestimate as only 20% of cases of elder abuse cases are reported. Elders who are ill, frail, disabled, mentally impaired, or depressed are at greater risk of abuse, but those who do not have these obvious risk factors can also find themselves in abusive situ- ations and relationships .
26 S. M. Dresden
Fewer than 5% of cases of abuse or neglect are identified and reported to authorities, and these delays in intervention may lead to increased morbidity and mortality . In the ED, elder abuse frequently goes undetected . It is not clear why elder abuse detection in the ED is so low, but it may be related to lack of formal training in identifying signs of abuse, uncer- tainty about the appropriate steps to take after identification, and doubts about the effectiveness of interventions .
Elder abuse can occur in multiple forms including :
• Physical abuse – inflicting, or threatening to inflict, physi- cal pain or injury on a vulnerable elder or depriving them of a basic need
• Emotional abuse – inflicting mental pain, anguish, or dis- tress on an elder person through verbal or nonverbal acts
• Sexual abuse – non-consensual sexual contact of any kind and coercing an elder to witness sexual behaviors
• Exploitation – illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder
• Neglect – refusal or failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder
• Abandonment – the desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person
Although extreme cases may be apparent during routine ED assessment, most cases are subtle and present with non- specific signs. Victims may be either unable or unwilling to report the problem. Differentiating between unintentional and intentional injuries and between illnesses that occurred despite appropriate care or because of neglect often requires collecting detailed information from multiple sources, which takes time .
Identifying elder abuse can be assisted by using standard- ized screening questions. The American Medical Association screening questions for abuse or the Elder Abuse Suspicion Index can be used to help identify elder abuse in the ED [81, 86]. Sensitivity and specificity of these screens are subopti-
Chapter 2. Components of an Effective Geriatric… 27
mal; however, they may provide some structure and context to allow for evaluation of possible elder abuse .
Elder Abuse Suspicion Index :
1. Have you relied on people for any of the following: bath- ing, dressing, shopping, banking, or meals?
2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids, or medical care or from being with people you wanted to be with?
3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
4. Has anyone tried to force you to sign papers or to use your money against your will?
5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
6. Doctor: Elder abuse may be associated with findings such as poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?
The patient can answer “yes,” “no,” or “unsure.” A response
of “yes” on one or more of questions 2 through 6 should prompt concern for abuse or neglect.
When elder abuse is identified or reasonably suspected, members of the health-care team are mandated to file a report in most US states . Generally, reports are filed through Adult Protective Services (APS), which are govern- ment agencies responsible for receiving and investigating elder abuse reports. In many EDs, social work acts as a liaison between the primary care team and APS. However, if social work is not available, the treating clinicians can and should file a report on their own.
Palliative Care Needs
According to the World Health Organization, palliative care is “an approach that improves the quality of life of
28 S. M. Dresden
patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Palliative care :
• Provides relief from pain and other distressing symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten nor postpone death
• Integrates the psychological and spiritual aspects of patient
• Offers a support system to help patients live as actively as
possible until death
• Offers a support system to help the family cope during the
patient’s illness and in their own bereavement
• Uses a team approach to address the needs of patients and their families, including bereavement counseling, if
• Will enhance quality of life and may also positively influ-
ence the course of illness
• Is applicable early in the course of illness, in conjunction
with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications
The ED is starting to be recognized as a potential source for palliative care. Identifying and addressing patients’ pallia- tive care needs in the ED can relieve suffering and change the care trajectory for patients with severe or terminal chronic diseases such as dementia, heart failure, chronic obstructive pulmonary disease, stroke, or cancer. Early use of palliative care has been shown to promote quality of life, as well as reduce costs associated with treatments [90–92]. Models of palliative in the ED most frequently focus on identifying patients with palliative care needs and helping to expedite palliative care consultation [93, 94]. This model of ED-based palliative care consultation has been shown to improve qual- ity of life in patients with advanced cancer without detrimen- tal effect on 1-year survival . It is likely that this model can
Chapter 2. Components of an Effective Geriatric… 29
be applied to other serious and terminal diseases such as dementia, heart disease, and chronic obstructive pulmonary disease.
Depending on availability within a health system, ED-based palliative care consultation or referral may be able to address the following common palliative care concerns:
• Uncontrolled pain or other symptoms in patients with life- limiting illnesses
• Complex goals of care
• Hospice placement
• Outpatient palliative care referral
In addition to referral to palliative care, palliative care needs can be directly addressed in the ED. Common palliative care needs for patients in the ED include pain, difficulty with medications, feeling overwhelmed, home care needs, and aligning care with patient goals. In the following chapters, we will discuss further treatment of malignant pain in the ED and goals of care discussions in the ED, as these are two of the most common palliative care needs that can be addressed directly in the ED.
Approach to Palliative Care in the ED
For clinicians in the ED, a simple approach to palliative care can be helpful to ensure that emergency clinicians address the most time-sensitive and impactful aspects of end-of-life care during an ED visit. One such method is the “ABCD” method from the Education in Palliative and End-of-Life Care for Emergency Medicine (EPEC-EM) curriculum :
• A (advance care plan) – Is an advance care plan available to review?
• B (better symptoms) – Can symptoms such as dyspnea or pain be better controlled?
• C (caregivers) – Are the patient’s clinical context and recent functional changes discussed with caregivers?
• D (decision-making) – Does the patient have decision- making capacity, or is the legal surrogate identified and accessible?
30 S. M. Dresden
After addressing these important aspects of care, treatment decisions which better align with patients’ wishes can be made with patients and their caregivers, whether those wishes are entirely for life-sustaining treatment, entirely for comfort care, or commonly a blend of life-sustaining treatment and consid- eration of physical, psychosocial, and spiritual comfort.
This overview highlights the multifaceted needs of older adults which have not traditionally been addressed in the ED. This is not a comprehensive list of ways to better care for older adults in the ED, and there are many models for how this person- centered care can be delivered to older adults with acute care needs. Improving care for older adults in these domains depends on increased education of emergency clinicians and reliance on a multidisciplinary team. Guidelines such as the Geriatric Emergency Department Guidelines go into detail on how to implement teams and processes to address these common needs of older adults. Rather than going into detail on how to implement these processes, the following chapters in this book will discuss illustrative cases which highlight the needs of older adults in the ED and strategies to address those needs. Based on hospital and local resources, the teams and protocols in a given geriatric ED will vary; however, the focus always should be on providing high-quality, accessible, integrated, people-centered health services for older adults. When this goal is achieved, patients will benefit from fewer hospitalizations, falls, adverse drug events, delirium, and func- tional decline and better overall quality of life.
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65. Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on sur- vival. J Am Geriatr Soc. 2003;51(4):443–50.
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67. McCusker J, Cole MG, Dendukuri N, Belzile E. Does delirium increase hospital stay? J Am Geriatr Soc. 2003;51(11):1539–46.
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Cognitive Impairment in the ED
Jill M. Huded and Todd I. Smith
ACE Acute care for elders
AD8 Alzheimer’s disease-8
ADL Activity of daily living
AGS American Geriatrics Society
BAS Brief Alzheimer Screen
bCAM Brief Confusion Assessment Method CAM Confusion assessment method
DLB Dementia with Lewy bodies
DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
ED Emergency department
EQUiPPED Enhancing quality of prescribing practices for
older veterans discharged from the emer-
FTD Frontotemporal dementia
GNL Geriatric nurse liaison
J. M. Huded (*) · T. I. Smith
Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
© Springer Nature Switzerland AG 2019 39 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_3
40 J. M. Huded and T. I. Smith
GRACE Geriatric Resources for Assessment and Care of Elders
HBPC Home-based primary care
HELp Hospital Elder Life Program
MMSE Mini-mental state examination
MoCA Montreal cognitive assessment
O3DY Ottawa 3 day-year
OMCT Orientation-memory-concentration test PIM Potentially inappropriate medication
QCS Quick confusion scale
SAEM Society of Academic Emergency Medicine SBT Short blessed test
SIS Six-item screener
Mr. C is a 72-year-old veteran with a history of depres- sion, atrial fibrillation, stage 2 chronic kidney disease, prior tobacco use, and cognitive impairment who is brought to the emergency department (ED) by his wife for weight loss and leg swelling. She provides much of the history, reporting that he has lost 20–25 lbs over the prior 6 months. His appetite is poor, and several months ago he developed progressive bilateral ankle swelling not associated with trauma, pain, or warmth. He has not displayed cardiopulmonary symptoms. On examination, the patient appears older than his stated age with evi- dence of temporal wasting. No cardiac murmurs or pulmonary crackles are present. Symmetric 1+ bilateral lower extremity edema to the mid-shins is noted. He is cooperative and can follow commands, however looks to his wife when asked questions. Complete blood count and renal function panel are unremarkable other than low serum albumin at 3.1 g/dL. Chest X-ray shows sta- ble hyperinflation.
Chapter 3. Cognitive Impairment in the ED 41 Geriatric ED Evaluation
Upon completion of examination by the ED clinician, the patient and wife are greeted by the geriatric nurse liaison (GNL). The GNL obtains additional history from the veter- an’s wife, learning out that he was diagnosed several years ago with early-onset dementia. Prior to this diagnosis, he was an active community leader and respected reverend who recently was forced to step down from preaching after repeated confu- sion while giving Sunday sermons. He no longer drives after getting lost while driving in their neighborhood. His wife must now assist with his self-care needs, medications, and doctor’s appointments, making it difficult for her to continue volun- teering or attending to her own health needs. No longer does the couple have a flourishing work and social calendar, as their daily schedules now revolve around Mr. C’s eating, bath- ing, dressing, and medication needs.
The GNL performs geriatric screens for delirium, func- tional status, fall risk, and caregiver burden. The Brief Confusion Assessment Method (bCAM) is used to assess for delirium. Mr. C displays inattention and disorganized thinking, and his wife reports new sluggishness over the last week since his haloperidol dose was increased. Because he qualifies for delirium by criteria of the bCAM, screening for dementia is deferred. Katz Activities of Daily Living (ADLs) are used to assess functional status. He requires assistance with bathing, dressing, toileting, transferring, continence, and feeding, therefore scores 0 out of 6 points and is unable to perform ADLs without the assistance of others. Formal gait assessment is deferred as the patient required two nursing assistance to transfer from his wheelchair to the ED bed. He uses a cane at baseline and has had two falls in the prior 6 months at home. Caregiver burden assessment via the Modified Caregiver Strain Index is completed by his wife. She scores 24 out of 26 points, suggesting a high level of caregiver burden. Lastly, his medications are reviewed by the ED pharmacist. Notable medications include donepezil 5 mg
42 J. M. Huded and T. I. Smith
nightly, haloperidol 2 mg scheduled three times daily with an additional 2 mg dose as needed, trihexyphenidyl 25 mg every morning, and stool softeners.
Discussion of Findings
This case demonstrates several geriatric syndromes frequently encountered in the ED: delirium superimposed on baseline dementia, functional dependency, falls, frailty, polypharmacy, and caregiver burden. The patient’s tenuous status to remain at home could go unrecognized if the ED evaluation is focused solely on the chief complaints of weight loss and lower extrem- ity swelling, highlighting the importance of specialized acute care of the older adult. We will focus specifically on dementia and delirium screening and interventions in this chapter, given the prevalence of cognitive impairment in the acute care set- ting and the priority of older adults to remain “mentally sharp” . The Society of Academic Emergency Medicine (SAEM) Geriatrics Task Force recognized the prevalence of cogni- tive impairment and importance of mental status screening in the ED in its Geriatric Emergency Care Model. Later, in 2014, recommendations for staffing, environmental modifica- tions, screening, policies, and outcome measures for dementia and delirium were published in the Geriatric Emergency Department Guidelines . Both sets of guidelines acknowl- edge the complexity of older adults’ medical needs, the impact of cognitive impairment on ED presentation and overall functional decline, and the importance of sensitive and quick screening tools for delirium and dementia.
Diagnostic criteria for delirium, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Chapter 3. Cognitive Impairment in the ED 43
(DSM-5), include an acute and frequently fluctuating distur- bance in attention along with a change in cognition (such as memory deficit, language disturbance, disorientation, percep- tual disturbance) . Up to 25% of hospitalized older adults may experience delirium [4, 5] with an estimated prevalence of 7–17% upon presentation to the ED.  Up to 70% of delirium cases go undetected by clinicians in the ED, inpa- tient, and community settings. Nearly a quarter of these patients will be discharged home from the ED [7–9], putting them at risk for medication noncompliance and poor post- acute care follow-up. Hospital mortality rates in patients with delirium rival those of sepsis and acute myocardial infarction. Standard screening tools for delirium are recommended given its association with functional decline, increased risk of pro- longed hospitalization and mortality, and healthcare expendi- tures . Even if triggers for delirium are identified and targeted, delirium may persist for several weeks to months.
Delirium Forms and Features
The cardinal features of delirium are acuity of onset and inat- tention. Typically, the onset of delirium occurs over hours to days. Because changes in mental status often wax and wane in delirium, patients may present to the ED during a period of relative lucidity, making it crucial to obtain collateral infor- mation from friends and family. Inattention is displayed as difficulty following a conversation, easy distraction, or perse- veration. It can be assessed through repetition tasks, months of the year or days of the week recited backwards, or digit spans. Level of consciousness is commonly impaired, ranging from somnolence or lethargy to hyperalert; however, a change in consciousness is not required to diagnose delirium. Lastly, patients may have disorganized thinking, displayed as hallucinations, delusions, disjointed speech, or abnormal thought processes.
Delirium may present as hypoactive, hyperactive, or mixed forms, with hypoactive delirium having the worst prognosis.
44 J. M. Huded and T. I. Smith
The restlessness, agitation, vigilance, and hallucinations (typi- cally visual) of hyperactive delirium make this form more easily recognizable by healthcare providers. Patients may switch back and forth between hyperactive and hypoactive delirium in the mixed form.
The foundation of the evaluation of delirium is a thorough history to determine if the patient’s mental status is a change from baseline and the acuity of changes. An accurate history will also determine potential causes, guiding the treatment plan. A widely adopted bedside diagnostic tool used to iden- tify delirium is the Confusion Assessment Method (CAM) . Its high sensitivity (94–100%) and specificity (90–95%), along with variations tailored for unique settings, have facilitated its widespread clinical use. The Brief Confusion Assessment Method (bCAM)  is recommended by the Geriatric Emergency Department Guidelines as the tool used to confirm suspected delirium (see Fig. 3.1). The bCAM includes specific questions that clinical staff can use to assess each of the four CAM features (acute altered mental status, inattention, altered consciousness, and disorganized thinking). Positive screens for delirium should be followed by evaluation for the underlying cause (see Fig. 3.2). Brain imaging, typically a non-contrast computed tomography of the brain, should be performed if concerned for head trauma or other neurologic insult. Evaluation for infection, meta- bolic derangements, toxins, polypharmacy, sensory impair- ment, dehydration, pain, and constipation should also be considered.
Delirium Interventions in the ED
Delirium treatment is threefold: curbing further alteration in mental status through delirium preventative measures,
Cognitive Impairment in the ED 45
Feature 1: Altered Mental Status or Fluctuating Course
> 1 errors
0 or 1 errors
bCAM Negative No delirium
bCAM Negative No delirium
bCAM POSITIVE DELIRIUM PRESENT
bCAM Negative No delirium
Feature 2: Inattention
“Can you name the months backwards from December to July?”
Feature 3: Altered Level of Consciousness
Feature 4: Disorganized Thinking
1) Will a stone float on water?
2) Are there fish in the sea?
3) Does one pound weight more than two
4) Can you use a hammer to pound a nail?
Command: “Hold up this many fingers” (Hold up two fingers). “Now do the same thing with the other hand” (Do not demonstrate).
Figure 3.1 The brief confusion assessment method. (From Han et al. )
correcting precipitating factors, and treating behavioral mani- festation such as agitation or hallucinations through non- pharmacological and pharmacological means (Table 3.1). Nonpharmacological strategies and avoidance of high-risk medications should be enacted for all older adults treated in aging-friendly EDs, i.e., for both those at risk for delirium and diagnosed with delirium. Optimization of the environment can be performed with basic modifications to ED layout and patient rooms such as noise reduction strategies, large face clocks and visible calendars, and patient-controlled diurnal lighting. If hearing or visual impairment are suspected, many aging-friendly EDs now have hearing amplifiers  and magnifying glasses available for patient use. Avoidance of
46 J. M. Huded and T. I. Smith
Perform Delirium Screen (bCAM)
Proceed with dementia screening
1. Consider inpatient admission and sitter.
2. Contact legal guardian or DPOA.
3. Offer food and drink as appropriate. 4. Minimize ED LOS as appropriate.
5. Avoid physical restraints and indwelling
Negative for delirium
Positive for delirium
2. Hearing and vision evaluation. 1. Medication review. 3. Pain assessment.
4. Incontinence and constipation
1. Brain imaging.
2. CXR and UA for infectious workup.
3. CBC, CMP, TSH, B-12, ABG,
Figure 3.2 ED delirium algorithm
Chapter 3. Cognitive Impairment in the ED 47
Table 3.1 Nonpharmacological and pharmacological strategies for delirium
Nonpharmacological strategies for delirium
Correct sensory deficits (hearing aids or amplifiers, cerumen disimpaction, eyeglasses or magnifying glasses)
Optimize environmental sensory stimulation (noise reduction strategies, diurnal lighting)
Reorientation (large face analog clocks, visible calendars, dry erase boards, identify healthcare team members)
Avoid physical restraints
Avoid indwelling bladder catheterization
Encourage supervised mobility
Encourage family/friends to remain at bedside
Consider a bedside sitter
Provide adequate nutrition and fluids
Minimize invasive procedures
Pharmacological strategies for delirium
Avoid high-risk medications (anticholinergic medications, sedatives/hypnotics, narcotics)
Consider medications to treat delirium in severely agitated patients who:
Are at risk for harming themselves or others or
Medical care is disrupted or delayed due to agitation
Haloperidol 0.5–1.0 mg po or IM
Avoid IV given the risk of QTc prolongation
Double dosage if initial dose is ineffective
Most older patients respond to 1–2mg total
Quetiapine is antipsychotic of choice for patients with Lewy body dementia and Parkinson disease
Initial dose is 12.5–25 mg po daily or q12H
48 J. M. Huded and T. I. Smith
invasive procedures, restraints, and indwelling Foley catheter- izations are now commonly used quality metrics.
Pharmacological strategies include avoidance of high-risk medications and the use of antipsychotic medications in agi- tated patients at risk of harm to themselves or others. Polypharmacy is an independent predictor of delirium among older adults who require inpatient admission after evaluation and treatment in the ED. One study found positive CAMs in 69% of inpatient older adults receiving polypharmacy, com- pared to 30% of those without polypharmacy (a relative risk of for delirium of 2.33) . The American Geriatrics Society (AGS) updated its Beers Criteria in 2015, a list of potentially inappropriate medications (PIMs) that should be avoided in older adults . Mechanisms to avoid the prescription of PIMs have been developed by EDs in an effort to reduce the number of patients discharged with suboptimal prescriptions, estimated to be up to 30% . The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUiPPED) program is one such model aimed at reducing the prescription of PIMs through the implementation of clinical decision support, ED provider education, and individual ED provider feedback on prescription practices, resulting in a relative reduction in PIM prescription by almost 50% at one site [17, 18]. If medication administration in the ED is required for behavioral manifes- tations of delirium such as severe agitation, pharmacologic options are limited to antipsychotics. Benzodiazepines should be avoided unless the trigger for delirium is alcohol or benzo- diazepine withdrawal .
Mr. C, as described above, is a common example of a patient with cognitive impairment encountered in the ED. His base- line cognitive impairment increased his frailty and poor
Chapter 3. Cognitive Impairment in the ED 49
reserve to acute or subacute insults, such as malnutrition and medication changes. Patients with dementia visit the ED more frequently and have higher rates of hospitalization and ED revisits than those without dementia . Up to two-thirds of community-dwelling individuals with dementia will require hospitalization at least once every 3 years , the majority entering the acute care setting through the ED. ED costs of care may be up to 75% higher for those with a dementia diag- nosis based on Medicaid and Medicare cost findings .
As opposed to the acute onset of delirium, dementia is a progressive and sustained decline in memory. A diagno- sis of dementia also requires impairments in at least one other cognitive function (language, executive, or visual-spa- tial) with interference in one’s daily life. The most common causes are Alzheimer’s dementia, accounting for approximately 60% of cases, and vascular dementia, accounting for 20% of cases. Other neurodegenerative causes include dementia with Lewy bodies (DLB), Parkinson’s disease, and frontotemporal dementia (FTD). Nondegenerative etiologies include chronic traumatic encephalopathy, alcohol-related dementia, and infec- tion-related dementia. If no functional impairment is present however there are objective signs of memory loss on testing, this is considered mild cognitive impairment (MCI). Six to 15% of patients with MCI will progress to dementia. Of note, not all chronic cognitive changes in older adults are diagnostic of a neurodegenerative process. Normal aging is associated with declines in processing speed, attention, and memory formation.
There are many tools available to detect dementia in the ED setting (Table 3.2). The Mini-Mental State Examination (MMSE) is well-validated and has widespread use in many settings; however, it can be time-consuming (taking up to 10 min to perform), cumbersome in the ED (requiring the patient to draw), and suboptimal for detecting mild cognitive impairment, FTD, and DLB . It was copyrighted in 2001,
J. M. Huded and T. I. Smith
Table 3.2 Tools for dementia evaluation. Sensitivities and specificities for all but the six-item screener, Montreal cogni-
Weighted six-item test evaluating
Four-item test used to detect mild
Four-item test sharing elements with
Designed for informant caregivers.
tive assessment, and mini-mental state examination were obtained from studies performed in the ED setting
64 (no CI provided) b
c 63 (53–72)
Three questions on temporal orientation
orientation, registration, and attention
Eight performance and memory-based
Six-item test focusing on orientation,
Quick confusion scale
memory, and concentration
and three-item recall
Short blessed test Brief Alzheimer’s
Three-item recall and clock drawing
Montreal cognitive Mini-cog assessment
Cognitive Impairment in the ED 51
30 points total. ≤ 26 = abnormal normal. 30 points total. ≤24 = abnormal normal Add 1 point if less than 12 years of education
Carpenter et al.  Wilber et al. 
Stair et al. 
Wilber et al. 
Tsoi et al. 
52 J. M. Huded and T. I. Smith
therefore requires permission to be used in the clinical set- ting. The Montreal Cognitive Assessment (MoCA) is similar to the MMSE in design and time requirements. The MoCA was designed to detect mild cognitive impairment and is ide- ally used in those who score 24–30 on the MMSE . In the ED setting, we recommend the Short Blessed Test (SBT), also known as the Orientation-Memory-Concentration Test (OMCT) . The SBT typically takes up to 5 min to perform with good sensitivity for dementia (95%), however has less specificity when compared to the MMSE (65%). Other quick cognitive tests include the Brief Alzheimer Screen (BAS) , Ottawa 3 Day-Year (O3DY) , Alzheimer’s Disease-8 (AD8) [27, 28], Quick Confusion Scale (QCS) , Six-item Screener (SIS) [30, 31], and Mini-Cog .
Dementia Interventions in the ED
Dementia screens suggestive of cognitive impairment should be followed by specific management while the patient is in the ED in addition to thoughtful post-ED interventions (see Fig. 3.3). Information obtained through cognitive evaluation in the ED changed treatment plans and disposition in 100% of patients in one study . In addition to determining if the patient’s current mental status is near their baseline, the elec- tronic medical record should be used to determine if a legal guardian or enacted durable power of attorney (DPOA) for healthcare is on file. Similar to any patient with delirium, frailty, or acute illness, those with dementia should be provided nutrition while in the ED if clinically appropriate and receive timely workup and treatment.
Cognitive Impairment Interventions upon Discharge from the ED
Significant opportunities for post-ED interventions for those with diagnosed or suspected delirium or dementia exist. The ED visit may signal a decline in functional status, mounting
Chapter 3. Cognitive Impairment in the ED 53
Consider referral to Geriatrics Clinic or Neuropsychology if concern dementia despite negative evaluation.
Negative for dementia
Perform Dementia Screen
Post-ED dementia interventions for consideration
1. Geriatrics referral
2. Neuropsychology testing
3. Home health aide 4. Adult day care 5. Respite care
6. Outpatient social work referral
Positive for dementia
Figure 3.3 ED dementia algorithm
ED dementia management
1. Confirm baseline mental status.
2. Contact legal guardian or DPOA.
3. Offer food and drink as appropriate.
4. Minimize ED LOS as appropriate.
54 J. M. Huded and T. I. Smith
caregiver burden, and suboptimal medication regimen rooted in progressive cognitive impairment. An intentional, struc- tured investigation of dementia may serve as a springboard to investigate these coexisting geriatric syndromes. For Mr. C, an accurate assessment of dementia could not be performed given current delirium. However, discussion of his recent change in mental status then allowed for discussion of his failing health and increased home care needs.
The Geriatric Emergency Department Guidelines high- light the importance of tailoring post-ED care to the most appropriate setting, i.e., avoiding unnecessary hospitaliza- tions and enabling older adults to receive ED follow-up care through home and community supports. For patients with cognitive impairment, thoughtful consideration of post-ED care is especially pertinent given the risk of cognitive and functional decline during and following hospitalization . Hospitalized patients diagnosed with delirium have shown twice the rate of cognitive decline during the year following an acute admission. Clinicians in aging-friendly EDs are expected to “pause before hospitalization” for those with baseline cognitive impairment . Evaluation and develop- ment of interdisciplinary, comprehensive care plans for older adults may initially be met with resistance given the potential for added time to ED workflow. However, transitional care nurses tasked with developing and coordinating these plans in the ED have decreased acute admission rates . Further research to evaluate the quality of life and satisfaction of ED care following an upfront investment of geriatric resources is needed.
Hospital at Home is one alternative to hospitalization for those with acute medical illness. Up to one-third of older adults with an acute medical condition warranting inpatient admission can be safely and successfully treated through the Hospital at Home model . In addition to decreased risk of delirium, Hospital at Home has been found to lower costs and mortality rates while improving satisfaction . Other home care models include Geriatric Resources for Assessment and Care of Elders (GRACE)  and home-based primary care (HBPC) .
Chapter 3. Cognitive Impairment in the ED 55
Programs shown to mitigate the number and duration of delirium episodes, in addition to decreasing costs and 30-day readmissions, for older patients requiring hospital- ization include Acute Care for Elders (ACE) units [39, 40] and Hospital Elder Life Program (HELp) . ACE units are specialized inpatient units using teams of geriatric spe- cialists to provide patient-centered care, medication review, environmental optimization, early discharge planning, and rehabilitation. ACE teams include geriatric-trained physi- cians, therapists, pharmacists, social workers, case manag- ers, dieticians, and nurses. The HELp model specifically targets delirium through interventions for dementia, sleep deprivation, immobilization, sensory impairment, and dehydration.
For patients with significant care needs, referrals for nonskilled care in the home (i.e., home health aides), respite care, adult day care, and long-term care homes can be performed prior to discharge from the ED. These refer- rals and other social work resources in the ED are often essential to timely care transitions. If a social worker is not available in the ED, prompt referral to outpatient Geriatrics clinic or a multidisciplinary home care program should be considered. Home health aides are ideal for patients requiring services for personal care, such as bathing, toilet- ing, and dressing. Medicare and most private health insur- ances will not pay for an aide if there is no skilled medical or therapy need. Certain long-term care insurance and Veterans Administration benefits may be used for home health aide services. Respite care is temporary planned or emergency care providing relief to the family caregiver. Respite care can be performed in the home and in skilled nursing facilities. Adult day care is a wonderful option for many patients with cognitive impairment whose priority is to remain living at home with family caregiver support but would benefit from care in a structured environment during the day. Initiating these outpatient services while in the ED, as opposed to post-ED follow-up several weeks to months later, can likely decrease ED revisits, hospitalization, and additional patient morbidity.
