Geriatric Patients and the Emergency Department

1. Wasn’t she here last week? Frequent Flyers and other Vexing Tales of the Emergency Department • Optimizing Transitions from the Emergency Department: Transitions/Frequent flyers – Part 1 Geriatric Patients and the Emergency Department # 3 in a 6 part series related to Geriatric Care and Emergency Medicine

2. About This Webinar Series 2 Assessment of the Older Veteran Cognitive Status in the Older Veteran Optimizing Transitions from the Emergency Department: Transitions/Frequent flyers – Part 1 Geriatric Medication Challenges Pain Management Challenges Optimizing Transitions from the Emergency Department: Transitions/Frequent flyers – Part 2

3. Speakers Alan Hirshberg, MD, MPH, FACEP is the Associate Chief of Staff at the Lebanon VA Medical Center, in Lebanon, PA. He is a residency trained Emergency Physician on the VHA Emergency Medicine Field Advisory Council and ACEP Emergency Medicine Clinical Practice Committee who regularly works with VHA facilities to assist them with challenges related to Emergency Medicine practice. Carolyn K. Clevenger, DNP, GNP-BC is a Gerontological nurse practitioner whose research and clinical interests center around care of persons with dementia. She is Assistant Dean for MSN Education at the School of Nursing and Associate Program Director for the Atlanta VA Quality Scholars Program. Dr. Clevenger is the Principle Investigator of the HRSA-funded project to implement Interprofessional Collaborative Practice for Primary Palliative Care. An initiative housed on six inpatient services or units at Emory University Hospital. She serves on the Georgia Older Drivers’ Taskforce, a committee of the Governors Office of Highway Safety, and the Atlanta VAMC’s Dementia Committee. Nicki Hastings, MD, MHS is a Geriatrician at the Durham VA Medical Center in Durham, NC. She is Director of the Durham Geriatrics PACT Clinic and an Investigator with the Durham Geriatrics Research and Education Center (GRECC) and Center for Health Services Research in Primary Care.

4. Disclosures No financial relationships or conflicts to disclose.

5. Educational Objectives Participants in this session will be able to: • Recognize common factors associated with repeat visits to the ED among Veterans 65 and older; • Describe the roles of the Emergency Department Team - physician, nurse, social worker, pharmacist, and psychologist - in caring for older Veterans’ with dementia in the ED setting; • Discuss best practices for management and discharge planning for patients who are frequent fliers in the ED.

6. The older patient (65+ years) Account for 13-15% of all ED visits nationally ED visits of patients 65-74 years of age increased 34% from 1993-2003 Older patients have higher rates of test use and longer ED stays than the general population 5x higher risk of ICU admission and 3.5 x the risk of hospitalization

7. The older patient May have difficulty communicating the nature of their needs to the Emergency Department (ED) staff and may also be unable to understand their treatment plans due to visual/auditory/cognitive impairment. Repeat ED visits can be a marker of ongoing care failure and should be reviewed Discharge plans may require coordination through community agencies The older patient attempting suicide is at greater risk of completion of the act May require admission

8. Elders at Risk Homelessness Multiple co-morbid conditions – heart failure and headache Low income Psychiatric illness – anxiety, bipolar disorder, personality disorder, and schizophrenia Prescription for opiod use

9. Top conditions encountered Neuropsychiatric – delirium, dementia Falls – main cause of admission 15-30% Coronary disease – 20% c/o dyspnea or chest pain as principal complaints Polypharmacy and adverse drug effects – 11% of ED visits for those older than 65 vs. 1-4% for those younger, 33% of adverse affects related to warfarin, insulin, and digoxin. Alcohol and Substance abuse – the children of the sixties are now elderly, etiology up to 14% of presentations related to associated delirium as well as withdrawal effects, associated mood disorder, or associated complications of use Abdominal pain – up to 13% of older patients, mortality 6-8x higher than younger population Infections – 4% main complaint of which 25% pneumonia, 22% urinary infection, and 18% sepsis/bacteremia Social cause/functional decline – 9% of social admissions resulted from infectious,(24%) cardiovascular(14%), neurologic(9%), digestive(7%), pulmonary(5%) or other causes. 1-year mortality was up to 34% Elder abuse/neglect – 10% rate of elderly abuse per national statistics

10. The Special Case of Dementia in the ED Carolyn K. Clevenger, DNP, GNP-BC Associate Program Director, Atlanta VA Quality Scholars Assistant Dean and Associate Professor, Emory Nursing

11. “But all of our patients drive themselves here…” Naughton BJ, Moran MB, Kadah H et al. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med. Jun 1995;25(6):751-755. • 26-40% of older ED patients have cognitive impairment • Dementia (21.8%) • Delirium (24%) • Delirium on top of dementia

12. Challenges • Long wait times for people with atypical presentations • Wandering • Fast-paced environment • Slow thinkers • Poor historians • Transfer sheets • Recognition of impairment

