Why Provide Specialized Care for Older Adults in the ED?

Making the Case One-Pager

Reproduced and available for download with permission from The West Health Institute
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Patients over the age of 65 made more than 21 million emergency department (ED) visits in 2015.

This number represents a significant increase from about 16 million emergency department (ED) visits in 20011, and is expected to continue to rise given the number of Americans aged 65+ is expected to double to 98 million+ by 20602.

Older adults account for a disproportionate number of potentially avoidable patient hospital admissions from the ED.

Older adults account for 46% of all ED visits resulting in hospitalization3. Approximately one out of every 10 hospital admissions is potentially avoidable, and the majority (60%) of those admissions are for patients 65+4.

Geriatric EDs can reduce the likelihood of avoidable patient admissions to the hospital.

Comprehensive geriatric assessment (CGA) in the ED has been linked to reduced likelihood of admission at index ED visit in a growing number of studies5-10, without increasing mortality risk8,11-15. CGA and enhanced transitions of care planning in the ED may also reduce or delay nursing home admission12,15. Averting avoidable admission prevents the risk of iatrogenic complications and reduced functioning that can occur in hospitalized and institutionalized patients.

Geriatric ED programs have been shown to increase patient satisfaction.

Avoiding unnecessary hospitalizations is in keeping with the “4Ms Framework” of the growing “Age Friendly Health System” initiative16, specifically “What Matters” to the patient. Older adult patients that received comprehensive geriatric assessment and enhanced transitions of care services reported higher patient satisfaction12,17,18.

Physical therapy services in the ED are associated with reduced ED revisits.

Falls are the leading cause of injury-related morbidity and mortality among Americans aged 65 and older19, resulting annually in over 2.8 million ED visits19 and $31.9 billion in direct medical costs to Medicare20. Receiving physical therapy (PT) services (e.g., a referral) in the ED during ED visits for a ground-level fall has been associated with significantly lower likelihood of a fall-related ED revisit within 30 days and 60 days among adults 65+21. Expanding PT services in the ED may reduce future fall-related ED utilization and fall-related morbidity and mortality.

Older Adults with Dementia Revisit the ED at Significantly Higher Rates

Older adults with dementia are between 2.322 – 3.723 times more likely to revisit the ED within 30 days of index ED visit compared to older adults without dementia. The ED has the potential to play a role in connecting patients and caregivers to appropriate medical and social resources for management of dementia and other comorbidities. Care transition protocols improve disease management and are associated with reduced ED utilization24. Additionally, coordination of care and services for dementia patients is a goal of the National Plan to Address Alzheimer’s disease25, and programs such as the Veterans Affairs’ “Partners in Dementia Care” have demonstrated value in improving dementia patients’26 and caregivers’27 outcomes as well as reducing ED and hospital utilization28.

Delirium can be fatal for older adults, underscoring the need for proper identification and management in the ED.

Of the nearly 20 million older adults seen in the ED each year29, approximately 8-17% present to the ED suffering from delirium30. Patients with delirium have a 12-month mortality rate between 10-26%31, which is comparable to patients with sepsis or acute myocardial infarction32. Delirium is an independent predictor of mortality among ED patients diagnosed with delirium compared to patients without delirium, and the strongest association has been found at 30 days following an ED visit33. EDs that screen for delirium and incorporate appropriate protocols may help reduce missed diagnosis of this potentially fatal condition.

Sources

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2Mather M, Jacobsen LA, Pollard KM. Aging in the United States. Population Bulletin (Population Reference Bureau). 2015;70(2).

3WHI. Geriatric Emergency Department Factsheet (2013 HCUP-NEDS data). West Health Institute;2017.

4Stranges E, Stocks C. Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2008. Rockville, MD: Agency for Healthcare Research and Quality; 2010.

5Hwang U, Dresden SM, Rosenberg MS, et al. Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use. Journal of the American Geriatrics Society. 2018;66(3):459-466.

6Aldeen AZ, Courtney DM, Lindquist LA, et al. Geriatric Emergency Department Innovations: Preliminary Data for the Geriatric Nurse Liaison Model. Journal of the American Geriatrics Society.  014;62(9):1781-1785.

7Keyes DC, Singal B, Kropf CW, et al. Impact of a New Senior Emergency Department on Emergency Department Recidivism, Rate of Hospital Admission, and Hospital Length of Stay. Annals of Emergency Medicine. 2014;63(5):517-524.

8Wallis M, Marsden E, Taylor A, et al. The Geriatric Emergency Department Intervention model of care: a pragmatic trial. BMC Geriatrics. 2018;18(1):297.

