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Recognizing and Managing Elder Abuse in the Emergency Department
Case
An 85-year-old right-handed woman who recently had been diagnosed with mild cognitive impairment arrived at the ED via emergency medical services (EMS) for evaluation of a reported fall. She was accompanied by her daughter, who resided with the patient and was her primary caregiver. The patient stated that she had tripped on a wet rug in the bathroom of her home, striking her head and face on the edge of the sink without losing consciousness. Her daughter reported that she was not assisting her mother when the fall occurred, but had witnessed the fall from the hallway and called EMS. At the patient’s home, EMS found the patient to be alert, oriented, and ambulatory with normal vital signs that remained stable throughout prehospital transport.
The remainder of the patient’s history was provided almost entirely by her daughter, who constantly interrupted her mother whenever she attempted to directly answer a question or provide information. On physical examination, the patient had bilateral tenderness, edema, and periorbital ecchymoses, and a left eye that was nearly swollen shut. Extraocular movements were normal, visual acuity was intact, and sclerae were noninjected. The patient had tenderness over both maxillary sinuses, and edema and ecchymosis of her left cheek. There was also tenderness, ecchymoses, and edema on the lateral aspects of both forearms, and decreased range of motion of her right lower arm and wrist. With the exception of the patient not knowing the date during the orientation part of the thorough neurological examination, the remainder of the physical examination was unremarkable.
Radiological evaluation found no evidence of traumatic brain injury, but did reveal an acute fracture of the left zygomatic arch, an acute displaced nasal bone fracture, an age-indeterminate fracture of the right zygomatic arch, and an acute right ulnar fracture. Considering all of these findings, particularly the pattern of acute injuries, the emergency physician (EP) considered elder abuse as the possible etiology of the patient’s acute and chronic injuries.
Although the patient had initially agreed with her daughter’s description of the events—including her claim that she had fallen—when the EP questioned the patient alone, she related a history of frequent verbal and less frequent physical abuse by her daughter. The patient further noted that immediately before sustaining the injuries that brought her to the ED, her daughter had been insisting that she sign documents to give her control of her banking and finances. After refusing to sign the papers, the patient said that she and her daughter got into an argument, which she noted “they tended to do frequently.” The patient admitted that during this argument, her daughter struck her in the face repeatedly with the cane that the daughter had grabbed with her right hand.
The EP admitted the patient to the hospital for management of her orthopedic injuries and related pain, and to formulate a safe discharge plan. During admission, additional diagnostic testing revealed multiple old rib fractures, anemia, and a low-serum albumin, which suggested poor nutritional status.
Epidemiology
The term elder abuse refers to harm or the risk of harm to an older adult from either action or negligence committed by someone in a relationship of trust, or when a victim has been targeted because of age or disability. Elder abuse encompasses physical, sexual, or psychological abuse, neglect, and financial exploitation.1-5 Identified victims of elder abuse typically suffer from multiple forms of abuse.1-5
At present, elder abuse annually affects 5% to 10% of community-dwelling older adults,1-6 and nursing-home residents are at increased risk of abuse.7-10 Poor medical outcomes, including depression and dementia,11 and much higher mortality6,12,13 have been linked to victims of elder abuse.
Etiology
When treating older adults, it is critically important for EPs and the ED staff to consider and identify elder abuse in the differential diagnosis.14,15 Presently, only an estimated 1 in 24 cases of abuse is recognized and reported to the authorities,2 and much of the subsequent morbidity and mortality of elder abuse results from poor detection. A visit to the ED for an acute injury or illness may be the only time socially isolated older adults leave their homes.15-17 Additionally, the ED setting is uniquely suited to identify mistreatment, as a patient typically may be evaluated for several hours by providers from multiple disciplines who are able to observe, interact with, and examine the patient.15 The ED already exercises a similar essential role in the identification and initial intervention for both child abuse18,19 and intimate partner violence among younger adults.20,21
Recognition
Unfortunately, at present, ED providers rarely recognize and report elder abuse.22-24 Though the reasons for this are not entirely understood, inadequate training, lack of time and space to conduct complete evaluations, reluctance to become involved with the legal system, and challenges to distinguishing intentional from unintentional injuries may be contributing factors.24,25 A focus on improving EP and ED staff approaches to elder abuse is relevant and timely given the growing elderly population.
Risk Factors
When evaluating elderly patients, providers should consider research suggesting that some older adults may be at particularly high risk for abuse.4,26-29 Notably, individuals who have cognitive impairment are more likely to be victims of abuse.30-32 Health-related demographic characteristics such as poor physical and mental health, substance abuse, low income/socioeconomic status, and social isolation all may increase the potential for mistreatment.
Family History
Similar to situations resulting in intimate partner violence, a family history of abuse and exposure to traumatic events may increase risk, and those responsible for elder abuse often turn out to be spouses, romantic partners, or an adult child living with the elderly parent—though paid caregivers also can be abusive.
Suspicion of abuse should be increased when individuals in caregiving roles have a history or show signs of mental illness, substance abuse, financial dependence on the victim, or caregiver stress. Considering that a caregiver may be overwhelmed is particularly relevant when an elderly patient exhibits behavioral issues.
Medical History
Obtaining a clear and thorough medical history from the patient and caregiver, both together and alone, is paramount to assessing the potential for abuse. Many indicators from the history may suggest the possibility of mistreatment (Table 1)33-37 and although challenging in a busy ED, a comprehensive head-to-toe examination is crucial to adequately assess abuse. Suspicious physical findings and injury patterns of physical abuse, sexual abuse, and neglect are listed in Table 2.33-37 Ongoing research is aimed at improving ED providers’ ability to differentiate accidental injuries, such as fall injuries, from injuries caused by physical elder abuse.
Injury Patterns
Preliminary studies have indicated that physical abuse injuries most commonly occur on the head, neck, and upper extremities.38,39 A study comparing abuse victims to accidental injury sufferers found that abuse victims often had large bruises (>5 cm) on the face, lateral right arm, or posterior torso.40 Preliminary results from a study in progress suggest that injuries to the left periorbital area, neck, and ulnar forearm may be much more common in abuse than in accident.
Imaging Studies
Emergency radiologists are contributing additional concerning findings indicative of elder abuse,38,41,42 such as the concomitant presence of old and new fractures, high-energy fractures inconsistent with the purported mechanism, and distal ulnar diaphyseal fractures.41,42 The ultimate goal is to identify pathognomonic injury patterns similar to those found in child abuse cases, to assist ED providers.
Laboratory Studies
Although there are no laboratory tests to definitively identify abuse or neglect, specific findings that may indicate abuse include anemia, dehydration, malnutrition, hypothermia/hyperthermia, and rhabdomyolysis.43 In addition, inappropriately high- or low-medication levels and the presence of illicit drugs, which are not often checked in elderly patients in the ED, may be a sign of abuse.43
Laboratory studies that reveal undetectable levels of a patient’s prescription medications may indicate a caregiver’s intentional or neglectful withholding of such medications—especially diversion of opioid medications prescribed for painful conditions.43 Likewise, elevated levels of prescribed drugs may point to intentional or unintentional overdose, whereas the presence of nonprescribed drugs or toxins may suggest poisoning.43
Screening Tools
To improve identification of elder abuse in the ED, universal or targeted screening tools are under consideration. Though several screening tools for elder abuse are already available, none have been validated in the ED.15,44,45 Research sponsored by the National Institute of Justice to identify an ED-specific screening tool is ongoing.15
Elder Abuse Suspicion Index
The Elder Abuse Suspicion Index (EASI) is a short screening tool that has been validated for cognitively intact patients being treated in family practice and ambulatory care settings, and may be used in EDs.44 The tool comprises six questions: five for patient response, and a sixth question for clinician response. This tool is available at http://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index.46
Interventional Measures
When elder mistreatment is suspected or confirmed, health care providers must first address any acute medical, traumatic, or psychological issues. Bleeding, orthopedic injuries, metabolic abnormalities, infections, and agitation must be treated and/or stabilized, while neglected or inappropriately managed chronic medical conditions may require treatment.
Hospitalization should be considered for an older adult who needs extended treatment or observation and, in cases of immediate or continued danger of abuse, separation from contact with the suspected abuser. These measures present several challenges, particularly if the suspected abuser is the patient’s health care proxy, in which case early involvement of the hospital’s legal department, social services, and administration may be necessary—especially in navigating the guardianship process.
Engaging security also may be necessary if the patient requires one-to-one patient watch or when the perpetrator must be removed from the ED. Social workers, patient services representatives, and law enforcement officials should be informed when such intervention is necessary.
In instances when a patient is not at risk of immediate harm, interventions can be more individualized. Coordination with primary care physicians (PCPs) must also be facilitated prior to discharge, to ensure consistent longitudinal follow-up care, and social workers should provide any needed out-of-hospital resources to the patient—and caregiver—such as Meals-on-Wheels, medical transportation services, adult day care/senior center participation, and substance abuse treatment.
Patient Decision-Making Capacity
When a patient experiencing abuse declines interventions or services, the EP must evaluate the patient’s decision-making capacity. In unclear cases, a psychiatric evaluation can help to assess decision-making capacity. If the victim is deemed to have capacity with regard to care and/or discharge, the patient’s choice of returning to an unsafe environment must be respected, as is true in instances of intimate partner violence among younger adults—but not in child abuse cases. In such situations, the EP should nevertheless discuss safety planning, offer psychoeducation about violence and abuse, suggest appropriate community referrals, and encourage abused patients to return or call a contact person whenever they desire or feel the need to talk further. For a victim who is deemed not to possess capacity, providers should proceed with treatment considered to be in the best interest of the patient.
Reporting Abuse
Emergency department providers should notify the appropriate authorities when elder abuse is suspected or identified. A report may be made to the local Adult Protective Services (APS), but this agency operates much differently than Child Protective Services. Case workers with APS will not open a case while a patient is in the ED or hospital, as it is deemed a safe environment and any investigation they undertake will only commence upon discharge. Because of this, contacting the local police department prior to discharge should be considered.
