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Cover Story//Geriatric Emergency Medicine
 
 
 
Preparing for the ‘Geri-Boom’
A special report 
 
 
An 87-year-old woman was brought into our emergency department by EMS accompanied by her neighbor after having been found down in her apartment. She was alert and oriented and offered no complaints. She could not recall what happened but her neighbor had seen her in her usual state of health the previous night. An initial physical exam yielded no obvious injuries. She told us that she lived alone and had some medical problems, but she couldn’t remember what they were. Her neighbor reported that she was “fairly independent”. Her presentation represented a challenging but increasingly common clinical scenario: What exactly was her baseline functional and mental status? We had little background information about both what happened in the past 18 hours and her medical history, medications, and possible allergies. Was there an underlying medical cause of her fall? Would her specific age-related physiologic changes and/or co-morbidities complicate our management and her outcome?  Despite her initial stable vital signs and a normal exam except for mild amnesia, a thorough ED evaluation and work-up yielded a complex narrative of events and surprising significant clinical findings. A combination of a change in medication dosage and an occult urinary tract infection had made her dizzy, causing her to fall. She suffered a subdural hematoma and an inferior pubic rami fracture, as well as mild troponin leak, representing ischemia. Her hospital course was long and complicated by nosocomial pneumonia and delirium. After discharge to a rehabilitation facility, she finally returned home.

Several years ago we noticed the striking number of patients over the age of 85 years of age in need of acute care. Even more striking was the fact that the vast majority were coming from home. Clearly, a shift in population demographics had occurred which made us seriously question whether the medical community in general and emergency physicians (EPs) in particular were adequately trained to deal with this shift.

According to the 2006 U.S. Census Bureau report, 12.4% of the U.S. population, or approximately 37 million people, are age 65 years of age or over [1]. By 2030, this percentage will increase to approximately 21% of the population, or 76 million. Perhaps of even greater concern is that the fastest growing segment of the population is the age group 85 and older. Based on a 2005 Emergency Department Summary report the greater than 65 age group accounts for 16.7 million ED visits, or 14.5% of total ED visits and 41.6% of in-patient admissions nationwide [2]. If current population-based visit rates remain the same, in 2035, patients 65 and older will make 39 million ED visits, or 26% of total visits [3]. Compared with previous generations, older people today are living longer, healthier, and better – remaining independent and highly functional well past retirement. Although advances in health education, technology, and medicine have helped enable the elderly to tolerate chronic medical conditions such as heart disease, diabetes, depression, and arthritis, at the same time, many of the elderly suffer from functional impairment, chronic underlying illness, and acute exacerbations of chronic illnesses that cause them to seek emergency care in ever-increasing numbers.

When the elderly require emergency care, the subtleties and complexities of their clinical presentations, their need for age appropriate evaluations, their consumption of ED resources, their ED lengths of stay, and their rates of subsequent in-patient admissions, particularly to critical care units, are all significantly higher than they are for younger patients [4], [5] Correct diagnosis – especially when signs and symptoms of illness are atypical or absent – and rapid, appropriate treatment will often enable the elderly to avoid a life of dependence.

The emergency physician of the 21st century requires an enhanced skill set and innovative strategies to provide the emergency care necessary for geriatric patients to overcome what could be considered a turning-point  event – a potentially catastrophic illness or occurrence that may be life-threatening or life-changing. An ED visit can result in geriatric patients experiencing a permanent functional decline, a reduction in health-related quality of life, and an increased likelihood of needing nursing home admission.6  Approximately 25% of elderly patients return to the ED within 90 days of an initial visit [6]. Several studies reveal an increased one-year mortality following an ED visit by a geriatric patient [7]. Clearly, this is an ED patient population that is particularly vulnerable and requires focused expert care. 
 
