Chapter 34 Geriatric care

The elderly come to emergency department for a wide variety of reasons. Their presentation will most commonly be due to an acute medical illness, but equally there will often not be an obvious ‘medical’ emergency, but simply a crisis. What the older patient in the emergency department needs, more than anything else, is for you to take a careful history, which includes speaking to family, carers, friends and local doctor. Always check that the patient’s own account of him/herself is accurate, by asking someone else who knows the patient (this will often save time, unnecessary investigations and costs). Always consider the possibility of underlying medical problems as the cause of the current presentation, especially when the initial triage suggests that the presenting problem is merely ‘social’. Often, the biggest dilemma is deciding whether or not the patient can safely be sent home (see the discharge checklist in Box 23.1, Chapter 23, ‘The ill patient’), especially for those patients with minor, undifferentiated illnesses or falls, whose initial investigations have not shown any significant abnormality. Mistakes are often made when these decisions are rushed and ill-informed, leading to poor outcomes for the patient, including readmission to hospital and increased morbidity and mortality.

This chapter is a guide to help you in assessing older patients who present to the emergency department with one of the six geriatric syndromes: confusion, depression, falls, immobility, incontinence and dependency in activities of daily living (ADLs). In addition to conventional history taking and examination, emergency department geriatric assessment requires detailed assessment of functional status and social context. It is also important to note hearing and vision impairment, nutritional status and dental hygiene, as well as to review all medications. It is important that you familiarise yourself with the post-acute care services or early discharge programs that are available locally.

The rapidly increasing population of older Australians is placing enormous pressures on all aspects of our healthcare system, especially emergency departments. Many changes in primary care and community care of the elderly have left patients and their carers with little option other than to call an ambulance in response to a crisis situation or illness. Numerous studies on the elderly in emergency departments have shown similar findings. Older persons come to hospital more often by ambulance, wait longer in the emergency department, have a much higher rate of admission to hospital, have increased mortality, undergo more investigations and cost more money to treat. They are at increased risk of further deterioration or readmission after discharge from the emergency department.

Geriatric medicine is not simply general medicine in old people. There are significant differences in the approach to care, diagnosis and decision making in the frail aged. There are several important principles of practice:

It should be assumed that the patient will not remember much of what he or she has been told during their visit to the emergency department. It is wise to take a paternalistic approach, similar to when dealing with paediatric patients, where extra time is spent explaining the medical issues to the patient’s family or carers. This is not meant to suggest that the majority of our older patients are mentally incompetent, but merely to stress the importance of good communication, especially in those situations where the older patient is dependent on a variety of coordinated community services to remain at home.

THE GERIATRIC SYNDROMES

1 Acute confusion

Presentation with acute confusion offers both diagnostic and management challenges to the doctor and the staff of the emergency department. A busy emergency department is an unsatisfactory environment in which to treat an acutely confused older person, but the confused patient is something that you will be expected to manage time and time again. The family of the patient will find the situation particularly stressful. Be careful not to label the patient as suffering from dementia, until such time as a clear history of a dementing illness can be obtained. Dementia is largely a diagnosis of exclusion, and you need to actively exclude delirium and psychiatric conditions such as depression before arriving at such a significant diagnosis. Dementia, depression and delirium frequently coexist, and it can be very difficult to separate them.

Diagnosis

• It is always best to assume that the confused patient has some underlying acute medical problem that is contributing to the acute confusion, and to set about finding it!

• A collateral history from reliable informants must always be sought.

• Assess baseline and contributing factors (Figure 34.1).

• The Confusion Assessment Method (Figure 34.2) is a brief tool that helps to diagnose delirium. This is used in conjunction with the Mini Mental Status Examination (MMSE, Box 34.1) that should be completed in all cases to objectively document the current level of cognitive impairment.

• Physical examination is often difficult as the patient may struggle against your efforts to complete the examination. However, physical examination remains a very important component of the initial assessment and can sometimes quickly reveal the underlying problem, such as acute retention of urine, faecal impaction or even acute pain from a broken bone.