9Conroy SP, Ansari K, Williams M, et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’. Age and Ageing. 2014;43(1):109-114.

10Wright PN, Tan G, Iliffe S, et al. The impact of a new emergency admission avoidance system for older people on length of stay and same-day discharges. Age and Ageing. 2014;43(1):116-121.

11Silvester KM, Mohammed MA, Harriman P, et al. Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources. Age and Ageing. 2014;43(4):472-477.

12Mion LC, Palmer RM, Meldon SW, et al. Case finding and referral model for emergency department elders: A randomized clinical trial. Annals of Emergency Medicine. 2003;41(1):57-68.

13Caplan GA, Williams AJ, Daly B, et al. A Randomized, Controlled Trial of Comprehensive Geriatric Assessment and Multidisciplinary Intervention After Discharge of Elderly from the Emergency Department—The DEED II Study. Journal of the American Geriatrics Society. 2004;52(9):1417-1423.

14Miller DK, Lewis LM, Nork MJ, et al. Controlled Trial of a Geriatric Case-Finding and Liaison Service in an Emergency Department. Journal of the American Geriatrics Society. 1996;44(5):513-520.

15Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomized controlled trials. BMJ. 2011;343.

16IHI. Age-Friendly Health Systems. 2019; http://www.ihi.org/Engage/Initiatives/Age-
Friendly-Health-Systems/Pages/default.aspx Accessed 2/11/2019.

17Cossette S, Frasure-Smith N, Vadeboncoeur A, et al. The impact of an emergency department nursing intervention on continuity of care, self-care capacities and psychological symptoms: Secondary outcomes of a randomized controlled trial. International Journal of Nursing Studies. 2015;52(3):666-676.

18Guttman A, Afilalo M, Guttman R, et al. An Emergency Department–Based Nurse Discharge Coordinator for Elder Patients: Does It Make a Difference? Academic Emergency Medicine. 2004;11(12):1318-1327.

19Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. 2016;65(37):993–998

20Burns E, Stevens J, Lee R. The direct costs of fatal and non-fatal falls among older adults – United States. J Safety Res. 2016;58:99-103.

21Lesser A, Israni J, Kent T, et al. Association Between Physical Therapy in the Emergency Department and Emergency Department Revisits for Older Adult Fallers: A Nationally Representative Analysis. Journal of the American Geriatrics Society. 2018;66(11):2205-2212.

22LaMantia MA, Stump TE, Messina FC, et al. Emergency Department Use Among Older Adults With Dementia. Alzheimer disease and associated disorders. 2016;30(1):35-40.

23Kent T, Lesser A, Howard J, et al. 30-Day Emergency Department Revisit Rates Among Medicare Beneficiaries With Dementia. Paper presented at: Society of Academic Emergency Medicine 2018; Indianapolis, IN.

24Wolinsky FD, Liu L, Miller TR, et al. Emergency Department Utilization Patterns Among Older Adults. The Journals of Gerontology: Series A. 2008;63(2):204-209.

25National Plan to Address Alzheimer’s Disease: 2017 Update. In: Services USDoHaH, ed 2017:109.

26Bass DM, Judge KS, Snow AL, et al. A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months. Alzheimer’s research & therapy. 2014;6(1):9-9.

27Bass DM, Judge KS, Lynn Snow A, et al. Caregiver Outcomes of Partners in Dementia Care: Effect of a Care Coordination Program for Veterans with Dementia and Their Family Members and Friends. Journal of the American Geriatrics Society. 2013;61(8):1377-1386.

28Bass DM, Judge KS, Maslow K, et al. Impact of the care coordination program “Partners in Dementia Care” on veterans’ hospital admissions and emergency department visits. Alzheimer’s & Dementia: Translational Research & Clinical Interventions. 2015;1(1):13-22.

29Kakuma R, Du Fort GG, Arsenault L, et al. Delirium in Older Emergency Department Patients Discharged Home: Effect on Survival. Journal of the American Geriatrics Society. 2003;51(4):443-450.

30Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet (London, England). 2014;383(9920):911-922.

31McCusker J, Cole M, Abrahamowicz M, et al. Delirium Predicts 12-Month Mortality. Archives of Internal Medicine. 2002;162(4):457-463.
32Gower L, Gatewood M, Kang C. Emergency Department Management of Delirium in the Elderly Western Journal of Emergency Medicine 2012 2(13):194-201.

33Israni J, Lesser A, Kent T, et al. Delirium as a predictor of mortality in US Medicare beneficiaries discharged from the emergency department: a national claims-level analysis up to 12 months. BMJ Open. 2018;8(5):e021258.

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