Functional Assessment & Discharge Planning

Older people, with complex medical and surgical problems, move through our EDs every day. Emerg physicians excel at rapid and focussed management of their medical problems. However we sometimes find the other necessary components of the assessment – cognitive, functional, psycho-social – to be challenging, time- and resource-intensive. Yet if we are to plan ED discharges that are safe and durable, all elements of that assessment need to be complete and excellent. And we know that management of such a complex situation cannot be handled by only one person – it’s a team sport.

This module follows three patients to the Emergency Department – all straightforward on the face of things, but complex once you dig deeper. We suggest a framework, some tools, and strategies for assessing ALL the components of their presentations. And we suggest some best practices for the most complicated of transitions – ED to nursing home.

Learning objectives:

At the end of this module the learner should be able to:

1. List strategies for gathering information about an older patient in the ED
2. Identify essential parts of a discharge plan for an older patient (the importance of cognitive and functional assessment, ambulation, ability to provide self-care, safety and establishing a follow-up plan appropriate for the vulnerable older patient
3. Name the Activities of Daily Living and Instrumental Activities of Daily Living and link them to safe ED discharge;
4. Establish members of the health-care team with whom to share care tasks; (ED nurse, family physician, community care provider, long-term care providers; ambulance crew)
5. List strategies for communicating with “downstream” care providers. (call long-term care; send written information back to LTC; fax a copy of chart or discharge summary to family doctor; provide a legible written copy of clinical record and plan to the patient; notify in writing the community care nurse about changes in care plan.)

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Medication Management in the Older ED Patient

Medication issues in older patients in the Emergency Department are among the most challenging and important areas of their management. In this era of chronic disease management, most older people come to the ED already taking five or more medications. Many ED visits are actually generated by an adverse effect of some medication, and most visits involve the administration or the addition of at least one more new drug. The potential for unwanted effects from interactions between the various drugs or interactions between the drugs and the patient’s diseases is almost unlimited – particularly in a physiologic system that is changing with age.

Throughout this module we will review the physiologic changes that occur with aging and demonstrate the effect they can have on how the aging body both processes and responds to medications. You will examine case studies, all of which could appear in your ED, that illustrate points about polypharmacy, communication, and strategies to manage especially high-risk medication classes.

Learning objectives:

At the end of this module you should be able to:

1. Describe the physiologic changes associated with healthy aging that affect medication use;
2. Explain physiologic changes that affect prescribing in the older patient;
3. Select appropriate drugs and dosages considering the patient’s acute and chronic diagnoses, other medications, and functional status;
4. Recognize high-risk medication classes and how they can be safely used or avoided;
5. Demonstrate an approach to polypharmacy including an awareness of drug-drug and drug-disease interactions;
6. Demonstrate strategies for effective communication about medications.

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Cognitive Impairment

Changes in cognition are relatively common in the older population. Over the age of 75, as many as 1 in 4 people have dementia, and 1 in 10 in the ED has delirium. Depression (with its cognitive changes) is more common in those over 75 than in any other age group. However these three conditions are often overlooked or incompletely assessed during an older patient’s stay in the ED.

This module explores why the 3Ds – Delirium, Dementia, and Depression – are essential topics in the ED and how their presentations can often be misleading for health care providers. We‘ll introduce some ED-friendly screening tools and strategies for managing the symptoms of delirium and dementia that can be challenging for patients, family members and care-givers.

Learning objectives:

At the end of this module you should be able to::

1. Describe the 3 D’s of cognitive impairment – delirium, dementia, and depression – and argue for their importance as ED diagnoses.
2. Use screening tools for these conditions to assess whether an older person is able to give an accurate history, participate in determining the plan of care, and understands discharge instructions.
3. Document an older person’s mental status and any change from baseline with special attention to determining if delirium has been superimposed on dementia.
4. Formulate an age-specific differential diagnosis for an older patient with new cognitive or behavioral impairment, and initiate a diagnostic work-up to determine the etiology, and initiate treatment.
5. List strategies to manage agitated patients such as addressing untreated pain, hypoxia, hypoglycemia and use of irritating tethers and environmental factors, disorientation.

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End of Life Issues & Symptom Management

Issues relating to the end of life are often a part of caring for older patients in the ED. While there seems like a gulf between the skills of the palliative physician and the Emergency physician, work in the ED frequently requires knowledge of the basics of high-quality palliative care.

This module looks at several ED patients to illustrate the basics. An awareness of disease trajectories and how to use it in addressing prognosis. The essentials of having a goals of care discussion in the ED. A review of the best practices in symptom management that are relevant to the ED.

Learning objectives:

At the end of this module you should be able to:

1. Describe disease trajectories, recognizing their link to prognosis and end-of-life decision making.
2. Use disease trajectories to inform discussion of goals of care and advance care planning in the ED.
3. Name the key components of an effective goals of care discussion.
4. Describe ED-appropriate management for pain, nausea, constipation, dyspnea, and anxiety.

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Trauma and Falls

The management of trauma is one of the core competencies of the Emergency Physician.  Trauma in the older patient has all of the complexity of trauma management in the younger patient – plus some extras!  Penetrating trauma is rare in older patients.  But blunt trauma is a major and frequent reason for older patients to present to the ED.

Older people who have fallen need evaluation in several modalities. A thorough ED assessment of a patient who has fallen – taking into account the changes of normal aging, medication, medical illness, as well as home environment — can have a profound effect on that person’s well-being and future function.

This module will explore the ways in which normal changes of aging affect standard trauma resuscitation, and make suggestions for the next time you have a “major trauma.”  We will also explore an approach to management of the routine patient who has fallen, and what constitutes an adequate ED work-up of the first-time or frequent faller.

Learning objectives:

At the end of this module you should be able to:

1.  Define special trauma management issues in the older patient regarding patterns of injuries and assessment of shock – how ATLS may be different over 65;
2. Describe an approach to a patient who has fallen, identifying potential causes of falls (identified by history, physical examination and functional assessment) as well as management of injuries, coordination of a discharge plan, and prevention of future falls.
3. Understand the importance of an interdisciplinary team in assessing older patients with falls.
4. Communicate the key components of a safe discharge plan for older patients who have fallen (e.g., accurate medication list, plan for follow-up), including considering the potential sites for discharge.

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Atypical Presentations

By Atypical Presentation of Disease, we mean all of those “vague complaints” that can make assessment of the complex older patient so time-consuming and challenging in the ED. Weakness, dizziness, confusion, falls, functional decline, “just not right.” These are all real symptoms that are often the only clues of serious life-threatening conditions. The Emergency physician needs a deep understanding of how and why the older person presents with these vague symptoms and strategies for history gathering, physical exam, and diagnosis.

This module accompanies one patient on his midnight arrival in the ED. It uses his case to explore the anatomy, physiology, and pharmacology behind his atypical presentation. It introduces lots of material about history, physical exam, and differential diagnosis that will help you the next time you pick up a chart that says “weakness.”

Learning objectives

At the end of this module you should be able to:

1. Explain the link between non-specific symptoms (weakness, fatigue, “dizziness,” confusion, increased falls, functional decline) and life-threatening or treatable conditions
2. Describe how adverse drug reactions, drug-drug interactions, and drug-disease interactions can present as “new” medical conditions
3. Recognize normal age-related changes in anatomy, physiology, and lab investigations that influence symptom presentation
4. List reasons that medical diagnoses in older patients can present with atypical symptoms (altered immune response, decreased adrenergic response, polypharmacy (one drug masks symptoms), cognitive impairment (inability to describe symptoms), decreased psycho-social support (no one around to monitor changes).

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