ASSESSING AND COMMUNICATING WITH OLDER PATIENTS



RAPID ASSESSMENT OF OLDER PATIENTS IN THE EMERGENCY DEPARTMENT

A Manual for Emergency Medicine Residents

Written by Eve D. Losman, MD. Adapted from material created by Brent Williams, MD for the Comprehensive Program to Strengthen Physicians' Training in Geriatrics.

University of Michigan Medical School

UMHS / SJMH Emergency Medicine Residency Program

2003

TABLE OF CONTENTS

Introduction 2

Background 3-4

Instructional materials:

Assessing Patients’ Functional Status 5

Screening for Cognitive Impairment 6-9

Screening for Depression 10-11

Evaluating Patients with Gait Instability or (non-syncopal) Falls 12-13

Communicating with Older Patients 14

SAFE questions

Competence / Decision Making Capacity

Polypharmacy and Adverse Drug Events 15-18

Summary of Assessment tools:

Functional impairment – ADLs, IADLs 19

Gait instability/risk for falls

Timed Up and Go Test 19

Cognitive Impairment

Serial 7’s 19

Mini-Cog 20

Mini-Mental State Examination (general) 20

3-item one-minute recall 20

Clock Drawing Test 20

Major Depressive Illness

2-question Screener 21

Mini-Mental State Examination (detailed) 22-23

UMHS Specific and Web-based Resources 24

Reference List 25-28

Introduction

All physicians who care for adults are caring for an increasingly large number of older patients. Older patients are more likely than younger patients to have unrecognized co-morbidities and impairments that increase their risk of medical morbidity, functional decline, and mortality. Often, older patients' co-morbidities are unrecognized by health care professionals since they may not be the primary focus of clinical encounters, and are unrecognized or not mentioned by the patients themselves.

Functional impairments and cognitive and affective problems are particularly prevalent among older patients, and can be improved with early recognition and treatment.

Physicians who care for older adults should be able to recognize functional, cognitive, and affective impairment among their patients to enable appropriate management or referral. Information and tools are now available for all physicians to rapidly and accurately identify clinically important impairments among older patients.

Completing a brief assessment of older patients requires effective use of a broad range of skills in medical interviewing. Application of a few simple interviewing techniques will substantially enhance the amount and accuracy of information obtained in speaking with older patients.

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Background

Why is assessment of the older adult an issue for Emergency Medicine Physicians?

The segment of our population greater than 65yrs of age is growing (currently ~12% and anticipated to increase to ~20-25% in the next forty years).

Geriatric patients make up ~16-18% of ED visits currently. It is anticipated that their utilization of the ED will increase proportionally to their numbers in the population and that their reliance on the ED for acute and sub-acute health care will also grow. Their length of stay in the ED, complexity of evaluation, and rate of admission are all significantly higher than the rates for younger patients.

Emergency Department visits by elder adults have been characterized as a “sentinel event.” Geriatric patients experience functional decline and a decrease in their health- related quality of life after an ED visit. In addition, ~25% of these patients will have a return to the ED within 90 days of their initial visit. Chin et al. found that “after adjustment for demographic and social factors, the most consistently powerful predictors of poor recovery were more deficiencies in activities of daily living at baseline, reports of needing more help with everyday tasks . . .”

In a survey of practicing EM physicians conducted in 1991, the majority of responders felt that they did not have adequate training in Geriatrics and that managing the medical complaints of elderly patients was more difficult as compared to younger patients.

Of the responders who completed residency training, 53% felt that inadequate time was spent of geriatric issues and 69% felt that there was insufficient CME available in geriatric emergency medicine.

Elderly patients with common clinical presentations (eg. abdominal pain, chest pain, confusion, etc.) in the ED were rated as more difficult to manage and more consumptive of resources by greater than 45% of responders.

Based on a focus group we held in August 2001, EM residents at UMHS identified numerous complicating factors in their ability to care for elderly patients.

- Lack of knowledge / comfort in caring for certain conditions.