Mandatory elder abuse-reporting laws vary from state to state. Health care providers should therefore contact their respective state or city department of health to obtain local legislation.
Multidisciplinary Approach
Ideally, a multidisciplinary, ED-based intervention team modeled on child abuse teams18,19 would help to optimize treatment and ensure the safety and treatment of vulnerable older adults. These teams could conduct thorough medical, forensic, and social work assessments, allowing ED providers to attend to other patients. The team could also assist in arranging for appropriate and safe dispositions. An innovative Vulnerable Elder Protection Team was recently launched at New York-Presbyterian Weill Cornell Medical Center to provide these services, and its impact is currently being evaluated.
Case Conclusion
The EP who treated the patient realized that blows from a blunt object held by a right-handed person would tend to land on the left side of the victim’s face and upper torso, and that a right-handed victim who successfully blocked the blows intended for her face would instead sustain an isolated right ulna or radius midshaft fracture. These findings, together with the concomitant presence of both old and new fractures, led the EP to question the patient alone and, after obtaining a different history of the events that led to the injuries, admit her for further evaluation, treatment, and interventions to prevent continuing abuse.
Summary
Elder abuse has the potential to affect an increasing number of older adults in this growing population, and an ED visit may offer the only opportunity to identify victims and provide intervention, in turn reducing morbidity and mortality. The results of ongoing research will improve the ability of EPs and ED staff to accurately assess the presence or risk of elder abuse and respond more effectively. It is essential that EPs always consider elder abuse and neglect as a possible etiology when evaluating injuries in this population. Moreover, when identified, addressing elder mistreatment may dramatically improve quality of life or save the lives of these vulnerable patients.
1. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Bonnie RJ, Wallace RB, eds. Washington, DC: National Academies Press; 2003:1-552. https://www.nap.edu/read/10406/chapter/1. Accessed April 4, 2017.
2. Lifespan of Greater Rochester, Inc; Weill Cornell Medical Center of Cornell University; New York City Department for the Aging. Under the radar: New York state elder abuse prevalence study: self-reported prevalence and documented case surveys 2011.http://ocfs.ny.gov/main/reports/Under%20the%20Radar%2005%2012%2011%20final%20report.pdf. Published May 2011. Accessed April 4, 2017.
3. Connolly MT, Brandl B, Breckman R. The Elder Justice Roadmap: A Stakeholder Initiative to Respond to an Emerging Health, Justice, Financial, and Social Crisis. https://www.justice.gov/elderjustice/file/829266/download. National Center for Elder Abuse. Published January 2014. Accessed April 4, 2017.
4. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292-297. doi:10.2105/AJPH.2009.163089.
5. Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272. doi:10.1016/S0140-6736(04)17144-4.
6. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947-1956. doi:10.1056/NEJMra1404688.
7. Ortmann C, Fechner G, Bajanowski T, Brinkmann B. Fatal neglect of the elderly. Int J Legal Med. 2001;114(3):191-193.
8. Schiamberg LB, Oehmke J, Zhang Z, et al. Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home. J Elder Abuse Negl. 2012;24(1):65-83. doi:10.1080/08946566.2011.608056.
9. Rosen T, Pillemer K, Lachs M. Resident-to-resident aggression in long-term care facilities: an understudied problem. Aggress Violent Behav. 2008;13(2):77-87. doi:10.1016/j.avb.2007.12.001.
10. Shinoda-Tagawa T, Leonard R, Pontikas J, McDonough JE, Allen D, Dreyer PI. Resident-to-resident violent incidents in nursing homes. JAMA. 2004;291(5):591-598. doi:10.1001/jama.291.5.591.
11. Dyer CB, Pavlik VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48(2):205-208.
12. Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA. 1998;280(5):428-432.
13. Dong XQ, Simon MA, Beck TT, et al. Elder abuse and mortality: the role of psychological and social wellbeing. Gerontology. 2011;57(6):549-658. doi:10.1159/000321881.
14. Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of nonmedical problems among older adults presenting to the emergency department. Acad Emerg Med. 2014;21(6):651-658. doi:10.1111/acem.12395.
15. Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying elder abuse in the emergency department: toward a multidisciplinary team-based approach. Ann Emerg Med. 2016;68(3):378-382. doi:10.1016/j.annemergmed.2016.01.037.
16. Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29(1):257-273. doi:10.1016/j.cger.2012.09.004.
17. Heyborne RD. Elder abuse: keeping the unthinkable in the differential. Acad Emerg Med. 2007;14(6):566-567. doi:10.1197/j.aem.2007.01.015.
18. Kistin CJ, Tien I, Bauchner H, Parker V, Leventhal JM. Factors that influence the effectiveness of child protection teams. Pediatrics. 2010;126(1):94-100. doi:10.1542/peds.2009-3446.
19. Hochstadt NJ, Harwicke NJ. How effective is the multidisciplinary approach? A follow-up study. Child Abuse Negl. 1985;9(3):365-372.
20. Choo EK, Gottlieb AS, DeLuca M, Tape C, Colwell L, Zlotnick C. Systematic review of ED-based intimate partner violence intervention research. West J Emerg Med. 2015;16(7):1037-1042. doi:10.5811/westjem.2015.10.27586.
21. Rhodes KV, Rodgers M, Sommers M, et al. Brief motivational intervention for intimate partner violence and heavy drinking in the emergency department: a randomized clinical trial. JAMA. 2015;314(5):466-477. doi:10.1001/jama.2015.8369.
22. Teaster PB, Dugar TA, Mendiondo MS, et al; The National Committee for the Prevention of Elder Abuse; The National Adult Protective Services Association. The 2004 survey of state adult protective services: abuse of adults 60 years of age and older. http://www.napsa-now.org/wp-content/uploads/2012/09/2-14-06-FINAL-60+REPORT.pdf. Published February 2006. Accessed March 10, 2017.
23. Blakely BE, Dolon R. Another look at the helpfulness of occupational groups in the discovery of elder abuse and neglect. J Elder Abuse Negl. 2003;13:1-23.
24. Evans CS, Hunold KM, Rosen T, Platts-Mills TF. Diagnosis of elder abuse in U.S. emergency departments. J Am Geriatr Soc. 2017;65(1):91-97. doi:10.1111/jgs.14480.
25. Jones JS, Veenstra TR, Seamon JP, Krohmer J. Elder mistreatment: national survey of emergency physicians. Ann Emerg Med. 1997;30(4):473-479.
26. Amstadter AB, Zajac K, Strachan M, Hernandez MA, Kilpatrick DG, Acierno R. Prevalence and correlates of elder mistreatment in South Carolina: the South Carolina elder mistreatment study. J Interpers Violence. 2011;26(15):2947-2972. doi:10.1177/0886260510390959.
27. Friedman LS, Avila S, Tanouye K, Joseph K. A case-control study of severe physical abuse of older adults. J Am Geriatr Soc. 2011;59(3):417-422. doi:10.1111/j.1532-5415.2010.03313.x.
28. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: global situation, risk factors, and prevention strategies. Gerontologist. 2016;56 Suppl 2:S194-S205. doi:10.1093/geront/gnw004.
29. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):S248-S254.
30. Cooney C, Howard R, Lawlor B. Abuse of vulnerable people with dementia by their carers: can we identify those most at risk? Int J Geriatr Psychiatry. 2006;21(6):564-571. doi:10.1002/gps.1525.
31. Lachs MS, Williams C, O’Brien S, Hurst L, Horwitz R. Risk factors for reported elder abuse and neglect: a nine-year observational cohort study. Gerontologist. 1997;37(4):469-474.
32. Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W. Screening for abuse and neglect of people with dementia. J Am Geriatr Soc. 2010;58(3):493-500. doi:10.1111/j.1532-5415.2010.02737.x.
33. Collins KA. Elder maltreatment: a review. Arch Pathol Lab Med. 2006;130(9):1290-1296. doi:10.1043/1543-2165(2006)130[1290:EMAR]2.0.CO;2.
34. Gibbs LM. Understanding the medical markers of elder abuse and neglect: physical examination findings. Clin Geriatr Med. 2014 Nov;30(4):687-712. doi:10.1016/j.cger.2014.08.002.
35. Palmer M, Brodell RT, Mostow EN. Elder abuse: dermatologic clues and critical solutions. J Am Acad Dermatol. 2013;68(2):e37-e42. doi:10.1016/j.jaad.2011.03.016.
36. Speck PM, Hartig MT, Likes W, et al. Case series of sexual assault in older persons. Clin Geriatr Med. 2014;30(4):779-806. doi:10.1016/j.cger.2014.08.007.
37. Chang AL, Wong JW, Endo JO, Norman RA. Geriatric dermatology: part II. Risk factors and cutaneous signs of elder mistreatment for the dermatologist. J Am Acad Dermatol. 2013;68(4):533.e1-.e10. doi:10.1016/j.jaad.2013.01.001.
38. Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64(1):10-14. doi:10.1016/j.carj.2012.12.001.
39. Rosen T, Bloemen EM, LoFaso VM, Clark S, Flomenbaum NE, Lachs MS. Emergency department presentations for injuries in older adults independently known to be victims of elder abuse. J Emerg Med. 2016;50(3):518-526. doi:10.1016/j.jemermed.2015.10.037.
40. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196. doi:10.1111/j.1532-5415.2009.02330.x.
41. Rosen T, Bloemen EM, Harpe J, et al. Radiologists’ training, experience, and attitudes about elder abuse detection. AJR Am J Roentgenol. 2016;207:1210-1214.
42. Wong NZ, Rosen T, Sanchez AM, et al. Imaging findings in elder abuse: a role for radiologists in detection. Can Assoc Radiol J. 2017;68(1):16-20. doi:10.1016/j.carj.2016.06.001.
43. LoFaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):713-28. doi:10.1016/j.cger.2014.08.003.
44. Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc. 2004;52(2):297-304.
45. Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI). J Elder Abuse Negl. 2008;20(3):276-300. doi:10.1080/08946560801973168.