56 J. M. Huded and T. I. Smith
ED geriatric assessment revealed overmedication with halo- peridol, progressive functional impairment, and severe care- giver burden. Mr. C’s GNL developed a care plan with the input of his ED physician, pharmacist, and social worker. No acute medical conditions warranting an inpatient admission were discovered in the ED. His outpatient psychiatrist was contacted for assistance with modifying the haloperidol dose, a trial run at a VA-contracted adult day care facility was arranged, and a request for home health aide hours was made. In addition, Mr. C was referred to outpatient Geriatrics clinic and Caregiver Support Services. This comprehensive plan aligned with his wife’s wish of continuing to care for him at home. Equipping Mr. C’s wife with tools and resources to address his increasing frailty avoided hospitalization for social concerns or respite and minimized his risk for further delirium and avoided the hazards of hospitalization.
1. Delirium should be considered an acute medical condition warranting evaluation for the underlying cause and treat- ment, given its increased risk of mortality and functional decline.
2. The CAM or one of its derivatives, such as the bCAM, is a bedside tool used to identify delirium, and ED utilization of these tools can reduce the 70% of delirium cases that have historically gone undetected during ED visits.
3. Delirium preventative measures, such as medication review, hydration, ambulation, sensory optimization, reorientation, and avoidance of physical restraints and external devices, are key components of delirium treat- ment in the ED.
4. Patients with dementia are frequently treated in the ED and, if hospitalized, at increased risk for delirium and long- term cognitive decline. Therefore, implementing ED meth-
Chapter 3. Cognitive Impairment in the ED 57
ods that promote safe discharge plans and appropriate
follow-up care should be utilized.
5. The Short Blessed Test is a timely, sensitive, and relatively
specific test to evaluate for dementia in the ED setting.
6. Opportunities for specialized inpatient programs, such as Acute Care for Elders, and early outpatient referrals should be considered for patients diagnosed with new or
progressive dementia in the ED.
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14. Hein C, Forgues A, Piau A, Sommet A, Vellas B, Nourhashemi F. Impact of polypharmacy on occurrence of delirium in elderly emergency patients. J Am Med Dir Assoc. 2014;15(11):850 e811–55.
15. By the American Geriatrics Society Beers Criteria Update Expert P. American Geriatrics Society 2015 updated beers crite- ria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46.
16. Hastings SN, Schmader KE, Sloane RJ, et al. Quality of pharma- cotherapy and outcomes for older veterans discharged from the emergency department. J Am Geriatr Soc. 2008;56(5):875–80.
17. Vandenberg AE, Stevens M, Echt KV, et al. Implementing the EQUiPPED medication management program at 5 VA emer- gency departments. Fed Pract: Health Care Professionals VA DoD PHS. 2016;33(4):29–33.
18. Moss JM, Bryan WE 3rd, Wilkerson LM, et al. Impact of clini- cal pharmacy specialists on the design and implementation of a quality improvement initiative to decrease inappropriate medi- cations in a veterans affairs emergency department. J Manage Care Specialty Pharm. 2016;22(1):74–80.
19. Gower LE, Gatewood MO, Kang CS. Emergency department management of delirium in the elderly. West J Emerg Med. 20 12;13(2):194–20 1.
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20. LaMantia MA, Stump TE, Messina FC, Miller DK, Callahan CM. Emergency department use among older adults with dementia. Alzheimer Dis Assoc Disord. 2016;30(1):35–40.
21. Rudolph JL, Zanin NM, Jones RN, et al. Hospitalization in community-dwelling persons with Alzheimer’s dis- ease: frequency and causes. J Am Geriatr Soc. 2010;58(8): 1542–8.
22. Anthony JC, LeResche L, Niaz U, von Korff MR, Folstein MF. Limits of the ‘Mini-Mental State’ as a screening test for dementia and delirium among hospital patients. Psychol Med. 1982;12(2):397–408.
23. Velayudhan L, Ryu SH, Raczek M, et al. Review of brief cogni- tive tests for patients with suspected dementia. Int Psychogeriatr. 2014;26(8):1247–62.
24. Schnitker LM, Martin-Khan M, Burkett E, et al. Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments. Acad Emerg Med Off J Soc Acad Emerg Med. 2015;22(3):285–98.
25. Mendiondo MS, Ashford JW, Kryscio RJ, Schmitt FA. Designing a brief Alzheimer screen (BAS). J Alzheimer’s Dis: JAD. 2003;5(5):391–8.
26. Molnar FJ, Wells GA, McDowell I. The derivation and valida- tion of the Ottawa 3D and Ottawa 3DY three- and four-question screens for cognitive impairment. Clin Med Geriatr. 2008;2: 1–11.
27. Galvin JE, Roe CM, Powlishta KK, et al. The AD8: a brief informant interview to detect dementia. Neurology. 2005;65(4): 559–64.
28. Galvin JE, Roe CM, Xiong C, Morris JC. Validity and reliabil- ity of the AD8 informant interview in dementia. Neurology. 2006;67(11):1942–8.
29.Stair TO, Morrissey J, Jaradeh I, Zhou TX, Goldstein JN. Validation of the Quick Confusion Scale for mental status screening in the emergency department. Intern Emerg Med. 2007;2(2):130–2.
30. Wilber ST, Carpenter CR, Hustey FM. The six-item screener to detect cognitive impairment in older emergency depart- ment patients. Acad Emerg Med Off J Soc Acad Emerg Med. 2008;15(7):613–6.
31. Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment
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among potential subjects for clinical research. Med Care.
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33. Dziedzic L, Brady WJ, Lindsay R, Huff JS. The use of the mini-
mental status examination in the ED evaluation of the elderly.
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34. Gross AL, Jones RN, Habtemariam DA, et al. Delirium and
long-term cognitive trajectory among persons with dementia.
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acute medical care for cognitively impaired individuals: a call always to pause before hospitalization. J Am Geriatr Soc. 20 18;66(2):219–21.
36. Leff B, Burton L, Bynum JW, et al. Prospective evaluation of clinical criteria to select older persons with acute medical ill- ness for care in a hypothetical home hospital. J Am Geriatr Soc. 1997;45(9):1066–73.
37. Caplan GA, Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. A meta-analysis of “hospital in the home”. Med J Aust. 2012;197(9):512–9.
38. Counsell SR, Callahan CM, Clark DO, et al. Geriatric care man- agement for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623–33.
39. Fox MT, Persaud M, Maimets I, et al. Effectiveness of acute geriatric unit care using acute care for elders components: a systematic review and meta-analysis. J Am Geriatr Soc. 2012;60(12):2237–45.
40. Flood KL, Maclennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981–7.
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42. Carpenter CR, Bassett ER, Fischer GM, et al. Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer’s screen, short blessed test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med. 2011;18(4):374–84.
Chapter 3. Cognitive Impairment in the ED 61
43. Wilber ST, Lofgren SD, Mager TG, et al. An evaluation of two screening tools for cognitive impairment in older emergency department patients. Acad Emerg Med. 2005;12(7):612–6.
44. Tsoi KKF, Chan JYC, Hirai HW, Wong SYS, Kwok TCY. Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA Intern Med. 2015;175(9):1450–8.
Syncope in a Rural Emergency Department Setting
Lucy Morse and Lee A. Lindquist
Ms. Patricia Spencer is an 81-year-old woman, accompa- nied by her son, who arrives at the emergency depart- ment of a hospital in a small town in rural Illinois following a fall that resulted from what she describes as a “fainting spell.” She describes “feeling a little sick to the stomach and then a bit dizzy” while standing at her kitchen sink. She reports gripping the edge of the sink as her vision started to “get grainy around the edges and then go gray” and lowering herself to the floor. She regained consciousness after an unknown period of time that she says she thinks “wasn’t all that long.” She was able to stand back up by using a nearby chair for support, at which point she called her son, who left work and
L. Morse (*) · L. A. Lindquist
Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
© Springer Nature Switzerland AG 2019 63 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_4
64 L. Morse and L. A. Lindquist
drove her to the emergency department. They report driving approximately 45 min in order to get to the emer- gency room, during which time Ms. Spencer says she felt “a little weak and shaken up” but otherwise normal.
Upon further questioning, she denies experiencing palpitations or a racing heart. She denies feeling chest tightness or pressure and did not experience shortness of breath but thinks she might have been breathing a little faster when she realized what was happening. When prompted, she notes she felt “a little warm” before losing consciousness. Although she notes that it took her “a few seconds” to become oriented after regaining consciousness, she denies any lasting confu- sion; she also denies incontinence or injury to her mouth or tongue following the episode. When asked whether anything similar had happened to her before, Ms. Spencer notes that she fainted once as a young adult while standing in church after skipping break- fast, but she has not lost consciousness since then. She notes one near fall 2 months prior, caused by slipping on the ice while retrieving her mail; she was able to catch herself on the mail post and right herself with- out injury.
Atorvastatin 10 mg once daily
Celecoxib 200 mg once daily
Patricia’s past medical history is significant for par-
tial small bowel obstruction 3 years ago which resolved spontaneously with supportive treatment. She has no history of heart anomalies or arrhythmia and also denies family history of arrhythmia or sudden cardiac death. She has a history of osteoarthritis in her hands and in both hips. She had a bilateral total hip arthro- plasty 8 years ago without complication.
Chapter 4. Syncope in a Rural Emergency Department… 65
Patricia is a never smoker, does not drink alcohol or caffeine, and lives alone in her home in rural Illinois. Home is single floor but has several steps at the entranceway. Her son lives nearby and is her primary source of support; he helps her with grocery shopping and some chores, but she cooks and cleans for herself and manages her own medication and finances independently.
Blood pressure taken immediately upon presenta- tion to the ED is 142/80, with heart rate of 72 bpm. Cranial nerves II–XII are intact bilaterally. Cardiac exam reveals regular rate and rhythm, S1 and S2 audi- ble, and no S3, S4, murmurs, rubs, or gallops. Basic MSK exam reveals range of motion and strength equal throughout bilateral upper and lower extremities, nota- bly with 5/5 strength in hip flexion and extension bilat- erally. There is no evidence of trauma (bruising, tenderness) to the head, trunk, or legs; there is full range of motion and no tenderness to palpation at any bony landmarks of the hip. Left wrist is slightly tender upon flexion and palpation. Wrist has full range of active motion and extension and flexion are 5/5 strength. Patient is alert and oriented x3; light touch and pain perception are intact bilaterally in upper and lower extremities.
Diagnostic Approach and Questions Raised
What are the appropriate next steps in working up this syn- copal episode?
Should Ms. Spencer’s hypertension be treated? Does her age impact the decision-making?
Is it safe for Patricia to be living independently? Would returning to her home environment be considered high risk?
66 L. Morse and L. A. Lindquist
Diagnostic Workup of Syncope in the Older
Common Causes of Syncope in the Older Adult
Syncope is a common complaint in the older adult, accounting for up to 3% of all ED visits, and is more common in older adults relative to the general population . While only 10% of syncope is cardiac in origin in adults of ages 18–65, 40% of cases are cardiac in origin in the older adult population . Several other common non-cardiac causes of syncope in the older adult can be grouped together in the category of neurally mediated syncope: these include carotid sinus hypersensitivity, situational syncope, and vasovagal syncope. Orthostatic hypo- tension is a major cause of syncope in older adults, accounting for up to 30% of syncopal episodes by some estimates; this is defined as a drop of >20 mmHg systolic or >10 mmHg diastolic upon standing . Older adults are frequently prone to ortho- static hypotension because they do not drink enough fluids in a day. Normally with age, older adults lose their thirst mecha- nism, so frequently the first sign of dehydration is syncope. Further complicating the lack of fluid, many older adults expe- rience incontinence and so may limit their fluid intake if they are planning to go outside of the home or to a specific event. If the older adult is dehydrated, it is likely that orthostatic hypo- tension will be present and easily remedied by giving fluids in the ED and encouraging daily fluid intake.
Postprandial hypotension is also disproportionately observed in older adults and should be considered if the clini- cal context is suggestive .
Data on relative prevalence of these etiologies is limited and mixed, in part due to the absence of confirmed diagnosis in up to 40% of syncopal episodes presenting to the emer- gency department; however, since the introduction of diag- nostic approaches such as tilt-table testing, it has been shown that vasovagal syncope is underdiagnosed and accounts for a significant proportion of syncopal episodes in older adults [6, 16]. Critically, many cases of syncope in older adults are mul- tifactorial in origin, and contributing factors such as poly-
Chapter 4. Syncope in a Rural Emergency Department… 67 pharmacy and underlying comorbidities may go unrecognized
as causal agents in the episode . Our Patient
Although not strongly indicated based on symptoms, a cardiac cause must be carefully considered due to the patient’s age. Although the patient has no history of arrhythmia and has no history consistent with MI or CHF, she does take a statin, sug- gesting that she may be at risk for heart disease which is a significant independent risk factor for syncope of cardiac ori- gin . By virtue of her age, gender, and hyperlipidemia, assessing for an arrhythmogenic or structurally mediated cause should be a priority. However, her HPI indicates a pro- drome highly consistent with vasovagal syncope: this evidence is particularly notable considering that classic vasovagal symptoms, including nausea, warmth, dizziness, and diaphore- sis, are less commonly seen in older adults with vasovagal syncope . Vasovagal origin is also made more likely by her account of beginning to experience symptoms while she had been standing for some time; this feature, however, should also lead us to consider a delayed orthostatic hypotension.
The patient’s presentation is less concerning for high-risk causes such as seizure or stroke. The absence of significant con- fusion or incontinence makes seizure unlikely, and although TIA or ischemic stroke may also be considered in the context of the patient’s age and possible CV risk factors, TIA very rarely pre- cipitates a true loss of consciousness. The patient’s absence of paralysis or focal neurological deficits in her history and physical should also redirect the physician away from this possibility .
Diagnostic Workup: Avoiding Overtesting in the Emergency Department
An EKG is safe, noninvasive, and inexpensive; considering baseline frequency of cardiac cause in syncope in older adults,
68 L. Morse and L. A. Lindquist
it should be performed upon presentation. In the case of a negative EKG, however, echocardiography is not indicated unless there is some suspicion for structural heart disease . Similarly, a Holter monitor should not be considered in this patient if the EKG is normal; based on the isolated nature of this incident and her lack of a cardiac history, it would be unlikely to add value to the diagnostic approach and intro- duces the possibility of incidental findings which would lead to further unnecessary testing .
Orthostatic Vital Signs
Due to the nature of the patient’s given history, orthostatic vital signs should be assessed at both 1 and 3 min after stand- ing . The patient should also be questioned as to the length of time that she was standing prior to experiencing symptoms in order to better establish likelihood of orthostatic versus vasovagal etiology.
Overtesting in the Context of the Geriatric Patient
Imaging (MRI and head CT) in the absence of focal neuro- logical deficits, paralysis, or another cause for high clinical suspicion should be avoided. Similarly, EEG testing in the absence of symptoms suggestive of seizure is not indicated. Due to the patient’s description of a prodrome and her insis- tence of a lack of “palpitations” or chest-localized symptoms, tilt-table testing should not be ordered: it is cumbersome and time-consuming, and most importantly, confirmation of the clinical suspicion of vasovagal syncope is unlikely to alter the management approach taken with this patient at this time.
Hypertension in the Emergency Department
The attending physician notes Ms. Spencer’s high blood pres- sure and requests past records from her PCP. Her charts indicate past pressure taken 18 months ago was 134/80;
Chapter 4. Syncope in a Rural Emergency Department… 69
however, the physician considers whether or not to treat the hypertension observed in this encounter.
Is treatment indicated based on Ms. Spencer’s most recent measurement? Are there special considerations in treating hypertension in the older adult?
Hypertension in Older Adults: When to Treat
Current guidelines from the ACC/AHA recommend treat- ing a blood pressure with systolic >130 or a diastolic pres- sure >80; based on her measurements in the emergency room, Patricia would be diagnosed with stage 1 hyperten- sion and should be treated with a target of <130/80 . However, Patricia’s elevated systolic with non-hypertensive diastolic measurement is likely an effect of “white-coat hypertension” within the context of an emergency room setting that can be stress-inducing and disorienting, espe- cially for older adults. Furthermore, evidence for treatment thresholds for hypertension in adults over 80 years old is inconclusive. Some studies have shown a trade-off between decreased stroke risks with an increase in all-cause mortal- ity with aggressive blood pressure management . However, one large-scale RCT indicated greater improve- ments in all-cause mortality, cardiovascular events, and stroke for individuals over 75 with a target of 120 relative to 140 systolic BP . Other research has shown that the use of moderate to high levels of antihypertensive medica- tion is associated with increased risk of injurious falls and that risk is further elevated in patients with a prior history of injurious falls .
Current guidelines for adults ages 60 and over released by the AAFP and ACP based on the most recent RCTs and meta-analyses taken together recommend a goal of <150 systolic BP and <140 systolic BP in the case of high stroke risk only: no benefit in all-cause mortality was con- sistently demonstrated in lowering systolic BP below 140 mmHg .
70 L. Morse and L. A. Lindquist
In approaching the treatment of this patient, the focus should be on first establishing her baseline blood pressure outside of a clinical environment through the use of home blood pressure monitoring, which would permit a current, averaged value that could be used to assess the value of an antihypertensive. Possible side effects of commonly pre- scribed antihypertensives such as thiazide diuretics and ACE inhibitors must also be considered within the context of this patient specifically: electrolyte disturbances in older adults can precipitate life-threatening consequences, and the risk of hypotension due to hypovolemia leading to an injurious fall is particularly important to consider in the case of a community-dwelling adult in a rural setting where access to immediate care and emergency response services is limited [15, 17].
Considering the patient as an individual with low stroke risk and higher risk of falls, antihypertensives should not be initiated based on this blood pressure measurement; how- ever, primary care follow-up based on current, averaged measurements in the patient’s home environment is indicated.
Assessment of Risk in the Older Adult
Patricia and her son are relieved to hear that her syncope is unlikely to be caused by a heart condition and that she will be sent home with a home blood pressure monitor to track her vitals. Ms. Spencer notes that she was lucky that her episode happened in the kitchen, near her telephone, and that her son was able to come so quickly and drive her to the hospital. Her son wants to know what the physicians think about his moth- er’s safety in her home.
How do you think about the risks associated with Ms. Spencer’s living situation? What steps can you take to assess and manage these risks in the context of emergency care?
Chapter 4. Syncope in a Rural Emergency Department… 71 Functional Assessment of the Older Adult
in the Emergency Department Setting
Older adults are at higher risk for hospital admission and emergency department readmission following initial presen- tation to the emergency department relative to the general adult population. It is hypothesized that this trend, in part, can be attributed to incongruity between the episodic care model for acute illness upon which emergency department care hinges and the complex factors and comorbidities that underlie chief concerns bringing older adults to the emer- gency room . In the setting of an emergency department without a pre-existing system to assess function and risk in older adult patients, a realistic approach would be to screen for overall risk with a simple itemized tool, such as the ISAR (identify seniors at risk) six-item survey . Based on the outcome of this screen, further testing for common geriatric syndromes could be initiated. One example of a systematized approach to screening older adult patients for risk in the emergency department is the GEDI WISE program at Northwestern Memorial Hospital: specialized nurses screen for cognition, delirium, fall risk, functional status, care transi- tions, and caregiver strain using a series of validated tools if an ISAR >2 detected in any ED patient aged 65 or over .
Application of some or all of these tools could be used to better treat Patricia. Although her case does not necessitate hospital admission or involve inpatient testing, her presenta- tion at the emergency department can be seen as an opportu- nity to connect her with services and care that may better allow her to age in place and work to avoid a repeat syncopal episode with an injurious fall or a mechanical fall like the near-miss that she describes taking place several months earlier.
Next Steps and Post-discharge Planning
Within the context of this ED encounter, providers should prioritize gait assessment in combination with a timed get up
72 L. Morse and L. A. Lindquist
and go test (TUG test) . If she tests positive, she should be connected with appropriate PT and OT services, and assis- tive devices should be discussed with the patient and her son. The patient should be connected with social work to facilitate a home safety evaluation, which may lead to recommenda- tions for modification of her home environment, and safety precautions such as a wearable medical alert device. Other precautions should include a basic cognitive test in order to rule out cognitive impairment or dementia as a factor in her recent episode and an assessment of caregiver strain in the case of her son: although her son’s proximity and presence in Patricia’s daily life are a critical reason that her discharge can be considered low risk, it is also important to establish that the current structure is sustainable before she returns to her home. This is made especially critical in the context of the rural community in which she lives, where her access to resources that would facilitate her instrumental ADLs would otherwise be severely limited. Through the initiation of these sequences in the emergency department, Patricia will be better able to retain her current level of independence and avoid the need to transition to assisted living, and the likeli- hood of an avoidable return to the emergency room will be diminished.
Ms. Spencer is discharged after a brief stay in observation, where telemetry further reinforced the absence of a cardiac cause of her syncope. Later blood pressure readings remained somewhat elevated but did drop to 130/80 over the course of her stay. TUG test time was 11 s, cognition was found to be within a normal range, and caregiver strain was found to be low (upon further discussion, it was revealed that her grand- son and daughter-in-law were also involved in her support). Although the TUG test was not definitively high risk, it was considered borderline within the social context such that the patient received a consult with PT and OT services, who rec-
Chapter 4. Syncope in a Rural Emergency Department… 73
ommended an outpatient evaluation at a later date. Home safety evaluation was scheduled for later that week. Patient was discharged with educational materials about vasovagal syncope as well as verbal instructions and information on prodromal symptoms and safety measures. She was also pro- vided with a prescription for a home blood pressure monitor, with instructions to follow-up with primary care after several days of use.
• Syncope in adults is often multifactorial, and assessment should take into account medications and underlying comorbidities. Cardiac cause of syncope is more frequent in older adults, as is syncope due to orthostatic and post- prandial hypotension; however, reflex syncopes are also very common in older adults and may be less readily rec- ognized in this population due to decreased frequency of classic prodromal symptoms.
• Blood pressure readings in the emergency room are often not reflective of an older adult’s average values, and treatment should not typically be initiated based on this measurement. Treatment indications for hypertension in older adults remain complex and must be approached within the context of risks associated with medication, including electrolyte disturbances and hypotension- induced falls.
• Assessing an older adult’s ability to age in place should be based on a multidisciplinary approach that takes into account common geriatric syndromes such as falls, func- tional dependence, and cognitive changes, while also including appraisal of determinants such as social support and home environment. Steps can be taken in the emer- gency department to screen for possible obstacles to independent living and to connect patients with medical and social services to decrease risk and promote safe inde- pendent living if indicated.
74 L. Morse and L. A. Lindquist References
1. Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of his- tory in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001;37(7):1921–8.
2. Aldeen AZ, Courtney DM, Lindquist LA, Dresden SM, Gravenor SJ. Geriatric emergency department innovations: pre- liminary data for the geriatric nurse liaison model. J Am Geriatr Soc. 2014;62(9):1781–5.
3. Ali NJ, Joly L, Grossman SA. Syncope in older people in the emergency department. In Geriatric emergency medicine. Springer; 2018. p. 147–61.
4. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hyper- tension in patients 80 years of age or older. N Engl J Med. 20 08;358(18):1887–98.
5. Berry SD, Kiel DP. Treating hypertension in the elderly: should the risk of falls be part of the equation? JAMA Intern Med. 20 14;174(4):596–7.
6. Chen LY, Gersh BJ, Hodge DO, Wieling W, Hammill SC, Shen W-K. Prevalence and clinical outcomes of patients with multiple potential causes of syncope. Paper presented at: Mayo Clinic Proceedings. 2003.
7. Geriatric EDGTF, Physicians ACoE, Association EN. Geriatric emergency department guidelines. Ann Emerg Med. 20 14;63(5):e7.
8. Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. 2007;120(10):841–7.
9. Hogan TM, Constantine ST, Crain AD. Evaluation of syncope in older adults. Emerg Med Clin. 2016;34(3):601–27.
10. Kapoor WN. Evaluation and management of the patient with syncope. JAMA. 1992;268(18):2553–60.
11. McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc. 1999;47(10):1229–37.
12. Puisieux F, Bulckaen H, Fauchais AL, Drumez S, Salomez- Granier F, Dewailly P. Ambulatory blood pressure monitor- ing and postprandial hypotension in elderly persons with falls
or syncopes. J Gerontol Ser A Biol Med Sci. 20 0 0;55(9): M535–40.
13. Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA. Pharmacologic treatment of hypertension in adults aged
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60 years or older to higher versus lower blood pressure tar- gets: a clinical practice guideline from the American College of Physicians and the American Academy of family physicians pharmacologic treatment of hypertension in adults. Ann Intern Med. 2017;166(6):430–7.
14. Shumway-Cook A, Brauer S, Woollacott M. Predicting the prob- ability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896–903.
15. Siscovick DS, Raghunathan T, Psaty BM, et al. Diuretic therapy for hypertension and the risk of primary cardiac arrest. N Engl J Med. 1994;330(26):1852–7.
16. Tan MP, Parry SW. Vasovagal syncope in the older patient. J Am Coll Cardiol. 2008;51(6):599–606.
17. Tinetti ME, Kumar C. The patient who falls: “It’s always a trade- off”. JAMA. 2010;303(3):258–66.
18. Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;2017:24430.
19. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: a randomized clinical trial. JAMA. 2016;315(24):2673–82.
and Hospitalizations from Post-acute
and Long-Term Care Facilities
Post-Acute and Long-Term Care Facilities: INs and OUTs: The Nursing Home “Frequent Flyer” and Avoiding the Avoidable
Tuesday, 1:30AM – emergency department (ED) arrival referred by local “nursing home” – Ms. “M,” 85-year-old lady with past medical history of allergic bronchopulmonary aspergillosis and bronchiectasis complicated by recurrent hemoptysis, paroxysmal A-fib not on anticoagulation due to bleeding risk, HTN, NIDDM, CVAs with mild residual right- side leg weakness, chronic anxiety and depression, hypothy- roidism, and malnutrition. She was recently hospitalized for 2 weeks due to recurring hemoptysis and underwent IR-guided angio-bronchoscopy without identifying the source
F. Heitor (*)
Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Northwestern Medical Group, Chicago, IL, USA
© Springer Nature Switzerland AG 2019 77 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_5
78 F. Heitor
of bleed. Thoracic surgery was consulted but did not recom- mend further invasive intervention due to significant risks versus low likelihood of success. Hospice consultation was offered but the patient declined. She elected to remain “full code” and was fully coherent and able to make informed decisions regarding her healthcare. She is unmarried and with no kids of her own, as well as no close family contact. A friend was designated her Healthcare Power of Attorney (HPOA), and she was admitted to a skilled nursing facility (SNF) for subacute rehabilitation after hospital discharge. During SNF stay, she presented, over a period of 3 weeks, four episodes of hemoptysis of about 100 to 200 ml associated with anxiety attacks and was referred to the nearest ED for acute care. On all occasions, she was re-admitted or stayed in observation and had extensive diagnostic workup performed. She was also again offered hospice enrollment but repetitively declined. Furthermore, on all occasions, upon coming back to the SNF, there were multiple medication discrepancies and changes on her antidepressant regimen. On this last hospital stay, she was discharged on Clonazepam 1 mg PO TID PRN anxiety and Ambien 10 mg PO qHS, and her long-term Sertraline 150 mg PO qday was no longer active in her medi- cation list. She was re-admitted to the SNF on Friday at 10PM. Admission procedures were performed by a new nurse who paged the on-call covering physician who did not have access to the electronic medical records. Through nurse report, the physician reviewed the discharge medication list. The patient was evaluated by her regular facility physician on Monday morning and noted to be very somnolent.
“Why Does the Nursing Home Keep Sending This Patient Back to the ED?”
