In March, 2021, GEDC invited four interdisciplinary experts in geriatric emergency department (ED) care to participate in an Expert Panel Webinar. The event was well attended, and participants were able to get clinical tips from nursing, social work, physical therapy, and occupational therapy perspectives.
I was lucky enough to host this webinar and have summarized my main takeaways below.
Nurse Specialist & Program Director
Michelle Moccia, RN, DNP, ANP-BC, GS-C
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
- Extend the “D” and “E” of the primary survey (ABCDE) to determine cognition and to explore the person’s normal living environmental including caregivers;
- 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);
- Consider if the current living situation will prevent a failed discharge plan
- Think “familiar face”, not “frequent flyer.”
Physical Therapist
Suzie Ryer, MPT, GCS, CEEAA
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:
- 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.
- 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.
- 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.
Occupational Therapist
Kara McLoughlin, BSc (Hons), OT, MSc (OT)(c)
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:
- Ask high-yield questions to all older patients: How did you get here? It gives information about insight, recall, orientation, comprehension, judgement.
- Ask about washing and dressing as a way of understanding function, cognition, support network, and mobility/falls.
- 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.
- Ask about shopping and food preparation to assess mobility, cognition, and social support.
- Remember that age and frailty are two different concepts and are not synonymous.
Social Work Manager
Maya Genovesi, LCSW, MPH
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:
- 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.
- Document clearly and with PHONE NUMBERS! Document surrogate information, social supports. READ the social work notes. They often contain nuggets of patient history.
- 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.
- Investing more with interactive care and time while in the ED can save time with avoidable admissions and reduce Length of stay downstream.
The Interdiscplinary Team on the Case
Case Study
Mr. Vieilleux is 84 who lives with his 82 yo wife, who may have some early dementia and is his main caregiver. He’s in the ED after a fall while getting out of his walk-in shower. His wife says she thinks he slipped while sitting down on the shower-side chair.
Past Medical History: Coronary artery disease; previous CABG with an admission four years ago for congestive heart failure (maybe because of a medication mix-up); Type 2 Diabetes; COPD (no admissions); poly myalgia rheumatica; osteoarthritis.
Medications: Amlodipine; metoprolol; atorvastatin; furosemide; ASA; metformin; sitagliptin; steroid inhaler; salbutamol inhaler; prednisone 2 mg; acetaminophen
The doctor says he has an undisplaced longitudinal patellar fracture and has placed him in a straight-leg splint as the only treatment and has declared him “medically stable” and “good to go.”
Key Takeaways
- Assess the cognitive ability of both people – the patient and the caregiver
- Assess mobility and function
- Establish links to community care – meals on wheels, follow up with home assessment, a friendly visitor service
- Help with transitions of care – communication with PCP, with pharmacy, arranging transport home and to follow up appointments
Contributing Faculty