BIBLIOGRAPHY
 
1. Data from the 2006 US Census Bureau.
2. Nawar EN, Nisla RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Advance data from Vital and Health Statistics, No 386. June 29, 2007.
3. Calculated from data from the US Census Bureau, National Population Projections. Available at: http://www.census.gov/population/www/projections/natproj.html.
4. Roberts DC, McKay MP, Shaffer A. Increasing Rates of Emergency Department Visits for Elderly Patients in the United States, 1993 to 2003. Ann Emerg Med 2008;51:769-774.
5. Strange GR, Chen EH. Use of Emergency Departments by Elder Patients: A Five-Year Follow-Up Study. Acad Emerg Med 1998;5(12):1157.
6. Chin et al. Ann Emerg Med 1999; vol 34, no 5:595-603.
7. Magauran B et al, editors. Emergency Medicine Clinics Of North America – Geriatric Emergency Medicine. May 2006; Vol. 24:2
8. JAMA 2008;3 00:1154-11
9. Derlet RW et al. Development of An Emergency Department Overcrowding Scale: Results of the National ED Overcrowding Study (NEDCOS). Acad Emerg Med 2002;9:366a.

 
 
Continue to next page for 9 elder-care strategies gleaned from the geriatric ED
 
{mospagebreak title=Lessons Learned} 
Cover Story//Geriatric Emergency Medicine
 
 
 
Lessons Learned
9 elder-care strategies gleaned from the geriatric ED at New York
Presbyterian–Weill Cornell Medical Center


1. Look Beyond The Birth Year
It has been said that 70 is the new 50. Or maybe 80 is the new 50. Either way, the idea of age is changing rapidly. Who exactly is an “elderly” patient? As the older population grows, the heterogeneity of this age group is increasing. A wide range of physical and cognitive functioning exists. The concept of physiologic age versus biologic age is more important than ever. The EP must be able to distinguish the two in order to optimally care for elderly patients. Although many older people have chronic diseases such as heart disease, diabetes, hypertension, and cancer, an increasing number are very healthy and have better physiologic reserve than some younger individuals. Being over 65 doesn’t mean that a patient is inherently sickly or fragile. In the end, the EP must look beyond the date of birth to who the individual is.

2… But Don’t Disregard Age
Even if an elderly patient appears robust and healthy and reports no medical problems, he is no longer 22. Age-related changes to any organ system may predispose him to illness or injury. And silent, as yet undiagnosed, medical problems may manifest for the first time during a stressful event, such as an infection or a trauma. EPs must be aware of the delicate threshold that divides “healthy” and “ill” which older patients often cross during an ED visit.

3. What’s their baseline status?
Subtle functional and cognitive changes that can occur in an elderly patient, like a minimal shift in gait, a mild decrease in appetite, or a slight decline in memory, can represent clinically significant and dangerous pathophysiology. “Normal” may be difficult to discern during an acute illness. And older patients often can’t communicate clearly what is wrong or rather choose to downplay a symptom or event out of fear of what it means and what will happen to them in the hospital.

4. The Friends and Family Plan
A patient’s family, friend or home health aide is often the EP’s best source of reliable information. These caregivers know the patient best and will be the first to recognize subtle changes in baseline status. They can also supply you with medical and surgical history, medication lists, and allergy profiles. Equally important may be the caregiver’s calming presence for the elderly patient who finds herself in the unfamiliar, noisy, over-stimulating environment of the ED. A loved-one’s face or voice may be the difference between a quiet versus a delirious patient. Don’t ask family and friends to leave the ED.

5. Expect the Unexpected
Elderly patients classically present atypically. In other words, signs and symptoms may be confusing or even absent in the context of major illness or injury. A urinary tract infection may manifest as mild forgetfulness or confusion, or a heart attack with minimal nausea. And if these patients are misdiagnosed, it could have catastrophic consequences. With the elderly, subtle findings often have real meaning. Don’t expect the elderly patient’s case to present in a textbook fashion.

6. Forget Ockham’s Razor
According to Ockham’s Razor, the simplest answer will more often be correct then a more complex convoluted one. As useful as this tenet may be in the rest of medicine, in geriatric emergency medicine, it is often not applicable. Frequently, in older patients several problems have occurred concurrently leading to several more problems. The clinical presentation may be confusing, as in the older woman’s fall described in the first paragraph. An infection and medication side effect caused dizziness, leading to her fall, and resulting in a pelvic fracture, an intracranial bleed, and injury to her heart. Often, wrapping up the case with a simple red bow will result in missing diagnoses that could be fatal to the patient.

7. Embrace Your Inner Sherlock
Taking care of older patients is some of the most challenging work in the emergency department. When young people get sick, there is usually a single, simple explanation. In geriatric emergency medicine, the EP must become a clever sleuth. An approach to educating residents is actually applicable to all who provide care for this group: Instead of thinking of the undifferentiated abdominal pain in an older person as a scary chart to pick up, think of it as an exciting clinical and therapeutic challenge that has great rewards. It’s going to require a little more time and likely more resources, and the elderly patient may stay in the ED a little longer, but if the proper diagnosis and management can result, the payoff for everyone can be huge.

