Comprehensive Geriatric Assessment in the Emergency Department
9.2 Inside the Emergency Department
Older people form a small but important proportion of emergency department (ED) attendees; for example, in England, people aged 65+ accounted for an estimated 20%
(3.6 million out of 18.3 million) of attendees to EDs in 2012/2013. But older people in the ED tend to wait longer for a final decision on the next step (e.g. discharge home or admission), and so their presence results in a greater impact than these figures might suggest. Some of the increased length of stay in the ED relates to complexity; older people often present with combinations of cognitive impairment, multiple comorbidi- ties, polypharmacy and functional impairment. These interacting issues, combined with non-specific presentations, make assessment and management challenging. The accu- mulation of such deficits is one means of assessing frailty [8], which is an independent predictor of falls, delirium, disability, hospitalisation and care home admission [9–11].
9.2.1 ‘Organised Chaos’
Traditionally, ED care is focused on ‘doing the most for the most’, prioritising those who are more likely to have life-threatening or time-critical conditions to be seen first. Commonly used triage systems are known to disadvantage older adults who are more likely to present late and to underestimate their symptoms. Chronic crowd- ing or ‘boarding’ of patients designated for admission can mean that some patient assessments are undertaken in unsuitable, makeshift spaces. In addition, the physi- cal environment in many EDs creates practical difficulties and can be disorientating for people with sensory, cognitive or functional limitations.
The ED setting is sometimes described as ‘organised chaos’, with multiple simul- taneous demands placed on clinical staff, caring for multiple patients with variable illness acuity and at various stages in their assessment and treatment. In the ED, deci- sions are often made on the basis of a single encounter and often without a complete history. This is particularly true in those patients with cognitive impairment who present without a key informant. Other clinical records may not be available, includ- ing primary care records. It may be necessary to make urgent clinical decisions before the results of investigations are available. All of these factors add to the diffi- culty in reaching an accurate diagnosis and formulating a comprehensive plan.
In keeping with the general concept of frailty (a key tenet of which is the vulner- ability to catastrophic decline in the face of apparently minor stressors), an ED atten- dance alone can be harmful, with prolonged hospital admission adding to the insult.
For example, crowding in the ED is associated with increased mortality, increased length of stay, medical accidents, patient harm and reduced staff morale [12–18];
admission can add to the harms through deconditioning [19]. How much of the harms seen with current models of acute care for older people are related to the environment or processes of care, over and above the presenting problem, is unclear. But it is worth noting that the hospital at home literature has consistently shown mortality benefits for patients treated at home compared to an acute hospital [20].
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9.2.2 Identifying Older People with Frailty in Urgent Care
In light of these complexities illustrated in the assessment and treatment decisions for older people with frailty in the ED, it seems logical to highlight this population as being at high risk as soon as possible.
Although there is limited evidence for the discriminant ability of frailty scales in the urgent care context [21], meaning that the tools alone are not sufficiently precise to direct clinical care, frailty identification offers a number of advantages. Firstly, it can prompt a more holistic clinical assessment, guided by the principles of Comprehensive Geriatric Assessment (CGA) [22]. Secondly, it may influence clinical decision-mak- ing; identifying an individual with a Clinical Frailty Scale of 9 indicates that they are high risk of death as an inpatient [23]. This might prompt more aggressive treatment or alternatively a more palliative approach. Thirdly, it can guide decisions on the best place for ongoing care, by identifying the risk of readmission for those being dis- charged or the potential for benefit from specialist geriatric services for those being admitted. Finally, measuring the magnitude and nature of frailty in the ED and map- ping this onto patient flow pathways can guide service design and evaluation.
Whilst some might be tempted to state that more studies are required to further define frailty [24], or enlighten a frailty identification process in the ED, others would argue that there is already sufficient data to be acting on this issue now [25].
Moreover, practical application and ease of use of a tool within the pressurised, fast- paced urgent care context is a very relevant consideration. An instrument can have the best reliability and validity, but these benefits will not be realised if the instru- ment is not used because it is too difficult, takes too long or can only be used by a few trained people. With that in mind, it is reassuring to know that several com- monly used frailties or risk stratification tools designed for use in the ED setting are quick, simple and easy to complete (Fig. 9.1).
9.2.3 Clinical Evaluation
The reality of frailty is well exhibited in common emergency presentations in older people, some examples of which are described here.
9.2.4 Falls
Falls are a common reason for older people to present to urgent care and result from various combinations of diseases and functional and cognitive impair- ments. Some of the contributory factors are amenable to treatment or modifica- tion. It is important to carefully differentiate between syncopal and non-syncopal falls is important but not always easy because of memory impairment, recall bias or syncope-related antero- or retrograde amnesia, which are common. All too often, direct witness accounts are not available, meaning that the clinician has to base their judgement on the balance of probabilities. Falls from a
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standing height—‘stealth trauma’—can be associated with severe injuries in older people with frailty, which can be easily missed.
9.2.5 Pain
Pain can be difficult to assess because of communication barriers, so non-verbal cues may be more useful. Pain management in people with dementia may be chal- lenging because of comorbidities and polypharmacy. The importance of assessing changes in the individual’s normal behaviour patterns as an indicator of increasing stress levels or potential pain cannot be underestimated. The modified Abbey pain scale emphasises involving the person’s carers/family. Early, effective pain relief is self-evidently important but also reduces the risk of incident delirium.
9.2.6 Sepsis
Sepsis is a huge challenge in older people with frailty, being both over- and under- diagnosed. Volume replacement will be needed in most cases unless fluid overload is evident (remember sacral oedema may be the only sign). Care bundles can be helpful
050100150
Time to complete (sec)
CFS ISAR PRISMA 7 Silver code
Fig. 9.1 Box and whisker plot for the time taken to complete four commonly used risk stratifica- tion tools in the ED. CFS Clinical Frailty Scale [26], ISAR Identification of Seniors At Risk [27], PRISMA 7 the Program on Research for Integrating Services for the Maintenance of Autonomy [28], Silver Code [29]
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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.