46. National Initiative for the Care of the Elderly. EASI: Elder Abuse Suspicion Index. http://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index. Accessed April 5, 2017.
Case
An 85-year-old right-handed woman who recently had been diagnosed with mild cognitive impairment arrived at the ED via emergency medical services (EMS) for evaluation of a reported fall. She was accompanied by her daughter, who resided with the patient and was her primary caregiver. The patient stated that she had tripped on a wet rug in the bathroom of her home, striking her head and face on the edge of the sink without losing consciousness. Her daughter reported that she was not assisting her mother when the fall occurred, but had witnessed the fall from the hallway and called EMS. At the patient’s home, EMS found the patient to be alert, oriented, and ambulatory with normal vital signs that remained stable throughout prehospital transport.
The remainder of the patient’s history was provided almost entirely by her daughter, who constantly interrupted her mother whenever she attempted to directly answer a question or provide information. On physical examination, the patient had bilateral tenderness, edema, and periorbital ecchymoses, and a left eye that was nearly swollen shut. Extraocular movements were normal, visual acuity was intact, and sclerae were noninjected. The patient had tenderness over both maxillary sinuses, and edema and ecchymosis of her left cheek. There was also tenderness, ecchymoses, and edema on the lateral aspects of both forearms, and decreased range of motion of her right lower arm and wrist. With the exception of the patient not knowing the date during the orientation part of the thorough neurological examination, the remainder of the physical examination was unremarkable.
Radiological evaluation found no evidence of traumatic brain injury, but did reveal an acute fracture of the left zygomatic arch, an acute displaced nasal bone fracture, an age-indeterminate fracture of the right zygomatic arch, and an acute right ulnar fracture. Considering all of these findings, particularly the pattern of acute injuries, the emergency physician (EP) considered elder abuse as the possible etiology of the patient’s acute and chronic injuries.
Although the patient had initially agreed with her daughter’s description of the events—including her claim that she had fallen—when the EP questioned the patient alone, she related a history of frequent verbal and less frequent physical abuse by her daughter. The patient further noted that immediately before sustaining the injuries that brought her to the ED, her daughter had been insisting that she sign documents to give her control of her banking and finances. After refusing to sign the papers, the patient said that she and her daughter got into an argument, which she noted “they tended to do frequently.” The patient admitted that during this argument, her daughter struck her in the face repeatedly with the cane that the daughter had grabbed with her right hand.
The EP admitted the patient to the hospital for management of her orthopedic injuries and related pain, and to formulate a safe discharge plan. During admission, additional diagnostic testing revealed multiple old rib fractures, anemia, and a low-serum albumin, which suggested poor nutritional status.
Epidemiology
The term elder abuse refers to harm or the risk of harm to an older adult from either action or negligence committed by someone in a relationship of trust, or when a victim has been targeted because of age or disability. Elder abuse encompasses physical, sexual, or psychological abuse, neglect, and financial exploitation.1-5 Identified victims of elder abuse typically suffer from multiple forms of abuse.1-5
At present, elder abuse annually affects 5% to 10% of community-dwelling older adults,1-6 and nursing-home residents are at increased risk of abuse.7-10 Poor medical outcomes, including depression and dementia,11 and much higher mortality6,12,13 have been linked to victims of elder abuse.
Etiology
When treating older adults, it is critically important for EPs and the ED staff to consider and identify elder abuse in the differential diagnosis.14,15 Presently, only an estimated 1 in 24 cases of abuse is recognized and reported to the authorities,2 and much of the subsequent morbidity and mortality of elder abuse results from poor detection. A visit to the ED for an acute injury or illness may be the only time socially isolated older adults leave their homes.15-17 Additionally, the ED setting is uniquely suited to identify mistreatment, as a patient typically may be evaluated for several hours by providers from multiple disciplines who are able to observe, interact with, and examine the patient.15 The ED already exercises a similar essential role in the identification and initial intervention for both child abuse18,19 and intimate partner violence among younger adults.20,21
Recognition
Unfortunately, at present, ED providers rarely recognize and report elder abuse.22-24 Though the reasons for this are not entirely understood, inadequate training, lack of time and space to conduct complete evaluations, reluctance to become involved with the legal system, and challenges to distinguishing intentional from unintentional injuries may be contributing factors.24,25 A focus on improving EP and ED staff approaches to elder abuse is relevant and timely given the growing elderly population.
Risk Factors
When evaluating elderly patients, providers should consider research suggesting that some older adults may be at particularly high risk for abuse.4,26-29 Notably, individuals who have cognitive impairment are more likely to be victims of abuse.30-32 Health-related demographic characteristics such as poor physical and mental health, substance abuse, low income/socioeconomic status, and social isolation all may increase the potential for mistreatment.
Family History
Similar to situations resulting in intimate partner violence, a family history of abuse and exposure to traumatic events may increase risk, and those responsible for elder abuse often turn out to be spouses, romantic partners, or an adult child living with the elderly parent—though paid caregivers also can be abusive.
Suspicion of abuse should be increased when individuals in caregiving roles have a history or show signs of mental illness, substance abuse, financial dependence on the victim, or caregiver stress. Considering that a caregiver may be overwhelmed is particularly relevant when an elderly patient exhibits behavioral issues.
Medical History
Obtaining a clear and thorough medical history from the patient and caregiver, both together and alone, is paramount to assessing the potential for abuse. Many indicators from the history may suggest the possibility of mistreatment (Table 1)33-37 and although challenging in a busy ED, a comprehensive head-to-toe examination is crucial to adequately assess abuse. Suspicious physical findings and injury patterns of physical abuse, sexual abuse, and neglect are listed in Table 2.33-37 Ongoing research is aimed at improving ED providers’ ability to differentiate accidental injuries, such as fall injuries, from injuries caused by physical elder abuse.
Injury Patterns
Preliminary studies have indicated that physical abuse injuries most commonly occur on the head, neck, and upper extremities.38,39 A study comparing abuse victims to accidental injury sufferers found that abuse victims often had large bruises (>5 cm) on the face, lateral right arm, or posterior torso.40 Preliminary results from a study in progress suggest that injuries to the left periorbital area, neck, and ulnar forearm may be much more common in abuse than in accident.
Imaging Studies
Emergency radiologists are contributing additional concerning findings indicative of elder abuse,38,41,42 such as the concomitant presence of old and new fractures, high-energy fractures inconsistent with the purported mechanism, and distal ulnar diaphyseal fractures.41,42 The ultimate goal is to identify pathognomonic injury patterns similar to those found in child abuse cases, to assist ED providers.
Laboratory Studies
Although there are no laboratory tests to definitively identify abuse or neglect, specific findings that may indicate abuse include anemia, dehydration, malnutrition, hypothermia/hyperthermia, and rhabdomyolysis.43 In addition, inappropriately high- or low-medication levels and the presence of illicit drugs, which are not often checked in elderly patients in the ED, may be a sign of abuse.43
Laboratory studies that reveal undetectable levels of a patient’s prescription medications may indicate a caregiver’s intentional or neglectful withholding of such medications—especially diversion of opioid medications prescribed for painful conditions.43 Likewise, elevated levels of prescribed drugs may point to intentional or unintentional overdose, whereas the presence of nonprescribed drugs or toxins may suggest poisoning.43
Screening Tools
To improve identification of elder abuse in the ED, universal or targeted screening tools are under consideration. Though several screening tools for elder abuse are already available, none have been validated in the ED.15,44,45 Research sponsored by the National Institute of Justice to identify an ED-specific screening tool is ongoing.15
Elder Abuse Suspicion Index
The Elder Abuse Suspicion Index (EASI) is a short screening tool that has been validated for cognitively intact patients being treated in family practice and ambulatory care settings, and may be used in EDs.44 The tool comprises six questions: five for patient response, and a sixth question for clinician response. This tool is available at http://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index.46
Interventional Measures
When elder mistreatment is suspected or confirmed, health care providers must first address any acute medical, traumatic, or psychological issues. Bleeding, orthopedic injuries, metabolic abnormalities, infections, and agitation must be treated and/or stabilized, while neglected or inappropriately managed chronic medical conditions may require treatment.
Hospitalization should be considered for an older adult who needs extended treatment or observation and, in cases of immediate or continued danger of abuse, separation from contact with the suspected abuser. These measures present several challenges, particularly if the suspected abuser is the patient’s health care proxy, in which case early involvement of the hospital’s legal department, social services, and administration may be necessary—especially in navigating the guardianship process.
Engaging security also may be necessary if the patient requires one-to-one patient watch or when the perpetrator must be removed from the ED. Social workers, patient services representatives, and law enforcement officials should be informed when such intervention is necessary.
In instances when a patient is not at risk of immediate harm, interventions can be more individualized. Coordination with primary care physicians (PCPs) must also be facilitated prior to discharge, to ensure consistent longitudinal follow-up care, and social workers should provide any needed out-of-hospital resources to the patient—and caregiver—such as Meals-on-Wheels, medical transportation services, adult day care/senior center participation, and substance abuse treatment.
Patient Decision-Making Capacity
When a patient experiencing abuse declines interventions or services, the EP must evaluate the patient’s decision-making capacity. In unclear cases, a psychiatric evaluation can help to assess decision-making capacity. If the victim is deemed to have capacity with regard to care and/or discharge, the patient’s choice of returning to an unsafe environment must be respected, as is true in instances of intimate partner violence among younger adults—but not in child abuse cases. In such situations, the EP should nevertheless discuss safety planning, offer psychoeducation about violence and abuse, suggest appropriate community referrals, and encourage abused patients to return or call a contact person whenever they desire or feel the need to talk further. For a victim who is deemed not to possess capacity, providers should proceed with treatment considered to be in the best interest of the patient.
Reporting Abuse
Emergency department providers should notify the appropriate authorities when elder abuse is suspected or identified. A report may be made to the local Adult Protective Services (APS), but this agency operates much differently than Child Protective Services. Case workers with APS will not open a case while a patient is in the ED or hospital, as it is deemed a safe environment and any investigation they undertake will only commence upon discharge. Because of this, contacting the local police department prior to discharge should be considered.