- Inadequate knowledge / experience to risk stratify elderly patients (eg. admission v discharge in a patient who may not be acutely ill, judging the severity of illness in an elderly patient, etc.)

- Lack of information about the patient (eg. patient unable to provide history, absence of meaningful records from the NH, absence of family to provide background information).

- Lack of knowledge of “systems of care” that impact Geriatric patients.

Background, continued:

Although older adults present with ACUTE complaints, they have underlying CHRONIC conditions that greatly impact their evaluation, treatment, and recovery.

- Adults over the age of 65 have an average of 1.5 chronic illnesses.

- Those with chronic illnesses account for 75% of the health care costs in the United States.

*** If we wish to provide excellent care to the older adults who come to our EDs, we can not simply focus on the ACUTE problem and ignore their chronic conditions. ***

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Adapted from slides created by Brent Williams, MD for the DWR grant.

Assessing a Patients’ Functional Status

Definition: Functional impairment is defined as difficulty performing, or requiring the assistance of another person to perform, one or more of the following Activities of Daily Living:

Functional impairment - ADLs and IADL

Activities of Daily Living (ADLs) – all are important

Transferring – do you need help getting out of bed?

Toileting – can you go to and use the bathroom by your self?

Dressing – do you need help getting dressed?

Grooming / Hygiene – do you need help bathing and brushing your teeth / hair?

Eating / Feeding – are you able to eat on your own?

Dressing / Grooming / Hygiene are the first of these activities to go in the demented patient and Eating / Feeding is the last.

Instrumental Activities of Daily Living (IADL) – starred items are particularly important

* Food Preparation – can you cook for your self?

* Shopping – do you go out / do the grocery shopping?

* Taking Medications – do you take medications independently or does someone help you? Ask also about compliance with medication regimen.

Housekeeping / Laundry – are you able to clean your home?

Handling Finances – do you balance your check book and keep track of your finances?

Telephone – are you able to use the phone?

Outdoor Mobility / Transportation – are you able to negotiate walking in the street? And are you able to use public transportation / drive your car?

Prevalence: Approximately 75% of persons over age 75 limit their activities due to functional impairment each year; 40% experience restricted activity in two consecutive months. Almost 50% of people 85 years of age and older require assistance in one or more ADL. As many as 25% of older community-dwelling adults have at least one impairment in their IADLs.

Among patients admitted to general medical hospital units, 40% have at least one ADL impairment, 65% have one or more IADL impairments, and 30% have mobility impairment.

Clinical implications: ADL impairment is a stronger predictor of hospital outcomes (functional decline, length of stay, institutionalization, and death) than admitting diagnoses, Diagnosis Related Group, and other physiologic indices of illness burden. ADL impairment is also a risk factor for nursing home placement, emergency room visits, and death among community-dwelling adults.

Approximately 25% to 35% of older patients admitted to the hospital for treatment of acute medical illness lose independence in one or more ADL. Risk factors for loss of independence in ADLs during hospitalization include advanced age, cognitive impairment, and IADL impairments at admission.

Screening for Cognitive Impairment

All clinicians should screen older patients to rule out cognitive impairment who:

a. Are age 80 or above

b. Are undergoing elective surgery

c. Have recently been discharged from the hospital

d. Undergo unexplained decline in functional status

e. Have unexplained sleep difficulties or behavioral disturbances

f. Have poor adherence with medical or behavioral regimens

Patient who rule in (score positive) on any screening test for dementia should be referred for further evaluation.

The most common causes of cognitive impairment in elderly patients are dementia, delirium, and depression.

Dementia:

A symptom that by definition entails a fall in intellectual ability from the person’s previous level of performance causing an altered pattern of activity in the setting of normal consciousness. Note that there is nothing mentioned about age, reversibility and progression.

Delirium:

Delirium is a disorder of attention, and should be considered in patients with waxing and waning attention or level of consciousness. Delirium is commonly a side effect of medications, and is often unrecognized by clinicians.