• Routine haematology and biochemistry, urine and blood cultures, ECG and chest X-ray (CXR) should suffice as preliminary investigations in the majority of cases. Abnormal thyroid function, vitamin B₁₂ and folate deficiency are uncommon causes of acute confusion that should be excluded.

• CT brain scan is a second-line investigation, unless there is evidence of objective neurological signs or a high index of suspicion for possible recent head injury, especially in those cases presenting with a ‘fall and long lie’. Confused and agitated patients usually need sedation to be scanned; it is not appropriate to sedate a patient unless the investigation is absolutely necessary.

• Even after hospital admission and lengthy investigations, up to one-third of these patients will be discharged from hospital without a clear precipitant having been identified.

Figure 34.1 Acute confusion—why is this patient confused now?¹

Figure 34.2 Confusion assessment method²

Box 34.1 Folstein Mini Mental Status Examination (MMSE)³

Year…………. 1 State…….. 1

Season……….. 1 City………. 1

Date…………. 1 Suburb……… 1

Month………… 1 Hospital…….. 1

Day of the week…1 Floor……….. 1

Registration of three items………………………3

Spell WORLD backwards or serial sevens…………….5

Recall of three items at one minute……………….3

Able to name two objects (pen and watch)…………..2

Able to repeat ‘no ifs, ands, or buts’….1

Able to follow three-stage command………………..3

Able to read and obey ‘close your eyes’…1

Write a sentence………………………………..1

Copy intersecting pentagons or draw a clock face……1

Total…………………………………………..30

Management

• Broad-spectrum intravenous antibiotics should be commenced if there is any evidence of infection (neutrophil leukocytosis, elevated temperature, cultures positive), but only after urine, wound and blood cultures have been collected.

• Avoid iatrogenic precipitants (such as indwelling urinary catheters, addition of multiple medications, use of restraints).

• Individual nursing is probably the most effective ‘treatment’—it prevents problems such as falls and wandering, and reduces the need for sedating medications.

• Families can play a crucial role in helping to reorientate patients to their current surroundings.

• If wandering patients cannot be safely contained within the department, there is a priority to move them to a safe environment within the hospital. Physical restraint is almost never indicated, but remains overused in Australian hospitals.

• Careful use of low dosage of major tranquillisers such as risperidone or haloperidol is appropriate to manage paranoid and persecutory delusions or aggressive behaviour.

2 Depression

The spectrum of depressive disorders differs in the elderly. Major depression occurs in only 1.5%, but depression of clinical significance occurs in up to 13.5%. In addition, depressive symptoms including anxiety symptoms, phobias and somatisation are extremely common. There is a very strong correlation between depressive symptoms and use of health services, and the rate at which older people develop depression is highly dependent on preceding disability.

Management

1. It is important to perform a full mental status examination on geriatric patients, especially when you suspect depression, self-neglect, squalor syndrome or excessive alcohol intake.

2. Assess cognition using the MMSE. Depression and dementia can be very difficult to differentiate.

3. The Geriatric Depression Scale (GDS, Box 34.2) may help you decide whether there is a likelihood of depression being present.

4. Assess degree of suicidality (passive and active) and decide if you feel that either is present. Older patients will commonly tell you that they wish they were dead, especially in the setting of acute illness, pain and disability.

5. It is never appropriate to institute antidepressant therapy in the emergency department without first consulting the duty geriatrician or psychiatrist.

6. The presence of passive suicidal ideation or depressed mood should prompt discussions with family and a referral to the emergency department social worker for psychological support.

7. If the patient is to be sent home, involvement of social supports (both family and community) is essential to reduce the risk of self-harm.