Mandatory elder abuse-reporting laws vary from state to state. Health care providers should therefore contact their respective state or city department of health to obtain local legislation.
Multidisciplinary Approach
Ideally, a multidisciplinary, ED-based intervention team modeled on child abuse teams18,19 would help to optimize treatment and ensure the safety and treatment of vulnerable older adults. These teams could conduct thorough medical, forensic, and social work assessments, allowing ED providers to attend to other patients. The team could also assist in arranging for appropriate and safe dispositions. An innovative Vulnerable Elder Protection Team was recently launched at New York-Presbyterian Weill Cornell Medical Center to provide these services, and its impact is currently being evaluated.
Case Conclusion
The EP who treated the patient realized that blows from a blunt object held by a right-handed person would tend to land on the left side of the victim’s face and upper torso, and that a right-handed victim who successfully blocked the blows intended for her face would instead sustain an isolated right ulna or radius midshaft fracture. These findings, together with the concomitant presence of both old and new fractures, led the EP to question the patient alone and, after obtaining a different history of the events that led to the injuries, admit her for further evaluation, treatment, and interventions to prevent continuing abuse.
Summary
Elder abuse has the potential to affect an increasing number of older adults in this growing population, and an ED visit may offer the only opportunity to identify victims and provide intervention, in turn reducing morbidity and mortality. The results of ongoing research will improve the ability of EPs and ED staff to accurately assess the presence or risk of elder abuse and respond more effectively. It is essential that EPs always consider elder abuse and neglect as a possible etiology when evaluating injuries in this population. Moreover, when identified, addressing elder mistreatment may dramatically improve quality of life or save the lives of these vulnerable patients.
Case
An 85-year-old right-handed woman who recently had been diagnosed with mild cognitive impairment arrived at the ED via emergency medical services (EMS) for evaluation of a reported fall. She was accompanied by her daughter, who resided with the patient and was her primary caregiver. The patient stated that she had tripped on a wet rug in the bathroom of her home, striking her head and face on the edge of the sink without losing consciousness. Her daughter reported that she was not assisting her mother when the fall occurred, but had witnessed the fall from the hallway and called EMS. At the patient’s home, EMS found the patient to be alert, oriented, and ambulatory with normal vital signs that remained stable throughout prehospital transport.
The remainder of the patient’s history was provided almost entirely by her daughter, who constantly interrupted her mother whenever she attempted to directly answer a question or provide information. On physical examination, the patient had bilateral tenderness, edema, and periorbital ecchymoses, and a left eye that was nearly swollen shut. Extraocular movements were normal, visual acuity was intact, and sclerae were noninjected. The patient had tenderness over both maxillary sinuses, and edema and ecchymosis of her left cheek. There was also tenderness, ecchymoses, and edema on the lateral aspects of both forearms, and decreased range of motion of her right lower arm and wrist. With the exception of the patient not knowing the date during the orientation part of the thorough neurological examination, the remainder of the physical examination was unremarkable.
Radiological evaluation found no evidence of traumatic brain injury, but did reveal an acute fracture of the left zygomatic arch, an acute displaced nasal bone fracture, an age-indeterminate fracture of the right zygomatic arch, and an acute right ulnar fracture. Considering all of these findings, particularly the pattern of acute injuries, the emergency physician (EP) considered elder abuse as the possible etiology of the patient’s acute and chronic injuries.
Although the patient had initially agreed with her daughter’s description of the events—including her claim that she had fallen—when the EP questioned the patient alone, she related a history of frequent verbal and less frequent physical abuse by her daughter. The patient further noted that immediately before sustaining the injuries that brought her to the ED, her daughter had been insisting that she sign documents to give her control of her banking and finances. After refusing to sign the papers, the patient said that she and her daughter got into an argument, which she noted “they tended to do frequently.” The patient admitted that during this argument, her daughter struck her in the face repeatedly with the cane that the daughter had grabbed with her right hand.
The EP admitted the patient to the hospital for management of her orthopedic injuries and related pain, and to formulate a safe discharge plan. During admission, additional diagnostic testing revealed multiple old rib fractures, anemia, and a low-serum albumin, which suggested poor nutritional status.
Epidemiology
The term elder abuse refers to harm or the risk of harm to an older adult from either action or negligence committed by someone in a relationship of trust, or when a victim has been targeted because of age or disability. Elder abuse encompasses physical, sexual, or psychological abuse, neglect, and financial exploitation.1-5 Identified victims of elder abuse typically suffer from multiple forms of abuse.1-5
At present, elder abuse annually affects 5% to 10% of community-dwelling older adults,1-6 and nursing-home residents are at increased risk of abuse.7-10 Poor medical outcomes, including depression and dementia,11 and much higher mortality6,12,13 have been linked to victims of elder abuse.
Etiology
When treating older adults, it is critically important for EPs and the ED staff to consider and identify elder abuse in the differential diagnosis.14,15 Presently, only an estimated 1 in 24 cases of abuse is recognized and reported to the authorities,2 and much of the subsequent morbidity and mortality of elder abuse results from poor detection. A visit to the ED for an acute injury or illness may be the only time socially isolated older adults leave their homes.15-17 Additionally, the ED setting is uniquely suited to identify mistreatment, as a patient typically may be evaluated for several hours by providers from multiple disciplines who are able to observe, interact with, and examine the patient.15 The ED already exercises a similar essential role in the identification and initial intervention for both child abuse18,19 and intimate partner violence among younger adults.20,21
Recognition
Unfortunately, at present, ED providers rarely recognize and report elder abuse.22-24 Though the reasons for this are not entirely understood, inadequate training, lack of time and space to conduct complete evaluations, reluctance to become involved with the legal system, and challenges to distinguishing intentional from unintentional injuries may be contributing factors.24,25 A focus on improving EP and ED staff approaches to elder abuse is relevant and timely given the growing elderly population.
Risk Factors
When evaluating elderly patients, providers should consider research suggesting that some older adults may be at particularly high risk for abuse.4,26-29 Notably, individuals who have cognitive impairment are more likely to be victims of abuse.30-32 Health-related demographic characteristics such as poor physical and mental health, substance abuse, low income/socioeconomic status, and social isolation all may increase the potential for mistreatment.
Family History
Similar to situations resulting in intimate partner violence, a family history of abuse and exposure to traumatic events may increase risk, and those responsible for elder abuse often turn out to be spouses, romantic partners, or an adult child living with the elderly parent—though paid caregivers also can be abusive.
Suspicion of abuse should be increased when individuals in caregiving roles have a history or show signs of mental illness, substance abuse, financial dependence on the victim, or caregiver stress. Considering that a caregiver may be overwhelmed is particularly relevant when an elderly patient exhibits behavioral issues.
Medical History
Obtaining a clear and thorough medical history from the patient and caregiver, both together and alone, is paramount to assessing the potential for abuse. Many indicators from the history may suggest the possibility of mistreatment (Table 1)33-37 and although challenging in a busy ED, a comprehensive head-to-toe examination is crucial to adequately assess abuse. Suspicious physical findings and injury patterns of physical abuse, sexual abuse, and neglect are listed in Table 2.33-37 Ongoing research is aimed at improving ED providers’ ability to differentiate accidental injuries, such as fall injuries, from injuries caused by physical elder abuse.
Injury Patterns
Preliminary studies have indicated that physical abuse injuries most commonly occur on the head, neck, and upper extremities.38,39 A study comparing abuse victims to accidental injury sufferers found that abuse victims often had large bruises (>5 cm) on the face, lateral right arm, or posterior torso.40 Preliminary results from a study in progress suggest that injuries to the left periorbital area, neck, and ulnar forearm may be much more common in abuse than in accident.
Imaging Studies
Emergency radiologists are contributing additional concerning findings indicative of elder abuse,38,41,42 such as the concomitant presence of old and new fractures, high-energy fractures inconsistent with the purported mechanism, and distal ulnar diaphyseal fractures.41,42 The ultimate goal is to identify pathognomonic injury patterns similar to those found in child abuse cases, to assist ED providers.
Laboratory Studies
Although there are no laboratory tests to definitively identify abuse or neglect, specific findings that may indicate abuse include anemia, dehydration, malnutrition, hypothermia/hyperthermia, and rhabdomyolysis.43 In addition, inappropriately high- or low-medication levels and the presence of illicit drugs, which are not often checked in elderly patients in the ED, may be a sign of abuse.43
Laboratory studies that reveal undetectable levels of a patient’s prescription medications may indicate a caregiver’s intentional or neglectful withholding of such medications—especially diversion of opioid medications prescribed for painful conditions.43 Likewise, elevated levels of prescribed drugs may point to intentional or unintentional overdose, whereas the presence of nonprescribed drugs or toxins may suggest poisoning.43
Screening Tools
To improve identification of elder abuse in the ED, universal or targeted screening tools are under consideration. Though several screening tools for elder abuse are already available, none have been validated in the ED.15,44,45 Research sponsored by the National Institute of Justice to identify an ED-specific screening tool is ongoing.15
Elder Abuse Suspicion Index
The Elder Abuse Suspicion Index (EASI) is a short screening tool that has been validated for cognitively intact patients being treated in family practice and ambulatory care settings, and may be used in EDs.44 The tool comprises six questions: five for patient response, and a sixth question for clinician response. This tool is available at http://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index.46
Interventional Measures
When elder mistreatment is suspected or confirmed, health care providers must first address any acute medical, traumatic, or psychological issues. Bleeding, orthopedic injuries, metabolic abnormalities, infections, and agitation must be treated and/or stabilized, while neglected or inappropriately managed chronic medical conditions may require treatment.
Hospitalization should be considered for an older adult who needs extended treatment or observation and, in cases of immediate or continued danger of abuse, separation from contact with the suspected abuser. These measures present several challenges, particularly if the suspected abuser is the patient’s health care proxy, in which case early involvement of the hospital’s legal department, social services, and administration may be necessary—especially in navigating the guardianship process.
