Comprehensive Geriatric Assessment in the Emergency Department
9.3 Why CGA in the ED?
98
as guides but have generally not been validated or designed for older people with frailty (Table 9.1). Many abnormalities in older people are incidental, best exempli- fied by the ubiquitous ‘dipstick-positive UTI’. The conundrum here is that asymp- tomatic bacteriuria, which commonly causes positive urine dips, is prevalent (up to 50% of care home residents), and the treatment of asymptomatic bacteriuria confers no benefit [30]. A clinical diagnosis of urinary tract infection requires the presence of two or more of dysuria, frequency, suprapubic tenderness, urgency, polyuria and haematuria in the absence of any other good explanation for the apparent sepsis [31].
The importance of a CGA approach is evident when considering the range of potential issues when implementing a conventional sepsis care bundle, as illustrated in Table 9.1.
99
discussing the patient are as important if not more so than the individual assessments)
• Development of a coordinated and integrated plan for treatment
• Reducing iatrogenesis (accurate diagnosis, medication reviews, avoiding unnec- essary procedures, such as urinary catheters)
• Early discharge planning
• Follow-up (case management)
It is also worth noting that environments designed to prevent cognitive and phys- ical functional decline through early mobilisation, orientation, wayfinding, familiar- ity and socialisation improve outcomes [35]. Table 9.2 lists published ED CGA studies and assesses the components of CGA defined as in the list above that appeared to have been delivered as part of each intervention. Whilst this is not a formal meta-regression analysis, there does appear to be some correlation between improvements in outcomes and the greater number of CGA components offered. All seven of those studies describing interventions containing five or more of the listed domains of CGA being delivered were able to show improvement in service met- rics, in contrast to one out of the four with less than five CGA components. Whilst it seems likely that the more robust in depth and breadth an intervention might be, the more likely it is to have an impact, there is also a growing awareness that all components of CGA are likely to be necessary for an effective service. From a clini- cal perspective, there appears to be a synergistic effect, with the whole being greater than the sum of the parts. This is nicely illustrated in clinical scenarios which dem- onstrate interaction between disciplines—the interdisciplinarity of CGA—rather than just having individual disciplines undertaking assessment with recourse to an MDT discussion, operating within a flattened hierarchy that allows constructive challenge. This is nicely illustrated by clinical scenarios which demonstrate the ben- efit of the interaction between disciplines rather than solely the individual assess- ments. This interaction is facilitated by having a flattened hierarchy to enable constructive interdisciplinary challenge. For example, the option to admit for reha- bilitation by a therapist concerned about falls at home might be challenged by point- ing out that admission often increases the risk of falls and that home-based rehabilitation may offer substantial benefits. Equally therapists will bring useful information to the diagnostic process—for example, the patient who is ‘fit to return home’ that develops new dyspnoea on mobilisation might prompt a re-evaluation of respiratory function and identify potentially new diagnoses.
That this assessment is a process and not a discrete event is also a key; the process should continue in an iterative manner over the course of the acute stay, and the diagnostic elements should be sensitive to deviations from the anticipated pathway.
For example, if the initial treatment plan for an individual with a fall and hip pain but no fracture was to ‘increase analgesia, reduce anti-hypertensives and aim to return home once able to walk 5 m unaided using a frame’, yet after 14 hours, pain remains a problem, the diagnosis may need to be revisited and further imaging considered.
The team caring for an individual needs to know and respect each other’s roles and know and understand what each other is doing and how the medical treatment will impact upon the rehabilitation goals and vice versa. For example,
9 Comprehensive Geriatric Assessment in the Emergency Department
100
Table 9.2ED-based CGA studies deconstructed TrialPopulationIntervention PCMDIDCIPRIEDCMImpact on outcomes CGA components, key: + evident; ? not clear; − absentCount of componentsReadmissionAdmission Activities of daily living
Admission to long-term careMortality Miller et al. (1996) [36]65+Geriatric case finding and liaison service involving gerontological nurse specialist and ED staff++???+?33 m ↔N/AN/A↔↔ McCusker et al. (2001, 2003) [37, 38]
65+, ISAR ≥ 2, for discharge Gerontological nurse specialist, consultation with ED and geriatric medical staff
+++??NA+430d ↑N/A4 m ↓N/AN/A Mion et al. (2003) [39]65+, for dischargeGerontological nurse specialist, consultation with ED staff
+++++NA?530d ↔ 120d ↔N/AN/A30d ↓ 120d ↔30d ↔ 120d ↔ Caplan et al. (2004) [40]75+, for dischargeGerontological nurse specialist, consultation with geriatric medical staff ++++?NA+530d ↓ 18 m ↓N/A6 m ↓↔↔ Basic and Conforti (2005) [41]
65+ with geriatric syndrome
Gerontological nurse specialist+????+−2N/A↔During HOS ↔N/AN/A Foo et al. (2012) [42]65+, living at homeEmergency nurse trained in geriatric care, consultation with ED physician or gerontological nurse specialist ++++++−63 m ↓ 6 m ↓ 9 m ↓ 12 m ↓ N/AN/AN/A↔
S. Conroy et al.
101
Arendts et al. (2012, 2013) [43, 44]
65+ with geriatric syndrome Allied health personnel, consultation with other specialists when required +??−??−128d ↓ 1y ↑↓N/AN/A28d ↔ 1y ↔ Wright et al. (2014) [45]70+ with geriatric syndrome
Multidisciplinary geriatric team+++++++7N/A↓N/AN/AN/A Foo et al. (2014) [46]65+, TRST ≥ 2, for discharge Gerontological nurse specialist++−?−NA+33 m, 6 m, 9 m, 12 m ↔N/A3 m ↓ 6 m ↓ 9 m ↓ 12 m ↓ N/A↔ Ellis et al. (2012) [47]65+ with geriatric syndrome
Gerontological nurse specialist and geriatrician, ACE unit +++?++?57d ↔ 30d ↔↔N/A12 m ↔12 m ↔ Keyes et al. (2014) [48]65+Nurses, social workers, pharmacist, and physician
+++++++730d ↔↓N/AN/AN/A Conroy et al. (2014) [49]
65+ with geriatric syndrome Interdisciplinary team, geriatrician, liaison with ED, access to dedicated area +++++++77d ↔ 30d ↔ 90d ↓
↓N/AN/AN/A Key: PC patient centred, MD multidimensional assessment, ID interdisciplinary intervention, CIP coordinated, integrated plan, RI reduced iatrogenesis, ED early discharge planning, CM case management 9 Comprehensive Geriatric Assessment in the Emergency Department
102
whilst therapists would not need to know the detailed intricacies of the manage- ment of acute heart failure, it is important that they know that intravenous diuret- ics might be required for the first few days that will result in polyuria and then be able to incorporate continence needs into the rehabilitation plan. Equally, doctors will need to appreciate that just because a patient has grade 5 power on the MRC grading system, this does not necessarily translate into useful func- tional ability.