A large percentage of older adults visiting emergency depart- ments (EDs) are nursing facility (NF) residents. A National Nursing Home Survey conducted by the Centers for Disease Control and Prevention (CDC) concluded that 8% of NF
Chapter 5. ER Referrals and Hospitalizations… 79
residents throughout the United States had an ED visit in 90 days and that 40% of those visits (involving more than 50,000 residents) were deemed preventable . Of those 8% residents, 15% (more than 18,000 residents) had two or more ED visits in that time period.
Besides obvious cost issues, it can certainly be frustrating to ED staff to admit the same patient multiple times, espe- cially if coming from a nursing facility where, technically, patients are under medical care. Many conditions are pre- ventable and able to be appropriately managed at certain facilities; nonetheless, there is a large misunderstanding regarding the type and amount of care provided throughout the various types of facilities. There is an absolute goal to avoid unnecessary ED referrals, but, on certain occasions, it is impossible not to do so without compromising patient safety.
Understanding “Nursing Home”: What Is It Exactly?
Typically the term “nursing home” refers to an extended or long-term care (LTC) facility and can be also described as “memory care.” Most long-term care is not medical care but rather assistance with activities with daily living or custodial care (such as help with bathing, dressing, grooming, moving in or out of bed or chair, toileting, and eating). Nursing facilities can also provide rehabilitative care to patients following hos- pital discharge. This is known as subacute or post-acute reha- bilitation and is delivered in “skilled” nursing facilities (SNFs) specialized in providing full-time care to individuals with functional or cognitive impairments and with the need for continuous skilled care. These skilled services include intravenous therapy, artificial nutrition and hydration, com- plex wound care, ostomy care or rehabilitation with physical therapy (PT), occupational therapy (OT), or speech therapy (ST) . In SNFs, post-acute (or subacute) care consists of about 1–2 h of therapy a day (PT, OT, and/or ST) and about 2–3 h of nursing care daily with physician evaluations once or
80 F. Heitor
twice a week. This setting is much different from acute reha- bilitation facilities (“inpatient” rehabilitation) where, follow- ing hospital discharge, patients will receive 3–5 h of daily therapy along with at least 5 h of daily nursing care and a 24/h on-site physician with specialty consults and diagnostics pro- cedures readily available.
Long-term skilled nursing care is often needed for people with chronic medical conditions, severe pain, or permanent disabilities. Skilled nursing care may be needed on either a short-term or long-term basis .
The term “nursing home” may also be generally used for assisted living (AL) facility and independent living (IL) facil- ity. These are two models of residential care following a non- medical model but rather a more homelike care .
Assisted living (AL) communities (or assisted care) are designed for residents who are unable to safely live indepen- dently but do not require a high level of care. Assistance with medications, meals, housekeeping, and perhaps some activi- ties of daily living are provided. Social activities and sched- uled transportation are also available in most settings. Typically, living space consists of a private apartment with a limited kitchen area, support staff available 24 h, and access to licensed nurse services. Residents remain fairly indepen- dent, getting assistance as needed. Some might have extended assistance from personal caregivers [2, 4].
Independent living (IL) communities (or senior apart- ments, retirement villages, retirement communities, congre- gate care, or continuing care retirement community – CCRC) are directed for residents with few medical problems and who are very independent. They might live in a variety of apartment sizes and options (from studios to large 2+ bed- rooms) and have access to on-site fine dine services with custom-designed meal packages, housekeeping, social activi- ties, and entertainment events (many sites offering concierge services) .
There is some stigma related to the term “nursing home.” For many, it evokes a demeaning setting and minimizes the broad significance that it has. It refers to a multitude of senior
Chapter 5. ER Referrals and Hospitalizations… 81
living possibilities with various amounts of support and an industry that is growing supported by close federal and state monitoring and regulations.
Post-acute and Long-Term Care Facilities STATS
According the 11th edition of the Centers for Medicare & Medicaid Services’ (CMS) Nursing Home Data Compendium :
– More than 15,600 nursing facilities participate in the CMS programs with an overall occupancy rate of about 80%.
– Over 1.4 million people live in US nursing facilities; this roughly corresponds to 2.6% of the population above 65 years of age and 9.5% of those 85 and above.
– Overall, 15% of the nursing facility population is under age 65, while 7.8% are over 95 years.
– Nearly 66% are women.
– Almost 15% of occupants have more than five impair-
ments in activities or daily living (bed mobility, dressing, eating, transferring, and toileting) or severe cognitive impairment.
– More than 34% have severe bowel and/or bladder incontinence.
Post-acute and Long-Term Care Facilities Staffing Nuances: Understanding Nursing Care at Nursing Facilities
Nursing facilities in the United States are regulated under the Nursing Home Reform Act, a part of the OBRA-78 or Omnibus Budget Reconciliation Act of 1987, a federal law signed by President Ronald Reagan [14, 15]. This was the first major revision of the federal standards for care at nursing
82 F. Heitor
facilities since the creation of Medicare and Medicaid in 1965. Facilities aiming to receive Medicare and Medicaid funding ought to provide services so that each resident can “attain and maintain her highest practicable physical, mental, and psycho-social well-being” [6, 7]. OBRA has had a significant impact and changed drastically the care at nursing facilities, guarantying the rights of residents of such certified facilities.
Both federal and state laws regulate nursing facility staff- ing standards. Federal standard requirements for nursing services are described as “sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psy- chosocial well-being of each resident” . There is no enforcement for a minimum number of nursing staff per facil- ity. According to the Code of Federal Regulations, unless a specific waiver is in place, the regulation specifies the facility must have [8, 12, 16]:
– A registered nurse (RN) – at least 8 consecutive hours/ day, 7 days/week.
– A registered nurse to serve as a full-time (40 h per week) director of nursing (DON) and may serve as charge nurse for facilities with 60 or fewer residents.
– One RN and one licensed nurse (RN or LVN/LPN) for the two remaining shifts, with no adjustment for resi- dent acuity .
Staffing standards vary widely between states. A 2010 review disclosed the following findings comparing standards for a 100-bed nursing facility to standardize the data across states :
– Twenty states had higher requirements for RNs than the federal requirements.
– Fifteen states had the same requirements.
– Sixteen states had lower requirements.
The analysis of these standards was measured and con- verted as care hours per resident day (hprd). Reviewing the data, the federal minimal requirement staffing standards for
Chapter 5. ER Referrals and Hospitalizations… 83
registered nurses (RNs) was 0.08 RN hprd (hours per resident-day) and for licensed nurses (LN) was 0.30 LN hprd (hours per resident-day).
Across states, LN care ranged from a low of 0.14 LN hprd (hours per resident day) in Alabama and Virginia to a high of 1.08 hprd in Delaware.
Per abovementioned review, in 2010, US nursing facili- ties had a staffing average of 0.71 RN hours, 0.80 LVN-LPN hours, and 2.41 nursing assistant (NA) hprd (3.9 total hours) .
Understaffing and high staff turnover usually are major issues in skilled nursing and long-term care facilities leading to quality problems . As above, regulation requires “suffi- cient” nursing staff to meet the needs for the facilities’ resi- dents, and there is plenty of evidence that better care is linked to higher levels of staffing [9, 10].
With this is mind, in 2014, the Consumer Voice launched a national staffing campaign  with a long-term goal of pass- ing a legislation to mandate that each resident in a nursing facility receives, daily, at least 4.1 h of nursing care (2.8 h from nursing assistants, 0.55 h from licensed practical nurses, and 0.75 h from registered nurses). This was deemed the minimum amount of care in order to prevent common quality of care problems such as dehydration, loss of ability to perform basic activities of daily living (such as eating and dressing), pressure ulcers, and falls. Efforts are still in place (Tables 5.1 and 5.2).
Post-acute and Long-Term Care Facilities: Understanding Medical Care
Health care in nursing facilities is based on the interplay of three factors: interdisciplinary teamwork; expertise in the care of comorbid, disabled, and elderly patients; and compli- ance to government regulations.
Besides nursing care, physical/occupational and speech therapy consist the bulk of the care provided at skilled and long-term care facilities. Usually, there is also availability of
84 F. Heitor
Table 5.1 Definitions of nursing facility staffing
DON Director of nursing (per federal requirement a DON must be a licensed RN. States may have their own requirements)
RN Registered nurse (2-year degree, 3-year diploma, 4-year degree, or more education. Licensed in a state)
LPN/ Licensed practical nurse/licensed vocational nurse LVN (1-year degree. Licensed in a state)
LN Licensed nurse (can be a RN or LVN/LPN)
NA Nursing assistant or nurse’s aide
CNA Certified nursing assistant (NA who completed 75 h of training and passed a competency exam)
Certified nursing assistants (CNAs) provide the majority of hands- on care in nursing facilities
psychology and podiatry consults, and most of the facilities do also offer psychiatry and physical and rehabilitation medi- cine consults. Geriatricians, internists, or family practitioners generally provide medical care.
A physician involved in nursing facility care must undergo an initial and periodic credentialing and privileging process by the facility and is responsible for maintaining a schedule of visits that are appropriate to the facility resident’s medical condition and in accordance to payer regulations. Physicians may practice individually, along with mid-level providers or as members of a group practice. Residents at skilled nursing facilities (SNFs) are seen within 72 h of admission and at least two–three times in the 1st month and, if stable, once a month thereafter. This minimum schedule is required by federal regulation but is not sufficient for many residents with a high level of medical complexity and acuity, requiring far more medical attention . For long-term care, residents are seen within 30 days of admission and then routinely at least once every 2 months. Physicians may delegate every other sched- uled visit to a nurse practitioner (NP) or physician assistant (PA), but admission visits have always to be performed by the physician.
Chapter 5. ER Referrals and Hospitalizations… 85
Table 5.2 Nursing hours per resident day reported in all US nursing homes in 2014 compared to recommended minimum staffing levels and expected staffing levels
Total number of nursing homes (15,391) and percentiles 90%N= 1539
Median N = 7696
25%N= 3848 10%N= 1539
CMS study recommended minimum standard
Average CMS expected
staffing based on resident acuity
RN LVN/ CNA hours LPN hours per hours per per resident resident resident day day day
1.36 1.26 3.27 0.98 1.02 2.80 1.00 0.90 2.64 0.72 0.81 2.40
0.53 0.60 2.08 0.39 0.39 1.83 0.75 0.55 2.80
1.08 0.66 2.43
Total nursing hours per resident day
5.39 4.55 4.54 3.97
3.53 3.18 4.10
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4833431/ table/t1-hsi-9-20 16-0 13/
The physician is not physically on-site at the nursing facil- ity. Overall, physicians make rounds at facilities usually once or twice a week.
Post-acute and Long-Term Care Facilities: Understanding Diagnostics and Ancillary Services
Skilled nursing and long-term care facilities (SNFs and LTCs) are equipped to offer and manage peripheral IVs and PICC line placements, initiation of nasogastric tube
86 F. Heitor
feedings, urinary catheter placement, staple and suture removal, and wound care.
Only certain ancillary services such as portable imaging (X-rays, ultrasound including venous duplex), electrocardio- grams, and blood draws are available . Contracted third- party vendors, who are not on-site, provide these services. Typically, the imaging vendor travels to the facility and the test is performed usually within 24 h. Laboratory specimens (urine, stool, blood) are collected by the facility nurse or by a phlebotomist from the outside lab where the samples are processed. Typically, specimen collection occurs in the morn- ings on weekdays only, and, for most part, there is a possibil- ity of a “STAT” order to be placed usually taking more than couple of hours and limited to business hours on weekdays. It is not uncommon for nursing facilities to receive post-hospital discharge instructions for blood test on weekend, and that is, by default, not available. Diagnostics or procedures requiring to be performed within half or 1 h are not possible in the nursing facility setting and require transfer to the local emer- gency department .
Transfusions, IV chemotherapy, hemodialysis, BiPAP ini- tiation, continuous telemetry, and minor surgeries are typi- cally not performed at SNFs  (Table 5.3).
Star Rating System: Understanding Quality Among Facilities
Through public reporting of performance, in order to encourage nursing facilities to pursue higher quality and to assist consumers decide between facilities, the Centers for Medicare and Medicaid Services (CMS) maintains a website comparing ratings among the facilities. This information, the “Nursing Home Compare,” can be found by searching for facilities by location or name at http://www.medicare.gov/ nursinghomecompare/.
A five-star rating system incorporates health inspections, quality measures, and staffing into an overall score [2, 18].
Chapter 5. ER Referrals and Hospitalizations… 87
Some access to
In average, 3 h/day
In average, 3 h/day
At least 5 h/day
Table 5.3 Care and services available at different types of nursing facilities
Provided primarily nursing assistants certified in long-term nonprofessional care with LPN and by CNAs and
Available 24 h
Available 24 h
Available 24 h
by CNAs and
nursing assistants certified in long-term
(RNs) certified in rehabilitation
care with LPN and
is no physician
Typically, there is no
Acute rehab Provided Table 5.3 (continued) Physician Service
physiatrists Available 24 h
Provided primarily by
geriatric and internal
by geriatric, internal
Obs: Psychology and
podiatry consults are
Medicare requires or family medicine evaluation every physicians 60 days
or family medicine
Care typically one to
Obs: Psychology and podiatry consults are
contracted service by
orders can take more Services offered per done by request availability. “STAT” contracted agencies without urgent than few hours
Chapter 5. ER Referrals and Hospitalizations…
Services offered per contracted agencies. Done by request
orders can take more availability “STAT” without urgent than few hours
90 F. Heitor
This information, readily available, gives each nursing facility a rating between one and five stars. Facilities with five stars are considered to have quality “much above average,” whereas a one-star rating is considered “much below average.”
Multiple factors account for the rating. Since the website launching in 1998, the type and amount of information pro- vided have substantially increased, and one of the main criti- cisms is that the results are heavily based on self-reported data. The website information reflects results from state health inspection database and staffing ratios plus quality measures as reported by the facilities themselves. It is also possible to find reports pertaining federal sanctions imposed by CMS against facilities cited with deficiencies due to violat- ing federal standards of care .
CMS reports 18 different quality measures derived from resident assessments conducted by the facilities and submit- ted to CMS. These qualities measures derive from Minimum Data Set (MDS), a national database with assessments done by the facility, on every resident, at regular intervals. The data reflects each resident’s health, physical functioning, mental status, and general well-being and is used by the nursing facil- ity to assess each resident’s needs and to develop a plan of care. The rating system is very complex, and half of the 18 measures are not at all used to calculate the rating, with a drawback that the distribution of ratings for quality measures is “allowed to shift” with three of the nine measures (catheter, the long-stay pain measure, and short-stay pressure ulcers) being risk-adjusted .
Furthermore, an obvious limitation, as disclosed on CMS data sources: “All of these data are reported by the nursing homes themselves. Nursing home inspectors review it, but don’t formally check it to ensure accuracy… The information should be interpreted cautiously and used along with infor- mation from the Long Term Care Ombudsman’s office, the State Survey Agency, or other sources.” 
Another data source is the Medicare claims data. It utilizes invoices submitted to Medicare by nursing facilities and hos-
Chapter 5. ER Referrals and Hospitalizations… 91
pitals for payment purposes and is used to calculate hospital readmission rate, emergency room visits, and discharges . Health inspection surveys are conducted though a feder- ally validated protocol by state agencies and visits occur unannounced each year. Inspections take into account com- plaint investigations conducted during the three most recent
state inspections [19, 20].
The inspection report by the Department of Health and
Human Services lists deficiencies as “F-Tags,” according to the potential level of harm, along with a summary statement of the deficiency. These deficiencies can vary tremendously. They might be seemingly minor (e.g., “observed healthcare cook in the kitchen drying drops of liquid in a blender bowl with a paper towel – the bowl should have been air dried. This then generates a “tag” with the report “based on obser- vation, interview, and record review, the facility failed to ensure food was prepared under sanitary conditions by fail- ing to air-dry blender bowl” – this impacts on the star rat- ing). Deficiency might carry potentially worse outcomes (e.g., “failing to have a program that investigates, controls, and keeps infection from spreading” – as in observing some- one not washing hands or not using gloves for a wound dressing change).
All the detailed information is publically and readily avail- able at the CMS website under health inspections, “most recent standard health inspection” full report (Fig. 5.1).
Practices and Procedures: Understanding Treatment Limitations at Nursing Facilities
There is a pervasive myth that nursing facilities are like hos- pital facilities. While skilled nursing and long-term care facili- ties are able to offer some extent of in-depth medical care, they are primarily resident and communities directed and focus on promoting autonomy and choice in a less structured environment, striving for a more residential type of atmo- sphere .
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Nursing Homes reported quality
0% 5% 10% 15% 20% 25% 30%
Nursing Homes reported quality
Figure 5.1 Comparison of star ratings between nursing facilities and state inspections. Nursing facilities’ self-reported rating tends to be higher compared to state health inspection scores. Note: Composite score including only nursing homes certified by either Medicare or Medicaid. (Source: Kaiser Family Foundation analysis of Nursing Home Compare date, February 2015. https://kaiserfami- lyfoundation.files.wordpress.com/2015/05/8726-figure-3.png)
Some medical care limitations include restrictions of high- risk medications such as sedatives, hypnotics, and antipsy- chotics and strict regulation to complete elimination of physical restraints (any mechanical of physical device, mate- rial, or equipment attached to of adjacent to the resident’s body, restricting freedom of movement and normal access to their body). There is sufficient empirical evidence that, in many cases, physical restraints cause more harm than benefit and there is increasingly focus on ethical care at nursing facilities. Furthermore, federal and state laws, along with nursing facility advocates, have significantly curbed the use of such therapies. The target is to address alternatives to the need of restraints, either physical or pharmacological, by increasing supervision and providing specialized attention in order to suit each individual needs .
As noted in multiple studies, falls do not warrants the use of a physical restraint even though restraints have been
Chapter 5. ER Referrals and Hospitalizations… 93
traditionally used as a fall prevention approach. As evidence shows, restraints have serious drawbacks and can contribute to serious injuries. There is no good evidence that the use of physical restraints, including but not limited to side rails or bed alarms, will prevent or reduce falls in nursing facilities. Additionally, falls that occur while a person is physically restrained often result in more severe injuries [23–26].
Nursing facilities do not have on-site pharmacy.
For instance, upon admission to a nursing facility, a patient might not have any medication available for hours (until medications verified by nurse, by admitting physi- cian, requested in pharmacy, order completed, and delivered to facility). Having this in mind, it is essential to take into account that, before referring a patient to a nursing facility, it is very important to give the patient any soon upcoming scheduled meds prior to patient leaving the hospital (espe- cially antibiotics, pain control, or time-sensitive medications). Medications are provided by a vendor pharmacy. A consul- tant pharmacist reviews medication use, and there is an increasing focus to encourage residents and families to par- ticipate in care planning meetings at the facility and to raise any concerns regarding medication schedules. Facility nurses also play an invaluable role in monitoring and giving feed-
back about medication appropriateness.
Nursing homes do carry “emergency kits” designed to pro-
vide certain medications to residents during emergency situ- ations only. Federal and state laws regulate procedure and requirements for the kits and noncompliance results in Drug Enforcement Administration (DEA) audits. These emer- gency kits contain only a small quantity of medications to be dispensed when pharmacy services are not available. The contents of the kit need to be in accordance with facility poli- cies and procedures and are determined in consultation with the pharmacist and the facility’s medical director and director of nursing (DON).
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There are increasing concerns and scrutiny regarding the use of high-risk or psychotropic medications at nursing facili- ties. The federal government implemented, in 2012, a pro- gram to reduce the use of antipsychotics in such facilities – The “National Partnership to Improve Dementia Care in Nursing Homes” . This resulted in a decline of such medication use to about a third nationwide (from 23.9% of residents in 2012 to about 15.7% in 2017) . Further decline is expected, and the Centers for Medicare and Medicaid Services (CMS) has a goal of an additional 15% reduction of antipsychotic medication use by 2019 [27, 28].
Controlled medications do require a valid prescription in order to be dispensed at nursing facilities. So, upon admission to a skilled nursing facility (SNF), if a patient does not have a valid prescription from hospital discharge, invariably there will be delays in obtaining such treatment.
On November 2017, the CMS implemented several regula- tory changes including significant limitations on the use of PRN or “as needed” psychotropics. Per CMS, psychotropic is “any drug that affects brain activities associated with men- tal processes and behavior.” This definition encompasses antipsychotics, antidepressants, anxiolytics, and hypnotics. Nonetheless, in addition to these medication classes, state surveyors also consider other drugs that may affect brain activity as psychotropics: mood stabilizers, anticonvulsants, muscle relaxants, anticholinergics, antihistamines, NMDA receptor modulators, and over-the-counter or natural or herbal products (such as melatonin).
The CMS has placed a 14-day limit on the duration of PRN psychotropic medications. For continuation of use, the order needs to be extended by the attending physician with documentation of clinical rationale for extension along with providing specific duration of use. For antipsy- chotics, the 14-day limit may not be extended, and instead a new order needs to be placed with documentation of rationale and benefit. There are no exceptions for hospice residents .
Chapter 5. ER Referrals and Hospitalizations… 95 Putting It All in Perspective
The term “frequent flyer” is well known to medical staff, and, contrary to the beneficial association pertaining to the airline industry, the implications of recurring hospitalizations are stressful, costly, and dangerous. Nonetheless, avoiding re- hospitalizations and the “super utilizers” is not a straightfor- ward task, but there is certainly room for improvement in averting what is indeed avoidable.
Potentially avoidable hospitalizations are defined as hospi- tal admissions that could have been warded off if the condi- tion was timely prevented or treated outside of the emergency room or an inpatient hospital setting.
A CMS research in long-term care (LTC) facilities revealed that about 45% of hospital admissions among individuals receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005 .
Per data from the National Nursing Home Survey, fever, chest pain, heart disease (mainly heart failure), mental status changes, gastrointestinal bleeding, urinary tract infections, metabolic disturbances, pneumonia, diseases of the skin, and injuries due to falls have been identified as reasons for potentially preventable visits to an ED. Furthermore, injuries from falls were the most common conditions accounting for potentially preventable ED visits by nursing home residents (Fig. 5.2).
When evaluating factors involved in re-hospitalizations, it is important to take into account that nursing facility resi- dents often have multi-comorbidities, and not always appro- priate resources are available at such facilities to proper manage complications or changes in baseline health status. Sometimes, for patient safety, a transfer to the ED is truly unavoidable but hospitalization could be prevented. For instance, if a nursing home resident who is on Coumadin has a fall with associated head injury, mostly universally there will
96 F. Heitor
Fall injuries (36%) Heart Conditions (19%) Pneumonia (12%) Other (33%)
Figure 5.2 Conditions related to potentially preventable ED visits by nursing home residents in a 90-day period . (Other: fever, mental status changes, gastrointestinal bleeding, urinary tract infec- tions, metabolic disturbances, and diseases of the skin). (Source: CDC/NCHS, National Nursing Home Survey 2004)
be a transfer to the closest ED. For most part, a CT scan of the brain for intracranial bleeding assessment is expected, and, once hemorrhage is ruled out, considering that patient is at “baseline”, the nursing facility will be ready to accept the patient back. However, many times the patient ends up being hospitalized and multiple work ups are conducted. In this case, there is a true opportunity to avoid re-hospitalization since, for most part, the patient was at baseline health status, and, likely, workups for possible underlying issues might have already been done at the nursing facility (e.g., urinalysis, blood tests). Unfortunately due to gaps in communication and limitations of medical records continuity, many investiga- tions ended up being duplicated many times unnecessarily. With this in mind, it is of extreme importance a good com- munication between providers regarding patient status and treatment expectations.
A decision to whether or not refer a nursing facility resi- dent to hospital is multifactorial and often an imprecise pro- cess influenced by the patient’s medical needs, rights, and probable outcomes, as well as the limitations of care in the
Chapter 5. ER Referrals and Hospitalizations… 97
nursing facility and outside social pressures, such as family wishes and financial costs .
There are many programs and initiatives geared toward improving potentially preventable hospitalizations. North- western Memorial Hospital in Chicago has an initiative, as part of GEDI WISE (Geriatric Emergency Department Innovations through Workforce, Informatics, and Structural Enhancements), a Health Care Innovation Award funded by CMS, to reduce hospitalizations by providing geriatric-specific care to older patients. This effort is based on a multidisciplinary approach to elder care with interventions by geriatric specialized nurse practitioners and social workers at the emergency department, advocating for elderly patients, without urgent medical need, to be redirected back home with a proper follow-up plan.
Indiana University has also a project, OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care), aimed to lower the number of unnecessary hospitalizations by recognizing medical conditions in patients early, improv- ing communication when transfers to hospitals do need to occur and improving advance care planning for terminally ill patients .
The INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to assist skilled nursing facilities with early identification, assessment, intervention, documentation, and communication of changes in a resident’s condition. The effective implementation of this program has been associated with significant reductions in hospitalizations of nursing facilities’ residents. Better commu- nication and increasing familiarity with this program are the most important steps for its success over time .
Overall, there is a robust body of evidence that, to reduce avoidable hospitalizations, there is a need to improve support for nursing facility infrastructure, clinical practice, and com- munication tools for health professionals, increased attention to reducing the frequency of medically futile care, and finan- cial and other incentives for NHs and their affiliated hospitals to improve care .
98 F. Heitor
The recurrent hospitalizations on the vignette initially pre- sented illustrate a problematic issue of many layers. Ms. M’s recurrent readmissions could have been prevented by better communication between facilities and healthcare providers. Furthermore, the transitions of care resulted in another potential risk factor for her health, polypharmacy.
Ms. “M’s” medication regimen was improved with discontinu- ation of Clonazepam and Ambien. Sertraline was continued and patient’s mentation slowly improved. She was offered psychology consult at the SNF, and, along with close follow- ups by the attending physician, a clear plan of care was estab- lished with nurse education in the event of large volume hemoptysis and close monitoring of blood counts with outpa- tient blood transfusions as appropriate. Eventually, after ongoing discussions and poor progress on rehabilitation therapy, the patient requested hospice consult and soon after was discharged home under hospice care.
1. Christine Caffrey, CDC Potentially preventable emergency department visits by nursing home residents: Untied States, 2004, NCHS Data Brief, No. 33 (April 2010); http://www.cdc.gov/nchs/ data/databriefs/db33.pdf. Accessed Feb 2018.
2. Huded J, Heitor F. Skilled nursing facilities and post- hospitalization options for older adults. In: Lindquist L, editor. New directions in geriatric medicine. Cham: Springer; 2016.
3. https://www.medicare.gov/coverage/long-term-care.html. Accessed Feb 2018.
4. https://www.caring.com/articles/assisted-living-vs-nursing-home- care. Accessed Feb 2018.
Chapter 5. ER Referrals and Hospitalizations… 99
5. Centers for Medicare & Medicaid Services’ (CMS) Nursing Home Data Compendium, 11th Edition 2015; CMS.gov;https:// http://www.cms.gov/Medicare/ProviderEnrollmentandCertification/ CertificationandComplianc/Downloads/nursinghomedatacom- pendium_508-2015.pdf; Accessed Feb 2018. https://www.census. gov/programs-surveys/popest.html. Accessed Feb 2018.
6. U.S. Centers for Medicare and Medicaid Services, prepared by Abt Associates Inc. Appropriateness of minimum nurse staffing ratios in nursing homes. Report to Congress: Phase II final (Vol. I–III). Baltimore, MD. 2001.
7. Abt Associates Inc. Nursing home staffing study TEP presenta- tion. Prepared for the CMS Medicare nursing home compare 5-star TEP panel. Durham: Abt Associates; 2011.
8. Nursing home staffing standards in state statutes and regula- tions; Charlene Harrington. Ph.D., R.N.; Department of Social and Behavioral Sciences; University of California San Francisco; December 2010. http://theconsumervoice.org/uploads/files/ issues/Harrington-state-staffing-table-2010.pdf
9. Harrington C, Schnelle JF, McGregor M, Simmons SF. The need for higher minimum staffing standards in U.S nursing homes. Health Serv Insights. 2016;9:13–9. https://doi.org/10.4137/HSI. S38994.
