5 Ways to Geriatricize Your ED
With Chris Carpenter
Geriatric EDs, or Senior EDs, have been popping up around the country. The idea behind them is that having a separate space, a distinct staff, and specialized protocols, can help provide better care to older adults. However, for many EDs and hospital systems this is simply not feasible. In this episode, Chris Carpenter presents five high-yield, low-cost ways that those of us working in non-senior EDs can take some of the principles of geriatric emergency medicine and apply them either to our own practice or implement them in our own EDs, without a lot of funding.ALiEM blog post
Distinguish Geriatric ED Model from Traditional Model
Know that there is a model of care  for Geriatric Emergency care, defined by the Geriatric ED Guidelines. They are free, easily accessible, and pragmatic and consist of 42 evidence-based guidelines for care. They discuss the importance of understanding co-morbid illness, geriatric syndromes (delirium, demenia, fall risk, polypharmacy, frailty) , psychosocial constraints, some unique protocols and infrastructure  and team-based approaches [4,5].
When a patient comes in with a fall, and you notice they’ve been there many times before with falls, in what ways could you go the extra step to do what you can to help prevent future falls? This may mean helping them get PT/OT or a home assessment, depending on your resources available. Or it may mean counseling the patient, or doing a good med rec. Few general ED providers document baseline functional capacity such as falls or gait assessment but EDs focused on older adults often do. Approximately 1-in-3 community-residing adults over age 65 suffer standing level fall annually, but few receive guideline-directed fall prevention measures and fall-risk stratification is in infancy. As many as 1-in-3 non-injurious fall victims discharged home experience significant functional deterioration within 3-months . However, knowing which individual patients fall into that group, and whether the deterioration is preventable is more difficulty .One tool to risk-stratify patients for their risk of a fall in 6 months is the following 4-item questionnaire:
- Presence of non-healing foot sore?
- Any fall in the last 12 months?
- Inability to cut their own toenails?
- Self-reported depression?
A score of one or more “yes” responses in a community dwelling older adult indicates a higher risk of future falls.
A falls evaluation should consider at least the following four factors: the causes (intrinsic and extrinsic), the consequences, a safe discharge assessment, and potential ways of preventing future falls 
Approximately 30%-40% of community-dwelling adults over age 65 in the ED will have dementia or mild cognitive impairment if formally assessed  and 10% will have delirium . Delirium is a symptom, not a disease. If the patient is “alert and attentive” that essentially rules our delirium. You can detect delirium with the delirium triage screen and the bCAM [3,17]. The next step is to attempt to identify the cause(s) of delirium and then to prevent worsening, or prevent it in non-delirious patients . For more on delirium, see an earlier podcast with Kevin Biese. Dementia is common, and frequently not recognized, but it plays an important part in the ED assessment and management of patients. Some potential tools include the Mini-Cog and Ottawa 3DY, which are <30 second validated screens that you can build into most assessments
Check out the Beers list of potentially high-risk medications, including things like NSAIDS, codeine, anti-cholinergics, benzos . We’ve discussed high risk medications and potentially dangerous med combos on GEMCAST before. In general, “Start low, and go slow” is the mantra in geriatric medicine.
Transitions of Care
The ED is not an island of care; it’s part of a continuum of multiple care providers for older people. Operations & outcomes will improve if you establish communication with upstream and downstream providers. Know what other members of the team (PT/OT/SW/Family doc/community care providers can contribute that complements or supplements emergency management. For example, is there a mechanism in your ED to have feedback and feed forward systems in place? If a clinic sends a patient to the ED, is there a way for them to get information to you about why the patient is there? If you see a patient in the ED and discharge them, is there a way to send info to the PCP that the patient had been there and what you did, what needs to be followed up, etc? Rather than re-invent the wheel when trying to communicate with other physicians, with nursing facilities, or outpatient services, or home health, having systems in place can help patients get the care they need.
The following three figures illustrate some of the factors that contribute to causing a fall, the inability to prevent a fall, and potential injuries or secondary effects from the fall.
- Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies. Clin Geriatr Med. Feb 2013;29(1):31-47. http://www.ncbi.nlm.nih.gov/pubmed/23177599
- Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geratr Soc. May 2007;55(5):780-791. http://www.ncbi.nlm.nih.gov/pubmed/1749320
- Rosenberg M, Carpenter CR, Bromley M, et al. Geriatric Emergency Department Guidelines. Ann Emerg Med. May 2014;63(5):e7-e25. http://www.ncbi.nlm.nih.gov/pubmed/24746437
- Sinha SK, Bessman ES, Flomenbaum N, Leff B. A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model. Ann Emerg Med. Jun 2011;57(6):672-682. http://www.ncbi.nlm.nih.gov/pubmed/21621093
- McCusker J, Verdon J, Vadeboncoeur A, et al. The elder-friendly emergency department assessment tool: development of a quality assessment tool for emergency department-based geriatric care. J Am Geriatr Soc. Aug 2012;60(8):1534-1539. http://www.ncbi.nlm.nih.gov/pubmed/22860623
- Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF. Physician and Nurse Acceptance of Geriatric Technicians to Screen for Geriatric Syndromes in the Emergency Department. West J Emerg Med. Dec 2011;12(4):489-495. http://www.ncbi.nlm.nih.gov/pubmed/22224145
- Hogan TM, Olade TO, Carpenter CR. A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013. Acad Emerg Med. Mar 2014 21(3):337-346. http://www.ncbi.nlm.nih.gov/pubmed/24628759
- Tirrell G, Sri-on J, Lipsitz LA, Camargo CA, Kabrhel C, Liu SW. Evaluation of older adult patients with falls in the emergency department: discordance with national guidelines. Acad Emerg Med. Apr 2015 22(4):461-467. http://www.ncbi.nlm.nih.gov/pubmed/25773899
- Carpenter CR, Lo AX. Falling Behind? Understanding Implementation Science in Future Emergency Department Management Strategies for Geriatric Fall Prevention. Acad Emerg Med. Apr 2015 22(4):478-480. http://www.ncbi.nlm.nih.gov/pubmed/25773899
- Carpenter CR, Avidan MS, Wildes T, Stark S, Fowler S, Lo AX. Predicting Community-Dwelling Older Adult Falls Following an Episode of Emergency Department Care: A Systematic Review. Acad Emerg Med. Oct 2014 21(10):1069-1082. http://www.ncbi.nlm.nih.gov/pubmed/25293956
- Sirois MJ, Emond M, Ouellet MC, et al. Cumulative incidence of functional decline following minor injuries in previously independent older Canadian emergency department patients. J Am Geriatr Soc. 2013 61(10):1661-1668. http://www.ncbi.nlm.nih.gov/pubmed/24117285
- Carpenter CR. Deteriorating functional status in older adults after emergency department evaluation of minor trauma-opportunities and pragmatic challenges. J Am Geriatr Soc. Oct 2013;61(10):1806-1807. http://www.ncbi.nlm.nih.gov/pubmed/24117290
- Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four sensitive screening tools to detect cognitive impairment in geriatric emergency department patients: Brief Alzheimer’s Screen, Short Blessed Test, Ottawa3DY, and the Caregiver Administered AD8. Acad Emerg Med. Apr 2011 18(4):374-384. http://www.ncbi.nlm.nih.gov/pubmed/21496140
- Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. Mar 2009;16(3):193-200. http://www.ncbi.nlm.nih.gov/pubmed/21496140
- Han JH, Bryce SN, Ely EW, et al. The effect of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients. Ann Emerg Med. Jun 2011;57(6):662-671. http://www.ncbi.nlm.nih.gov/pubmed/21272958
- Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med. Sep 2010;56(3):244-252. http://www.ncbi.nlm.nih.gov/pubmed/20363527
- Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method. Ann Emerg Med. Nov 2013 62(5):457-465. http://www.ncbi.nlm.nih.gov/pubmed/23916018
- Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. Sep 2010;56(3):261-269. http://www.ncbi.nlm.nih.gov/pubmed/20619500
- Keyes DC, Singal B, Kropf CW, Fisk A. Impact of a New Senior Emergency Department on Emergency Department Recidivism, Rate of Hospital Admission, and Hospital Length of Stay. Ann Emerg Med. May 2014;63(5):517-524. http://www.ncbi.nlm.nih.gov/pubmed/24342817
- Platts-Mills TF, Glickman SW. Measuring the Value of a Senior Emergency Department: Making Sense of Health Outcomes and Health Costs. Ann Emerg Med. May 2014;63(5):525-527. http://www.ncbi.nlm.nih.gov/pubmed/24342812
- Neta G, Glasgow RE, Carpenter CR, et al. A Framework for Enhancing the Value of Research for Dissemination and Implementation. Am J Public Health. Jan 2015;105(1):49-57. http://www.ncbi.nlm.nih.gov/pubmed/25393182
This podcast uses sounds from freesound.org by Jobro and HerbertBoland.
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Dr. Christina Shenvi is an associate professor of Emergency Medicine at the University of North Carolina. She is fellowship-trained in Geriatric Emergency Medicine and is the founder of GEMCast. She is the director of the UNC Office of Academic Excellence, president of the Association of Professional Women in Medical Sciences, co-directs the ACEP/CORD Teaching Fellowship, is on the Annals of EM editorial board, is on the Geriatric ED Accreditation board of governors, and she teaches and writes about time management at timeforyourlife.org.