Engaging security also may be necessary if the patient requires one-to-one patient watch or when the perpetrator must be removed from the ED. Social workers, patient services representatives, and law enforcement officials should be informed when such intervention is necessary.
In instances when a patient is not at risk of immediate harm, interventions can be more individualized. Coordination with primary care physicians (PCPs) must also be facilitated prior to discharge, to ensure consistent longitudinal follow-up care, and social workers should provide any needed out-of-hospital resources to the patient—and caregiver—such as Meals-on-Wheels, medical transportation services, adult day care/senior center participation, and substance abuse treatment.
Patient Decision-Making Capacity
When a patient experiencing abuse declines interventions or services, the EP must evaluate the patient’s decision-making capacity. In unclear cases, a psychiatric evaluation can help to assess decision-making capacity. If the victim is deemed to have capacity with regard to care and/or discharge, the patient’s choice of returning to an unsafe environment must be respected, as is true in instances of intimate partner violence among younger adults—but not in child abuse cases. In such situations, the EP should nevertheless discuss safety planning, offer psychoeducation about violence and abuse, suggest appropriate community referrals, and encourage abused patients to return or call a contact person whenever they desire or feel the need to talk further. For a victim who is deemed not to possess capacity, providers should proceed with treatment considered to be in the best interest of the patient.
Reporting Abuse
Emergency department providers should notify the appropriate authorities when elder abuse is suspected or identified. A report may be made to the local Adult Protective Services (APS), but this agency operates much differently than Child Protective Services. Case workers with APS will not open a case while a patient is in the ED or hospital, as it is deemed a safe environment and any investigation they undertake will only commence upon discharge. Because of this, contacting the local police department prior to discharge should be considered.
Mandatory elder abuse-reporting laws vary from state to state. Health care providers should therefore contact their respective state or city department of health to obtain local legislation.
Multidisciplinary Approach
Ideally, a multidisciplinary, ED-based intervention team modeled on child abuse teams18,19 would help to optimize treatment and ensure the safety and treatment of vulnerable older adults. These teams could conduct thorough medical, forensic, and social work assessments, allowing ED providers to attend to other patients. The team could also assist in arranging for appropriate and safe dispositions. An innovative Vulnerable Elder Protection Team was recently launched at New York-Presbyterian Weill Cornell Medical Center to provide these services, and its impact is currently being evaluated.
Case Conclusion
The EP who treated the patient realized that blows from a blunt object held by a right-handed person would tend to land on the left side of the victim’s face and upper torso, and that a right-handed victim who successfully blocked the blows intended for her face would instead sustain an isolated right ulna or radius midshaft fracture. These findings, together with the concomitant presence of both old and new fractures, led the EP to question the patient alone and, after obtaining a different history of the events that led to the injuries, admit her for further evaluation, treatment, and interventions to prevent continuing abuse.
Summary
Elder abuse has the potential to affect an increasing number of older adults in this growing population, and an ED visit may offer the only opportunity to identify victims and provide intervention, in turn reducing morbidity and mortality. The results of ongoing research will improve the ability of EPs and ED staff to accurately assess the presence or risk of elder abuse and respond more effectively. It is essential that EPs always consider elder abuse and neglect as a possible etiology when evaluating injuries in this population. Moreover, when identified, addressing elder mistreatment may dramatically improve quality of life or save the lives of these vulnerable patients.
1. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Bonnie RJ, Wallace RB, eds. Washington, DC: National Academies Press; 2003:1-552. https://www.nap.edu/read/10406/chapter/1. Accessed April 4, 2017.
2. Lifespan of Greater Rochester, Inc; Weill Cornell Medical Center of Cornell University; New York City Department for the Aging. Under the radar: New York state elder abuse prevalence study: self-reported prevalence and documented case surveys 2011.http://ocfs.ny.gov/main/reports/Under%20the%20Radar%2005%2012%2011%20final%20report.pdf. Published May 2011. Accessed April 4, 2017.
3. Connolly MT, Brandl B, Breckman R. The Elder Justice Roadmap: A Stakeholder Initiative to Respond to an Emerging Health, Justice, Financial, and Social Crisis. https://www.justice.gov/elderjustice/file/829266/download. National Center for Elder Abuse. Published January 2014. Accessed April 4, 2017.
4. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292-297. doi:10.2105/AJPH.2009.163089.
5. Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272. doi:10.1016/S0140-6736(04)17144-4.
6. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947-1956. doi:10.1056/NEJMra1404688.
7. Ortmann C, Fechner G, Bajanowski T, Brinkmann B. Fatal neglect of the elderly. Int J Legal Med. 2001;114(3):191-193.
8. Schiamberg LB, Oehmke J, Zhang Z, et al. Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home. J Elder Abuse Negl. 2012;24(1):65-83. doi:10.1080/08946566.2011.608056.
9. Rosen T, Pillemer K, Lachs M. Resident-to-resident aggression in long-term care facilities: an understudied problem. Aggress Violent Behav. 2008;13(2):77-87. doi:10.1016/j.avb.2007.12.001.
10. Shinoda-Tagawa T, Leonard R, Pontikas J, McDonough JE, Allen D, Dreyer PI. Resident-to-resident violent incidents in nursing homes. JAMA. 2004;291(5):591-598. doi:10.1001/jama.291.5.591.
11. Dyer CB, Pavlik VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48(2):205-208.
12. Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA. 1998;280(5):428-432.
13. Dong XQ, Simon MA, Beck TT, et al. Elder abuse and mortality: the role of psychological and social wellbeing. Gerontology. 2011;57(6):549-658. doi:10.1159/000321881.
14. Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of nonmedical problems among older adults presenting to the emergency department. Acad Emerg Med. 2014;21(6):651-658. doi:10.1111/acem.12395.
15. Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying elder abuse in the emergency department: toward a multidisciplinary team-based approach. Ann Emerg Med. 2016;68(3):378-382. doi:10.1016/j.annemergmed.2016.01.037.
16. Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29(1):257-273. doi:10.1016/j.cger.2012.09.004.
17. Heyborne RD. Elder abuse: keeping the unthinkable in the differential. Acad Emerg Med. 2007;14(6):566-567. doi:10.1197/j.aem.2007.01.015.
18. Kistin CJ, Tien I, Bauchner H, Parker V, Leventhal JM. Factors that influence the effectiveness of child protection teams. Pediatrics. 2010;126(1):94-100. doi:10.1542/peds.2009-3446.
19. Hochstadt NJ, Harwicke NJ. How effective is the multidisciplinary approach? A follow-up study. Child Abuse Negl. 1985;9(3):365-372.
20. Choo EK, Gottlieb AS, DeLuca M, Tape C, Colwell L, Zlotnick C. Systematic review of ED-based intimate partner violence intervention research. West J Emerg Med. 2015;16(7):1037-1042. doi:10.5811/westjem.2015.10.27586.
21. Rhodes KV, Rodgers M, Sommers M, et al. Brief motivational intervention for intimate partner violence and heavy drinking in the emergency department: a randomized clinical trial. JAMA. 2015;314(5):466-477. doi:10.1001/jama.2015.8369.
22. Teaster PB, Dugar TA, Mendiondo MS, et al; The National Committee for the Prevention of Elder Abuse; The National Adult Protective Services Association. The 2004 survey of state adult protective services: abuse of adults 60 years of age and older. http://www.napsa-now.org/wp-content/uploads/2012/09/2-14-06-FINAL-60+REPORT.pdf. Published February 2006. Accessed March 10, 2017.
23. Blakely BE, Dolon R. Another look at the helpfulness of occupational groups in the discovery of elder abuse and neglect. J Elder Abuse Negl. 2003;13:1-23.
24. Evans CS, Hunold KM, Rosen T, Platts-Mills TF. Diagnosis of elder abuse in U.S. emergency departments. J Am Geriatr Soc. 2017;65(1):91-97. doi:10.1111/jgs.14480.
25. Jones JS, Veenstra TR, Seamon JP, Krohmer J. Elder mistreatment: national survey of emergency physicians. Ann Emerg Med. 1997;30(4):473-479.
26. Amstadter AB, Zajac K, Strachan M, Hernandez MA, Kilpatrick DG, Acierno R. Prevalence and correlates of elder mistreatment in South Carolina: the South Carolina elder mistreatment study. J Interpers Violence. 2011;26(15):2947-2972. doi:10.1177/0886260510390959.
27. Friedman LS, Avila S, Tanouye K, Joseph K. A case-control study of severe physical abuse of older adults. J Am Geriatr Soc. 2011;59(3):417-422. doi:10.1111/j.1532-5415.2010.03313.x.
28. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: global situation, risk factors, and prevention strategies. Gerontologist. 2016;56 Suppl 2:S194-S205. doi:10.1093/geront/gnw004.
29. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):S248-S254.
30. Cooney C, Howard R, Lawlor B. Abuse of vulnerable people with dementia by their carers: can we identify those most at risk? Int J Geriatr Psychiatry. 2006;21(6):564-571. doi:10.1002/gps.1525.
31. Lachs MS, Williams C, O’Brien S, Hurst L, Horwitz R. Risk factors for reported elder abuse and neglect: a nine-year observational cohort study. Gerontologist. 1997;37(4):469-474.
32. Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W. Screening for abuse and neglect of people with dementia. J Am Geriatr Soc. 2010;58(3):493-500. doi:10.1111/j.1532-5415.2010.02737.x.
33. Collins KA. Elder maltreatment: a review. Arch Pathol Lab Med. 2006;130(9):1290-1296. doi:10.1043/1543-2165(2006)130[1290:EMAR]2.0.CO;2.
34. Gibbs LM. Understanding the medical markers of elder abuse and neglect: physical examination findings. Clin Geriatr Med. 2014 Nov;30(4):687-712. doi:10.1016/j.cger.2014.08.002.
35. Palmer M, Brodell RT, Mostow EN. Elder abuse: dermatologic clues and critical solutions. J Am Acad Dermatol. 2013;68(2):e37-e42. doi:10.1016/j.jaad.2011.03.016.