10. Harrington C, Choiniere J, Goldmann M, Jacobsen FF, Lloyd L, McGregor M, Stamatopoulos V, Szebehely M. Nursing home staffing standards and staffing levels in six coun- tries. J Nurs Scholarsh. 2012;44:88–98. https://doi.org/10.111 1/j.1547-5069.20 11.0 1430.
11. Harrington C, Carrillo H, Blank BW, O’Brian T. Nursing facili- ties, staffing, residents, and facility deficiencies, 2005–10. San Francisco: University of California; 2011.
12. Lin H. Revisiting the relationship between nurse staffing and quality of care in nursing homes: an instrumental variables approach. J Health Econ. 2014;37:13–24.
13. http://theconsumervoice.org/betterstaffing. Accessed Feb 2018.
14. Federal law and regulations on nurse staffing issues; Nursing Home Reform Act of 1987. http://theconsumervoice.org/uploads/ files/issues/Federal-Law-Regulations-Final.pdf. Accessed Feb
Accessed Feb 2018.
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16. e-CFR: electronic code of federal regulation, part 483 – https:// http://www.ecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/Title42/42cfr483_ main_02.tpl. Accessed Feb 2018.
17. Dimant J. Roles and responsibilities of attending physicians in skilled nursing facilities. J Am Med Dir Assoc. 4(4):231–43.
18. http://www.medicare.gov/nursinghomecompare/. Accessed Feb 2018.
19. Center for Medicare Advocacy, The myth of improved quality in nursing home care: setting the record straight again. April 2014. Thomas, K.
20. https://www.medicare.gov/nursinghomecompare/Data/Data- Sources.html. Accessed Feb 2018.
21. https://careconversations.org/skilled-nursing-care-fact-vs-myth. Accessed Feb 2018.
22. Gastmans C, Milisen K. Use of physical restraint in nursing homes: clinical-ethical considerations. J Med Ethics. 2006;32(3):148–52. https://doi.org/10.1136/jme.2005.012708.
23. https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/downloads/ SCLetter07-22.pdf. Accessed Feb 2018.
24. Neufeld RR, Libow LS, Foley WJ, Dunbar JM, Cohen C, Breuer B. Restraint reduction reduces serious injuries among nursing home residents. J Am Geriatr Soc. 1999;47:1202–7.
25. Si M, Neufeld RR, Dunbar J. Removal of bedrails on a short-term nursing home rehabilitation unit. Gerontologist. 1999;39:611–4.
26. Tinetti ME, Liu YB, Ginter S. Mechanical restraint use and fall related injuries among residents of skilled nursing facilities. Ann Intern Med. 1992;116:369–74.
27. https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/SurveyCertificationGenInfo/National- Partnership-to-Improve-Dementia-Care-in-Nursing-Homes. html. Accessed Feb 2018.
28. Risky antipsychotic drugs still overprescribed in nursing homes, NPR Shots, February 5, 2018. https://www.npr.org/sections/ health-shots/2018/02/05/583435517/risky-antipsychotic-drugs- still-overprescribed-in-nursing-homes. Accessed Feb 2018.
29. https://www.cms.gov/Outreach-and-Education/Outreach/NPC/ D o w n l o a d s / 2 0 1 7- 0 9 – 0 7- D e m e n t i a – C a r e – i n – N u r s i n g – H o m e s – C a l l – Presentation.pdf. Accessed Feb 2018.
30. https://innovation.cms.gov/initiatives/rahnfr/. Accessed Feb 2018.
31. Potentially Preventable Emergency Department Visits by Nursing Home Residents: United States, 2004 – NCHS Data
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Brief, No. 33, April 2010; Christine Caffrey, ph.d., division of
health care statistics.
gency-room-visits-among-elderly-patients/. Accessed Feb 2018.
33. Cohen-Mans eld J, Lipson S. To hospitalize or not to hospitalize? That is the question: an analysis of decision making in the nurs-
ing home. Behav Med. 2006;2(2):64–70.
34. Ouslander JG, Bonner A, Herndon L, Shutes J. The INTERACT
quality improvement program: an overview for medical direc- tors and primary care clinicians in long-term care. J Am Med Dir Assoc. 2014;15(3):162–70. https://doi.org/10.1016/j. jamda.2013.12.005.
35. Ouslander JG, Lamb G, Perloe M, Givens JH, Kluge L, Rutland T, et al. Potentially avoidable hospitalizations in nursing home residents: frequency, causes, and costs. J Am Geriatr Soc. 2010;58(4):627–35.
Can Home Visits Make
a Difference to Emergency Department Visits? “I will just stop by his place on the way home: Who knew it would
be a journey?”
Dwayne Dobschuetz and Katherine O’Brien
The first, second, and third time I met Jim was in the emer- gency department. His diagnoses after those initial visits were always the same: chest pain, syncope, or simply “I had too much to drink.” After the third visit, I completed a geri- atric assessment, in which I found him to be malnourished, socially isolated, and a Vietnam vet. When it came time for a follow-up phone call, I found that he did not have a phone number listed. I looked up his given address and found that he was nearby. Rather than simply writing it off, I felt that I could simply stop by the address on my bike ride home. The address was a bar and he had mentioned that he lived above.
D. Dobschuetz (*) · K. O’Brien
Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern Medicine Home Care Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
e-mail: firstname.lastname@example.org; Katherine.email@example.com
© Springer Nature Switzerland AG 2019 103 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_6
104 D. Dobschuetz and K. O’Brien
When I arrived, I asked where the apartments were, and the bartender said that there were no apartments. They then quizzed me more, and I identified myself as a nurse, and someone finally exclaimed, “Oh, you mean Jim.” His ethnic name didn’t translate and so everyone just called him that. I then was led up to his studio apartment and found the door open. I stepped in and sucked in air. It was an eye-opening experience to say the least. Dishes filled the counter. There was paper and trash strewn around the kitchenette area. Everything was in disarray. I didn’t look in every area of the living space, as I didn’t want to invade his privacy. The apart- ment’s appearance did not improve with the second visit. Books were piled up and clutter was everywhere. I was able to complete a physical exam on Jim and tried to do a com- prehensive geriatric assessment. I noticed that his medica- tions were lined up neatly on a table; these medications seemed to be the only part of his medical care that he was compliant with. At this point, I tried to reach out to his VA provider but never heard back from him. In all of his 13 visits to the ED or admissions to our hospital over the previ- ous 6 months, I was unable to find any contact made with “his” physician. He had a pacemaker, but the only time that it was ever evaluated was when he had been admitted to the hospital. In the process of leaving Jim, the owner of the bar and the building approached and asked to speak with me, and she shared some information about his social history. He had been a resident there for the past 10 years. He was becoming increasingly withdrawn from his family, calling them only infrequently and not even seeing them at holi- days. He had two older brothers who did not live in the city. I left my card and number and stated that Jim needed more help and that I would try and find some type of assistance for him.
A month passed and I received a call from the bar owner, just as I had contemplated another visit. She expressed her concern over his most recent hospitalization. I looked it up and didn’t find it. Our hospital had been on bypass, and as a
Chapter 6. Can Home Visits Make a Difference… 105
result, Jim was diverted to a nearby hospital where he was admitted for several days and treated for dehydration. I real- ized then that the hospital encounters I had numbered were only a small percentage of his encounters with the health- care system. He was being admitted to other hospitals depending on when and where he called 911. The owner was distraught over the possibility that she or one of her employ- ees would find him dead in the apartment. The only reason that anyone knew of his difficulty this time was that he had left his door ajar and someone saw him staggering and falling to the floor, prompting a call to 911. When I arrived for a follow-up, I found his vitals were normal, reactions fine, and no pain or difficulties encountered except for some hesitancy going up the stairs. This time I noticed, in addition to the nor- mal mess, many chicken bones and whiskey bottles lying on the floor. I picked up a bottle and didn’t even recognize the brand. It was a gallon jug. “It costs $15.95 at Walgreens” was his response when queried. “Someone broke into my place while I was gone and trashed the place.” I explained that other than the whiskey bottles, it didn’t look any different. I shared that everyone was concerned for his well-being and that he needed help if he was to remain living on his own. He agreed, stating that he seldom went further than to McDonald’s for food and to the Walgreens for liquor. The bar was no longer letting him in, not wanting to contribute to his ongoing condition.
Contacting protective services was my next step along with talking to one of his brothers who told me “Jim tells me that he only has two drinks per night.” Jim’s brother then stated that “they must be half-bottle glasses!” When I recontacted the agency for follow-up, I was referred to another agency that did the home safety check. However, they could not tell me the results of the evaluation, stating “patient confidential- ity.” I was told I could find out only from Jim himself. The owner told me later that two people had come by but had not spoken with her for any confirmation. She was frustrated that nothing had occurred after the evaluation.
106 D. Dobschuetz and K. O’Brien
Since I had not made much progress, I decided to call the VA to determine if there were any available resources for him. Phone tag ensued with the social worker assigned to him. Later, I even called the patient hot line but was told, “we will contact his doctor.” Obviously, I needed to redou- ble my efforts with contacting his doctor and the agencies themselves. To compound the problem, the owner told me that the previous weekend Jim had stood outside his apart- ment and urinated in the hallway. The situation was growing worse.
On another visit, 4 months after my initial contact, Jim himself gave me the name of the initial evaluator who had come to see him and gave me permission to contact him. The evaluator had found him decisional and found there was little that he could offer as a result. I was more than discouraged with this information, but several days later, I ran into a resident physician who worked at the VA. He directed me to a contact that had cared for Jim in the VA clinic. The resident physician then shared the frustration that their clinic had with Jim’s compliance with care, stating missed appointments and poor follow-through. I felt that I was at an end.
Several days later, I received a call from the VA social worker, who set Jim up with a housekeeper service which began to call on him twice a week. I noticed an almost immediate change in his environment. At this point she also set up several follow-up appointments that he kept, giving me hope that he might finally be turning a corner. It didn’t con- tinue. The housekeeping service lasted probably a month until he no longer answered his door or his phone and the service finally stopped coming.
Each time Jim was admitted, I would go to see him in the hospital. He would be eating as much as he could and receiving IV fluids for rehydration. He would be discharged with no change in his condition at home. He would continue to eat just enough to keep him alive, smoke two to three packs of cigarettes per day, and live in squalor, wearing the
Chapter 6. Can Home Visits Make a Difference… 107
same filthy clothes day after day. I almost jumped for joy when I found that after another visit to a nearby hospital, he was admitted to a subacute rehab facility for a brief stay after a fall. I tried to enlist their help to transition him to a facility for long-term care, but once again, I did not make any progress. It was at this point that I contacted the social worker at the VA to see if there might be a long-term VA facility where he could reside. I received a long formal appli- cation for a state facility, which seemed an answer to his care needs. I started to help him with the application until I was told by a social worker, who saw him on a recent admis- sion, that he did not want to move out of Chicago where he had lived for over 40 years.
While it had become increasing difficult for me to even stop by his apartment, I was astounded by the continued welcome from the owner of the building and the various bartenders. They continually expressed gratitude for my will- ingness to follow up with Jim. They felt I shared their con- cern for him and recognized that I was trying to do something. In my most recent encounter, Jim recounted that in January, he had been patting himself on the back for stay- ing out of the hospital for a month but then related that he had been back four times in February. He admitted that it was becoming increasingly difficult for him to manage and that he was no longer even taking his medications. He had run out. I told him that I would try again to coordinate with the various clinics and services to help him be in a place that would keep him healthy, but it would require his cooperation and buy-in.
I thought that by my visiting Jim at home, I could make a difference. Most of the time I felt discouraged by the lack of results from my attempts at care. Little did I realize the potential impact my visits could have upon his hospitaliza- tions. It has proved to be a test of perseverance and a lesson in the importance of individual responsibility and readiness that must be shared by the individual with whom we hope to assist.
108 D. Dobschuetz and K. O’Brien
The Score Card for “Jim”
July 2016–February 2017 6 months before intervention 13 Northwestern Medicine Encounters
3 ED visits
10 Hospital Admissions
No Home Visits
February 2017–February 2018 12 months after initia- tion of Home Visits
15 Northwestern Medicine Encounters
4 ED Visits
11 Hospital Admissions
7 Home Visits with APRN/No other Primary Visits
Conclusion: I should have visited more!
The Case for a Home-Based Primary Care Program Connected from a Geriatrics Emergency Department
The population of aging homebound patients is growing at an astonishing rate. The census bureau projects that by the year 2050, the population of age 65 and older will double and those age 85 and older will quadruple . About 5.6% (2 million) of the Medicare community population are completely or mostly homebound [2, 3]. Medicare enrollment is also projected to increase by more than 50% by 2030 . Those in need of per- sonal assistance with everyday activities increase from just under 10% of those in their late 60s to 20% of those 75–79 to over half of those 85 and older . In its present form, the US health-care system focuses resources on hospitals and nursing homes, which leads to massive displacement and suffering of our oldest old. Change will require a major overhaul of cur- rent practice patterns and social service provision. If we respect the values and preferences of our older adults to help
Chapter 6. Can Home Visits Make a Difference… 109
facilitate care within the home, this system redesign will emphasize services that allow frail and chronically ill citizens the choice to live at home as long as possible.
Defining Community-Based Home-Based Primary Care (HBPC)
HBPC is an interdisciplinary-based team model, which brings traditional clinic- and hospital-based practitioners to the home, addresses multiple domains of care, and involves a great deal of care coordination. HBPC is different from tradi- tional home health care, which typically addresses an acute need, such as physical therapy. Typically, the interdisciplinary HBPC team consists of health-care providers and community partners, working in conjunction with both the patient and their caregivers. Successful HBPC programs are typically truly integrated and include a wide variety of specialists including physicians, pharmacists, social workers, advanced practice providers, physical and occupational therapists, and dieticians . The interdisciplinary team is critical for the suc- cess of HBPC, as a complete assessment spans many areas including medical history and plan of care, nutritional status, functional status, cognitive status, medications, equipment, mental health, caregiver support and evaluation of caregiver burnout, safety, health maintenance, advanced care planning and goals of care, spiritual needs, and financial needs. HBPC addresses our most vulnerable patient populations: those who have functional, cognitive, and/or social impairments, who are dealing with multiple chronic conditions, who are at the end of life, and who are estimated to be half of the costli- est 5% of patients .
Benefits of Home-Based Primary Care
Home-based primary care has been demonstrated to have beneficial effects on the health-care system, patients, and
110 D. Dobschuetz and K. O’Brien
providers. Interventions targeted at the highest-need and highest-cost patients have the potential to produce sizeable financial benefits. In a large case control study, patients fol- lowed by one HBPC team had 17% lower Medicare costs (about $8477 less per beneficiary) over a 2-year follow-up period . In another study of a VA-based HBPC program, there was a 16.7% annual reduction in VA costs, 10.8% annual reduction in Medicare costs, and a 13.4% annual reduction in combined VA and Medicare costs. Not only were costs reduced, but there was a 25.5% reduction in hos- pital admissions and a 36.5% reduction in hospital days . Other studies have demonstrated a decrease in the number of emergency department visits, the total number of readmis- sions, the time between discharge and readmission, as well as a decreased in the overall number and number of bed days of admissions to long-term care facilities [6, 10]. Finally, the data from Independence at Home Project, which is a CMS- sponsored demonstration involving multiple HBPC practices, provided evidence for decreased readmissions to the hospital, reduced costs to the system, allowed patients to remain at home, and overall improved care . In addition to benefits to the system, there is evidence that HBPC practices provide benefit to patients that goes beyond the traditional clinic settings. Qualitative data has shown improved satisfaction from veterans enrolled in HBPC programs through the VA system. These veterans felt that HBPC helped to prevent hospitalizations, continue living at home, and gain access to care that they might not otherwise receive . In another qualitative review from a large, academic-based HBPC pro- gram, patients described multiple benefits of HBPC including access to providers, affordability (i.e., not having to finan- cially afford transportation to and from clinics), facilitating care coordination, and improved ability to remain at home . Finally, from a provider standpoint, the team approach to patient care that HBPC improves physician satisfaction . In addition, the case described above particularly demon- strates some of the valuable information that can be gleaned from a house call that one cannot uncover via traditional care
Chapter 6. Can Home Visits Make a Difference… 111
settings. Discovering the disarray of the home of the patient described above, as well as the state of his nutritional intake and substance use, provided important information to his provider to help further his care. Only within the home is the care team truly able to observe their patient functioning in their own environment, which traditional functional assess- ments cannot fully capture. As the health-care system shifts toward a value-based model, HBPC will continue to grow in importance as it is a successful way to provide high-level, quality care to the most complex patients.
After a typical emergency room visit, most providers recom- mend close follow-up for the patient with their primary care provider. Frustration can occur when these highly complex patients continually return to the emergency room without following through with the recommended follow-up. One issue may be that these patients are unable to access care. This is where HBPC can be invaluable, and emergency room providers can work to connect patients with HBPC programs. As demonstrated above, HBPC has the potential to reduce emergency room visits, admissions, and readmissions if imple- mented successfully. In summary, the rapid rate of growth of the elderly population, with many being homebound, justifies the need to transform the emphasis on traditional clinic and hospital-based care. Home-based primary care is an answer to this need and has demonstrated benefits for the system, patient, and providers.
2. Shafir A, Garrigues SK, Schenker Y, Leff B. Homebound patient and caregiver perceptions of quality of care in home-based pri- mary care: a qualitative study. J Am Geriatr Soc. 2016;64(8):
112 D. Dobschuetz and K. O’Brien
3. Ornstein K, Leff B, Covinsky KE, et al. Epidemiology of the homebound population in the United States. JAMA Intern Med. 20 15;175(7):1180–6.
4. Medicare provider utilization and payment data: physician and other supplier. Centers for Medicare & Medicaid Services web- site. https://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/ Physician-and-Other-Supplier.html. Updated 6 June 2017.
6. Stall N, Nowaczynski M, Sinha S. Systematic review of outcomes from home-based primary care programs for homebound older
adults. J Am Geriatr Soc. 2014;62(12):2243–50.
7. Cohen S. The concentration of health care expenditures and
related expenses for costly medical conditions, 2012. Statistical Brief #455. Agency for Healthcare Research and Quality. 2014. http://www.meps.ahrq.gov/mepsweb/data_files/publications/ st455/stat455.pdf.
8. De Jonge KE, Jamshed N, Gilden D, Kubisiak J, Bruce SR, Taler G. Effects of home-based primary care on Medicare costs in high-risk elders. J Am Geriatr Soc. 2014;62(10):1825–31.
9. Edes T, Kinosian B, Vukovic NH, Nichols LO, Becker MM, Hossain M. Better access, quality, and cost for clinically com- plex veterans with home-based primary care. J Am Geriatr Soc. 20 14;62(10):1954–61.
10. Naylor M, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. J Am Med Assoc. 1999;281(7):613–20.
11. Rotenberg J, Kinosian B, Boling P, Taler G. Home-based primary care: beyond extension of the Independence at home demon- stration. J Am Geriatr Soc. 2018;66(4):812–7.
12. Reckrey, et al. The team approach to home-based primary care: restructuring care to meet patient, program and system needs. J Am Geriatr Soc. 2015;63(2):358–64.
Medication Errors in Aging Adults: A Case-Based Approach to Medication Management
Abbie Lyden and Katherine Allen
An 82-year-old female with a history of atrial fibrillation, hypertension, chronic kidney disease, dementia, fibromy- algia, and insomnia presents to the emergency depart- ment (ED) by ambulance from a skilled nursing facility after an unwitnessed fall. Facility staff states that she was found on her bedroom floor and unable to get up. At baseline, she ambulates without assistance. Per records, she was recently diagnosed with a urinary tract infection and was started on trimethoprim-sulfamethoxazole. The facility reports she has had decreased oral intake recently.
A. Lyden (*)
Northwestern Medicine, Department of Pharmacy, Department of Emergency Medicine, Department of Pharmacy Practice, Rosalind Franklin University of Medicine and Science, Chicago, IL, USA e-mail: firstname.lastname@example.org
Department of Pharmacy, Department of Emergency Medicine, Northwestern Medicine, Chicago, IL, USA
© Springer Nature Switzerland AG 2019 113 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_7
114 A. Lyden and K. Allen
Her medication list includes tramadol (100 mg q6hr, recently started for fibromyalgia), warfarin (2 mg daily), diazepam (10 mg nightly for insomnia), lisinopril (5 mg BID), ferrous sulfate (325 mg BID), aspirin (81 mg daily), amlodipine (10 mg daily), and ibuprofen (600 mg q6hr prn, uses approximately twice per day per facility staff).
Initial vital signs: T 99.1F, HR 70, BP 130/90, RR 16, and SpO2 98% on room air.
She is oriented to self only (which is her baseline per facility staff). Her workup is remarkable for an elevated INR of 4.2, serum creatinine 2.4 mg/dL, and BUN 52 mg/dL. In the ED, she is diagnosed with prerenal acute kidney injury (AKI). All other workup is nega- tive; there is no evidence of bleeding and no musculo- skeletal findings from the fall. In the ED she receives IV fluids and is admitted for AKI. During her hospital stay, her antibiotic is changed to cephalexin, and her INR trends down to goal (2–3). Her ibuprofen is discontin- ued as it likely contributed to AKI, particularly in the setting of decreased oral intake. Her tramadol dose is decreased and dosed appropriately for her AKI.
Medication therapy is among the most widely used and highly valued interventions for treating diseases in aging adults given the potential positive impact on quality of life and survival . Yet, these benefits must be balanced with the risk of adverse drug events and resultant ED and hospital visits. In the United States, it was estimated that there were over 99,000 emer- gency hospitalizations for adverse drug events among patients >65 years of age between 2007 and 2009. Two-thirds of these were deemed to be unintentional .
When evaluating a patient’s risk of developing an adverse drug event, polypharmacy must be considered. Polypharmacy
Chapter 7. Medication Errors in Aging Adults… 115
is defined as the use of multiple medications by a patient. The specific cutoffs of numbers of medications associated with polypharmacy range from 5 to 20 but is often described as patients taking 6–9 medications. Excessive polypharmacy has also been described as taking more than ten medications. The presence of polypharmacy has been associated with adverse health outcomes in ED patients .
Greater than 90% of older adults in the ED are taking one or more medications with an average of 4–8 medications. Upon ED discharge, 30–50% are sent home with at least one new prescription . Hospital admission, falls from standing, and fall-related fractures have been associated with polypharmacy in emergency department patients . When prescribing to older adults, ED clinicians should consider the number and type of medications that the patient is already taking so as to avoid polypharmacy whenever possible. It should be noted that most geriatric patients in the ED have multiple disease states and thus many indications for medication therapy, which may require six or more medications. Underprescribing, generally defined as a lack of indicated drug or use of an ineffective dose, may occur due to clinician concern for adverse effects and lead to negative morbidities and quality of life. Clinicians, both in the ED and outpatient, at some times may choose to underpre- scribe to increase medication compliance, limit drug-drug inter- actions, or prioritize the treatment of serious disease states over preventative care. Care must be taken to decrease polyphar- macy yet avoid inappropriate underprescription .
Potentially Inappropriate Medications
and American Geriatrics Society Beers Criteria
In the case presented above, there are several high-risk medica- tions prescribed. For clinicians, it is important to identify these medications and utilize them appropriately or, in some cases, avoid them entirely. Here we will describe resources available to guide clinicians as well as present specific medication classes which when misused can lead to adverse events. Various criteria and approaches for identifying inappropriate medications in the elderly have been utilized, the American Geriatrics Society (AGS) Beers Criteria being the most commonly used method
116 A. Lyden and K. Allen
in the United States . Alternatively, the Drug Burden Index measures exposures to anticholinergic and sedative medica- tions as well as total numbers of medications and daily dosing and is intended to identify drug-related sources of impaired physical and cognitive performance in older people . High drug burden indices have been associated with functional decline in older adults living in the community and an increased risk of falls in long-term care facilities.
The American Geriatrics Society (AGS) Beers Criteria detail potentially inappropriate medications (PIM) for use in older adults and is the most widely cited and utilized method for evaluating appropriate medication use in this population . Initially developed in 1991 for use in the nursing home popula- tion in an attempt to reduce the frequency of medication errors, the Beers Criteria have been updated and released several times, most recently in 2015. The AGS Beers Criteria have been used by the National Committee for Quality Assurance and Pharmacy Quality Alliance to develop the quality measure Use of High-Risk Medications in the Elderly (HRM). The HRM quality measure is utilized by the Centers for Medicare and Medicaid Services to monitor the quality of care delivered to Medicare beneficiaries. A second quality measure, Potentially Harmful Drug-Disease Interactions in the Elderly, was similarly based on the AGS Beers Criteria. The quality measures and Beers Criteria include medications that should be avoided in the elderly along with medications that could exacerbate falls, dementia, and chronic kidney disease.
The most recent Beers Criteria  are divided into several sections/tables, which include lists of (1) potential inappropri- ate medications to avoid for many or most older adults, (2) medications for older adults with specific diseases or syn- dromes to avoid, and (3) medications to be used with caution (Table 7.1). The 2015 Beers Criteria have added on a section of drugs that should be avoided or have their dose adjusted based on an individual’s kidney function as well as a select number of drug-drug interactions that have been associated
Chapter 7. Medication Errors in Aging Adults… 117
Quality of recommendation
Table 7.1 Highlighted potentially inappropriate medications from 2015 Beers Criteria
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as
amine (oral) antihistamines
category, and drugs Anticholinergics
reaction may be appropriate
hypnotic; risk of confusion, dry mouth,
constipation, and other anticholinergic
Use of diphenhydramine in situations
effects or toxicity
such as acute treatment of severe allergic
Organ system, therapeutic
118 A. Lyden and K. Allen
Strength of Quality of recommendation
Avoid, except for
Increase of cerebrovascular accident
Table 7.1 (continued)
category, and drugs
Central nervous system
Avoid antipsychotics for behavior
Avoid in individuals
with creatinine clearance
<30 mL/min or for long-
term suppression of
schizophrenia, bipolar disorder, or short-term
use as antiemetic during
hepatotoxicity, and peripheral neuropathy, especially with long-term use; safer Potential for pulmonary toxicity,
nonpharmacological options (e.g., behavioral
harm to self or others
(stroke) and greater rate of cognitive
decline and mortality in persons with
problems of dementia or delirium unless
interventions) have failed or are not possible
and the older adult is threatening substantial
High rate of physical dependence,
Older adults have increased sensitivity
general, all benzodiazepines increase risk
tolerance to sleep benefits, greater risk
to benzodiazepines and decreased
metabolism of long-acting agents; in
of cognitive impairment, delirium, falls,
fractures, and motor vehicle crashes in
of overdose at low dosages
Medication Errors in Aging Adults…
120 A. Lyden and K. Allen
Quality of recommendation
May be appropriate for seizure disorders, rapid eye movement sleep disorders,
Benzodiazepine receptor agonists
Table 7.1 (continued)
category, and drugs
benzodiazepine withdrawal, ethanol
benzodiazepines in older adults (e.g.,
withdrawal, severe generalized anxiety
disorder, and periprocedural anesthesia
have adverse events similar to those of
hospitalizations; motor vehicle crashes, minimal improvement in sleep latency emergency department visits and delirium, falls, fractures); increased and duration
combination with Chlordiazepox- amitriptyline or
ide (alone or in
Avoid scheduled use
Risk of Clostridium difficile infection
Proton pump inhibitors
Avoid, unless for gastroparesis
for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or
and bone loss and fractures
chronic NSAID use); erosive esophagitis,
hypersecretory pathological condition, or
demonstrated need for
(e.g., due to failure of
trial or H blockers) 2
Can cause extrapyramidal effects,
including tardive dyskinesia; risk may be
greater in frail older adults
Medication Errors in Aging Adults…
122 A. Lyden and K. Allen
Quality of recommendation
Avoid, especially in
Not effective oral analgesic in dosages
category, and drugs
Avoid chronic use, unlessModerate
Increased risk of gastrointestinal bleeding
individuals with chronic
commonly used; may have higher risk of
neurotoxicity, including delirium, than
other alternatives are
not effective and patient
can take gastroprotective
agent (proton pump
inhibitor or misoprostol)
Table 7.1 (continued)
other opioids; safer alternatives available
Non-cyclooxygenase-selective NSAIDs, oral:
but does not eliminate risk. Upper
treated for 1 year; these trends continue
with longer duration of use
or peptic ulcer disease in high-risk groups, parenteral corticosteroids, anticoagulants, pump inhibitor or misoprostol reduces including those aged >75 or taking oral or or antiplatelet agents; use of proton
for 3–6 months and in ~2–4% of patients
gastrointestinal ulcers, gross bleeding, or approximately 1% of patients treated perforation caused by NSAIDs occur in
Organ system, therapeutic
Indomethacin is more likely than other NSAIDs to have adverse CNS effects.