13. Agenda Systematic Literature Review Study of Older ED Patients

14. Dementia in the ED: Setting • ED in academic medical center • 28,500 visits annually • 30% of visits made by persons over 65

15. Dementia in the ED: Sample • ED patients 70+ years old • One or more visits to the ED over 6 months • Two approaches • ED Visits • Individuals’ Patterns of ED Visits

16. Dementia in the ED: Method Centers for Disease Control and Prevention, National Center for Health Statistics. National Hospital Ambulatory Care Survey (NHAMCS). In: US Department of Health and Human Services, editor.2010 Retrospective chart review • Age*, gender*, race* • Length of stay* • Tests ordered* • Disposition* *Based on NHAMCS (CDC, 2010)

17. Dementia in the ED: Method Charlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP. The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. J Clin Epidemiol. 2008;61(12):1234-40. Study Additions • Evidence of cognitive impairment in ED, hospital or outpatient notes • Comorbidity score (Charlson) • Caregiver presence

18. Dementia in the ED: Results • Average age • 79 y.o. with no dementia • 81 y.o. with dementia • Gender • 59.3% female • Race • 59.9% white

19. Dementia in the Atlanta ED: Results • Reasons for seeking care

20. Dementia in the ED: Results • ED Visits • Sampled 300 visits • 199 by persons with no evidence of dementia • 101 by persons with documentation of dementia • 75 Recognized as such • 26 “Unrecognized”

21. Dementia in the ED: Results • During each visit • No difference in number of diagnostic tests by dementia status • More testing if person with dementia was not recognized/not documented as such • Length of stay (in ascending order) • Those without dementia • Those with recognized/documented dementia • Those with unrecognized/undocumented dementia

22. Dementia in the ED: Results • Disposition • Admission to hospital (in ascending order) • Persons without dementia • Persons with recognized/documented dementia • Persons with unrecognized/undocumented dementia

23. Dementia in the ED: Results • Pattern and Volume of ED Visits by Individuals • Each person with dementia made twice as many ED visits • Four times as many if NO Caregiver present • Fewer days between visits (33 vs 41)

24. Dementia in the ED: Results • Individuals’ Patterns • Persons with dementia had more ED visits over the study period (1.63 vs 2.15) • Selecting only persons with 2+ visits during the year, persons with dementia represent • 38.3% of all visits • 39.9% of 7-day revisits • 43.4% of 30-day revisits

25. Dementia in the ED: Discussion • Longer stays and more testing • History • Unclear about residential options • Potential for missed or delayed diagnosis • Evidenced by re-visits for similar complaints • Use of Observation status

26. Dementia in the ED: Literature Clevenger, C.K., Chu, T.A., Yang, Z. & Hepburn, K.W. (2012). Clinical Care of Persons with Dementia in the Emergency Department: a Review of the Literature and Agenda for Research. Journal of the American Geriatrics Society • What can the ED nursing staff DO? • Assessment • Communication • Adverse Events • Physical Environment • Education

27. Dementia in the ED: Literature • Assessment • Screen likely suspects • Six-item screener • Mini-cog FAQ • St Louis University Memory Screen or Montreal Cognitive Assessment

28. Screening tool for cognitive impairmentsensitivity 94%, specificity 86% Six-Item Screener Reproduced from Med Care, Callahan et al, The interviewer says the following: I would like to ask you some questions that ask you to use your memory. I am going to name 3 objects. Please wait until I say all 3 words and then repeat them. Remember what they are because I am going to ask you to name them again in a few minutes. Please repeat these words for me: apple, table, penny. (Interviewer may repeat names 3 times if necessary, but repetition is not scored.) Did patient correctly repeat all 3 words? Yes No Orientation Incorrect Correct What year is this? What month is this? What is the day of the week? Memory What are the 3 objects I asked you to remember? Apple Table Penny A score less than or equal to 4 (each correct answer counts as 1 point) corresponds to a positive screen for cognitive impairment; adapted from Callahan CM, Unverzagt FW, Hui SL, et al. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40:771-781.

29. Dementia in the ED: Literature • Communication • Nonverbal • Including touch, as appropriate • Emotional truth • If repeating, exactly same as the first

30. Dementia in the ED: Literature • Adverse Events (delirium, wandering, incontinence) • Nonverbal cues and nursing judgment • Is the chief complaint likely to cause pain? • Has the individual been in the ED for some time? • Anticipate and prevent dehydration • Make toilets visible

31. Dementia in the ED: Literature • Physical Environment (A page from Senior ED’s) • Natural light and quiet, glare-free floors • Clear signage for wayfinding • Proximity to nursing station

32. Dementia in the ED: Literature • Education • Geriatric Emergency Nursing Education (GENE) • Emergency Nurses Association & Hartford Institute for Geriatric Nursing

33. Dementia in the ED: Summary • Early recognition is key • Build in a standard measure • Secondary history of present illness • Caregiver • Transferring facility • Education • Atypical presentation • Residential care options for older adults