36. Speck PM, Hartig MT, Likes W, et al. Case series of sexual assault in older persons. Clin Geriatr Med. 2014;30(4):779-806. doi:10.1016/j.cger.2014.08.007.
37. Chang AL, Wong JW, Endo JO, Norman RA. Geriatric dermatology: part II. Risk factors and cutaneous signs of elder mistreatment for the dermatologist. J Am Acad Dermatol. 2013;68(4):533.e1-.e10. doi:10.1016/j.jaad.2013.01.001.
38. Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64(1):10-14. doi:10.1016/j.carj.2012.12.001.
39. Rosen T, Bloemen EM, LoFaso VM, Clark S, Flomenbaum NE, Lachs MS. Emergency department presentations for injuries in older adults independently known to be victims of elder abuse. J Emerg Med. 2016;50(3):518-526. doi:10.1016/j.jemermed.2015.10.037.
40. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196. doi:10.1111/j.1532-5415.2009.02330.x.
41. Rosen T, Bloemen EM, Harpe J, et al. Radiologists’ training, experience, and attitudes about elder abuse detection. AJR Am J Roentgenol. 2016;207:1210-1214.
42. Wong NZ, Rosen T, Sanchez AM, et al. Imaging findings in elder abuse: a role for radiologists in detection. Can Assoc Radiol J. 2017;68(1):16-20. doi:10.1016/j.carj.2016.06.001.
43. LoFaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):713-28. doi:10.1016/j.cger.2014.08.003.
44. Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc. 2004;52(2):297-304.
45. Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI). J Elder Abuse Negl. 2008;20(3):276-300. doi:10.1080/08946560801973168.
46. National Initiative for the Care of the Elderly. EASI: Elder Abuse Suspicion Index. http://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index. Accessed April 5, 2017.
1. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Bonnie RJ, Wallace RB, eds. Washington, DC: National Academies Press; 2003:1-552. https://www.nap.edu/read/10406/chapter/1. Accessed April 4, 2017.
2. Lifespan of Greater Rochester, Inc; Weill Cornell Medical Center of Cornell University; New York City Department for the Aging. Under the radar: New York state elder abuse prevalence study: self-reported prevalence and documented case surveys 2011.http://ocfs.ny.gov/main/reports/Under%20the%20Radar%2005%2012%2011%20final%20report.pdf. Published May 2011. Accessed April 4, 2017.
3. Connolly MT, Brandl B, Breckman R. The Elder Justice Roadmap: A Stakeholder Initiative to Respond to an Emerging Health, Justice, Financial, and Social Crisis. https://www.justice.gov/elderjustice/file/829266/download. National Center for Elder Abuse. Published January 2014. Accessed April 4, 2017.
4. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292-297. doi:10.2105/AJPH.2009.163089.
5. Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272. doi:10.1016/S0140-6736(04)17144-4.
6. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947-1956. doi:10.1056/NEJMra1404688.
7. Ortmann C, Fechner G, Bajanowski T, Brinkmann B. Fatal neglect of the elderly. Int J Legal Med. 2001;114(3):191-193.
8. Schiamberg LB, Oehmke J, Zhang Z, et al. Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home. J Elder Abuse Negl. 2012;24(1):65-83. doi:10.1080/08946566.2011.608056.
9. Rosen T, Pillemer K, Lachs M. Resident-to-resident aggression in long-term care facilities: an understudied problem. Aggress Violent Behav. 2008;13(2):77-87. doi:10.1016/j.avb.2007.12.001.
10. Shinoda-Tagawa T, Leonard R, Pontikas J, McDonough JE, Allen D, Dreyer PI. Resident-to-resident violent incidents in nursing homes. JAMA. 2004;291(5):591-598. doi:10.1001/jama.291.5.591.
11. Dyer CB, Pavlik VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48(2):205-208.
12. Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA. 1998;280(5):428-432.
13. Dong XQ, Simon MA, Beck TT, et al. Elder abuse and mortality: the role of psychological and social wellbeing. Gerontology. 2011;57(6):549-658. doi:10.1159/000321881.
14. Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of nonmedical problems among older adults presenting to the emergency department. Acad Emerg Med. 2014;21(6):651-658. doi:10.1111/acem.12395.
15. Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying elder abuse in the emergency department: toward a multidisciplinary team-based approach. Ann Emerg Med. 2016;68(3):378-382. doi:10.1016/j.annemergmed.2016.01.037.
16. Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29(1):257-273. doi:10.1016/j.cger.2012.09.004.
17. Heyborne RD. Elder abuse: keeping the unthinkable in the differential. Acad Emerg Med. 2007;14(6):566-567. doi:10.1197/j.aem.2007.01.015.
18. Kistin CJ, Tien I, Bauchner H, Parker V, Leventhal JM. Factors that influence the effectiveness of child protection teams. Pediatrics. 2010;126(1):94-100. doi:10.1542/peds.2009-3446.
19. Hochstadt NJ, Harwicke NJ. How effective is the multidisciplinary approach? A follow-up study. Child Abuse Negl. 1985;9(3):365-372.
20. Choo EK, Gottlieb AS, DeLuca M, Tape C, Colwell L, Zlotnick C. Systematic review of ED-based intimate partner violence intervention research. West J Emerg Med. 2015;16(7):1037-1042. doi:10.5811/westjem.2015.10.27586.
21. Rhodes KV, Rodgers M, Sommers M, et al. Brief motivational intervention for intimate partner violence and heavy drinking in the emergency department: a randomized clinical trial. JAMA. 2015;314(5):466-477. doi:10.1001/jama.2015.8369.
22. Teaster PB, Dugar TA, Mendiondo MS, et al; The National Committee for the Prevention of Elder Abuse; The National Adult Protective Services Association. The 2004 survey of state adult protective services: abuse of adults 60 years of age and older. http://www.napsa-now.org/wp-content/uploads/2012/09/2-14-06-FINAL-60+REPORT.pdf. Published February 2006. Accessed March 10, 2017.
23. Blakely BE, Dolon R. Another look at the helpfulness of occupational groups in the discovery of elder abuse and neglect. J Elder Abuse Negl. 2003;13:1-23.
24. Evans CS, Hunold KM, Rosen T, Platts-Mills TF. Diagnosis of elder abuse in U.S. emergency departments. J Am Geriatr Soc. 2017;65(1):91-97. doi:10.1111/jgs.14480.
25. Jones JS, Veenstra TR, Seamon JP, Krohmer J. Elder mistreatment: national survey of emergency physicians. Ann Emerg Med. 1997;30(4):473-479.
26. Amstadter AB, Zajac K, Strachan M, Hernandez MA, Kilpatrick DG, Acierno R. Prevalence and correlates of elder mistreatment in South Carolina: the South Carolina elder mistreatment study. J Interpers Violence. 2011;26(15):2947-2972. doi:10.1177/0886260510390959.
27. Friedman LS, Avila S, Tanouye K, Joseph K. A case-control study of severe physical abuse of older adults. J Am Geriatr Soc. 2011;59(3):417-422. doi:10.1111/j.1532-5415.2010.03313.x.
28. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: global situation, risk factors, and prevention strategies. Gerontologist. 2016;56 Suppl 2:S194-S205. doi:10.1093/geront/gnw004.
29. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):S248-S254.
30. Cooney C, Howard R, Lawlor B. Abuse of vulnerable people with dementia by their carers: can we identify those most at risk? Int J Geriatr Psychiatry. 2006;21(6):564-571. doi:10.1002/gps.1525.
31. Lachs MS, Williams C, O’Brien S, Hurst L, Horwitz R. Risk factors for reported elder abuse and neglect: a nine-year observational cohort study. Gerontologist. 1997;37(4):469-474.
32. Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W. Screening for abuse and neglect of people with dementia. J Am Geriatr Soc. 2010;58(3):493-500. doi:10.1111/j.1532-5415.2010.02737.x.
33. Collins KA. Elder maltreatment: a review. Arch Pathol Lab Med. 2006;130(9):1290-1296. doi:10.1043/1543-2165(2006)130[1290:EMAR]2.0.CO;2.
34. Gibbs LM. Understanding the medical markers of elder abuse and neglect: physical examination findings. Clin Geriatr Med. 2014 Nov;30(4):687-712. doi:10.1016/j.cger.2014.08.002.
35. Palmer M, Brodell RT, Mostow EN. Elder abuse: dermatologic clues and critical solutions. J Am Acad Dermatol. 2013;68(2):e37-e42. doi:10.1016/j.jaad.2011.03.016.
36. Speck PM, Hartig MT, Likes W, et al. Case series of sexual assault in older persons. Clin Geriatr Med. 2014;30(4):779-806. doi:10.1016/j.cger.2014.08.007.
37. Chang AL, Wong JW, Endo JO, Norman RA. Geriatric dermatology: part II. Risk factors and cutaneous signs of elder mistreatment for the dermatologist. J Am Acad Dermatol. 2013;68(4):533.e1-.e10. doi:10.1016/j.jaad.2013.01.001.
38. Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64(1):10-14. doi:10.1016/j.carj.2012.12.001.
39. Rosen T, Bloemen EM, LoFaso VM, Clark S, Flomenbaum NE, Lachs MS. Emergency department presentations for injuries in older adults independently known to be victims of elder abuse. J Emerg Med. 2016;50(3):518-526. doi:10.1016/j.jemermed.2015.10.037.
40. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196. doi:10.1111/j.1532-5415.2009.02330.x.
41. Rosen T, Bloemen EM, Harpe J, et al. Radiologists’ training, experience, and attitudes about elder abuse detection. AJR Am J Roentgenol. 2016;207:1210-1214.
42. Wong NZ, Rosen T, Sanchez AM, et al. Imaging findings in elder abuse: a role for radiologists in detection. Can Assoc Radiol J. 2017;68(1):16-20. doi:10.1016/j.carj.2016.06.001.
43. LoFaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):713-28. doi:10.1016/j.cger.2014.08.003.
44. Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc. 2004;52(2):297-304.
45. Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI). J Elder Abuse Negl. 2008;20(3):276-300. doi:10.1080/08946560801973168.