Medication Errors in Aging Adults…
the most adverse effects. Increased risk disease, and acute kidney injury in older Of all the NSAIDs, indomethacin has of gastrointestinal bleeding, peptic ulcer
bleeding, peptic ulcer disease, and acute
anticholinergic adverse effects, sedation,
Increased risk of gastrointestinal
kidney injury in older adults
Most muscle relaxants poorly tolerated
by older adults because some have
increased risk of fractures, effectiveness
at dosages tolerated by older adults
124 A. Lyden and K. Allen
with harm in the aging population. Use of medications included in the Beers Criteria is associated with adverse clini- cal outcomes and increased outpatient visits and hospitaliza- tions, leading to higher costs . In addition, use of medications included in the Beers Criteria by nursing home residents is associated with an increased number of ED visits, hospitaliza- tions, and death [10, 11].
Medications of particular mention in the ED geriatric population include anticoagulants, sedatives, and analgesics, due to increased risk of adverse drug reactions (Table 7.1). NSAIDs can lead to peptic ulcer disease or gastrointestinal bleed, while anticholinergics commonly lead to bladder out- flow obstruction and cognitive impairment. A study that used electronic data to survey adverse drug events (ADEs) associ- ated with emergency department visits for patients ≥65 years of age identified four types of medications (warfarin, insulin, oral antiplatelet agents, and oral hypoglycemics) which accounted for 67.0% of ADEs leading to ED visits .
Specific Classes of Medications
There are multiple factors in the aging population which may increase their likelihood of developing a drug-related prob- lem, which include frailty, coexistent medical problems, issues with memory, and medication use. When considering medica- tion use, it is important to consider nonprescribed over-the- counter (OTC) medications when evaluating an ED patient . One study of 3000 ambulatory adults greater than 75 years of age found that nearly 75% use at least one dietary supplement . Yet, clinicians may forget to question patients on OTC or herbal medication consumption during interviews, and three-quarters of patients >18 years of age report that they do not inform their clinicians about nonpre- scription therapies . Herbal or dietary supplement medi- cations most commonly used include ginseng, ginkgo biloba
Chapter 7. Medication Errors in Aging Adults… 125
extract, St. John’s wort, saw palmetto, kava, and valerian root. Dietary supplements are not without adverse effect; in fact, they have been found to have numerous clinically significant drug interactions and potentially adverse organ system toxici- ties. Some examples of these drug-drug interactions include increased risk of bleeding when ginkgo biloba is coingested with warfarin, whereas the consumption of St. John’s wort with warfarin may result in decreased INR and efficacy of anticoagulation. St. John’s wort, when coingested with sero- tonin reuptake inhibitors, can increase the risk of serotonin syndrome .
In the older adult, anticholinergic medications are associated with adverse effects, including memory impairment, confu- sion, hallucinations, dry mouth, blurred vision, constipation, nausea, urinary retention, impaired sweating, and tachycar- dia, and are extensively highlighted within Beers Criteria . In addition to the increased risk of falls and fracture, drugs with high anticholinergic activity and resultant seda- tive effects may have a negative impact on functional status and cognitive function. One study demonstrated anticholin- ergic use to be associated with decreased Mini-Mental State Examination scores in community-dwelling older people . The number of medications with anticholinergic activity is extensive and extends beyond just one medication class, including antihistamines, antidepressants, antimuscarinics (urinary incontinence), antipsychotics, antispasmodics, anti- emetics, skeletal muscles relaxants, and antiparkinsonian agents .
Anticoagulation is commonly used in older adults for non- valvular atrial fibrillation, valvular heart disease and pros- thetic heart valves, and venous thromboembolism. Although anticoagulation is of benefit to some groups of older adults,
126 A. Lyden and K. Allen
there are a number of concerns for its use in older patients, the most important of which is an increased risk of bleeding. Studies have demonstrated a correlation between age and major bleeding in anticoagulated older adults . Older adults taking concurrent aspirin or P2Y12 receptor antago- nists (e.g., clopidogrel) are at higher risk of bleed. The risk of an adverse event due to drug-drug interactions for patients prescribed oral vitamin K antagonists is of particular concern. The risk of bleeding with warfarin therapy is increased with coadministration of selective and nonselective nonsteroi- dal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors, omeprazole, lipid-lowering agents, and amiodarone . Direct oral anticoagulants (DOACs) have been used increasingly as an alternative to vitamin K antago- nists, but it should be noted that this class of medications requires avoidance or dose reduction in patients with renal insufficiency.
Sedatives and Antipsychotics
The use of medications with central nervous system effects has been associated with a 50% increase in the risk of falls in elderly individuals [18, 19]. Older patients have an increased sensitivity to benzodiazepine use and decreased metabolism of longer-acting agents. In addition, in older patients with renal or hepatic impairment, there may be delayed drug elimination contributing to drug accumulation and adverse effects. Benzodiazepine use has been associated with an increased risk of hospitalization for falls and hip fractures, delirium, cognitive impairment, and motor vehicle crashes in older adults. Importantly, short courses of benzodiazepines have similar adverse event risk as chronic use. Studies have demonstrated the rates of hip fractures and falls as high in the first 2 weeks of therapy with the highest risk being within the first 7 days [20, 21].
Sedatives and anxiolytics, antidepressants, antipsychot- ics, lithium salts, and stimulants have been implicated in a significant number of adverse drug event ED visits.
Chapter 7. Medication Errors in Aging Adults… 127
Zolpidem specifically was associated with 21% of all adult psychiatric medication-related ED visits in adults aged 65 or older . First- and second-generation antipsychotics can increase the risk of cerebrovascular accident and lead to greater rate of cognitive decline and mortality in older patients with dementia. With increasing evidence of poten- tial harm, it should be noted that there is conflicting evi- dence on antipsychotic effectiveness in delirium and dementia. For this reason, antipsychotic agents should be avoided for delirium or behavioral complications of demen- tia unless nonpharmacologic options (e.g., behavioral inter- ventions) have failed or are not possible and the older adult is of substantial harm to themselves and others . Short- term use of antipsychotics (e.g., quetiapine, risperidone, or haloperidol) should thus be restricted to individuals who are distressed and at risk to self or others, have psychosis, and have failed verbal and nonverbal de-escalation tech- niques. In these patients, it is important to limit the dose and duration of therapy.
Analgesics (NSAIDs and Opioids)
Studies have shown significant adverse events secondary to the use on nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults, including an increased risk of peptic ulcer disease or gastrointestinal bleed, renal impairment, and heart failure [23–25]. The risk of toxicity increases in patients tak- ing corticosteroids, anticoagulants, and antiplatelet agents. The use of concomitant proton pump inhibitors (PPIs) decreases but does not eliminate the risk of gastrointestinal bleed. In addition, scheduled PPIs for >8 weeks are generally avoided due to the risk of bone loss, fractures, and Clostridium difficile, as outlined in the Beers Criteria [7, 26].
Among the opioid analgesics, meperidine, propoxyphene, and codeine should generally be avoided. Meperidine does not appear to be an effective oral analgesic in dosages com- monly used and has been associated with a higher risk of neurotoxicity, including delirium . The use of propoxy-
128 A. Lyden and K. Allen
phene and codeine by older adults has been associated with hip fracture and an increased composite risk of hospitaliza- tion, ED visit, or death in older patients [10, 26].
Adverse drug events related to drug-drug interactions (DDIs) in older adults are common and may be life threatening. Among the most common include warfarin, as is the case with our patient who was recently started on an interacting antibiotic (trimethoprim-sulfamethoxazole). Trimethoprim- sulfamethoxazole can potentiate the effect of warfarin and increase the INR. The use of sulfonamides with sulfonylureas may lead to clinically significant hypoglycemia. When calcium-channel blocking agents such as diltiazem or vera- pamil are taken with other medications which interfere with their CYP3A4 metabolism, older adult patients are at greater risk for hypotension and delirium. Increased serotonin activ- ity leading to altered mental status has been described when SSRIs are used in combination with psychotropic medica- tions, opioids, and diuretics. It is important to use caution when initiating a geriatric patient on a new medication and pay particular attention to screening for drug-drug interac- tions .
Medication response differs in older adults due to the decline in organ functional reserve that occurs with aging. In the geri- atric population, responses to drugs may be increased, decreased, or remain relatively unchanged due to the variety of comorbid conditions, the use of concomitant medications, and the age-related physiologic changes that make responses to therapy heterogeneous and unpredictable. Complicating matters further, the aging process affects patients along a
Chapter 7. Medication Errors in Aging Adults… 129
spectrum, with some patients maintaining a relatively fit and healthy lifestyle, and others with frailty and multiple organ dysfunctions . For these reasons, concrete recommenda- tions for dosing medications in the geriatric population are hard to come by. Empiric dose reductions are often applied for safety concerns given the multitude of reasons elderly patients may have more pronounced effects from approved doses. Prescribers must consider how the below age-related changes affect their geriatric patients to safely and effectively prescribe drug treatments.
Let’s take a closer look into some of the pharmacody- namic changes that may be at play for our case patient.
As with our case patient, older adults in the ED often have reduced or inconsistent dietary intake, which can affect the absorption and bioavailability of certain medications. Our patient presents here with an elevated INR, which is most likely due to a decreased PO intake leading to inconsistent levels of vitamin K-laden foods which is essential in order to maintain the balance between the safety and efficacy of a therapeutic INR while on warfarin therapy. This increase in INR was compounded due to the recent initiation of an interacting antibiotic. If decreased oral intake is due to an acute illness, changes in the warfarin dose would likely not be necessary once the patient goes back to their normal rou- tine. Holding a dose or decreasing the warfarin dose while the patient is acutely ill may be sufficient. If the patient is unable to maintain a consistent diet, warfarin therapy may not be the best therapeutic option. Anticoagulant options that require less dietary consistency include low-molecular- weight heparins (LMWHs; e.g., enoxaparin, dalteparin) or some of the DOACs. However, as mentioned previously, DOACs are not without geriatric concerns due to their renal elimination.
130 A. Lyden and K. Allen
Our patient presents with a prerenal AKI due to decreased oral intake. Decreased renal clearance will lead to drug accu- mulation and adverse effects if drugs are not appropriately dose adjusted. For our patient, her tramadol dose is higher than recommended for her creatinine clearance and may have contributed to her fall. Clinicians must be aware that serum creatinine values in the geriatric population are not a reliable measure of renal function and should always calcu- late creatinine clearance in order to estimate glomerular fil- tration rates (GFR), using equations such as the Cockcroft-Gault equation (Fig. 7.1). While it is always impor- tant to calculate creatinine clearance, it is also important to understand the limitations of these calculations in the geriatric population. Serum creatinine values may not be an accurate estimate in patients who have significant muscle wasting and alterations to their lean body mass, thus leading to a seemingly low serum creatinine value resulting in an overly generous creatinine clearance or GFR. Outside of acute changes associated with an AKI, it is important to rec- ognize that GFR naturally decreases by approximately 10% per decade after age 20. By the time patients reach the age of 65, it should be assumed that they will only have 50% of the renal clearance capacity of their younger counterparts, even in the absence of diagnosed renal disease. Clinicians should remain attuned to this natural decline in renal clear- ance, as serum creatinine values tend to remain stable until at least 50% of filtration capacity is lost. Dose adjustments for renal dysfunction are commonly needed in the geriatric population .
(140 – Age) ́ Weight (kg) 72 ́ Creatinineserum (mg/dL)
́ 0.85 if female
Figure 7.1 Cockcroft-Gault equation. Estimate of creatinine clear- ance/glomerular filtration rate (GFR)
Chapter 7. Medication Errors in Aging Adults… 131
Liver Dysfunction and Protein Binding
Decline in hepatic blood flow and a decline in number and activity of the cytochrome P-450 oxidative enzyme system are associated with advanced age. These will both factor into drug metabolism in the geriatric population, by decreasing clearance of hepatic drugs and increasing half-lives. A prime example in our patient is the inappropriate use of the benzodiazepine diaz- epam to treat her insomnia, which likely contributed to this patient’s fall. Diazepam is metabolized via oxidative pathways and has a very long half-life, which makes it much more likely to accumulate in older adults and cause prolonged sedation. Furthermore, geriatric patients with liver dysfunction or other comorbidities that may affect albumin concentrations will have an effect on drugs that are highly protein bound, decreasing their volume of distribution and increasing maximal serum concentrations. Diazepam is also a drug that is highly protein bound; thus “normal” doses as recommended in the package insert will lead to more profound effects because there is more active drug than a patient with normal albumin concentrations. Specific dose recommendations for patients with mild-to-mod- erate hepatic impairment and alterations in protein binding are rather limited. Understanding the physiology of how aging relates to the liver’s clearance ability would explain why initiat- ing lower doses of highly protein-bound and hepatically cleared medications is prudent in the geriatric population .
Lean Body Mass
Older adults have an increased body fat percentage relative to lean body mass, as well as decreased total body water and muscle mass. These physiologic changes have an effect on the volume of distribution of drugs. Drugs that are lipophilic (e.g., benzodiazepines) will have an increased volume of distribu- tion in the geriatric population. Lipophilic drugs also tend to have longer half-lives since the drug is cleared more slowly as
132 A. Lyden and K. Allen
it takes longer to leech out of fat stores. Conversely, hydro- philic drugs will have a smaller volume of distribution in geriatric patients, resulting in higher maximal serum concen- trations, which will increase the potential for augmented response and risk of adverse effects .
Central Nervous System
Our case patient is on several CNS-active medications (e.g., tramadol, diazepam). Older adults have increased sensitivity and susceptibility to medications that are active in the CNS, which is proposed to be due to changes in receptor reserve and changes to intracellular signaling pathways . Common ailments in the elderly such as dementia or stroke can also alter the integrity of the blood-brain barrier, allowing addi- tional drug to penetrate the CNS. Additionally, poor oxygen- ation, changes in brain perfusion, and decreased CNS functional reserve will affect how geriatrics respond to CNS- active medications .
Practical Approaches to Patient Care
Accurate Medication Histories
Errors in prescribing can often be attributed to medication discrepancies, which occur when patients are unaware of the medications they should be taking and can lead to incorrect documentation in electronic health records and patient charts. One study of nearly 800 patients prescribed 15 medications found that every individual had at least one medication dis- crepancy. Examples of discrepancies included dosing/fre- quency errors or missing medications when comparing medication lists created by referring providers and home healthcare nurses . Obtaining accurate medication lists through medication reconciliation has been shown to decrease ED visits and rehospitalizations for patients by up to 37% .
Chapter 7. Medication Errors in Aging Adults… 133 Getting the Pharmacist Involved: Medication
Therapy Management Services
Medication use has become a mainstay of geriatric medical care. Given the high prevalence of prescription drug use in the geriatric population, understanding how to optimize drug therapy in this unique population becomes imperative. Pharmacists in the ED play an integral role in improving transitions of care within the healthcare continuum for the geriatric population. Older adults in the ED are prime candidates for medication therapy manage- ment (MTM) services which pair patients with a pharmacist in order to provide medication counseling and reconciliation to avoid potentially inappropriate prescribing and medication use. Several studies have demonstrated that pharmacist-driven MTM services in the emergency department and other clinical areas have significantly decreased hospital utilization and readmissions and led to cost reduction and decreased polypharmacy and inap- propriate prescribing [33–40]. The American Geriatric Society recommends that all geriatric patients receive an annual drug regimen review to allow for opportunities for discontinuation of unnecessary medications, as well as the addition of effective medications that may not be currently prescribed . As part of the 2010 Affordable Care Act, Medicare Part D prescription drug plans are required to offer medication therapy management (MTM) services to eligible patients, namely, those with certain diagnoses (varying dependent on the plan), a minimum number of prescription medications, and likelihood of exceeding a medi- cation cost threshold .
Older adults frequently require multiple medications due to chronic disease states, which places them at higher risk of polypharmacy, adverse drug events, and drug-drug interac- tions. The use of potentially inappropriate medications in the elderly can lead to adverse outcomes, including ED visits and hospitalizations. Recognizing high-risk medications in the
134 A. Lyden and K. Allen
elderly and taking into consideration physiologic changes in the geriatric population can help improve safe medication prescribing. Obtaining an accurate medication history and the use of a pharmacist medication therapy management can help to decrease adverse drug events in older adults in the ED.
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40. Moss JM, et al. Impact of clinical pharmacy specialists on the design and implementation of a quality improvement initia- tive to decrease inappropriate medications in a veterans affairs emergency department. JMCP. 2016;22(1):74–80.
41. Haag JD, et al. Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients. Am Health Drug Benefits. 2016;9(5):259–68.
Pain, Opioid Use, and Palliative Care of Older Adults in the Emergency Department
William P. Burns
Mary M is an 82-year-old woman with history of Stage IV breast cancer metastatic to the lung and bone who was brought to the emergency department from a nurs- ing home by ambulance because of back pain.
Upon arrival, Mary is alert and uncomfortable. She is initially alone in the emergency department, but her family is en route to meet her in the ED. She reports uncontrolled mid-thoracic back pain that feels sharp and does not radiate. It feels very similar to pain that she has suffered from for several years and has been attributed to compression fractures at T7 and T8 sec-
W. P. Burns (*)
Department of Emergency Medicine, University of Wisconsin, Madison, WI, USA
Division of Palliative Care, Department of Medicine, University of Wisconsin, Madison, WI, USA
© Springer Nature Switzerland AG 2019 139 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_8
140 W. P. Burns
ondary to metastatic disease. The spinal metastases had previously been treated with radiation and which pro- vided some pain relief. However, a second cycle of radiation was ineffective.
In the ED, she denies any recent falls or trauma. Additionally, she denies any lower extremity weakness and lower extremity numbness, specifically no saddle anesthesia. She also denies incontinence of bowel or bladder.
Review of Systems:
Positive for back pain.
Shortness of breath at baseline.
Negative for sedation, confusion, chest pain, nausea,
vomiting, abdominal pain, dysuria, weakness, and numbness.
Her past medical history is significant for breast cancer with metastases to the lung and bone, hypertension, hypercholesterolemia, and type 2 diabetes mellitus. She is on 4L of oxygen via nasal cannula at baseline.
Past surgical history: Right complete hip replacement 5 years ago and appendectomy 40 years ago.
Pulse 82 | Respiratory rate 14 | Oxygen saturation 98% on 4L NC | Blood pressure 110/90 | Temperature 37.0 Celsius | Pain score 9/10.
General: Chronically ill appearing and cachectic. HEENT: Temporal wasting, pupils normal in size and reactive.
Cardiac: Normal rate and rhythm, no murmur. Pulmonary: Rare crackles, good air movement, no wheezing.
Abdominal: No distension, no tenderness to palpation. Musculoskeletal: No lower extremity edema or swelling.
Chapter 8. Pain, Opioid Use, and Palliative… 141
Back: Tenderness to palpitation in the midline over her thoracic spine.
Neurologic: Alert and oriented to person, place, time, and situation. Cranial nerves intact. 5/5 strength in all four extremities, sensation intact in all four extremi- ties and perineum.
A review of the electronic medical record indicates that she was recently discharged from the hospital to a skilled nursing facility yesterday after a 7-day admission for severe back pain. During her hospitalization she received a CT pulmonary angiography which was negative for pulmonary embolism but showed continued progression of lung metastases and an MRI of her spine which was significant for progression of her known T7/T8 meta- static disease, but no cord compression was seen. At the time of that discharge, her pain was well controlled with two tablets of hydrocodone 10 mg/acetaminophen 325 every 6 h as needed for pain. Since discharge she has been taking it every 6 h and reports that her pain is only slightly improved for 2–3 h after each dose.
Additional review of the electronic medical record shows that Mary has been admitted seven times in the past 6 months. Her most recent discharge weight is 15 lbs below her baseline weight 9 months ago. Additionally, there is a recent note from her oncologist describing a meeting during which it was determined that there are no other disease-directed treatment options available.
Emergency Department Management
Address the Primary Complaint
Mary has poorly controlled, acute on chronic malignant pain which has and will continue to require opioids to maximize her function and minimize her suffering. Further increasing
142 W. P. Burns
hydrocodone/acetaminophen is not advisable as she is already receiving 2600 mg of acetaminophen per day (325 per tablet × 2 tablets per dose × 4 doses per day). The American Geriatric Society last updated their guidelines for pain con- trol in 2009 but at that time recommended a limit of 3000 mg per day .
The National Comprehensive Cancer Network has pub- lished guidelines for the initiation of short-acting opioids in both opioid-naïve and opioid-tolerant patients . The first step in any opioid conversion is to calculate the patient’s cur- rent daily requirement in oral morphine equivalents (OMEs). The relative potency of hydrocodone to morphine has been studied in cancer patients and has been found to vary from 1:1 to 1:2 with a median of 1:1.5 . Specifically, it was discov- ered that at hydrocodone doses higher than 40 mg per day, the equivalence was closer to 1:1. Given Mary’s daily require- ment of 80 mg hydrocodone, her total OME requirement would also be approximately 80 mg.
The National Comprehensive Cancer Network (NCCN) provides guidelines for the treatment of malignant pain. The guideline differs between opioid-naïve and opioid-tolerant patients. Based on FDA guidelines, patients are considered opioid-tolerant if they are receiving at least the following for 1 week or longer :
• Sixty milligrams oral morphine/day
• Twenty-five micrograms transdermal fentanyl/hour
• Thirty milligrams oral oxycodone/day
• Eight milligrams oral hydromorphone/day
• Twenty-five milligrams oral oxymorphone/day
• Equianalgesic dose of another opioid.
To treat severe pain, the NCCN guidelines suggest provid- ing a PO or IV dose equivalent to 10–20% of the total opioid dose equivalent the patient has received in the past 24 h . For Mary that would mean 8 (10%) to 16 (20%) OMEs. IV formulations benefit from a faster peak effect at 15 min com- pared to 60 min for PO formulations. Therefore, opioid- tolerant patients with pain that is not meaningfully improved by their initial dose may be re-dosed 15 min after an IV dose
Chapter 8. Pain, Opioid Use, and Palliative… 143
and 60 min after an oral dose. Additionally, it is possible to be more specific in dosing IV formulations as it is possible to easily administer doses that would otherwise require complex fractioning of tablets.
Morphine could be tried again with a longer dose interval, but since it was ineffective before, it is unlikely to be effective now. Hydrocodone is metabolized by the liver to active hydromorphone and inactive norhydrocodone, so hydromor- phone is likely the best next agent as she has been exposed in the past.
Sometimes patients taking opioids develop adverse effects to them. Alternatively, patients with significant tolerance to an opioid may not experience symptom relief with dose increases. In either case, the best practice is to transition the patient to a different opioid. This process is commonly referred to as opioid rotation. Opioid rotation is complex and very patient depen- dent. The examples provided below are just examples, and extreme care should be taken when performing opioid rota- tions .
1. Mary’s current 24-h opioid requirement = 80 mg hydrocodone.
Hydrocodone is approximately equivalent to oral
2. Eighty micrograms hydrocodone ≅ 80 mg oral morphine.
Thirty micrograms oral morphine ≅ 2 mg IV
3. Eighty micrograms oral morphine ≅ 5.3 mg IV hydromor-
phone per 24 h.
Correction for cross tolerance is typically a 25% reduc- tion but can be up to 50 or 75% depending on patient factors including pre-existing opioid toxicity, renal func- tion, and hepatic function.
4. A 25% reduction for cross tolerance = 0.75 × 5.3 = 4 mg IV hydromorphone per 24 h.
5. Four micrograms IV hydromorphone * 10% = 0.4 mg IV hydromorphone low-end starting dose.
The peak effect of all IV opioids in opioid-tolerant patients is approximately 6 min. Therefore, it is critical
W. P. Burns
to assess the patient’s pain level and screen for adverse effects shortly after dosing. Fifteen to 30 min post-dose is probably a more realistic timeline in a busy clinical environment. In contrast, the peak effect of immediate release oral opioids is approximately 60 min which decreases the rate at which doses can be administered safely.
Pain score unchanged or increased: Increase dose by
(b) Pain score decreased to 4–6: Repeat prior dose.
(c) Pain score decreased to 0–3: Continue at current
effective dose as needed.
Based on the opioid equivalence calculations above, Mary was given 0.5 mg IV hydromorphone. After 15 min she reports that her pain is unchanged and remains intolerably severe at 9/10. In response she was given 1.0 mg IV hydro- morphone. After another 15 min, she reported that her pain was improved but still severe at 7/10. In response she was given 1.0 mg IV hydromorphone again. After another 15 min, she reported that her pain was significantly improved to a tolerable level of 3–4/10. She remained comfortable for another 3 h, but then her pain then began to worsen, and she required another 1.0 mg IV hydromorphone dose before she was transported to her hospital room.
Discussion of Care Options
If the patient’s pain can be sufficiently controlled, it is rea- sonable to explore if the patient is open to a discussion of goals of care. Unfortunately, physician-initiated goals-of- care conversations frequently focus on determining a patient’s code status, rather than directly discussing patient’s goals. In order to avoid this common misstep, Dr. David Wang has developed an emergency department-focused approach to a 5-min goals-of-care conversation detailed in Table 8.1 .
Chapter 8. Pain, Opioid Use, and Palliative… 145
Table 8.1 Approaching 5-min ED goals-of-care conversations sys- tematically as a procedure
Elicit patient understanding of underlying illness and today’s acute change
If available, build on previous advance directives or documented conversations
Acquire sense of patient’s values and character (to help frame prognosis and priorities for intervention)
Name and validate observed goals, hopes, fears, and expectations
Discuss treatment options, using reflected language
Continually recenter on patient’s (not family’s) wishes and values
Recommended a course of action, avoiding impartiality when prognosis is dire
Summarize and discuss next steps
Introduce ancillary ED resources (eg, hospice/ observation unit, social work, chaplain)
Example Conversation Between Mary and the Emergency Physician (EP)
EP: Mrs. M, as physicians we always want to make sure that the care we provide is consistent with our patient’s wishes. Would it be okay with you if we discussed your hopes?
EP: What things are most important to you?
Mary: I need my pain to be better and I want to be at home with my family.
146 W. P. Burns
EP: I hear how important pain control and family are. Also, I can see that you have had to be in the hospital a lot recently. I see you met with your oncologist recently. Could you tell me what your understanding of that meeting was?
Mary: There are no more treatment options for the cancer while I am this weak. I was hoping the rehab would make me stronger, but I don’t think I can handle it.
EP: I hear your concern, and I worry that rehab won’t be as effective as we had hoped and will keep you from home and your family. If you had to choose between possibly having more time but spending lots of it in hospitals and rehab or possibly having less time but spend- ing it at home, do you have an idea which one you would prefer?
Mary: I want to be at home and can accept less time if I am comfortable, but I am afraid that my pain won’t be controlled.
EP: We want to support your goal to be at home and hear that pain control is a concern. We will treat your pain aggressively, and while you are here we will find a regimen that works.
Mary: Thank you.