Box 34.2 The Geriatric Depression Scale⁴

Are you basically satisfied with your life? …….X No

Have you dropped many of your interests and activities?……Yes X

Do you feel that your life is empty? ……Yes X

Do you often get bored? ….Yes X

Are you in good spirits most of the time? …..X No

Are you afraid that something bad is going to happen to you? …Yes X

Do you feel happy most of the time? …..X No

Do you often feel helpless?……..Yes X

Do you prefer to stay at home rather than

going out and doing new things?……Yes X

Do you feel that you have more

problems with memory than most?…..Yes X

Do you feel it is wonderful to be alive now? ……X No

Do you feel pretty worthless the way you are now?……Yes X

Do you feel full of energy?……..X No

Do you feel that your situation is pretty hopeless?…….Yes X

Do you think that most people are better off than you are?……Yes X

Total score (one point per question answered) 15

3 Falls

One-third of all people over the age of 65 years will fall every year, and half of these will fall repeatedly. Falls cause pain, fear, suffering, restriction of activities and death among older persons; in fact, they are the leading cause of accidental death in persons older than 85 years. Five per cent of falls lead to a fracture and 10% of fallers sustain other serious injuries. After a fracture, one in four will never regain their previous mobility.

Elderly fallers are different from their healthy, age-matched counterparts. Although some have medical conditions that cause the fall, most have no single diagnosis, but rather a combination of risk factors for falls. The more risk factors present, the greater the likelihood of further falls. Interventions targeted at these risk factors have been shown to reduce the rate of further falls.

Management

1. Complete a simplified falls risk assessment (Figure 34.3) on all older patients who present after having a fall.

2. Exclude postural hypotension.

3. Check vision.

4. Perform a neurological assessment.

5. Perform a gait assessment, including the time to ‘Up and Go’ test (Box 34.3) and review adequacy of footwear. Consult with the physiotherapist in the emergency department regarding the gait assessment and provision of mobility aid where appropriate.

6. Review all medications (in particular hypnosedative agents) and reduce medications where possible. However, medications that are often implicated in falls, such as beta-blockers or antidepressants, should not be ceased abruptly by the emergency department resident without appropriate consultation.

7. A follow-up occupational therapy home visit should be organised, as 50% of falls are due to extrinsic (environmental) factors.

Figure 34.3 Falls risk assessment⁵

Box 34.3 The time to ‘Up and Go’ test⁶

The time to ‘Up and Go’ test is a useful bedside test that correlates well with more sophisticated falls risk assessment. The patient should be able to arise from a chair, walk 6 metres and return to the seated position within 15 seconds. Failure to do so within this time limit constitutes an abnormal test and indicates a high risk of further falls.

4 Immobility

Mobility problems are a common link in those patients who have a number of the geriatric syndromes (incontinence, falls and dependency) and are often overlooked by young doctors. It is important to determine if the immobility is an acute or chronic problem and train yourself to comment on the gait. Is it safe or unsafe? Mobility is affected by falls (pain from fractures or soft tissue injury, fear of further falling, lack of confidence), and intercurrent illness (breathlessness, muscle weakness, dizziness, fear) in the acute setting. A brief period of gait retraining is often all that is required to restore confidence and safety, and is a good reason in itself to recommend admission to hospital. Those with long-standing mobility problems may need a much more intensive multidisciplinary team approach to get home, and should be referred to the geriatric service for assessment. The screening tool for immobility is the same as the falls risk assessment, and the time to ‘Up and Go’ test (Box 34.3) is a simple objective measure of gait that you could perform, although such tests have not been shown to accurately predict outcomes after discharge from the emergency department.

5 Incontinence

Urinary incontinence affects up to 20–30% of community-dwelling older persons, and 50–70% of those in long-term institutions. Incontinence creates embarrassment, isolation, depression and stigmatisation. It places significant burden on caregivers and carries the risk of institutionalisation. Incontinence predisposes to skin rashes and infections, decubitus ulcers, urinary tract infections (UTIs), urosepsis, falls and fractures. For these reasons, incontinence carries very high economic costs; yet despite its prevalence, morbidity and cost, incontinence is often neglected, poorly evaluated and often accepted as ‘a normal part of ageing’.