It is suggested by the presence of cognitive impairment with:

1. Acute onset (hours to days) and fluctuating course

2. Inattention (difficulty maintaining focus).

3. Disorganized thinking OR Altered level of consciousness

VAMPIRE: a mnemonic to guide your thinking when assessing these patients.

Vitals (metabolics, hydration, oxygenation)

Acute events (ie. MI, PE, CVA)

Medications (ie. sedative-hypnotics, pain medications, drug-drug interactions)

Pain Control

Infections (ie. UTI)

Restricted Mobility

Environment (ie. sleep deprivation, vision impairment, hearing impairment)

Depression:

Please see next section

Screening for Cognitive Impairment, continued:

Prevalence: The prevalence of clinically significant cognitive impairment is roughly 3% among persons 65 years of age, and doubles in prevalence every 5 years reaching 40-50% among persons 90 years of age or older. Most patients with dementia do not complain of memory loss or even volunteer symptoms of cognitive impairment unless specifically questioned.

Clinical implications: Many elderly patients seen by surgical and medical specialists and subspecialists have significant cognitive impairment, often undiagnosed. Unrecognized cognitive impairment is a risk factor for medication non-adherence, poor compliance with behavioral recommendations, difficulty navigating the health care system, and caregiver stress.

Assessment: Patients with suspected cognitive impairment should be screened for delirium and depression. Delirium is a disorder of attention, and should be considered in patients with waxing and waning attention or level of consciousness. Delirium is commonly a side effect of medications, and often unrecognized by clinicians.

Tools to Evaluate for Cognitive Impairment:

Substantial evidence exists that several rapid screening tests – some requiring less than a minute to administer – can be used to rule out dementia:

The Mini Mental State Exam

- A well validated instrument in both the in-patient and out-patient settings that is somewhat time consuming.

- Scored from 0 to 30

o Score >25 has a likelihood ratio of 0.1 for dementia (ie. the patient is very unlikely to be demented)

o Score 85 years.

Drug related mortality is the 9th leading cause of death for people >65 years of age.

It is estimated that ~30% of ADEs are preventable.

General Approach to prescribing for older adults in the ED:

- check for potential ADEs / drug – drug interactions

- strive for once a day dosing regimen to maximize compliance

- start with a low dose

o think about the CrCl

o think about hepatic metabolism

o think about volume of distribution

- avoid treating a medication side effect with another medication

Polypharmacy and ADE: continued

In whom should you think about an ADE as the cause of the presenting complaint?

- Older adults with > / = 6 active chronic diagnoses

- Older adults with > / = 9 medications

- Older adults with > / = 12 medication doses per day

- Older adults with a current ADE (50% will have another potential ADE in their medication list)

- Older adults with low body weight

- Older adults aged > 85 years

- Older adults with an estimated creatinine clearance < 50ml/min

Creatinine Clearance:

Serum creatinine is not an accurate measure of renal function in older adults as a result of sarcopenia (loss of muscle mass).

CrCl = (140 – age) x (body weight in Kg)

72 x serum creatinine in mg/dL

In males, multiply the result by 1.0; In females, multiple the result by 0.85.

Always use a creatinine of at least 1.0 in order to avoid overestimating clearance.

Age-Associated Changes in Pharmacokinetics and Pharmacodynamics

|Parameter |Age Effect |Disease, Factor Effect |Prescribing Implications |

|Absorption |Rate and extent are usually |Achlorhydria, concurrent |Drug-drug and drug-food interactions are |

| |unaffected |medications, tube feedings |more likely to alter absorption |

|Distribution |Increase in fat : water |CHF, ascites, and other |Fat-soluble drugs have a larger volume of |

| |ratio. Decreased plasma |conditions will increase body |distribution. Highly protein-bound drugs |

| |protein, particularly albumin|water |will have a greater (active) free |

| | | |concentration |

|Metabolism |Decreases in liver mass and |Smoking, genotype, concurrent |Lower doses may be therapeutic |