EP: When patients’ primary goal is for comfort and to stay at home, I strongly recommend that they consider additional support at home through hospice. Hospice nurses actively mon- itor and treat symptoms, arrange support equipment like oxygen or a hospital bed, deliver medications, and have backup teams that provide phone support, and if necessary, in-home support any time or day.
Chapter 8. Pain, Opioid Use, and Palliative… 147
I thought hospice was just for people who are dying.
Too many people are not enrolled in hospice until their time is very short, but the longer you are enrolled in hospice, the more you can ben- efit from the care team and their support. Patients and their families who enroll in hos- pice frequently wish they had enrolled in hos- pice earlier. If it is okay I will ask the social worker to follow-up with you to get more information about hospice?
I would appreciate that.
Barriers to Goals of Care Conversations
There are many barriers in the emergency department to goals of care conversations such as these: High patient vol- ume, frequent interruptions, and caring for other critically ill patients are some reasons why EPs are reluctant to start these conversations in the ED. In addition, education about the philosophy of, indications for, and specifics of hospice are rarely covered in emergency medicine training. Despite these barriers, a significant majority of attending physicians and residents believe palliative care to be an essential core compe- tence for their practice, and conducting an ED-focused goals of care conversation is a key skill which can be performed quickly in the ED .
What Can You Do in Your Clinical Practice?
A variety of individuals provide spiritual care in healthcare settings, but many hospitals employ professional chaplains. Certified professional chaplains must have a graduate-level
148 W. P. Burns
education in theology, at least 1 year of supervised postgradu- ate training in an accredited healthcare chaplaincy program, and complete ongoing educational requirements.
It is a common misconception among other healthcare providers that spiritual distress cannot be present if an indi- vidual doesn’t adhere to a religion. Instead it is better to approach the concept of spiritual care from the perspective that humans generally seek to find meaning in the events of our lives, actions, and relationships. For some individuals, reli- gion provides a structured system to help find that meaning. For others, silence, walks, fishing, rock climbing, painting, lis- tening to hair metal music, or any number of activities or actions is the mechanism that they process and find meaning in their lives.
Acute illness or trauma as well as life-limiting illnesses almost uniformly interrupt the normal lives of our patients. Consequently, their normal mechanisms for finding meaning are usually disrupted. One of the core functions of healthcare chaplains is to assess for such disruptions and after establish- ing rapport to help patients identify alternative mechanisms to process and find meaning.
A common barrier to chaplaincy referral is clinician con- cern that the patient or family may misperceive the chaplain’s presence as an indication of ominous news or imminent death. This perception may be because most professional healthcare chaplaincy referrals are triggered in association with cardiac arrest, major trauma, or deaths. However, chap- laincy referral can also be helpful for patients and family members in less extreme situations. Patient and family misperceptions can be prevented by first explaining that the chaplain is a part of the care team and an extra layer of sup- port. Occasionally a patient or family member may worry that a chaplain will proselytize to them, but you can assure them that proselytizing in the clinical environment is simply not allowed by organizations that accredit and govern profes- sional healthcare chaplains. If possible, it is always helpful to provide the chaplain with a quick explanation of the patient’s clinical situation. Chaplains have strong and rapidly effective rapport-building skills, but providing them some information can help them better prepare.
Chapter 8. Pain, Opioid Use, and Palliative… 149 Social Work Referral
Patients with serious illness and particularly those with lim- ited social support, advanced age, financial stress, mental health disorders, or functional decline benefit tremendously from the support of social workers. Social workers are staunch advocates for patients and their families in addition to providing psychosocial support, education, and assisting with connections to private and public resources.
Social workers frequently identify and then help address critical barriers confronting patients and families that were not identified by physicians. In some states social workers are the primary agents for completion of healthcare power of attorney forms, and/or in many health systems, they are the primary leaders of goals-of-care conversations.
When referring to hospice, social workers play a critical role as not all insurance plans include a hospice benefit. Additionally, although the hospice benefit does not cover residential care in a nursing home, veterans and patients with Medicaid can often qualify for nursing home care concur- rently with hospice.
In the case of Mrs. M, a social worker could be extremely helpful. They might explore how Mrs. M and her family mem- bers are each processing her decline. Also, it is very common for individuals in crisis to have difficulty naming their emo- tions which can serve as a block to them processing them which social workers can frequently assist with. Often, patients and their families will start to talk about death or funeral plan- ning after a change in goals of care, and social workers can often provide the best guidance among hospital staff.
Though anecdotal experience of patients with palliative care needs frequently using the emergency department is common for practicing emergency department clinicians, there is a paucity of reported evidence on the frequency with which patients use the ED for palliative care needs. This is compli- cated by a lack of consensus on what is classified as a pallia-
150 W. P. Burns
tive care need or the specific definition of palliative care . For many if not all medical professionals, the palliation of their patients’ physical symptoms such as pain, dyspnea, and nausea is an intrinsic part of their care. Palliative care is dif- ferentiated by a focus on pain as not only the result of physi- cal symptoms but also resulting from existential, psychosocial, and spiritual suffering. These topics have a significant amount of overlap, and therefore strict definitions are not available. The following topics were identified as descriptors of pallia- tive care needs by chaplains, pain medicine physicians, and palliative physicians: isolation, loneliness, abandonment, meaninglessness, hopelessness, guilt, religious uncertainty, and dying .
Identification of ED patients who may benefit from pallia- tive care can be guided by clinician gestalt or through formal screening questionnaires such as the SPEED screen. SPEED asks screening questions across five domains of palliative care needs: physical, spiritual, social, therapeutic, and psycho- logical .
Palliative Care Referral
Patients with palliative needs may benefit from inpatient pal- liative care consultation, or outpatient palliative care refer- ral, depending on their clinical situation. For hospitalized patients, palliative care consultation triggered on the basis of emergency physician or emergency nursing gestalt has been shown to significantly reduce hospital length of stay . Additionally, referral to palliative care from the emergency department was formally adopted as a Choosing Wisely recommendation by the American College of Emergency Physicians in 2013 .
For Mrs. M a palliative care consultation could provide several benefits. Management of cancer-associated pain is a core expertise of palliative care providers with specific exper- tise in the initiation and titration of both extended release formulations to provide consistent control of pain and con- sideration of other adjuvant therapies like steroids as an
Chapter 8. Pain, Opioid Use, and Palliative… 151
example. Additionally, palliative care consultation can help when patients are unsure about their goals of care. Palliative care providers can also help explain to patients and their families what specifically a home-based comfort-focused care plan might look like.
Hospice is a means for delivering palliative care that is unique to the United States. It is primarily a defined Medicare benefit that is included in many private insurance plans. Hospice can be difficult to explain to patients and, in fact, is often confusing for medical providers. The primary source of confusion seems to arise from the dual nature of hospice as both a philosophy of care and a defined insurance benefit.
Unfortunately, the philosophy of hospice care is fre- quently misunderstood to be only applied to care at the very end or last few days of life. More specifically, it can be gener- ally understood to be comfort-focused care that is provided to patients with serious, life-limiting conditions who either are no longer a candidate for curative or intensive life- extending therapies or whose goals are not consistent with the therapies that are available to them. However, just because the goals of a patient or their decision maker are consistent with hospice, it does not mean they are eligible for the hospice benefit.
The general philosophy of hospice could be interpreted to apply to a significant proportion of emergency depart- ment patients. The reality is that like most insurance bene- fits, hospice eligibility has specific restrictions. Most private insurers mirror Medicare guidelines; however, rarely, some plans still do not have a hospice benefit. Medicare requires a physician certify that a patient is terminally ill with a life expectancy of 6 months or less based on the normal course of their disease . In order to assure compliance, most hos- pice agencies follow a relatively standard set of disease- specific guidelines. Such guidelines can be exceptionally specific, and patients are sometimes unable to access hos-
152 W. P. Burns
pice services due to an inability to confirm a terminal condi- tion despite progressive decline.
Additionally, it is important to realize that the hospice benefit does not provide custodial care for patients who are unsafe at home. Patients with Medicaid or who are veterans may receive custodial care benefits to allow them to stay in a nursing home but that benefit is intrinsic for Medicaid and the Department of Veterans Affairs. Patients with private medical insurance or Medicare do not have the same benefit, and a nursing home placement would be out-of-pocket for them. Additionally, inpatient palliative care units do exist, but they function similarly to hospitals, in that the hospice must justify each day why the patient requires ongoing inpatient care. Some examples of reasons why a hospice patient might need an inpatient level of care include opioid titration requir- ing intravenous administration, a sudden loss of ability to take oral medications, or a sudden loss of caregivers at home among other reasons.
Because it is possible that patients may not be eligible for hospice, it is generally prudent to try to under-promise and over-deliver on the availability of hospice services. Rather than guaranteeing hospice services, clinicians in the ED may instead encourage patient and their families to engage in dialogue with hospice to understand if and how they can help.
Although pain frequently afflicts patients with life-limiting illnesses, it is not the only symptom. Fatigue, existential dis- tress, spiritual distress, anxiety, depression, xerostomia (dry mouth), dyspnea, loss of appetite, nausea, constipation, and diarrhea are common contributing symptoms. Few of these symptoms can be resolved in the emergency department, but often patients are unable to spontaneously identify them, so naming them for the patient and alerting the inpatient or continuity teams is the first step in alleviating or controlling the symptom. If a standardized symptom assessment tool is
Chapter 8. Pain, Opioid Use, and Palliative… 153
preferred, there are several in regular use. The Edmonton Symptom Assessment System (ESAS) is one of the oldest, best validated, and available online .
Fellowship training in hospice and palliative medicine is an option for graduates of emergency medicine residencies and offers additional practice opportunities including inpatient consultation, outpatient clinic, or hospice medical direction. However formalized graduate medical education is unlikely to be preferable or feasible for the vast majority of active emergency physicians. The Education in Palliative and End- of-Life Care or EPEC program has an emergency medicine provider-focused, 3-day-long curriculum called EPEC-EM which is typically held in the fall and provides instruction in essential clinical competencies .
Mary was admitted to the hospital to facilitate continued pain management via opioid titration. Further dose changes were necessary, but ultimately, she was well controlled with a fen- tanyl patch and with hydromorphone for breakthrough pain. After an additional discussion with the social worker as well as her family, she consented to an informational visit with a hospice liaison. Together they identified that it would make the most sense for Mary to stay with her daughter who would provide most of Mary’s care. When Mary was no longer able to complete her activities of daily living, the family planned to hire caregivers to be with Mary when her daughter was at work. After signing consents, the hospice was able to arrange for equipment like a hospital bed and an oxygen concentrator to be delivered to the home. Also, a hospice nurse was able to meet Mary and her daughter at home right after discharge to help them transition to home. Mary survived another 12 weeks at home with the support of her family and the hospice team.
154 W. P. Burns
• Consider palliative care consult or hospice referral, when appropriate, in patients who present to the emergency department.
• Utilize rapid opioid titration guidelines like the National Comprehensive Cancer Network guidelines for patients with cancer who present to the emergency department with uncontrolled pain.
• Consider having a focused goals of care conversation with patients who present to the emergency department with recurrent exacerbations of chronic, life-limiting illnesses.
1. ACEP. 2013 choosing wisely campaign.
2. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The
Edmonton Symptom Assessment System (ESAS): a simple method of the assessment of palliative care patients. J Palliat Care. 1991;7(2):6–9.
3. EPEC-EM. Education in palliative and end-of-life care.
4. Ferrell B, Argoff C, Epplin J, Fine P, Gloth FM, Herr K, Katz JD, Mehr DR, Reid C, Reisner L. Pharmacological management of per- sistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331–
5. GPO, G. P. O. Electronic Code of Federal Regulations, Title 42,
Chapter IV, Subchapter B, Part 418. 2018.
6. Lamba S, Pound A, Rella JG, Compton S. Emergency medicine
resident education in palliative care: a needs assessment. J Palliat
7. Reddy A, Yennurajalingam S, Desai H, Reddy S, de la Cruz M, Wu J, et al. The opioid rotation ratio of hydrocodone to strong opioids in cancer patients. Oncologist. 2014;19(11):1186–93. https://doi.
8. Richards CT, Gisondi MA, Chang CH, Courtney DM, Engel KG,
Emanuel L, Quest T. Palliative care symptom assessment for patients with cancer in the emergency department: validation of the screen for palliative and end-of-life care needs in the emer- gency department instrument. J Palliat Med. 2011;14(6):757–64. https://doi.org/10.1089/jpm.2010.0456.
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9. Strang P, Strang S, Hultborn R, Arner S. Existential pain – an entity, a provocation, or a challenge? J Pain Symptom Manag. 20 04;27(3):241–50. https://doi.org/10.10 16/j. jpainsymman.20 03.07.0 03.
10. Swarm RA, Abernethy AP, Anghelescu DL, Benedetti C, Buga S, Cleeland C, deLeon-Casasola OA, Eilers JG, Ferrell B, Green M, Janjan NA, Kamdar MM, Levy MH, Lynch M, McDowell RM, Moryl N, Nesbit SA, Paice JA, Rabow MW, Syrjala KL, Urba SG, Weinstein SM, Dwyer M, Kumar R. Adult cancer pain. J Natl Compr Cancer Netw. 2013;11(8):992–1022.
11. Wang DH. Beyond code status: palliative care begins in the emergency department. Ann Emerg Med. 2017;69(4):437–43. https://doi.org/10.1016/j.annemergmed.2016.10.027.
12. Wong J, Gott M, Frey R, Jull A. What is the incidence of patients with palliative care needs presenting to the Emergency Department? A critical review. Palliat Med. 2014;28(10):1197– 205. https://doi.org/10.1177/0269216314543318.
13. Wu FM, Newman JM, Lasher A, Brody AA. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med. 2013;16(11):1362–7. https:// doi.org/10.1089/jpm.2012.0352.
Acute Mental Status Changes and Over-the- Counter Medications in Older Adults
Katherine M. Hunold
Berta is a 78-year-old woman with history of pulmonary fibrosis, pulmonary hypertension, atrial fibrillation, and hypothyroidism. Her son brought her to the emergency department, although she has no complaints. She states that she is not sure where she is or why she is there but that she is “enjoying herself.”
Her son reports Berta is confused and unable to remember details, specifically “she does not know my name.” He reports that he went to check on his mother this evening because she had been having abdominal pain. He notes that she is eating less than usual and has been “eating Tums like candy.” She did not know the name of her son or her grandchildren when they arrived. She also could not remember why
K. M. Hunold (*)
Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
© Springer Nature Switzerland AG 2019 157 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_9
158 K. M. Hunold
he was coming or that she had been having abdomi- nal pain. He expressed that he is very worried about her and feels guilty that “we did not check on her sooner.” He denies any known falls. He confirms her medication list: clonazepam, digoxin, furosemide, levothyroxine, mirtazapine, sertraline, sildenafil, spi- ronolactone, and warfarin.
Her son reports that Berta lives at home and requires occasional help from her children who live in the area. She no longer drives. Her children have noted decreas- ing function but report that she can generally care for herself well. She is in charge of her own medications. Her routine grocery shopping is done for her by her children. Her daughter-in-law of >20 years is also pres- ent and confirms the recent history and patient’s base- line function.
Review of systems:
Positive for intermittent burning epigastric pain.
P 74 | RR 16 | SpO2 100% on home 2L NC | BP 98/67 | T 36.8 ̊C.
HEENT: Tacky mucous membranes.
Abdominal, Skin: WNL
Cardiac: Faint systolic ejection murmur. Musculoskeletal: No edema.
Neurologic: Alert to person, place; not time, situation. Cannot name objects but can describe their function. CN exam WNL. Motor and sensory exam WNL.
Emergency Department Initial Management
Berta is unable to provide a history in the ED. Luckily, her son accompanied her and provided important information. Unfortunately, histories in geriatric patents can be limited due
Chapter 9. Acute Mental Status Changes… 159
to both their acute presentation (i.e., dyspnea limiting ability to communicate) and memory loss. In these situations, elec- tronic medical records may provide additional medical history particularly if they are linked to other hospital systems.
Altered mental status in geriatric patients has many pos- sible etiologies. In Berta’s presentation there are several important etiologies to consider: medication side effect or toxicity, dehydration, electrolyte abnormality, acute renal injury, accidental or intentional drug overdose, intoxication, head injury, stroke, intracranial hemorrhage, etc.
Berta initially denied symptoms but reported burning epi- gastric pain on ROS. Geriatric patients often present with abnormal symptoms [1–5] for life-threatening diagnoses such as myocardial infarction, pulmonary embolism, aortic dissec- tion, aortic aneurysm, mesenteric ischemia, etc. In her case, her clinical presentation, physical exam, and vital signs were not concerning for pulmonary embolism or surgical causes of her symptoms. However, electrocardiography and cardiac enzyme testing should be performed as her epigastric pain may represent an unexpected presentation [1–3] of acute coronary syndrome.
Berta was confused and had naming difficulty, but the remainder of her neurologic exam including cranial nerves, strength, and sensation was normal. Polypharmacy is a com- mon cause of hospital admission in older adults  and should always be considered in an altered older adult , especially when they administer their own medications. Toxicologists are often consulted for cases of overdose on psychiatric or analgesic medications in these patients . It is also important to consider intentional ingestions as older adults are high-risk for suicide attempts .
Berta had no evidence of trauma on exam, but intracranial hemorrhage or hematoma is another important consider- ation in altered older adults, especially if they are taking anticoagulants such as warfarin. Elder abuse or neglect should also be considered in these patients.
Given the above considerations, Berta was also placed on cardiac monitoring, had labs drawn, and had an electrocardio-
160 K. M. Hunold
gram, chest X-ray, and CT scan of her brain. She was given famotidine for her epigastric pain and given 1 L of IV normal saline as she appeared clinically dehydrated. Aspirin was ini- tially held given the concern for possible intracranial hemorrhage.
HGB 13.8 HCT 40.6 Platelets 150
K 3.6 Cl 94 CO2 33
INR 2.2 PTT 36
Digoxin level 2.4
Within normal limits:
TSH Free T4
Hepatic function panel
Ammonia EtOH level
Chest X-ray (portable): No acute cardiopulmonary pathology. Stable appearance of chronic changes due to pulmonary disease.
CT brain: No acute findings.
Chapter 9. Acute Mental Status Changes… 161 ED and Hospital Course
These results demonstrated acute renal injury (baseline cre- atinine was 0.8, checked 2 weeks prior at a routine primary care visit), hypercalcemia, elevated troponin, elevated digoxin level, and other mild electrolyte abnormalities. She had EKG changes consistent with digoxin toxicity but no evidence of ST segment elevation. She had no evidence of infection in her history or laboratory results.
She was started on IV fluids for dehydration and treat- ment of hypercalcemia and given calcitonin for hypercalce- mia per hospital protocol, and she received IV potassium and magnesium replacement. She was given DigiFab for her ele- vated digoxin level per cardiology’s recommendations, though hypercalcemia was likely potentiating this effect [10–12]. She was given aspirin for the elevated troponin; she was contin- ued on home warfarin.
During her ICU admission, no medical explanation for hypercalcemia was found. It was thought to be due to large consumption of Tums over short period of time. Her troponin elevation was 0.02, above the upper limit of normal. This remained stable and then downtrended; she never had EKG changes consistent with ischemia. All of her laboratory abnormalities improved with continued IV and then oral hydration when she could tolerate.
Berta’s presentation may have been avoided if geriatric- specific interventions were made previously. Her son shared that she was no longer driving. Therefore, when she began to experience abdominal pain, she was unable to get to a doctor. She later shared with an inpatient team that she did not want to be a burden on her children and the Tums helped her pain.
During the hospitalization, she received physical and occu- pational therapy evaluations. These evaluations determined that she was safe to return home but confirmed her inability
162 K. M. Hunold
to drive a motor vehicle. Social work provided local resources for affordable transportation that Berta could arrange when needed; this prevented her feeling as though she was a bur- den to her children.
What Can You Do in Your Clinical Practice?
Digoxin increases cardiac inotropy by increasing intracellular calcium through reversible inhibition of the sodium-potassium ATPase pump. It has been associated with increased risk of death from any cause including cardiovascular deaths and stroke . Although digoxin use has decreased as new agents have become available, digoxin toxicity remains an important cause of ED presentation in geriatric patients and subsequent hospitalizations . Emergency medicine physi- cians must remember to consider this diagnosis.
Acute digoxin toxicity is usually characterized by nausea, vomiting, abdominal pain, cardiac dysrhythmias, and changes in color vision. Chronic toxicity has predominance of neuro- logic symptoms such as weakness, fatigue, confusion, and delirium . Arrhythmias are caused by increased intracel- lular calcium. Toxicity is more common in geriatric patients and is potentiated by hypokalemia, hypomagnesemia, hyper- calcemia [11, 12], as well as many common medications . Importantly, digoxin toxicity can occur at normal digoxin levels when hypercalcemia is present [11, 12]. However, there is no evidence to support the “stone heart theory” that states IV calcium is contraindicated in digoxin toxicity .
Supportive care with close cardiac monitoring for arrhyth- mias is the mainstay of treatment for digoxin toxicity. If an acute ingestion is known and the patient is awake, GI decon- tamination with activated charcoal can be considered . Digoxin-specific antibody fragments (digoxin-Fab) are indi- cated in patients with chronic poisoning in cases of life- threatening arrhythmias, hyperkalemia, or hemodynamic
Chapter 9. Acute Mental Status Changes… 163
instability with an elevated digoxin concentration. It should also be given if there is an acute ingestion leading to poison- ing. Rare, but important, side effects include heart failure, increased ventricular rate, and hypokalemia . Elderly patients have variable responses to the antibody treatment and may require additional supportive treatments .
Hypercalcemia can cause a wide range of symptoms includ- ing but not limited to weakness, dehydration, polydipsia, confusion, hallucinations, hyporeflexia, hypertension, dys- rhythmias, nausea, vomiting, and abdominal pain. EKG changes may be present: QT shortening, “coved” ST wave, and wide T wave. As above, beware of hypercalcemia’s effect on digoxin .
Calcium levels above 14, regardless of symptoms, should be treated. The recommended treatments are :
1. 0.9% normal saline at 500–1000 mL per hour for 2–4 h with titration to urine output or 2 L per day.
2. Furosemide to promote diuresis.
3. Correction of hypokalemia and hypomagnesemia if
4. Consider steroids to decrease absorption of calcium from
bone, calcitonin or bisphosphonates based on cause, and hemodialysis.
Hydration status is best measured by urine output . Dehydration may cause reductions in alertness and ability to concentrate and increase in headache and fatigue . It has also been implicated as the precipitating factor in urolithiasis, urinary tract infection, constipation, hypertension, venous thromboembolism, fatal coronary heart disease, stroke, den- tal disease, hyperosmolar hyperglycemic diabetic ketoacido-
164 K. M. Hunold
sis, gallstone disease, mitral valve prolapse, and glaucoma . Unsurprisingly, geriatricians believe that dehydration is a common precipitant for hospital admissions and it is associ- ated with increased morbidity and mortality [18, 21].
Direct comparison of IV and oral rehydration has not been extensively studied in the geriatric population. The mental status, ability to tolerate oral rehydration, and urine output of each patient should be considered when choosing initial rehydration modality and during reassessment.
In altered older adults, such as Berta, CT brain imaging is an important component of evaluation as intracranial etiologies are one of the most common causes of AMS in this group . CT brain imaging is also an important diagnostic tool in older adults after minor trauma, as clinical decision tools are not as robust as in younger populations . Accordingly, common CT head imaging decision tools such as the Canadian Heat CT Rules , New Orleans Criteria , and the NEXUS criteria  include older age as a trigger for head CT in minor trauma. Current research is ongoing on geriatric- specific head CT indications after trauma including antico- agulation [27, 28] and the utility of repeat head CT to assess for delayed traumatic intracranial bleeding .
Physical Therapy and Occupational Therapy
Patients who are discharged home and are unable to safely function are at risk for falls and return ED visits . Both physical therapy and occupational therapy can be beneficial as self-reported mobility  and ability to perform activities of daily living are often overestimated by elderly patients [32, 33]. Physical therapy and occupational therapy evaluations, in both the ED and inpatient settings, can help establish true abilities and aid in safe disposition planning.
Chapter 9. Acute Mental Status Changes… 165 Social Work
Geriatric patients often present to the ED with nonmedical problems that can affect their health such as poverty, social isolation, elder abuse, difficulty walking, lack of transporta- tion, difficulty scheduling a doctor’s appointment, difficulty getting prescriptions filled, and lack of dental care [34–38]. These and other “social syndromes” may increase inpatient mortality . Social workers can link patients to community resources that may help avoid a hospitalization during their current ED visit or prevent future ED visits . Additionally, social workers can assist in cases of suspected elder abuse, a diagnosis that is often missed by ED physicians [35, 41].
Comprehensive geriatrics consults in the ED are feasible  and reduce hospital admissions . Geriatrics consults decrease polypharmacy in inpatients  and improve func- tional outcomes in inpatient trauma patients , and these benefits may extend to elderly ED trauma patients being considered for discharge. If geriatrics consults are available in your ED or observation unit, learn what the capabilities are and consider it in appropriate patients.
Carefully consider if your geriatric patient requires hospital- ization or if their needs could be met as an outpatient or in an observation unit. Hospital admission is associated with decreased function status [46–48], delirium [47, 48], and pres- sure ulcers [47, 48]. Collectively, these outcomes are associated with longer hospital length of stay, higher medical costs, and higher mortality .
Meaningful and impactful geriatric evaluations including PT, OT, social work, and geriatrician evaluation can be per-
166 K. M. Hunold
formed in the ED  or an observation unit  if this is available at your hospital. These programs can prevent hospi- tal admissions while linking geriatric patients to high-yield resources prior to discharge home. While geriatric patients felt to be high-risk are often excluded from observation pro- tocols, many could be cared for in an observation unit .
Berta’s son expressed guilt over his mother’s presentation. In her son and other formal and informal caregivers, physicians must not overlook caregiver burden. Families often care for older adults with complex medical problems and social syn- dromes. The savings associated with family providing care is over $50,000 annually compared to paid caregivers . Caregiver burden is common in those helping chronically ill older adults, with 40% of caregivers reporting high burden . These caregivers report feeling abandoned and unrecognized by the healthcare system . You can help by integrating the caregiver into the care team, ensuring caregivers are caring for themselves too, and educating them on available resources .
Berta’s Post-discharge Course
Berta was discharged home from the hospital at her baseline mental status. She was appreciative for the resources pro- vided and agreed to go see her primary care doctor 1 week after discharge but call if she had questions or problems before then.
When she saw her primary care doctor 1 week later, Berta was at her baseline mental status and again thriving at home. She was performing her own activities of daily living again. She had in-home PT several times per week to assist with strengthening after her hospital stay, and she was taking advantage of community transportation options so that she did not have to burden her family.
Chapter 9. Acute Mental Status Changes… 167 Key Points
• Consider geriatric-specific factors or syndromes that may have led to the patient’s presentation, and mobilize appro- priate resources for success at discharge.
• Digoxin (and other medications) that a patient is supposed to be on could be contributing to their presentation; utilize medication review on every geriatric patient.
• Utilize other professionals including social work, physical therapy, and occupational therapy to establish a safe dis- position plan.
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14. See I, Shehab N, Kegler SR, Laskar SR, Budnitz DS. Emergency department visits and hospitalizations for digoxin toxicity: United States, 2005 to 2010. Circ Heart Fail. 2014;7(1):28–34. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000784.
15. Levine M, Nikkanen H, Pallin DJ. The effects of intrave- nous calcium in patients with digoxin toxicity. J Emerg Med. 2011;40(1):41–6. https://doi.org/10.1016/j.jemermed.2008.09.027.
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18. Maughan RJ. Hydration, morbidity, and mortality in vulnerable populations. Nutr Rev. 2012;70(Suppl 2):S152–5. https://doi. org/10.1111/j.1753-4887.2012.00531.x.