46. National Initiative for the Care of the Elderly. EASI: Elder Abuse Suspicion Index. http://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index. Accessed April 5, 2017.
The Geriatric ED and Clinical Protocols for the Emergency Care of Older Adults
Case 1
An 82-year-old man presented to the ED accompanied by his son, who stated that his father “had not been acting right” for the past 2 days. The patient was combative, yelling “Go away,” and was intermittently more confused than his baseline; he was also eating and drinking less than usual. He had a history of mild dementia, noninsulin-dependent diabetes, hypertension, and arthritis; there were no recent changes in his medication. The patient lived alone in an apartment across the hall from his son and had home healthcare aide 4 hours a day, 3 days a week. He was independent of activities of daily living (ADL), but needed help with shopping and cooking.
At presentation, the patient’s vital signs were: temperature, afebrile; heart rate (HR), 94 beats/minute; blood pressure (BP), 146/92 mm hg; respiratory rate (RR), 22 breaths/minute. Oxygen (O2) saturation was 96% on room air. A finger-stick glucose test was 103 mg/dL. He was hyperalert and agitated, and did not appear oriented to place or time. There were no focal neurological deficits; mucous membranes were mildly dry; and faint crackles were heard at the right base of the lungs. The patient was placed on a monitor in a curtained room in the ED, and was given 2 L O2 via nasal cannula, which improved O2 saturation to 99%. With his son present, an intravenous (IV) line was placed and blood was drawn. An electrocardiogram (ECG) showed a sinus rhythm without ischemic findings.
During evaluation, the patient continued to pull at the monitor lines and attempted to get off the stretcher. To calm his agitation, he was given haloperidol 2.5 mg and lorazepam 1 mg; 10 minutes after administration, he became sedated and difficult to arouse. His vital signs remained stable.
Laboratory analysis revealed a white blood cell count (WBC) of 12.5 K/uL, a negative troponin, a brain natriuretic peptide (BNP) of 80 pg/mL, and normal blood urea nitrogen (BUN) and creatinine levels. Urinalysis was negative for infection, but chest X-ray showed a right lower lobe infiltrate. Blood cultures were drawn, and the patient was continued on maintenance fluids and started on IV antibiotics to cover community-acquired pneumonia. He was admitted to the hospital for pneumonia and altered mental status.
As the patient’s sedative state was followed by periods of agitation, he was treated with additional haloperidol and lorazepam by the inpatient medical team, which resulted in further sedation. On hospital day 3, his urinary output decreased. He was given an IV bolus of 3 L normal saline over 6 hours, after which his mental status began to improve, and he was switched to oral antibiotics. His mental status returned to baseline and O2 saturation was 99% on room air. He was discharged home on hospital day 5 accompanied by his son.
Case 2
A 75-year-old man was brought to the ED with a 3-day history of worsening dyspnea on exertion, increased orthopnea, and increased bilateral lower extremity edema. He had a history of congestive heart failure (CHF), with an ejection fraction of 40%, and had been on 40 mg of furosemide daily at home; there were no recent changes to his medication. The patient was independent of ADL at baseline, living with his wife in a home with stairs.
His vital signs at presentation were: temperature, afebrile; HR, 86 beats/minute; BP, 160/90 mm hg; RR 30 breaths/minute; O2 saturation was 92% on room air. The patient had increased work of breathing and was speaking in four- to five-word sentences. Pulmonary examination revealed crackles half way up bilaterally. He also had 2+ pitting edema bilaterally in his lower extremities. He was otherwise alert and oriented.
On 4 L O2 via nasal cannula, the patient’s O2 saturation was 98%. Laboratory analysis revealed a BNP of 600 pg/mL, negative troponin, and normal creatinine level. Urinalysis was negative for evidence of infection. An ECG showed no changes, and chest X-ray revealed mild pulmonary congestion without an infiltrate. In the ED, an indwelling urinary catheter (IUC) was placed to monitor urinary output before the patient was given 40 mg of IV furosemide for diuresis. The patient was then admitted for management of exacerbation of CHF. As the medical team was preparing to discharge him on hospital day 2, his wife noticed that he was confused and not acting “like himself.” An investigation for causes of delirium included evaluation for infectious disease, which revealed an elevated WBC of 14.0 K/uL, stable creatinine; and urinalysis positive for bacteria, WBCs, leukocyte esterase, and nitrites. Since chest X-ray showed resolution of the vascular congestion, the patient no longer required supplemental O2.
The IUC was removed, and the patient was started on IV antibiotics for a urinary tract infection (UTI) secondary to IUC placement. The inpatient stay was prolonged for an additional 3 days until his delirium cleared and he could be continued on oral antibiotics as an outpatient.
Discussion
There is nothing extraordinary about these two cases. Every day elderly adults present to EDs throughout the country with confusion caused by pneumonia and dehydration that is sometimes initially attributed to worsening dementia and then complicated or prolonged by overuse of powerful sedating medications. Also, complications resulting from IUCs inserted in the ED all too often prolong hospitalizations. But by using protocols designed for better, more efficient emergency care of elderly patients, their ED care can be substantially improved and any subsequent inpatient care shortened.
The older adult population (ages 65 years and older) often presents to the ED with similar complaints to their younger counterparts—eg, chest pain, abdominal pain, dyspnea. However, the history, physical examination, and social assessment of elderly patients usually lead to a more comprehensive work-up, as older adults tend to present in an atypical fashion for both illness and trauma, thus necessitating a broader differential. In addition, they are more susceptible to adverse reactions from medications and procedures.
Regardless of the ultimate diagnosis, simply presenting to an ED as a patient (and sometimes spending many hours there) places older adults at elevated risk of morbidity and mortality. The challenge is to develop reliable tools to streamline the management of this population in order to increase diagnostic accuracy, decrease adverse events, and improve patient outcomes.
Clinical Protocols
Clinical protocols are one way in which we can educate and standardize the practice of multiple levels of provider, including nurses, midlevel providers, and physicians. Adopting protocols is natural for EPs—the key is to make sure the clinical protocol to be implemented is designed or modified for the ED setting in which it will be implemented.
In our ED, we have recently implemented the following two protocols for common scenarios in older adults: (1) assessment and management of delirium; and (2) decreased use of IUCs. These protocols employ the following stepwise project plan:
- Focus groups involving nurses, midlevels, residents, and attendings to assess ED provider knowledge, attitudes, and practice patterns regarding the clinical issue in older adult patients, and to guide development of the clinical protocol by understanding needs and constraints of the current ED environment;
- An extensive literature review of the clinical topic;
- Development of the clinical protocol by the workgroup;
- Implementation of protocol after multiple educational sessions using a scripted slide presentation to ensure all providers receive the same information; and
- Subsequent data analysis from the electronic medical record to assess the impact (ie, outcome) of the protocol.
Delirium
Delirium is a common syndrome in older adults, but is often unrecognized despite its clinical importance. Although 7% to 17% of older adults who present to the ED suffer from delirium,1-6 emergency physicians (EPs) miss 64% to 83% of cases, and 12% to 38% of patients with unrecognized delirium are actually discharged from the ED.1,6-8 Unfortunately, patients discharged from the ED with undetected delirium are three times more likely to die within 3 months than those whose delirium was recognized.
Life-threatening causes are more apt to be recognized early on in the ED. With this in mind, we developed a new, comprehensive, evidence-based protocol for recognition, diagnosis, management, and disposition of agitated delirium in older adults in the ED, with a focus on identifying and treating the commonly missed contributing causes: analgesia, bladder-urine retention, constipation, dehydration, environment, and medications.9
IUC Placement in the ED
The second protocol implemented at our institution is a new, evidence-based protocol for the placement, management, and reassessment of IUCs. As emphasized by the National American College of Emergency Physicians (ACEP) 2013 Choosing Wisely Campaign,10 inserting an IUC is a procedure that should be undertaken judiciously as it is associated with an elevated risk of infection, delirium, falls, and other adverse events. As of 2008, the Centers for Medicare and Medicaid Services no longer reimburses for hospital-acquired catheter-associated UTIs.11
After conducting focus groups of our ED providers, we learned that IUCs are placed more frequently than needed—often for reasons of convenience—and are rarely reassessed or removed if the patient is admitted to the hospital. Thus, our protocol highlights appropriate, possibly appropriate, and inappropriate indications for IUC placement, with an emphasis on trying alternative modes of urine collection, communicating among healthcare providers regarding the necessity of an IUC, and reassessment of the patient for IUC removal.
Our protocols have yielded early promising results, but further research is underway to determine their specific impact. The goal is to create a protocol that is feasible and effective for the specific institution and department to which it is applied. By ensuring all members of the healthcare team are involved in the development and design of a protocol, there is ownership of its implementation and use, with the overarching goal of improving patient care.
Geriatric ED Guidelines
In the beginning of 2014, new consensus-based Geriatric Emergency Department (GED) guidelines were published in order to “provide a standardized set of guidelines that can effectively improve the care of the geriatric population and are feasible to implement in the ED.”12 These guidelines are the result of a 2-year effort by representatives from ACEP, the American Geriatrics Society, the Society of Academic Emergency Medicine, and the Emergency Nurses Association, who were committed to optimizing the emergency-care delivery model for geriatrics. The participants encompassed both academic and community providers and included clinicians and researchers. These guidelines were formulated based on an 80% consensus among the representatives and, when possible, validated using existing literature at the time.
The genesis of the GED guidelines was multifactorial. In addition to the formation and rapid growth of geriatric interest groups and sections within EM academic organizations over the last 14 years, as well as the development of geriatric core competencies for EM residents in training, the 2010 Census Data results sharply outlined the details of the rapidly growing population of older adults in the United States. This acted as an alarm highlighting the need for a structured document containing best practice recommendations from geriatric emergency healthcare providers, researchers, and advocates. “The subsequent increased need for healthcare for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American healthcare system as a whole and to emergency departments specifically,” the authors of the GED guidelines noted.