| |liver blood flow may decrease|drug therapy, alcohol and | |

| |drug metabolism |caffeine intake may have more | |

| | |effect than aging | |

|Elimination |Primarily renal. Age-related |Renal impairment with acute and |Serum creatinine not a reliable measure of |

| |decrease in GFR |chronic diseases; decreased |renal function; best to estimate CrCl using|

| | |muscle mass results in lower |formula |

| | |creatinine production | |

|Pharmaco-dynami|Less predictable and often |Drug-drug and drug-disease |Prolonged pain relief with morphine at |

|cs |altered drug response at |interactions may alter responses |lower doses. Increased sedation and |

| |usual or lower concentrations| |postural instability to benzodiazepines. |

| | | |Altered sensitivity to β-blockers |

Geriatrics at Your Fingertips, 2003

Polypharmacy and ADE: continued

Top drugs in the ED that are linked to ADEs

-Antibiotics

-Cyclobenzaprine

-Digoxin

- Diphenhydramine

-Furosemide

-Ibuprofen and Indomethacin (all NSAIDs pose a risk)

-Insulin (all hypoglycemics pose a risk)

-Meperidine

-Phenytoin

-Warfarin

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Polypharmacy and ADE: continued

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Available Tools to Assess for an ADE:

- MICROMEDEX

o Can enter symptom and screen for ADE or ender a combination of medications to screen for an ADE.

- eProcrates

o a PDA pharmacy tool

- catalog/electronic/renal-failure.htm

o PDA tool for drug dosing in renal failure

- drug–

o web based tool

Summary of Relevant Assessment Tools

Functional impairment

Ask: “Do you have difficulty or require assistance with any of the following?”

Activities of Daily Living

Feeding yourself

Getting on and off the toilet

Transferring from bed to chair

Bathing

Dressing

Grooming

Instrumental Activities of Daily Living

Taking medications

Driving

Using the telephone

Shopping

Preparing food

Handling your finance

Doing housework

Doing Laundry

Transportation

Gait instability/risk for falls

Ask: “Have you fallen (without loss of consciousness) in the past year?”

Timed Up and Go Test

Ask the patient to get up from a chair without using his/her arms, walk 10 feet, and turn around, return to the chair, and sit down. (“Timed Get Up and Go” test)

Persons who take 10 seconds or less to complete this sequence of maneuvers are at low risk of falling. Persons who take >20 seconds to complete this sequence are at high risk of falling.

Cognitive impairment

Serial 7s

Examiner asks patient to count backwards from 100 by 7’s. (“Please count backwards from 100 by 7’s, subtracting 7 from 100 then 7 from each answer. I’ll tell you when to stop.”)

Stop the patient when s/he reaches 65 or is unable to calculate next answer. Test is negative for patients reaching 65.

Summary of Relevant Assessment Tools , continued:

Mini-Cog

|1. Instruct the patient to listen carefully to 3 unrelated words and then to repeat the words. |

|2. Clock Drawing Test (CDT): Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with |

|the clock circle already drawn on the page. |

|After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time, such as |

|11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to |

|complete the task. The CDT serves as the recall distracter. |

|3. Ask the patient to repeat the 3 previously presented words. |

Scoring:

Give 1 point for each recalled word after the CDT distracter. Score 1–3.

- A score of 0 indicates dementia (regardless of CDT results).

- A score of 1 or 2 with an abnormal CDT indicates dementia

- A score of 1 or 2 with a normal CDT indicates absence of dementia

- A score of 3 indicates absence of dementia (regardless of CDT results).

The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.

3-item recall at one minute

Examiner names 3 objects, taking about one second to say each. Examiner then asks the patient to name all 3 objects. Examiner repeats them until the patient learns all 3. (Examples: airplane, pencil, and daffodil)

After one minute, examiner asks patient to recall the three objects. Inability to recall any of the objects is a positive test.

Clock Drawing Test (CDT)

Examiner asks patient to: a) draw a circle, b) place numbers as on a clock face, and c) draw hands to indicate 8:20.Score test as either normal (circle complete, all 12 numbers in correct quadrants, hands within one number of correct place) or abnormal.