8. Watch for Lethal Drug Combos
Be aware of what has been described as the polypharmacy cascade. Many older people take several medications for chronic medical conditions. Adverse drug events and dangerous synergies can result. This is an increasing problem that is one of the leading causes of older patients presenting to the ED. In this era of sub-specialization, care givers often do not communicate well with one another, so multiple physicians may be prescribing different medications (or even the same medications at different doses) to an older patient. This almost ensures that adverse effects will take place. At times, the symptoms brought on by this polypharmacy may cause yet another prescription to be written. A presentation to the ED for a specific complaint may not be the result of a new illness, but rather a drug-to-drug interaction. Polypharmacy should be on every EP’s radar. It’s impossible to stay up to date with all the new drugs and their potential side effects, but one solution is for EPs to call their in-hospital pharmacist for more information when suspicion is high.

9. Communication and Community Are Key
Whether obtaining key medical information from the patient’s close friend, or informing the family that the CT scan will take another hour to complete, or learning from the primary care physician that the ECG is unchanged, good communication is vital. As well, a “community” or multi-disciplinary team approach is often necessary to provide the comprehensive care needed by the elderly. Physicians, nurses, social workers, pharmacists, friends, and family all must be utilized. Older patients’ problems are often multiple, so too should be the means to their solutions.
 
Continue to next page to read about the GEM Fellowship at New York Presbyterian-Weill Cornell Medical Center
{mospagebreak title=A GEM of a Fellow} 
Cover Story//Geriatric Emergency Medicine
 
 
 
 
A GEM of a Fellow
Emergency physicians can take geriatric emergency medicine to the next level with a GEM Fellowship at New York Presbyterian-Weill Cornell Medical Center

Because of the unique needs of the vulnerable geriatric population and the consequent need to train EPs to recognize and treat them, a Geriatric Emergency Medicine Fellowship program was started at New York Presbyterian Hospital/Weill Cornell Medical College in 2005. The fellowship was the first of it’s kind. If you were chosen to participate in this one year program, here’s what you could expect.

Focus
The physiological and pathophysiological effects of aging manifested by special geriatric syndromes (such as falls, delirium, and polypharmacy), atypical presentations of classic disease states, the under-treatment of pain in the ED, the impact of co-morbidities on both clinical care and outcome, end-of-life issues in the acute care setting, and the complexities of the interface between community, nursing home, and in-patient settings.

What the year looks like
The GEM fellow spends parts of the year in the ED, in-patient units, a nursing home, and out-patient clinics. In-patient rotations at New York Presbyterian/Weill Cornell assign the fellow to the acute care of the elderly unit (ACE), intensive care units, the palliative care consult service, and the geriatric consult service.

What You’ll Learn
Rotations with the house-call program and a skilled nursing home facility give the fellow greater insight into the challenges of assessment, diagnosis, and treatment in these environments and the critical importance of the interface between these settings and the hospital. The fellow also comes to understand the barriers that must be overcome to allow appropriate discharge planning for continued care in the community and nursing home. Specific goals include developing an improved understanding of the importance of continued management beyond the ED and the acute hospital stay, the benefits of a multi-disciplinary team approach, functional assessment tools which can be applied to the ED, and of the psychosocial, ethical, and legal issues related to caring for older people.

Beyond the Diagnosis: GEM Research    
As well as providing clinical expertise, the fellowship provides the opportunity to develop skills to conduct original research in the emergency care of the elderly, and to develop the ability to become academic educators. As a non-ACGME fellowship, it can be designed to be almost entirely budget-neutral for the institution by offsetting a PGY-5 level salary and benefits with a 12-hour clinical shift per week in the ED of the affiliated hospital as a residency trained, board-certified or eligible EP. The fellow is typically assigned the academic rank of instructor.


 

Comments   

# DignityBruce wilson 2011-06-14 22:17
Thanks for writing an article that is thorough, professional and caring. To be cared for properly in old age is a right that is not always received. Good communication between prescriber and pharmacist is important especially in the elderly who often take a number of medications.
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