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19. Shirreffs SM, Merson SJ, Fraser SM, Archer DT. The effects of fluid restriction on hydration status and subjective feelings in man. Br J Nutr. 2004;91(6):951–8. https://doi.org/10.1079/ BJN20041149.
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21. Weinberg AD, Minaker KL. Dehydration. Evaluation and management in older adults. Council on Scientific Affairs, American Medical Association. JAMA. 1995;274(19): 1552–6.
22. Xiao HY, Wang YX, Xu TD, Zhu HD, Guo SB, Wang Z, et al. Evaluation and treatment of altered mental status patients in the emergency department: life in the fast lane. World J Emerg Med. 2012;3(4):270–7. https://doi.org/10.5847/wje m.j.1920-8642.2012.04.006.
23. Mack LR, Chan SB, Silva JC, Hogan TM. The use of head com- puted tomography in elderly patients sustaining minor head trauma. J Emerg Med. 2003;24(2):157–62.
24. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391–6.
25. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343(2):100–5. https://doi. org/10.1056/NEJM200007133430204.
26. Mower WR, Hoffman JR, Herbert M, Wolfson AB, Pollack CV Jr, Zucker MI, et al. Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients. J Trauma. 2005;59(4):954–9.
27. Brewer ES, Reznikov B, Liberman RF, Baker RA, Rosenblatt MS, David CA, et al. Incidence and predictors of intracranial hemor- rhage after minor head trauma in patients taking anticoagulant and antiplatelet medication. J Trauma. 2011;70(1):E1–5. https:// doi.org/10.1097/TA.0b013e3181e5e286.
28. Gittleman AM, Ortiz AO, Keating DP, Katz DS. Indications for CT in patients receiving anticoagulation after head trauma. AJNR Am J Neuroradiol. 2005;26(3):603–6.
29. McCammack KC, Sadler C, Guo Y, Ramaswamy RS, Farid N. Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury. West J Emerg Med. 2015;16(1):43–9. https://doi. org/10.5811/westjem.2014.10.19488.
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30. Calder L, Pozgay A, Riff S, Rothwell D, Youngson E, Mojaverian N, et al. Adverse events in patients with return emergency department visits. BMJ Qual Saf. 2015;24(2):142–8. https://doi. org/10.1136/bmjqs-2014-003194.
31. Roedersheimer KM, Pereira GF, Jones CW, Braz VA, Mangipudi SA, Platts-Mills TF. Self-reported versus performance-based assessments of a simple mobility task among older adults in the emergency department. Ann Emerg Med. 2016;67(2):151–6. https://doi.org/10.1016/j.annemergmed.2015.07.007.
32. Sager MA, Dunham NC, Schwantes A, Mecum L, Halverson K, Harlowe D. Measurement of activities of daily living in hospital- ized elderly: a comparison of self-report and performance-based methods. J Am Geriatr Soc. 1992;40(5):457–62.
33. Elam JT, Graney MJ, Beaver T, el Derwi D, Applegate WB, Miller ST. Comparison of subjective ratings of function with observed functional ability of frail older persons. Am J Public Health. 1991;81(9):1127–30.
34. Fisher BS, Regan SL. The extent and frequency of abuse in the lives of older women and their relationship with health out- comes. Gerontologist. 2006;46(2):200–9.
35. Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of nonmedical problems among older adults pre- senting to the emergency department. Acad Emerg Med: Off J Soc Acad Emerg Med. 2014;21(6):651–8. https://doi.org/10.1111/ acem.12395.
36. Bosworth HB, Schaie KW. The relationship of social environ- ment, social networks, and health outcomes in the Seattle longi- tudinal study: two analytical approaches. J Gerontol B Psychol Sci Soc Sci. 1997;52(5):P197–205.
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42. Southerland LT, Vargas AJ, Nagaraj L, Gure TR, Caterino JM. An emergency department observation unit is a feasible setting for multidisciplinary geriatric assessments in compli- ance with the geriatric emergency department guidelines. Acad Emerg Med: Off J Soc Acad Emerg Med. 2018;25(1):76–82. https://doi.org/10.1111/acem.13328.
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Identifying Fall Risk in the Emergency Department
Chirley M. Rodriguez
Gladys is an 84-year-old woman with a past medical his- tory significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. She was brought to the emer- gency department (ED) by ambulance for a wound on her left lower extremity. She states that she lost her balance while walking and bumped her leg on the cor- ner of a coffee table. At first, she wasn’t concerned since she thought it was just a small abrasion. However, by the next day, it had become red and uncomfortable.
Gladys has had long-standing diabetes complicated by neuropathy as well as retinopathy. Although she ambulates independently, she reports feeling clumsy with her feet at times. It is a common occurrence for her to grab furniture or walls while ambulating in order to maintain balance; it is especially difficult for her to walk
C. M. Rodriguez (*)
Allegheny General Hospital, Pittsburgh, PA, USA e-mail: Chirley.RODRIGUEZ@ahn.org
© Springer Nature Switzerland AG 2019 173 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_10
174 C. M. Rodriguez
at night. Recently, Gladys was diagnosed with a lumbar compression fracture, and she has noted increased dif- ficulty with walking. She lives in a two-story home with her elderly husband, and she is very concerned about falling. Whenever she goes up stairs, she feels like she is holding on for her life.
Gladys is unable to list her current medications and cannot recall if she took any this morning. She mentions that her daughter and son-in-law typically organize her pill box, but they had to travel unexpectedly for per- sonal reasons.
On physical exam, she is noted to have an oral tem- perature of 98.6 °F, heart rate of 78, respiratory rate of 14, and blood pressure of 156/70. She is thin and is wear- ing glasses. She is well-groomed, and she is comfortably resting in the bed. Cardiac exam is notable for a 3/5 systolic crescendo decrescendo murmur in the aortic region. She has clear lung sounds in all fields. Her lower extremities are without gross deformity. Her left lower extremity has a healing area of desquamation with sur- rounding erythema over the lateral calf. The area is tender but without associated purulent drainage, indu- ration, or fluctuance. It measures approximately 8×5 cm.
X-ray of the lower extremity reveals no fractures. Lab results are notable for glucose of 243 mg/dL and leukocytosis to 13.1. Gladys is diagnosed with cellulitis of her left lower extremity. She is given IV cefazolin in the emergency department and a prescription for oral cephalexin as an outpatient. Prior to discharge, Gladys’s nurse cleans the abraded area and applies a dressing while instructing Gladys how to do the same at home. Gladys mentions to the nurse that she does not have anyone to pick her up from the hospital or take her to the pharmacy to get her new prescription filled. Because the ED is busy, and the bed is needed for other patients,
Chapter 10. Identifying Fall Risk in the Emergency… 175
her nurse suggests that social work meet Gladys in the lobby after discharge to assist her with these matters. Gladys is agreeable and tries to get out of bed with notable difficulty. She is able to stand up, but she needs to grab onto furniture and railings to stabilize herself. This is the first time Gladys is ambulating in the depart- ment, and the bedside nurse is now second guessing the discharge plan.
Geriatric ED Evaluation
The bedside nurse alerts the emergency physician, who in turn evaluates Gladys with a quick Timed Up and Go Test. It takes 36 s for her to stand up, walk 10 ft, turn around, and sit down. Since any result >12 s is concerning for gait problems, her discharge is postponed. Physical therapy is consulted in the ED. The physical therapist recommends a walker and home physical therapy, which both Gladys and the physician feel comfortable with. The social worker meets with Gladys and is able to coordinate therapy and a ride home for Gladys. She realizes it will likely be difficult for Gladys to fill her prescription, so she faxes the prescription to the hospital’s outpatient pharmacy and is able to have it filled prior to dis- charging Gladys home.
The US population is rapidly aging. By 2030 one out of every five Americans will be an older adult. By 2050 Americans aged 65 or older will number nearly 89 million people or more than double the number of older adults in the United States in 2010 . As the population ages, the needs and qual- ity of life of this growing population need to be addressed. Because of progression of comorbid conditions and economic and social pressures, older adults use healthcare resources,
176 C. M. Rodriguez
particularly the ED, more frequently than younger adults . The emergency department is a primary point of contact for these patients to be evaluated and can serve as a key place for medical and social issues to be identified and addressed .
Falls are a common problem for older adults which can lead to significant morbidity and increased healthcare costs for older adults. The CDC estimates that more than one out of four adults 65 years and older fall each year, and 2.8 mil- lion of these older adults are treated in the ED for fall-related injuries . Furthermore, 800,000 elderly patients require hospitalizations for fall injuries . Costs attributable to falls in 2015 alone were estimated at approximately $50 billion for both those that were fatal and nonfatal .
Though not typically evaluated in the ED, identification of risk factors for falls in older adults can have important impli- cations on patients’ long-term quality of life . Sometimes these risk factors are clear and related to the chief complaint. But often they are subtler and may even be actively con- cealed by the patient. Elderly patients may be battling depression, issues with mortality, and fear of loss of indepen- dence which may prompt them to hide previous falls or other risk factors. In order to maintain patients’ quality of life and prolong their independence, it is important for the ED team to evaluate risks for future falls.
How to Identify Fall Risk in the ED
The CDC offers an algorithm for fall risk screening, assess- ment, and intervention as part of the initiative Stopping Elderly Accidents, Deaths, and Injuries (STEADI) . The STEADI algorithm begins with screening questions and iden- tifying the number of falls within the past year, focusing on identifying issues with gait, strength, and balance, and finally recommending various interventions based on risk stratifica- tion including physical therapy for patients in moderate- and high-risk groups (Fig. 10.1). It was developed for use in the outpatient clinic but is extremely useful in the ED as well.
Chapter 10. Identifying Fall Risk in the Emergency… 177
Patient completed the Stay Independent brochure
Screen for fall risk
Patient scores 3 4 on the Stay Independent brochure OR
Clinician asks key questions: •Fell in past year?
– If YES ask, How many times? Were you injured? •Feels unsteady when standing or walking?
•Worries about falling?
Score 3 4 OR YES to any key question Evaluate gait, strength, & balance
Individualized fall interventions
•Vitamin D +/- calcium
• Refer for strength & balance
exercise (community exercise or fall prevention program)
Individualized fall interventions
Vitamin D +/- calcium
Refer to PT to improve gait, •
strength, and balance
Refer to a community fall prevention program
Score < 4
OR NO to all questions
• Timed Up & Go (recommended) • 30-Second Chair Stand (optional) • 4-Stage Balance Test (optional)
Conduct multifactorial risk assessment
• Review the Stay Independent brochure
• Falls history
• Physical exam, including:
– Postural dizziness/ postural hypotension
– Medication review
– Cognitive screening
– Feet & footwear check – Use of mobility aids
– Visual acuity check
HIGH RISK individualized fall interventions
• Educate patient
• Vitamin D +/- calcium
• Refer to PT to enhance
functional mobility & improve
strength & balance
• Manage & monitor hypotension • Manage medications
• Address foot probelms
• Optimize vision
• Optimize home safey
Follow up with HIGH RISK patient within 30 days
Review care plan
Assess & encourage fall risk reduction behaviors
Discuss & address barriers to adherence
Transition to maintenance exercise program when patient is ready
strength or balance probelms*
Gait, strength or balance problem
3 2 falls
*For these patients, consider additional risk assessment (e.g., medication review, cognitive screen, snycope).
Figure 10.1 CDC Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm 
Step 1: Screening
A number of fall risk screening questionnaires have been proposed for use in the ED. The fall risk questionnaire used in the STEADI program’s Stay Independent brochure was developed in a US Veteran community and assisted living population . The Stay Independent screening was later evaluated in a US and Thai ED. Although the whole screen was not found to be predictive of fall within
178 C. M. Rodriguez
6 months, return to the ED, hospitalization, or a composite score, some of the individual questions were associated with an increased risk of falls. Those questions were having fallen in the past year, using or having been advised to use a cane or walker to get around safely, feeling unsteady when walking, having to rush to the toilet, having lost some feeling in the feet, and taking medication that sometimes causes light-headedness or fatigue .
STEADI Stay Independent Screen [4, 8]:
• I have fallen in the past year (2 points).
• I use or have been advised to use a cane or walker to get
around safely (2 points).
• Sometimes I feel unsteady when I am walking (1 point).
• I steady myself by holding onto furniture when walking at
home (1 point).
• I am worried about falling (1 point).
• I need to push with my hands to stand up from a chair (1
• I have trouble stepping up onto a curb (1 point).
• I often have to rush to the toilet (1 point).
• I have lost some feeling in my feet (1 point).
• I take medicine that sometimes makes me feel light-headed
or more tired than usual (1 point).
• I often feel sad or depressed (1 point).
• Interpretation: ≥4 points indicate increased risk for falls.
Additional screens which have been developed for use in the ED include the Carpenter score which identified non- healing foot sores, any fall within the past year, inability to cut one’s own toenails, and self-reported depression as risk fac- tors for falls . The Tiedemann scale evaluates for two or more falls within the past year and if the patient takes six or more medications .
Carpenter Score :
• Presence of nonhealing foot sore?
• Any fall in last 12 months?
• Inability to cut own toenails?
Chapter 10. Identifying Fall Risk in the Emergency… 179
• Self-reported depression?
• Interpretation ≥1 “yes” responses is a community-dwelling
older adult at increased risk for falls.
Tiedemann Score :
• Two or more falls in the past year? (2 points).
• Take six or more medications? (1 point).
• Interpretation Score ≥2 indicates older adult at increased
risk for falls.
Step 2: Functional Testing
The purpose of screening is to identify patients who are at moderate-to-high risk of falling in the near future. Once patients at moderate to high risk are identified, either through screening (as recommended by the STEADI pro- gram) or gestalt, functional testing can be performed. One recommended functional assessment is the Timed Up and Go test (TUG) . In order to perform the TUG test, the pro- vider has the patient sit in a standard chair. The patient is asked to stand up from a seated position, walk 10 ft, turn, walk back, and sit down in the chair. The clinician is not only timing the patient but also observing postural stability, gait, and arm swing. It is also important for the provider to stand near the patient for safety. An older adult that takes 12 s or greater to complete the test is considered to be at risk for falling.
Other assessments include the 30 s chair stand and four- stage balance tests [12, 13]. The 30 s chair stand test is used to test leg strength and endurance. In order to perform this assessment, the patient is seated in the middle of a straight back chair without arm rests. The patient is instructed by the clinician to cross their arms across the chest, place hands over the opposite shoulder, and to keep the arms resting on the chest. The patient is to keep their feet flat on the ground with their back straight. The clinician, standing next to the patient,
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will say “go” signaling the patient to rise to a full standing position and sit back down repetitively. This standing and sitting is timed and continues for 30 s while the provider counts the number of times the patient stands. Scoring is based on age and gender averages. Any score below the aver- age indicates a risk for falls.
Thirty Second Chair Stand Test Averages  AGE MEN WOMEN
60-64 < 14 < 12
75-79 < 11 < 10
90-94 <7 <4
A below average score indicates a risk for falls.
The four-stage balance test can be used to assess static bal- ance . In this assessment the patient is taken through four standing positions, each more difficult to maintain than the prior. The provider demonstrates each position for the patient and stands beside the patient for safety. If the patient can successfully hold the position for 10 s without the need for support or moving their feet, then the next position is attempted. If unable to hold for 10 s, the test is stopped. The first position is with the feet side by side; second is with the instep of 1 ft touching the big toe of the other foot; third is a tandem stand with 1 ft in front of the other, heel touching toe; and fourth is standing on 1 ft. Those unable to hold any of the first three positions for at least 10 s are at increased risk of falling.
Chapter 10. Identifying Fall Risk in the Emergency… 181 Four-Stage Balance Test 
Finally, assessment for orthostatic hypotension may identify particular modifiable risk factors for falls. After the patient lies down for 5 min, the blood pressure and pulse should be measured. The patient should then stand and the pulse and blood pressure should be repeated. The standing blood pres- sure and pulse should then be repeated in 1 and 3 min. If the patient experiences light-headedness, a drop of systolic blood pressure ≥20 mmHg, or a drop of diastolic blood pressure of ≥10 mmHg, the patient may be at risk for falls.
Step 3: Intervene
When patients are identified as high risk for falls, additional measures should be put into place. When gait, strength, or balance issues are identified in the ED, referral to physical therapy in the ED or as an outpatient is likely warranted. Additionally, community exercise or fall prevention programs may be available and may be beneficial for some patients. Some patients may benefit from appropriate assist devices such as a cane or walker. Others may benefit from home or outpatient PT, inpatient rehabilitation, or subacute rehabili- tation. In some cases, inpatient or observation hospitalization may be necessary to facilitate initiation of inpatient or sub- acute rehabilitation. In these scenarios formal consultation by a physical therapist is beneficial.
1 Stand with your feet side-by-side.
2 Place the instep of one foot so it is touching the big toe of the other foot.
3 Tandem stand: Place one foot in front of the other, heel touching toe.
4 Stand on one foot.
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When patients are identified as having orthostatic hypo- tension, evaluating the patient’s fluid intake and medication lists for medications which may be high risk for orthostatic hypotension should commence. In some EDs, pharmacists can help review the patient’s medications to identify possible changes. All changes to home medications should be dis- cussed with the original prescribing physician or the patients’ primary care physician if possible.
In this case Gladys is a seemingly capable and indepen- dent elderly woman: she is well-groomed, she answers questions appropriately, and she reportedly lives indepen- dently with her husband. Without a formal complaint to the physician, there are many risk factors in her story that are likely to be missed or overlooked during the encoun- ter. Because Gladys arrived via ambulance and was evalu- ated for cellulitis, her gait was never assessed during the visit. Her gait, although seemingly unrelated to her chief complaint, is fundamental to her well-being and quality of life. After identifying Gladys’s gait instability, it is appro- priate for the bedside nurse to question discharging this elderly woman back to her multilevel home without fur- ther evaluation.
Gladys’ fall risk and lack of access to her medications were ultimately identified and addressed prior to discharge but were nearly missed. She could have been sent home without the ability to fill her antibiotic prescription, and she could have had worsening of her infection. Worsening infection could further increase her risk of falls and easily could have led to a poor outcome. A multidisciplinary approach to ED care for older adults like Gladys early on may have helped avoid these near misses.
1. Ortman JM, Velkoff VA, Hoga H. An aging nation: the older population in the United States. United States Census Bureau; 20 14. Available at https://www.census.gov/library/publica- tions/2014/demo/p25-1140.html. Accessed 25 Feb 2019.
Chapter 10. Identifying Fall Risk in the Emergency… 183
2. Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997–2007. JAMA. 2010;304(6):664–70.
3. Hwang U, Morrison RS. The geriatric emergency department. J Am Geriatr Soc. 2007;55(11):1873–6.
4. Rubenstein LZ, Vivrette R, Harker JO, Stevens JA, Kramer BJ. Validating an evidence-based, self-rated fall risk question- naire (FRQ) for older adults. J Saf Res. 2011;42(6):493–9.
5. Algorithm for Fall Risk Screening, Assessment, and Intervention. 20 17. https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508. pdf. Accessed 15 Jun 2018.
6. Stenhagen M, Ekstrom H, Nordell E, Elmstahl S. Accidental falls, health-related quality of life and life satisfaction: a pro- spective study of the general elderly population. Arch Gerontol Geriatr. 2014;58(1):95–100.
7. Sri-On J, Tirrell GP, Kamsom A, Marill KA, Shankar KN, Liu SW. A high-yield fall risk and adverse events screening ques- tions from the stopping elderly accidents, death, and injuries (STEADI) guideline for older emergency department fall patients. Acad Emerg Med. 2018;25(8):927–38.
8. Stay independent: learn more about fall prevention. 2017. https:// http://www.cdc.gov/steadi/pdf/Stay_Independent_brochure-print.pdf. Accessed 15 Jun 2018.
9. Carpenter CR, Scheatzle MD, D’Antonio JA, Ricci PT, Coben JH. Identification of fall risk factors in older adult emergency department patients. Acad Emerg Med. 2009;16(3):211–9.
10. Tiedemann A, Sherrington C, Orr T, et al. Identifying older people at high risk of future falls: development and validation of a screening tool for use in emergency departments. Emerg Med J. 2013;30(11):918–22.
11. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142–8.
12. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a mea- sure of lower body strength in community-residing older adults. Res Q Exerc Sport. 1999;70(2):113–9.
13. Rossiter-Fornoff JE, Wolf SL, Wolfson LI, Buchner DM. A cross-sectional validation study of the FICSIT common data base static balance measures. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Gerontol A Biol Sci Med Sci. 1995;50(6):M291–7.
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14. Assessment: 30-second chair stand. 2017. https://www.cdc.gov/ steadi/pdf/STEADI-Assessment-30Sec-508.pdf. Accessed 15 Jun 2018.
15. Assessment continued: the 4 stage balance test. 2017. https:// http://www.cdc.gov/steadi/pdf/STEADI-Assessment-4Stage-508.pdf. Accessed 15 Jun 2018.
Capacity, Advanced Planning, and Buying Time
Hashim Q. Zaidi
Ellen Roosevelt is an 89-year-old female with a medical history of coronary artery disease, hypertension, hyper- lipidemia, and Alzheimer’s dementia who is brought in the emergency department (ED) by emergency medical services (EMS) from her nursing home for mental sta- tus changes. EMS reports they were called to the facility where she resides after her nursing aide reported she has not been eating or drinking well for the last few days. Today she was noted to be less responsive to ques- tions from staff. She was found to have a fever of 102 °F and was tachypneic and hypoxic. When you, as the emergency department (ED) care team member, exam- ine her, you see an ill-appearing, cachectic, elderly female who is tachypneic and intermittently moaning in
H. Q. Zaidi (*)
Department of Emergency Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
© Springer Nature Switzerland AG 2019 185 L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4_11
186 H. Q. Zaidi
response to your questions. She withdraws from painful stimuli. She has pooled secretions in the back of her oropharynx and does not appear to have a gag reflex. She is hypotensive with pressure of 80/50 mmHg and is requiring 10 l of oxygen via nonrebreather mask to keep her oxygen saturation above 90%.
Your electronic medical records note the patient has been admitted multiple times over the last year for pneumonia and urinary tract infections, all treated with antibiotics to resolution. She has never been intubated in your facility. In the most recent hospital discharge summary, it is noted that she was listed as “Do Not Resuscitate (DNR)/Do Not Intubate (DNI),” a change from previous admissions, but it does not elaborate much further. The records also list the patient’s adult sister as her designated healthcare power of attorney (POA).
EMS brings paperwork from the nursing home which includes her facility-administered medication list. There is documentation from the facility that also supports she is listed as “DNR/DNI” under the facil- ity’s code status. She is accompanied by another resi- dent from the facility who identifies herself as a long-time friend of Ellen Roosevelt. When you inquire about care preferences or advance directives, she believes there may be a written set of advance directives as well as specific wishes on what she wanted done if she was gravely ill. She believes they may reside with her adult living sister but does not know what they state. She urges you to do everything you can to help her friend get well again. She informs you the patient is a widow with no living children and one adult sibling who has been designated as her POA. They do not know of any Practitioner Orders for Life-Sustaining Therapy (POLST) forms applica- ble to the patient.
Chapter 11. Capacity, Advanced Planning, and Buying… 187
Ms. Roosevelt has intravenous (IV) fluids started with basic labs sent off. A high-flow nasal cannula is applied to help comfortably oxygenate her which she tolerates well and improved her oxygen saturations to 94%. She is sat up to 30°, so her secretions do not bother her or pool in the back of her throat, and pil- lows used provide lumbar and neck support. She is given rectal acetaminophen with improvement in her fever. A chest X-ray reveals a right lower lobe pneu- monia. She is started on antibiotics for the pneumonia. Given her oxygen requirement, the charge nurse is concerned that the general medicine floor will not admit her. Given the reported DNR/DNI status, the emergency physician does not want to intubate her or admit her to the intensive care unit (ICU). How should the emergency department team proceed? What interventions should or should not be performed in the acute setting given her clinical status, recent medical history, and reported desires? What advance care directive considerations should be taken into account in the emergency department or if the patient goes to the intensive care unit?
Capacity and Competence
One of the challenges facing clinicians in situations similar to that presented in the case example is determining if the patient has decision-making capacity. In the example above where the patient’s clinical status is such that she is unable to communicate, it becomes straightforward to conclude she does not have the capacity to make her own medical deci- sions. Consider, however, if the patient had been verbally responsive or perhaps even able to hold a dialogue; the physi- cian is obligated legally and ethically to determine if the patient has decision-making capacity.
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The definition of capacity is broad reaching, context dependent, and often elusive. Additionally, capacity is often interchanged with competence in medical and legal literature. To standardize the terminology in this text, we will define capacity as “a threshold requirement for persons to retain the power to make decisions for themselves” . Capacity in this sense refers to the ability to understand relevant information, communicate a choice, appreciate a situation and its conse- quences, and reason about treatment choices .
Competence is a term that is often interchanged with capacity in the medical setting. It is vital to distinguish medi- cal capacity from the judicial use of word competency. As a legal term, competency refers to an individual’s sufficient ability in a broad sense to make legally recognized rational acts such as enter legal pleas, vote, prepare a will, testify, and make their own medical decisions .
Medical decision-making capacity is often determined by a physician and includes elements of the relevant criteria as seen in Table 11.1 . Medical decision-making capacity is a dynamic process that is determined by many factors. A patient may not have medical decision-making capacity at one point in time, but a change in clinical status at a later point may reverse that. In addition, a patient may have capac- ity in one decision but not in another depending on the nature and potential consequences of the decision in question . For example, a patient may be deemed to have capacity for a decision such as choosing the route of antibiotics for a low-risk infection in the emergency department but may not have decision-making capacity to refuse antibiotics all together if they are lacking in appreciating the situation and its consequences. Physicians caring for a patient in the acute setting have the added difficulty of having to determine decision-making capacity for complex far-reaching decisions in a short span of time. Hasty decisions without careful con- siderations to the principles of beneficence, nonmaleficence,
Chapter 11. Capacity, Advanced Planning, and Buying… 189
and justice within the limitations of that patient’s decision- making capacity may lead to compromised patient safety or autonomy.
Table 11.1 Definitions of the four decision-making abilities and the clinical characteristics of these abilities in the setting of older patients with dementia
The ability to comprehend basic information about a problem, its potential solutions, and the risks and benefits associated with those solutions
The ability of a person to recognize how a problem or solution pertains to his or her specific situation
This ability is often highly impaired in the setting of mild- to moderate-stage dementia benefits associated with those solutions
May be influenced by level of education and intelligence and how information is presented
Impairments manifest as a loss of insight or behaviors of denial in the clinical setting
the type and complexity of the decision, the range of impairment may vary considerably among patients with mild- to moderate- stage dementia
190 H. Q. Zaidi Table 11.1 (continued)
The ability to consider potential solutions to problems by:
1. Demonstrating how one solution is better in comparison to another
2. Describing how a solution would affect his or her everyday life
3. Demonstrating a logical thought process in determining a choice
The ability to render a clear choice for the decision under consideration
This ability is frequently impaired in mild and especially in moderate stages of dementia
Performance in this ability may decline rapidly along with the progression of cognitive decline
Expressing a choice
Impairment is often preserved despite the presence of impairments in other decisional abilities and, when present, is associated with more advanced stages of dementia
Reprinted from Lai and Karlawish . Copyright 2007 with permis- sion from Elsevier
Determining decision-making capacity is a challenge given the time constraints encountered in the emergency depart- ment. However, it remains a critical component of care provided and has far-reaching consequences. Often a deter- mination of medical decision-making capacity in the ED will
Chapter 11. Capacity, Advanced Planning, and Buying… 191
persist until a change in the patient’s mental status or ability to communicate. Occasionally, a more formal evaluation by a psychiatrist or ethics board will alter capacity decisions. The process for determining medical decision-making capacity may be influenced by local laws; therefore, local definitions for medical decision-making capacity as well as the institu- tional process should be well understood or reviewed when deciding if a patient has medical decision-making capacity.
