Michelle, a Nurse Specialist and Program Director of the Senior ED at St. Mary Mercy Hospital in Michigan kicked off the discussion. Her main take-home points

1. Extend the “D” and “E” of the primary survey (ABCDE) to determine cognition and to explore the person’s normal living environmental including caregivers;
2. Recognize that mismanagement of medications may be related to an undiagnosed cognitive disorder with unintended consequences; make sure patients with Parkinson’s Disease get their regular medication(s);
3. Consider if the current living situation will prevent a failed discharge plan
4. Think “familiar face”, not “frequent flyer.”

Physical Therapist, Suzie Ryer, is the Geriatric Clinical Specialist and Project Coordinator for Advocate Aurora’s Senior Services program in Wisconsin. Here are her tips:

1. Ask about mobility not just immediately before coming to ED but a week and a month before. This includes use assistive devices, assistance, and distance.
2. When assessing gait and mobility look beyond simply walking. Have the patient stand, walk, turn, and sit. It assesses strength, stamina, balance, coordination, mobility, as well as executive function. Think about gait speed as well.
3. Reassess that gait device used before ED visit is still appropriate upon discharge from ED and consider an alternative that will meet needs. She reviewed how to select and measure the best device – cane, crutch, walker, etc.

Kara McLoughlin participated all the way from Doublin, Ireland. Her input as an Occupational Therapist working with the Frail Intervention Therapy Team at Beaumont Hospital was powerful in its simplicity. Her pointers:

1. Ask high-yield questions to all older patients: How did you get here? It gives information about insight, recall, orientation, comprehension, judgement.
2. Ask about washing and dressing as a way of understanding function, cognition, support network, and mobility/falls.
3. Ask patients to do some basic functional tasks in the ED and observe them: put on socks and shoes and own clothes and go to the bathroom. Seeing a person in their own clothes gives a clinician a different impression of them.
4. Ask about shopping and food preparation to assess mobility, cognition, and social support.
5. Remember that age and frailty are two different concepts and are not synonymous.

Maya Genovesi, is a Social Work Manager in the ED & Rapid Evaluation Treatment Unit at Mount Sinai Hospital in New York City. Her tips emphasize some important reminders for ED care providers:

1. Approach all older patients with curiosity and eagerness. Engaging with the patient in a caring and concerned manner is an intervention in itself. Communicating that “I am interested in you” has incredible power.  This is especially important for those “familiar faces” and those who may be under-represented or disenfranchised.
2. Document clearly and with PHONE NUMBERS! Document surrogate information, social supports. READ the social work notes. They often contain nuggets of patient history.
3. Clinically appropriate and “safe enough” discharges and referrals preserve patient autonomy! Find out what services can add value once the patient leaves the ED. Find out what is important to the patient and their caregivers.  Take the long view —  think about a plan for a week, a month, and a year.
4. Investing more with interactive care and time while in the ED can save time with avoidable admissions and reduce Length of stay downstream.