Mini-Mental State Examination (MMSE)

10-items Folstein Mini-Mental State Examination takes about 10 minutes to complete. A copy of the MMSE and instructions for administration are provided below.

Major Depressive Illness

Two-question screener:

"During the past month, have you often been bothered by feeling down, depressed, or hopeless?" and

"During the past month, have you often been bothered by little interest or pleasure in doing things?"

Test is negative for patients who respond "no" to both questions.

UMHS Specific and Web-based Resources



- An excellent resource for general information, relevant formulas, practice guidelines for the management of a variety of common geriatric syndromes.

- This is a free service sponsored by the American Geriatrics Society and the John A Hartford Foundation.



- A web based version of much of the information contained in this manual.

- Gives you information on how to access the resources of the Turner Geriatric Center.

- This web address will become a link on our departmental home page in the near future.

The Cochrane database

- Available through the Taubman Library, this is a resource for EBM type analyses of a variety of topics.



- The website for the American Geriatrics Society.



- Has a “Senior Health” section with patient specific information as well as resources for the physician.



- The website for Society of Academic Emergency Medicine. There is a Geriatrics Interest Group with some good information for Emergency physicians.

Emergency Medicine Reference List:

Emergency Care of the Elder Person, Sanders AB (editor), 1996

Baraff LJ, Lee TJ, Kader S, Della Penna R. Effect of a Practice Guideline on the Process of Emergency Department Care of Falls in Elder Patients. Academic Emergency Medicine 1999; vol 6: pp 1216-1223.

Baraff LJ, Della Penna R, Williams N, Sanders AB. Practice Guideline for the ED Management of Falls in Community-Dwelling Elderly Persons. Annals of Emergency Medicine 1997; vol 30, no 4: pp 480-489.

Baraff LJ, Bernstein E, Bradley K, Franken C, Gerson LW, Hannegan SR, Kober KS, Lee S, Marotta M, Wolfson AB. Perceptions of Emergency Care by the Elderly: Results of Multicenter Focus Group Interviews. Annals of Emergency Medicine 1992; vol 21, no 7: pp 814-818.

Chin MH, Jin L, Karrison TG, Mulliken R, Hayley DC, Walter J, Miller A, Friedmann PD. Oler Patient’s Health Related Quality of Life Around an Episode of Emergency Illness. Annals of Emergency Medicine 1999; vol 34, no 5: pp 595-603.

Chin MH, Wang LC, Jin L, Mulliken R, Walter J, Hayley DC, Karrison TG, Nerney MP, Miller A, Friedmann PD. Appropriateness of Medication Selection for Older Persons in an Urban Academic Emergency Department. Academic Emergency Medicine 1999; vol 6: pp1232-1242.

Hedges JR, Singal BM, Rousseau EW, Sanders AB, Berstein E, McNamara RM, Hogan TM. Geriatric Patient Emergency Visits Part II: Perceptions of Visits by Geriatric and Younger Patients. Annals of Emergency Medicine 1992; vol 21, no 7: pp 808-813.

Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, Adverse Drug-Related Events, and Potential Adverse Drug Interactions in Elderly Patients Presenting to an Emergency Department. Annals of Emergency Medicine 2001; vol 38, no 6: pp 666-671.

Hustey FM, Meldon SW, Smith MD, Lex CK. The Effect of Mental Status Screening on the Care of Elderly Emergency Department Patients. Annals of Emergency Medicine 2003; vol 41, no 5: pp 678-684.

Mandavia D, Newton K. Geriatric Trauma. Emergency Medicine Clinics of North America 1998; vol 16, no 1: pp 257-274.

McCusker J, Cardin S, Bellavance F, Belzile E. Return to the Emergency Department among Elders: Patterns and Predictors. Academic Emergency Medicine 2000; vol 7: pp 249-259.