When determining capacity, it is important to identify the patient’s ability to express a choice, understand, appreciate, and reason [2, 6]. For example, if Ms. Roosevelt was awake and was able to express she did not want an IV placed, she would be expressing a choice. Patients may be able to express a choice such as with as much as yes or no answers, a nod, or even a grunt. Stability of choice is also something to be noted by the clinical team; patients may change their mind about decision, but an individual changing their mind minute to minute may not be adequately showing evidence of express- ing a clear decision. Patients with thought, memory, speech, auditory, or cognitive disorders may have a preference or choice but may have difficulty expressing that choice. Reasonable efforts should be made to involve these patients to probe for a communicable preference or decision, but this again may be hindered by time constraints in the emergency department. For many older adults, a choice may be present but not known to the care team until effective communica- tion is established through hearing amplification or transla- tion into the patient’s native language.
Despite being able to express a choice, decisional capacity may not be present if patients cannot express understanding of their current situation, appreciate the risks and benefits of the proposed choices, or reason through options logically. If Ms. Roosevelt is able to express that IVs are painful and expresses her choice that she does not want one, the conver- sation should advance to inquire if she understands why the medical team recommends IV access, what is her current medical state, what the other options are, and the risks of refusing the said intervention. Given that the ED is often
192 H. Q. Zaidi
filled with uncertainty, it frequently falls to clinicians in the ED to explain what the medical evaluation reveals or what the team is concerned about. One method is to discuss the situation, the decision to be made, and its risks, benefits, and alternatives with the patient and see if the patient is conducting logical reasoning with gentle probing. Asking them once again what their preference is, what they understand of what they have been told, and how they came to their decision can help clarify some of the above components. This series of questions not only determines the patient’s ability to under- stand relevant information but also if they can appreciate the situation as well as its consequences. In terms of their ability to reason, the clinician must analyze the process by which a patient reaches their concluding choice, not necessarily the choice itself. How did the patient come to their answer? Does their logic weigh why one option is better than another? What important pieces of information are they able to manipulate to come to a conclusion and do they align appro- priately with the current situation?
A common fallacy in determining capacity is presuming underlying cognitive or psychiatric disorders preemptively exclude patients from decision-making capacity. Physicians have been shown to often believe patients with dementia, depression, or psychosis or under involuntary commitment lack decision-making capacity without evaluation or consid- eration of the decision in question . These patients can- not be presumed to lack capacity until thought is given toward the components of capacity they preserve and those they lack. For example, a patient with a chronic stable underlying psychotic disorder may have decision-making capacity in regard to many healthcare decisions. Scrutiny is required, and a higher standard for capacity is needed in a high-risk situation with increased chances for an adverse outcome.
To provide a more structured assessment of capacity, sev- eral validated decision-making tools have been developed such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) . The interview typically takes
Chapter 11. Capacity, Advanced Planning, and Buying… 193
15–20 min and involves the clinical course beginning with the nature of the medical condition, treatment recommendation, risks, benefits, and alternatives and is followed by asking probing questions that delve into the patient’s ability to choose, understand, appreciate, and reason through a medical decision. However, standardized tools, such as the MacCAT-T, are not practical for use in the ED. Alternatively, the CURVES assessment tool provides an abbreviated screen more appropriate for the ED .
This mnemonic being developed helps to consolidate some of the integral aspects to answer for a capacity assess- ment (Fig. 11.1). The “Emergency” and “Surrogate” aspects help to frame the assessment for the acute setting to weigh imminent risk to the patient and if surrogate decision- making is available. It is important to recognize that in the acute setting being able to communicate with a surrogate decision-maker can help clarify goals of care and should be reasonably attempted by providers but also depends on the acuity of the situation and availability of the surrogate. It should be noted that surrogates include advance healthcare directives. When available these documents should be located and reviewed.
Choose and Communicate – Can the patient communicate a choice?
Understand – Does the patient understand the risks, benefits, alternatives, and consequences of the decision?
Reason – Is the patient able to reason and provide logical explanations for the decision? Value – Is the decision in accordance with the patient’s value system?
Emergency – Is there a serious and imminent risk to the patient’s well-being?
Surrogate- Is there a surrogate decision-maker available?
Figure 11.1 Mnemonic for the assessment of decision-making capacity and provision of emergency treatment. A patient lacks capacity if any of the prerequisite abilities (to choose and communi- cate, understand, reason, or value a decision) are absent. If a patient lacks capacity in an emergent situation and no surrogate decision- maker is available, then emergency treatment without informed consent may be provided for a medically warranted course of action. (Reprinted from Chow et al. , Page 423. Copyright 2010 with per- mission from Elsevier)
Does the patient have decision-making capacity?
Can emergency treatment without informed consent be provided?
194 H. Q. Zaidi
Advance Care Planning
Advance care planning is a process that helps support adults of any age or health state understand and share their per- sonal values, life goals, and preferences regarding future medical care . This process helps to inform and empower patients about current and future medical care options. The goal of advance care planning (ACP) is to ensure that medi- cal care is in line with the patient’s values, goals, and prefer- ences. ACP is particularly important near the end of life. This can help patients to receive quality end of life care which includes five valued components: adequate pain and symp- tom management, avoiding inappropriate prolonging of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones . Advance care planning is a proactive, continuous process between a patient and their healthcare team. However, the term is often conflated with a set of documents known as advance direc- tives. Advance directives, sometimes called as a living will, are documents to help outline care preferences and are com- pleted while a patient has decisional capacity and is able to express those wishes. The contents of these documents are highly variable and may contain generalities about what a patient would or would not prefer up to highly specific con- tents on specific interventions. There are advantages and disadvantages for each of the advance directive formats avail- able .
Advance directives are simply one set of tools to assist with advance care planning and help to document a patient’s wishes. Since the passage of the Patient Self Determination Act of 1990, mandating that all Medicare-certified institu- tions provide information regarding patients’ right to formu- late advance directives, use of advance directives has been increasing . Advance directives may be effective in reduc- ing hospitalization and chances of dying in a hospital, decreasing the use of life-sustaining (or death-prolonging) treatment, and increasing the use of palliative and hospice care. However, simply having advance directives does not
Chapter 11. Capacity, Advanced Planning, and Buying… 195
necessarily guarantee improved outcomes. The impact of advance directives depends on the type of advance directive a patient has completed and how ACP has been implemented overall .
Durable Power of Attorney for Healthcare and Living Wills
Several types of advance directives exist to help a patient clarify their wishes, and an emergency care provider may see one or more of these with a patient presenting to the ED in the United States. One of the most prevalent advance direc- tive forms is the Durable Power of Attorney for Healthcare (DPAHC). This legal document may go by several different names depending on the state nomenclature including “Healthcare Proxy” or “Healthcare Power of Attorney” or “Medical Power of Attorney,” but the contents are relatively similar. This type of form is a signed legal document authoriz- ing another person to make medical decisions on a patient’s behalf if they lack the ability or capacity to do so for them- selves . These forms can be state specific in the United States and may be combined with other components of advance directives. An example of a Power of Attorney for Healthcare for the State of Illinois can be seen in Fig. 11.2. One component often included in many DPAHC forms is a living will. The living will is a document that often helps out- line a patient’s wishes in specific medical circumstances. Commonly, it works to help clarify invasive resuscitation or prolonged life-support situations. This may be variable from state to state as well as patient to patient, and clinicians should be familiar with the state and local legal statutes sur- rounding validity and applicability of these documents.
Early studies of advance directives and the early formats of advance care planning failed to show meaningful improve- ment in important outcomes such as mechanical ventilation, days spent in the ICU, or reported pain . Since then, how- ever, an increased movement toward advance care planning
196 H. Q. Zaidi
Figure 11.2 A sample of a healthcare power of attorney form from the State of Illinois
beyond a single document or discussion has been promoted to help a patient and family members understand what their own wishes are in a complex medical situation and how to express them to healthcare providers. More recent studies have shown that advance care planning, particularly in the form of meaningful discussions in conjunction with well-documented advance directives, helps patients receive care that is in line with their wishes and may help to reduce family stress, anxiety, and depression [13, 17]. Studies of bereaved family members also report greater hospice use and improved communication with healthcare providers when advance directives are involved .
The challenges with advance directives are multiple and also lie at the heart of the issue of attempting to plan end of life care, i.e., patient and their loved ones often don’t know what they want for end of life care. Beyond the educational hurdles to be conquered before making informed planning decisions, even when that education is supplied, it may not stimulate informed advance care planning [19, 20]. If advance care planning does proceed, these preferences can be variable
Chapter 11. Capacity, Advanced Planning, and Buying… 197
and may quickly change when hospitalization or illness occurs . Additionally, physicians have difficulty extrapo- lating end of life preferences from advance directives; inter- estingly this was worse in primary physicians and more accurate in the emergency or critical care physicians that had never met the patient before . This is also amplified in difficult clinical scenarios resulting in physicians frequently making treatment decisions not consistent with an explicit advance directive . Though advance directives have not delivered the silver bullet for improving end of life care, they can be used as a foundation to help build advance care plan- ning and lead to high-quality end of life care.
Surrogate decision-making or “alternate decision-maker” is anyone exercising decisional authority on behalf of an inca- pacitated patient. This may be an appointee by a court, by a patient’s advance directive, or by DPAHC or a default sur- rogate depending on the situation. All US states honor the DPAHC or equivalent as well as court-appointed surrogate decision-maker. The DPAHC is described above in which a patient with decisional capacity identifies whom they would prefer to make decisions on their behalf should they lose capacity. Because advance directives are frequently not com- pleted, surrogate decision-makers are often assigned via legal statute [24, 25]. Significant variability arises between state differences in the “surrogacy ladder” and with the terminol- ogy used between states and districts in the United States. Among the 50 US states and District of Columbia, 41 juris- dictions have a provision for appointment of a default surro- gate for medical decision-making in the absence of an agent . Of those, 35 establish a surrogate hierarchy with the highest priority given to spouse, children, or parents. Seven states provide for a domestic partner or common-law spouse to become surrogate decision-makers and allow for same-sex partners to occupy one of the top rungs. Physicians should
198 H. Q. Zaidi
carefully familiarize and stay up to date with their local prac- tices for surrogate decision-makers. Six states require the surrogate decision-making hierarchy only be invoked in spe- cial circumstances, and four have no provisions on default surrogate decision-making. It is imperative the treating clinician be aware of local and state statutes regarding default surrogate decision-makers.
In the acute setting, it can be difficult to identify or con- tact the default surrogate decision-makers. In the clinical example above, most states, given no spouse or children, would default her sister as her decision-maker. This, how- ever, could be overridden by specific, legally valid advance directives such as a DPAHC that employs a friend or sig- nificant other in the decision-making role instead of the default surrogate decision-maker. Of note, significant oth- ers not legally married or with a DPAHC may not be given the same rights of default surrogate depending on the state and local statutes. Not surprisingly, these situations can become complicated, and physicians should always avail themselves to the hospital ethics or risk management team in times of uncertainty. Figure 11.3 provides a general hier-
• Patient with Decisional Capacity
• Designated Healthcare Power of Attorney
• Default Surrogate Decision Maker (Varies by State/District)
Figure 11.3 Hierarchy of decision-makers beginning from a patient with decisional capacity to the default surrogate decision-maker
Chapter 11. Capacity, Advanced Planning, and Buying… 199 archy of surrogate decision-makers following a patient with
Advance directives have a wide range of forms as described above and can have limited use in the acute setting . Patients and families often struggle with a multitude of choices even preceding end of life care, and the acute setting is often a suboptimal environment to establish meaningful discussions with patients or family members.
To standardize the instructions for healthcare profession- als when death was imminent, the Physician Orders for Life- Sustaining Treatment (POLST) was developed . The POLST form (Fig. 11.4) sought to standardized portable medical orders for patients with progressive, chronic illnesses regarding life-sustaining medical treatment, including resus- citation, intubation, antibiotics, artificial nutrition, and hydra- tion. The format gained increased favor and popularity among healthcare providers as it was thought to address many of the shortcomings in typical advance directives at the time as well as its ability to span a variety of settings, e.g., prehospital, ED, inpatient, nursing home, hospice, etc. . POLST forms support a degree of individualization that helps clarify patient preferences to actionable medical orders with ease . Additionally, POLST forms can be used by nonphysician facilitators to guide patients through the pro- cess of identifying what, if any, life-sustaining treatments they would want near death.
End of Life Care Communication
Rather than simply filling out forms, advance care planning should bring together the person, individuals they trust in decision-making, and clinicians to support discussions about the patient’s preferences regarding medical care. These dis- cussions should match the level of discussion the patient finds
200 H. Q. Zaidi
Figure 11.4 An example of a Physician Orders for Life-Sustaining Treatment (POLST) form from the State of Illinois available at http://www.polstil.org/
comfortable and should be revisited when health or life cir- cumstances change . End of life care discussion has been shown to decrease costs and promote a higher quality of death .
Chapter 11. Capacity, Advanced Planning, and Buying… 201
ED Goals of Care
Advance care planning can help direct care in the ED if it is performed prior to an ED visit . However, end of life care often brings patients to the emergency department. Up to 80% of cancer patients seek care in the ED in the last 6 months of life [31, 32]. The ED is often a difficult environ- ment to begin a goal of care discussion much less an end of life one. Aside from prognostic uncertainty, logistical and time constraints, and lack of familiarity by the patient and family to the care team, many ED staff members are not trained in end of life care. Many providers report feeling underprepared and may feel the ED is an inappropriate place to conduct such care . However, many critically ill patients in the ED have not had ACP discussions or do not have legal documentation. Though it is not the optimal site of ACP, dis- cussions about advance care planning in the ED can go a long way to help identify and honor patients’ wishes. The ED team should strive to provide care that is consistent with the patient’s values and goals. The initial steps should be to iden- tify or clarify any previous ACP and what the discussion has been to date with their primary physician or a specialist. The care team should inform the patient or surrogate decision- maker of their suspected diagnosis, prognosis, risks and ben- efits or treatment, and treatment alternatives. They should provide all options for care and treatment and attempt to connect the options back to any previously ACP and see if the current preferences align with previous preferences. Care values and goals can change dramatically moment to moment, and it should be noted not to assume they have remained unchanged in this particular acute setting.
One method to help clinicians walk through these steps is the “ABCD” method from the Education in Palliative and End-of-Life Care for Emergency Medicine (EPEC-EM) cur- riculum . In this paradigm, A (advance care plan) refers to if there is an advance care plan available to review? B (better symptoms) asks if there can be better symptom control done to mitigate overwhelming symptoms such as dyspnea or
202 H. Q. Zaidi
pain? C (caregivers) requests caregivers for information on the patient’s clinical context and recent functional changes? And finally, D (decision-making) asks if the patient has decision-making capacity to discuss goals or is the legal sur- rogate identified and accessible? This model helps ED clini- cians frame many of the difficulty questions that immediately apply to the acutely ill patient where end of life care may be needed.
Often the questions for the ED clinicians are related to choos- ing which interventions are appropriate for the patient? This is easy in the critically ill adult whose goals of care are to avail every medical therapy to prolong life or for the patient who has specified through clear advance directives that they should have comfort care only. The challenge lies in patients who may not have clear or any advance directives and are critically ill and there is uncertainty about what their goals are.
In our case example above, what should be done about Ms. Roosevelt’s airway? What about fluids? Vasopressors? Antibiotics? One of the luxuries often not afforded in the ED is time to evaluate fully a patient’s goals and care wishes and discuss with the family, friends, or long-term care providers to obtain that information. By identifying low-risk temporizing interventions, the ED team can help to facilitate appropriate care and be able to escalate or de-escalate care when and if the patient’s goals of care are found to be clearer.
For Ms. Roosevelt, it would be appropriate to start an IV line, provide IV fluids, draw labs, and obtain basic data such as imaging and electrocardiogram. These are not only nonin- vasive for the large part but also help provide information on the diagnosis and prognosis of her condition. However, if she is tachypneic and hypoxic, has pooled secretions in the back of her oropharynx, and does not appear to have a gag reflex, it appears that she requires endotracheal intubation; however, because there is confusion about a previous DNR/DNI status,
Chapter 11. Capacity, Advanced Planning, and Buying… 203
it is not clear if that would honor Ms. Roosevelt’s wishes. In situations like this, one useful tool for buying time for the ED care team is to initiate noninvasive ventilation for a short term while more information is gathered. While this is often seen for certain patients with reversible etiologies of respira- tory failure with an adequate mental status, it may be appro- priate in certain clinical situations after careful discussion with relevant decision-makers present with explicit parame- ters for its intentions, uses, and success and failure parameters . If aspiration is a significant concern, alternatives can include nasal bi-level positive airway pressure (BiPAP) and high-flow nasal cannula to help provide positive pressure and oxygenation short of endotracheal intubation.
Antibiotics are a controversial area in palliative care par- ticularly in the emergency department. Many providers see little to no harm in treating empirically until definitive goals of care can be achieved. This may be appropriate in certain situa- tions, but side effects, increased resistance patterns, and no data to show palliative effects of symptoms all weigh against its hasty use . Nearly 90% of hospitalized patients with advanced cancer receive antimicrobials in the week prior to their death and similarly with nearly a quarter of hospice patients [37, 38]. The ED is likely a prime area to improve appropriate antimicrobial use, and it begins with identifying the patient’s goals of care and advocating for them. Evidence- based and goal-directed counselling about infections at the end of life should be a component of advance care planning. If a patient’s goal is to maximize comfort, then it is reasonable to recommend no infectious evaluation and antimicrobial inter- vention. Adequate antipyretics, pain control, and symptom management should be identified as the priority in this case.
After initiating high-flow nasal cannula, the ED physician contacts Ms. Roosevelt’s sister, her only known living relative. She states she is the DPAHC and that on her last admission
204 H. Q. Zaidi
her sister had made it clear she did not want invasive therapies if she had another pneumonia. She states that Ms. Roosevelt had started a living will with her sister and her primary physi- cian but did not yet complete it. She states her sister was look- ing for comfort rather than more time spent in a hospital. They had discussed if she were to ever become critically ill, they would arrange for home hospice. With this information, the ED team is able to transition her to home hospice directly from the ED to her sister’s residence for comfort measures.
Resources for Patients and Providers
American Association for the Advancement of Retired Persons Printable Advance Directive Forms: https://www. aarp.org/caregiving/financial-legal/free-printable-advance- directives/
Aging with Dignity (5 Wishes) forms: https://www.aging- withdignity.org/
CaringInfo- National Hospice and Palliative Care Organization: http://www.caringinfo.org
POLST- National POLST paradigm: http://www.polst.org References
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Accredited healthcare care chaplaincy program, 148
Acute care for elders (ACE) units, 55
Acute care outpatient visits, 12, 13 Adult protective (APS)
services, 27 Advance care directives, 187,
Advance care planning, 194, 195,
197, 199, 201 Adverse drug events (ADEs),
related issues, 1, 2, 4, 6, 8
AGS Beers criteria, 116
Altered mental status in geriatric
patients, 159 Alternate decision maker, 197
American Geriatrics Society (AGS) Beers Criteria,
48, 115, 116 Analgesics (NSAIDs and
Opioids), 127, 128 Antibiotics, 203
Anticholinergic medications, 125 Anticoagulation, 125 Antidepressants, 126 Antipsychotics, 126
Artificial nutrition and hydration, 79
Assisted Living (AL) communities (Assisted
Baseline mental status, 166 Beers criteria, 19
course, 166 Bone mass, 7
Brief Confusion Assessment Method, 22, 23,
41, 44, 45
Cardiac murmurs, 5 Cardio-pulmonary system, 5–6, 8 Caregiver Burden, 166
Care values and goals, 201 Carpenter score, 20, 178 Case-based approach to
improving acute care delirium (see Delirium)
functional impairment, 56 weight loss and leg
swelling, 40 CDC Stopping Elderly
and Injuries (STEADI) Algorithm, 177
© Springer Nature Switzerland AG 2019
L. A. Lindquist, S. M. Dresden (eds.), Geriatric Emergencies, https://doi.org/10.10 07/978-3-030-12414-4
Centers for Disease Control and Prevention (CDC), 78
Centers for Medicare & Medicaid Services’
(CMS) Nursing Home
Data Compendium, 81 Central nervous system
(CNS), 132 Chaplain referral, 147, 148
CMS research in long term care (LTC) facilities, 95
Cockcroft-Gault equation, 130 Cognitive impairment, 55 Competence, 188
Complex wound care, 79 Comprehensive geriatric
consults, 104, 165 Constipation, 4, 8
CT brain imaging, 164
Decision making capacity, 187, 202
Dehydration, 163 Delirium, 21, 24
avoidance of high-risk
medications, 45 cardinal features, 43
cognitive impairment, 43, 52, 54
diagnosis, 49 evaluation of, 44
tools, 50–51 hyperactive, 43 hypoactive, 43 intentional, structured
investigation, 54 level of consciousness, 43
mental status, 52 nonpharmacological
strategies, 45, 47 pharmacological
strategies, 47, 48
quality of life, 54 screening tools, 43 treatment, 44
Delirium Triage Screen (DTS), 22, 23
Diagnostic and Statistical Manual of Mental
Edition (DSM-5), 43 Dietary intake, 129
Digoxin level, 161
Digoxin toxicity, 162–163 Disposition, 165, 166 DNR/DNI status, 202 DPAHC, see Durable Power of
Healthcare (DPAHC) Drug-drug interactions (DDIs)
in older adults, 128 Durable power of attorney for
healthcare (DPAHC), 52, 195–197
ED and Hospital Course, 161–162
ED-based cognitive impairment, 24
ED based interventions, 15 ED-based palliative care consultation or
referral, 29 ED clinicians, 202
ED cognitive screens, 25
ED goals of care, 201
Edmonton Symptom Assessment
System (ESAS), 153 Education in Palliative and
End-of-Life Care– Emergency Medicine (EPEC-EM) curriculum, 29, 201
Education in Palliative and End-of-Life Care
(EPEC) program, 153
Elder abuse, 25–27
Elder abuse suspicion index, 27 Emergency department (ED)
arrival, 77 Emergency department (ED)
care team member, 186 Emergency department focused
approach, 144 Emergency department initial
management, 159, 160 Emergency medical services
(EMS), 185 Emergency physician (EP),
145, 147 End of life, 109
care discussion, 200 Enhancing Quality of Prescribing
Practices for Older Veterans Discharged From Emergency Department (EQUiPPED) program, 48
Evidence based and goal directed
counselling, 203 Extended/Long Term Care (LTC) facility, 79
Failed verbal and non-verbal de-escalation
techniques, 127 Fall risk, ED, 173–176, 182
self-reported depression, 178
STEADI program, 177 Falls, muscles, 7
Fellowship training in Hospice
Medicine, 153 5-minute ED goals-of-care
conversations, 145 Fluid intake, 8
4 stage balance test, 180, 181 Functional decline, 21
Gastrointestinal tract, 4–5 Geriatric assessment and care
coordination, 13 Geriatric Emergency
Department (GED) guidelines, 13–14, 54
Geriatric Emergency Department Multi-
Disciplinary Team, 14 Geriatric Nurse Liaison
(GNL), 41 Geriatrics assessment, ED, 17
Geriatrics clinic and Caregiver Support Services, 56
Gladys’s gait instability, 182 Goals of care conversations, 147
Hair loss, 2, 8
Health care in nursing
facilities, 83 Healthcare power of attorney
(POA), 186 Health care system, 105
Health inspection surveys, 91 Hearing loss, 2, 3
HELp model, 55
High-Risk Medications in the
Elderly (HRM), 116 Home-based comfort-focused
care plan, 151 Home based Primary Care
108–111 Home care resources, 21
Hospice Referral, 151, 152 Hospital at Home, 54 Hospital discharge, 79 Hydration status, 163 Hypercalcemia, 163 Hypertension in older
Identification of Seniors at Risk (ISAR) score, 15
Identify seniors at risk (ISAR), 71
Independent Living (IL) communities, 80
Integrated health services, 11 Interventions to Reduce Acute
(INTERACT), 97 Intravenous fluids for
rehydration, 106 Intravenous therapy, 79
Kidneys and fluid balance, 5
Lean body mass, 131
Lithium salts and stimulants, 126 Liver dysfunction and protein
binding, 131 Living will, 194
Logical reasoning with gentle probing, 192
Long-term care facilities (LTCs), 85
Long-term skilled nursing care, 80
MacArthur Competence Assessment Tool
(MacCAT-T), 192, 193 Malignant pain
acute on chronic, 141
treatment of, 142 Medical decision-making
capacity, 188–192 Medicare, 55
Medicare Claims data, 90 Medication discrepancies, 132
Medication reconciliation, 18, 132
Medication response in older adults, 128–130, 132
Medication therapy, 114 Medication Therapy
services, 133 Mild cognitive impairment
(MCI), 49 Mini-Mental State Examination
(MMSE), 24, 49 Minimum Data Set (MDS), 90
Modified Caregiver Strain Index, 41
Montreal Cognitive assessment (MoCA), 25, 52
model, 17 Muscle loss, 7–8
National Committee for Quality Assurance and
National Comprehensive Cancer Network, 142
National Nursing Home Survey, 78, 95
NCCN guidelines, 142 Neurally-mediated syncope, 66 Non-skilled care in the home, 55 Nonsteroidal anti-inflammatory
drugs (NSAIDs) in
older adults, 127 Nursing facilities (NFs), 81–83
treatment limitations, 91, 93
Nursing home, 79, 80 placement, 21
Nursing Home Reform Act, 81
Occupational therapy (OT), 79 Opioid equivalence calculations,
144 Optimizing care, 98
Optimizing Patient Transfers, Impacting Medical
Quality and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC), 97
Oral morphine equivalents (OMEs), 142
Oral rehydration, 164 Orthostatic hypotension, 182 Ostomy care or rehabilitation
with physical therapy, 79 Over-the-counter (OTC)
medications, 124, 125
Pain management, 153 Palliative and hospice care,
27–30, 194 care needs, 149
Palliative Care Referral, 150 Patient Self Determination Act
of 1990, 194 People-centered care, 11
for older adults, 13 Pharmacodynamics, 129 Physical and occupational
therapy, 161, 164 and Speech Therapy, 83
Physician-initiatied goals-of-care conversations, 144
Physician Orders for Life- Sustaining Treatment
(POLST), 199, 200 Polypharmacy/functional
dependence, 15, 18, 114 Post-acute (sub-acute) care, 79 Post-acute and long-term care
ancillary services, 86 care and services, 87–89 medical care, 83 medications, 93, 94, 96 nursing care, 83
Postprandial hypotension, 66 Potentially avoidable
hospitalizations, 95 Potentially inappropriate
from 2015 Beers Criteria,
117–123 Practitioner Orders for Life
(POLST), 187 Prehospital emergency medical
systems, 12 Protective services, 105
Renal clearance, 130 Renal function, 8
and antipsychotics, 126 and anxiolytics, 126
Serotonin syndrome, 125
Short Blessed Test (SBT), 24 Skilled Nursing Facilities (SNFs),
78, 84, 85 Skin, 6
Social Work, 165 referral, 149
Speech therapy (ST), 79 SPEED, 150
Spiritual care in healthcare
settings, 147 Star rating system, 86–91
Stopping Elderly Accidents, Deaths and Injuries
(STEADI) program, 20, 176
Sub-Acute Rehab facility, 107 Supportive care with close
cardiac monitoring for
arrhythmias, 162 Surrogate decision making, 197,
198 Syncope, 65
antihypertensives, 70 cardiac work-up, 67–68 causes, 66–67
EEG testing, 68 functional assessment, 71 Holter monitor, 68 inpatient testing, 71 non-cardiac causes, 66 orthostatic vital signs, 68
30 second chair stand test, 179, 180
Tiedemann score, 20, 178
Timed up and Go (TUG) test, 20,
72, 175, 179 Tooth loss, 8
Transitional care nurse (TCN), 16
Validated decision making tools, 192
Vasovagal syncope, 73 Vision, 3