There are numerous primary causes of incontinence in the older person. These may be primarily related to the pelvic structures or there may be various contributing factors. Frequently, the aetiology is mixed and complex. With adequate assessment and appropriate management, many patients can be cured and almost all can be significantly improved. Where cure is not possible, assistance with social continence should be achieved.

Continence requires not only the integrity of lower urinary tract function but also adequate mentation, mobility, motivation and manual dexterity (the four Ms).

Initial assessment of incontinence

See Figure 34.4.

• Determine if the incontinence is a new or old problem.

• Determine the pattern of the incontinence (urge, stress, retention with overflow, mixed).

• Determine the contribution of the four Ms to the current presentation.

• Exclude infection in the urine (dipstick testing and midstream urine, MSU).

• Perform lower limb neurological examination.

• Perform rectal examination and abdominal palpation, excluding the presence of significant post-voiding residual volume (catheter or ultrasound).

Figure 34.4 Incontinence—why is this patient incontinent now?

Diagnosis and management

1. Frequency–volume chart helps to accurately define the pattern of incontinence.

2. Bowel management (prescribe enemas and aperients if constipated).

3. Treat urine infection if this is present.

4. Medication review. Drugs predisposing to incontinence include diuretics (especially frusemide), calcium channel antagonists, anticholinergics (including antipsychotics, antispasmodics, anti-Parkinson’s agents) and benzodiazepines.

5. Screening for prostate pathology with the prostate-specific antigen test (PSA).

Indwelling urinary catheters are not indicated in the routine management of incontinence. The only indications for the insertion of a urinary catheter are:

• to relieve retention with overflow incontinence

• to monitor urinary output (as part of haemodynamic monitoring)

• an in-out catheter to collect a urine specimen and to exclude acute retention

• when incontinence is contributing to perineal or sacral skin sepsis.

Individualised toileting, such as prompted two-hour toileting, may improve continence in the cognitively impaired patient.

Faecal incontinence

Continence of faeces depends on sphincter function and rectal motility, as well as the four Ms of continence. Chronic constipation complicated by faecal impaction with overflow, diarrhoeal illnesses and continence problems related to dementia and acute confusion would be the commonest causes. Initial assessment is similar to the urinary incontinence assessment:

• exclusion of faecal impaction (digital rectal examination and plain abdominal X-ray)

• stool culture if diarrhoea is truly present.

6 Dependency in activities of daily living (ADLs)

You will be encouraged to send both young and old patients directly home from emergency department and to try to avoid their admission. This is not a bad thing, as admission to hospital is associated with physical, cognitive and functional decline in the elderly. However, the elderly are often seen as ‘bed blocking’ or not really sick enough to warrant admission, especially when there is a chronic shortage of inpatient beds. This combination of bed shortage and the sub-acute, atypical presentation of older patients can lead to hasty, poor discharge decisions.

You should be very wary of the frail elderly patient whose triage assessment lists social factors, ‘not coping’ or ‘acopia’ as the main presenting problem. Such patients commonly have a combination of identifiable medical conditions that are collectively responsible for their current inability to manage their activities of daily living (ADLs), and appropriate medical treatments often improve these patients to the point where they can continue to cope at home. This is often the aim of a geriatric admission to hospital. What may initially present as a simple case of ‘not coping’ will often result in weeks of hospitalisation with the patient eventually returning home. Obviously, this is not a role for the emergency department. Nonetheless, you should become familiar with a brief assessment of ADLs (Figure 34.5). This should become part of your routine medical assessment because being dependent in basic ADLs is a powerful predictor of poor health outcomes from acute illness.

Figure 34.5 Dependency in activities of daily living (ADLs)

Involvement of the emergency department social worker is important in the early stages, especially if you are sending the patient directly home. Many emergency departments now have specific aged care teams available to help coordinate services on discharge. Your patient may temporarily need services to cope once they go home, but do not assume that appropriate services can be arranged immediately (especially after hours and on weekends).