Meldon SW, Mion LC, Palmer RM, Drew BL, Connor JT, Lewicki LJ, Bass DM, Emerman CL. A Brief Risk Stratification Tool to Predict Repeat Emergency Department Visits and Hospitalizations in Older Patients Discharged from the Emergency Department. Academic Emergency Medicine 2003; vol 10: pp 224-232.

Mion LC, Palmer RM, Anetzberger GJ, Meldon SW. Establishing a Case Finding and Referral System for At-Risk Older Individuals in the Emergency Department Setting: The SIGNET Model. JAGS 2001; vol 49: pp 1379-1386.

O’Keefe KP, Sanson TG. Elderly Patients with Altered Mental Status. Emergency Medicine Clinics of North America 1998; vol 16, no 4: pp 701-715.

Sanders AB. Care of the Elderly in Emergency Departments: Conclusions and Recommendations. Annals of Emergency Medicine 1992; vol 21, no 7: pp 830-834.

- Shah MN, Rathouz PJ, Chin MH. Emergency Department Utilization by Noninstitutionalized Elders. Academic Emergency Medicine 2001; vol 8, no 3: pp267-273.

Singal BM, Hedges JR, Rousseau EW, Sanders AB, Berstein E, McNamara RM, Hogan TM. Geriatric Patient Emergency Visits Part I: Comparison of Visits by Geriatric and Younger Patients. Annals of Emergency Medicine 1992; vol 21, no 7: pp 802-807.

Strange GR, Chen EH, Sanders AB. Use of Emergency Departments by Elderly Patients: Projections From A Multicenter Data Base. Annals of Emergency Medicine 1992; vol 21, no 7: pp 819-824..

Geriatric Reference List:

Alexander NB. Gait disorders in older adults. Journal of the American Geriatrics Society 1996; 44: 434-451.

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guidelines for the prevention of falls in older persons. Journal of the American Geriatrics Society 2001; 49: 664-672.

Beers MH. Explicit Criteria for Determining Potentially Inappropriate Medication Use by the Elderly: An Update. Archives of Internal Medicine 1997; 157: 1531-1536.

Chodosh J, McCann RM, Frankel RM, et al., Geriatric assessment and the twenty minute visit. Rochester, New York: Division of Geriatrics, University of Rochester, School of Medicine and Dentistry; 1997.

Cohen HJ, Feussner JR, Weinberger M, Carnes M, Hamdy RC, Hsieh F, Phibbs C, Lavori P. A controlled trial of inpatient and outpatient geriatric evaluation and management. NEJM 2002; 346: 905-912.

Gill TM, Desai MM, Gahbauer EA, Holford TR, Williams CS. Restricted activity among community-living older persons: Incidence, precipitants, and health care utilization. Annals of Internal Medicine 2001; 135: 313-321.

Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH., Interventions for preventing falls in the elderly; Cochrane Database Systematic Reviews. 2001; 3: CD000340.

Inouye SK, Peduzzi PN, Robison JT, Hughes JS, Horwitz RI, Concato J. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA 1998; 279: 1187-1193.

Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. NEJM 1995; 332: 1338-44.

Moore AA, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. American Journal of Medicine 1996;100:438-443.

Mulligan R, Mackinnon A, Jorm AF, Giannakopoulos P, Michel JP. A comparison of alternative methods of screening for dementia in clinical settings. Archives of Neurology 1996; 53: 532-6.

Podsiadlo D, Richardson S. The timed "Up and Go": a test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society. 1991; 39: 142-148.

Siu AL. Screening for dementia and investigating its causes. Annals of Internal Medicine 1991; 115:112.

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Assessment

Management

Referral

Medical conditions

Functional impairment

Cognitive problems

Depression

Medications

Relationships

Social support

Financial resources

CHRONIC CONDITION

(Function)

ACUTE PROBLEM

(Diseases)

Mini - Cog

3-item recall = 0

3 item recall = 1-2

3-item recall = 3

Non-demented

Demented

[?]DEHqrs t † á

í

î

ùúu&þ‘’ÀÁ,DDemented if Clock Draw is Abnormal

Non-demented if Clock Draw is Normal

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