34. Improving Post-ED Transitions for Older Patients S. Nicole Hastings, M.D., M.H.S.

35. Post-ED Transitions • The majority of older adults evaluated in the ED are not admitted to the hospital. • In VAMC EDs, ~75% of older patients are treated and released • Outpatient ED visits are increasingly intensive. • In VAMC EDs, 45-65% of patients are prescribed at least one new medication;25% told to change or stop a baseline medication

36. Frequent Users Frequent Flyers, Super Users Use ED on multiple occasions; account for a disproportionally high number of ED visits Majority are not elderly, but some are Frequent users are sicker (physical and mental), challenging life circumstances

37. Obstacles to Safe and Effective Transitions • The medication maze • Communication hurdles • The follow-up leap of faith • Scratching the surface

38. The Medication Maze New medications and dosage changes Different prescribers Multiple medications and chronic conditions Common ED discharge drugs (e.g. NSAIDs, opioid analgesics, antibiotics) are often risky for older patients Over the counter drugs Medication Reconciliation Across Transitions

39. Communication hurdles • Between providers • Direct communication between ED and PCP rare- not always possible; not always necessary • 17% of VA PCPs always/almost always promptly notified of ED visits • Between providers and patients and their families

40. Follow Up Leap of Faith • Primary Care • Poor patient understanding of whether it’s needed, and if so, how soon • Inefficiencies if providers unaware of needs • Specialty Referrals • Patient’s role, timing

41. Scratching the Surface • Substance abuse • Depression • Housing or food insecurity • Elder abuse • Caregiver stress • Poorly controlled chronic diseases

42. Improving ED Transitions Get collateral history of medication use, if possible, esp OTC Drug-drug, drug-disease interactions, renally dose Educate about possible side effects, and what to do if they occur

43. Improving ED Transitions • Enhanced communication between providers • Synchronous vs Asynchronous • PCP notification of ED visits: necessary but not sufficient • Focus on quality of content and action items for PCP

44. Improving ED Transitions • Enhanced communication with patients and families • Standardized content of discharge instructions

45. Improving ED Transitions • Enhanced communication with patients and families • Screening for communication barriers such as hearing and cognitive impairment • Including companions/family members in discharge discussions • Communication methods such as the “teach back”, asking patients or surrogates to repeat key information in their own words • Printed materials – attention to font size and literacy level

46. Follow-up Care • Plan for how outstanding tests and appointments to be completed • Expectations for when/how they will be contacted • Explicit discussion regarding resolution of sx/warning signs • Updated telephone contacts, for patient and/or caregiver

47. Scratch below the surface • Ask • Substance abuse • Depression • Housing or food insecurity • Elder abuse • Caregiver stress • Poorly controlled chronic diseases • Engage other team members • Communicate concerns findings to PCP and patient; direct referrals when appropriate

48. Thanks for your Attention!

49. Bibliography “Review: Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriatness, and Consequences of Unmet Health Care Needs,” AnreaGruneir, Mara J. Silver and Paula A. Rochon, Med Care Res Rev 2011 68:131 http://mcr.sagepub.com/content/682/131 “Older Patients in the Emergency Department: A Review,” Nikolaos Samaras, Thierry Chevalley, Dimitrios Samaras, and Gabriel Gold, Annals of Emergency Medicine, September 2010, 56:3,261-269. “Older Adults in the Emergency Department: A Systematic Review of Patterns of Use, Adverse Outcomes, and Effectiveness of Interventions,” FaranakAminzadeh, William Dalziel, Annals of Emergency Medicine, March 2002;39:3,238-247. “How Frequent Emergency Department Use by US Veterans Can Inform Good Public Policy,” Jesse Pines, Annals of Emergency Medicine, 2013, pending publication. The Merck Manual, Hospital Care and the Elderly: Provision of Care to the Elderly: Merck Manual Professional, http://www.merckmanuals.com/professional/geriatrics/provision_of_care_to_the_elderly/hospital_care_and_the_elderly.html

50. Bibliography Survey: Many Elderly Are in the Dark at ED Discharge, http://www.acep.org/content.aspx?id=46032 “What Patients Really Want From Health Care,” Allan Detsky, JAMA, Dec 14, 2011;Vol306, #22, p2500-2501. “Health Services Use of Older Veterans Treated and Released from Veterans Affairs Medical Center Emergency Departments.” Hastings SN et al. J Am Geriatr Soc 2013; 61:1515-1521. “Quality of Pharmacotherapy and Outcomes for Among Older Veterans Discharged from the Emergency Department.” Hastings et al. J Am Geriatr Soc 2008; 56 (5):875-880. “The evolution of changes in primary care delivery underlying the Veterans Health Administrations’s quality transformation”.Yano EM et al. Am J Public Health 2007;97:2151-2159. “Older Veterans and Emergency Department Discharge Information.” Hastings SN et al. BMJ QualSaf2012 Oct;21:835-842.