Emergency care for the older adult involves treating both acute illnesses and injuries, as well as exacerbations of chronic disease. The most common reasons older adults present to the ED include falls, chest pain, adverse medication effects, neuropsychiatric disorders, alcohol and substance abuse, elder abuse and neglect, abdominal pain, and infections. The older adult will often present with vague symptoms, atypical presentations of common diseases, multiple acute conditions, and confounding medical comorbidities. Additionally, up to 40% of older adults will have cognitive impairment that is not readily apparent to emergency providers, further complicating their medical and psychosocial evaluation and disposition. For this reason, innovative approaches are necessary to deliver optimal care to this population.
Validated screening tools are used in other care settings and can rapidly identify those at high risk for poor outcomes. The Identification of Seniors at Risk (ISAR) (Table 15–2) is one such screening tool useful in the ED. It is comprised of 6 questions that identify older adults who are at high risk for poor health outcomes and intense health care resource utilization. Patients self-report functional capacity, need for assistance, visual acuity, memory, and recent hospitalization, and number of medications. If positive, the ISAR would then be followed by targeted interventions to address patients’ needs.
Table 15-2.Adapted universal screening and risk assessment. ||Download (.pdf) Table 15-2. Adapted universal screening and risk assessment.
|High risk for poor health outcomes, high utilization || |
Before the illness or injury that brought you to the Emergency, did you need someone to help you on a regular basis? (yes)
Since the illness or injury that brought you to the Emergency, have you needed more help than usual to take care of yourself? (yes)
Have you been hospitalized for 1 or more nights during the past 6 months (excluding a stay in the Emergency Department)? (yes)
In general, do you see well? (no)
In general, do you have serious problems with your memory? (yes)
Do you take more than three different medications every day? (yes)
|Fall Risk || |
Approximately 33% of all older adults will fall annually, and 10% of such falls will result in major injuries. Falls are the leading cause of injury and injury-related death resulting in significant morbidity, disability, and decreased independence and quality of life. ED screening with the Timed Up & Go Test (see Table 15–2) is a simple means to rapidly identify patients at risk for falls with minimal equipment, training, or professional expertise. Identifying risk factors that contribute to falls, such as gait instability and environmental hazards, is important to create safe discharge plans for older adults.
Delirium is an emergency medical condition that affects 10% of older adults in the ED and independently carries a high morbidity and mortality. Delirium can prolong hospital length of stay, increase dependence, and is independently associated with poor health outcomes. It is underrecognized and undertreated in the ED. The Confusion Assessment Method (CAM) (see Table 15–2) is a validated tool that has been adapted for use in the ED. CAM-rated delirium is associated with falls resulting in injuries, inadequate pain control, and increased sedative or restraint use, all of which can result in prolonged hospitalization, poor functional outcomes, institutionalization, and increased mortality. This 5-minute test can differentiate delirium from dementia by the presence of mental status changes that are acute in onset and fluctuating in course, characterized by inattention, disorganized thinking, and an altered level of alertness. Older adults identified as having delirium often require admission. If discharged, they are often non-compliant with medications and unable to recall discharge instructions, placing them at risk for ED revisit and rehospitalization.
Between 16% and 40% of older adults presenting to the ED will have some form of cognitive impairment. In one study, 70% of those discharged home with cognitive impairment had no prior history of dementia and were less likely to have assistance with home care. Thus, the cognitively impaired will require focused ED assessment and multidisciplinary case management to ensure their cognitive limitations do not result in poor health outcomes.