In response to a growing national interest in geriatric ED patients and an ever-increasing competition to attract patients from this demographic by EDs across the country, there has been a surge of self-designated GEDs during the last few years. Currently, more than 70 hospitals claim to have GEDs, raising the question of what sort of geriatric patient care is actually being delivered in these EDs. The question is of increased importance because very few of these “GEDs” are in academic centers or are associated with thought leaders in EM. In fact, when 30 self-designated GEDs that were snowball sampled in 2013 by researchers who asked what specific changes they had made toward the goal of improving care for the elderly, several rescinded this self-designation.
Because of heightened concerns for the needs of the increasing geriatric population overall, and the rise in the proportion of ED visits by this demographic, the authors of the GED guidelines state that “the contemporary emergency medicine management model may not be adequate for geriatric adults,” and offer the new GED guidelines as a basis on which EDs can consider ways to improve care for older adults while addressing the unique needs of this population. The GED guidelines propose specific methods and processes by which ED care of the elderly can be optimized. The authors note that “similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved the care both in individual EDs and system-wide, resulting in better, more cost-effective care and ultimately better patient outcomes.”
The GED guidelines consist of 40 specific recommendations in six general categories: (1) staffing/administration; (2) equipment/supplies; (3) education; (4) policies/procedures/protocols; (5) follow-up/transitions of care; and (6) quality-improvement measures. This template outlines how to construct an effective GED program. The following highlights recommendations for each of these categories:
Staffing/Administration. Set qualifications and responsibilities for the medical director, nurse manager, staff physicians, nurses, and specialists, as well as accessibility to specialist ancillary services, with the goal of establishing hospital site-specific staff and coordination of local resources.
Equipment/Supplies. Develop potential physical and structural enhancements that address issues of mobility, comfort, safety, and behavioral needs (including memory cues and sensorial perception) while decreasing iatrogenic complications, such as the development of pressure ulcers (eg, the use of reclining chairs and pressure-redistributing foam mattresses).
Education. Provide nurse and clinical provider education and specialty-specific training focusing on contemporary, research-based geriatric-specific material, with regular assessment for interdisciplinary core competencies.
Policies/Procedures/Protocols. Implement a directed, comprehensive approach to facilitate screening and assessment of geriatric patients for added needs/post-ED adverse outcomes, as well as validated, ED-feasible screening tools/instruments for delirium and dementia, medication management, falls, use of urinary catheters, and the provision of palliative care.
Follow-up/Transitions of Care. Design discharge processes best suited for older patients (eg, large-font instructions), as well as collaborate with community resources to provide home-health services and home safety assessment in order to facilitate care following discharge.
Quality Improvement. Implement a system to collect and monitor pertinent and prevalent geriatric emergency care indicators (eg, incidence of injurious falls and documentation of fall risk assessment) designed to increase staff education and program success.
The authors clearly state that the GED guidelines represent recommendations. They are not a mandate for every ED, nor are they a list that requires 100% compliance. Instead, the document provides the potential steps to be taken, the rationale for these recommendations, and an outline of the resources available to aid in the transition from theory to implementation in any ED. The goal is to ensure better, safer, and age-appropriate treatment. In summary, these guidelines represent an effort to improve and even transform emergency care for older adults on the brink of one of the most significant challenges facing our healthcare system both in and beyond the ED.
Moving forward, the authors of the GED guidelines have defined a plan that “includes dissemination, implementation, adaptation, and refinement.” In addition to approval by each of the organization’s board of directors and the copyright of the material in 2013, the ED guidelines have now been widely disseminated through publication in numerous news articles (including international publications) and discussions on satellite radio. Tracking of new GEDs is planned. In addition, the prioritization of the guidelines is underway using a modified Delphi method, with the express purpose of assessing the relative potential benefits and harms associated with each recommendation by providing a weighted list from most important to least important.
A “Geriatric Emergency Department Boot Camp” is being developed to bring the recommendations to hospitals interested in “geriatricizing” their EDs. Geriatric EM leaders will act as consultants, providing training and a toolbox of resources. Specific reviews and revisions of the GED guidelines will take place in a 4- to 5-year cycle. Clearly, a next important step is the development of a GED certification system based on outcome studies of the individual components.
Criticisms of the GED guidelines have already been voiced among some EM providers. Specific concerns include a fear of partitioning the ED (as has occurred with pediatrics); an increase in cost and decreased efficiency; the need to maintain general expertise among EM physicians; the lack of evidence-based data upon which the recommendations were made; the fact that some guidelines were extrapolated from other clinical settings; and the belief that these changes will be too logistically difficult and take too much time.
The fact remains that the wave of geriatric patients (the “silver tsunami”) is already beginning to hit the shores of our hospitals. And GEDs are already here to help absorb the impact. The lack of iron-clad evidence for many of the recommendations should not be an absolute obstacle, but rather part of the natural evolution and improvement of similar endeavors. Nor should GEDs contain empty beds while younger adults sit in the waiting room, or conversely, force the elderly to wait for space in the GED when there are empty beds in the main ED. Ideally, the GED should be the location where the ED staff can implement these guidelines, which they can afterwards utilize in any part of the ED. These guidelines are designed to provide the best available expert opinion on how to deliver better geriatric care in the ED. The imperative for this goal is clear and necessitates this educated “leap-of-faith.” Change is never easy and often comes with an upfront cost of time, resources, and money. Moreover, there is nothing in a well-designed GED that may not also benefit, or at least will not adversely affect care of a younger adult as well. Therefore, flexibility and optimal utilization of space in a busy ED need not be sacrificed.
Conclusion
To improve diagnostic evaluation and care of the increasing number of geriatric patients presenting to the ED, reliable tools, protocols, and guidelines must be developed and implemented to ensure diagnostic accuracy, decrease adverse events, and improve patient outcomes. Fortunately, the new GED consensus guidelines are flexible and do not need to be wholly embraced—lending themselves to modifications and institution-specific adoptions. The “protocolization” and implementation of the guidelines may improve patient flow, operational efficiency, and, most importantly, the quality of care delivered. And likely, these guidelines will provide the foundation for future education and research into the improved emergency care of older adults.
The GED guidelines can be accessed at http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2.
Dr Stern is an assistant professor of medicine and codirector, geriatric emergency medicine fellowship, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York; and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital.
Dr Mulcare is an instructor of medicine and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York. She is a former fellow of geriatric emergency medicine.
- Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13(2):142-145.
- Naughton BJ, Moran M, Ghaly Y, Michalakes C. Computed tomography scanning and delirium in elder patients. Acad Emerg Med. 1997;4(12):1107-1110.
- Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med. 1995;25(6):751-755.
- Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39(3):248-253.
- Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5):678-684.
- Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163(8):977-981.
- Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200.
- Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. 2002;39(3):338-341.
- Rosen T, Connors S, Halpern A, et al. Improving emergency department identification and management of agitated delirium in older adults: implementation and impact assessment of a comprehensive clinical protocol emphasizing commonly missed contributing causes using an A-B-C-D-E-F mnemonic. Sys Qual Rev J. 2013;11(special issue):203,204. http://www.nypsystem.org/pdf/System-Quality-Review-2013.pdf. Accessed June 4, 2014.
- Choosing Wisely: ACEP Lists 5 Tests to Question. Medscape Web site. http://www.medscape.com/viewarticle/812600. Accessed June 4, 2014.
- Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA. 2007;298(23):2782-2784.
- American College of Emergency Physicians; American Geriatrics Society; Emergency Nurses Association; Society for Academic Emergency Medicine. Geriatric Emergency Department Guidelines. http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2. Accessed June 4, 2014.
Case 1
An 82-year-old man presented to the ED accompanied by his son, who stated that his father “had not been acting right” for the past 2 days. The patient was combative, yelling “Go away,” and was intermittently more confused than his baseline; he was also eating and drinking less than usual. He had a history of mild dementia, noninsulin-dependent diabetes, hypertension, and arthritis; there were no recent changes in his medication. The patient lived alone in an apartment across the hall from his son and had home healthcare aide 4 hours a day, 3 days a week. He was independent of activities of daily living (ADL), but needed help with shopping and cooking.
At presentation, the patient’s vital signs were: temperature, afebrile; heart rate (HR), 94 beats/minute; blood pressure (BP), 146/92 mm hg; respiratory rate (RR), 22 breaths/minute. Oxygen (O2) saturation was 96% on room air. A finger-stick glucose test was 103 mg/dL. He was hyperalert and agitated, and did not appear oriented to place or time. There were no focal neurological deficits; mucous membranes were mildly dry; and faint crackles were heard at the right base of the lungs. The patient was placed on a monitor in a curtained room in the ED, and was given 2 L O2 via nasal cannula, which improved O2 saturation to 99%. With his son present, an intravenous (IV) line was placed and blood was drawn. An electrocardiogram (ECG) showed a sinus rhythm without ischemic findings.
During evaluation, the patient continued to pull at the monitor lines and attempted to get off the stretcher. To calm his agitation, he was given haloperidol 2.5 mg and lorazepam 1 mg; 10 minutes after administration, he became sedated and difficult to arouse. His vital signs remained stable.
Laboratory analysis revealed a white blood cell count (WBC) of 12.5 K/uL, a negative troponin, a brain natriuretic peptide (BNP) of 80 pg/mL, and normal blood urea nitrogen (BUN) and creatinine levels. Urinalysis was negative for infection, but chest X-ray showed a right lower lobe infiltrate. Blood cultures were drawn, and the patient was continued on maintenance fluids and started on IV antibiotics to cover community-acquired pneumonia. He was admitted to the hospital for pneumonia and altered mental status.
As the patient’s sedative state was followed by periods of agitation, he was treated with additional haloperidol and lorazepam by the inpatient medical team, which resulted in further sedation. On hospital day 3, his urinary output decreased. He was given an IV bolus of 3 L normal saline over 6 hours, after which his mental status began to improve, and he was switched to oral antibiotics. His mental status returned to baseline and O2 saturation was 99% on room air. He was discharged home on hospital day 5 accompanied by his son.
Case 2
A 75-year-old man was brought to the ED with a 3-day history of worsening dyspnea on exertion, increased orthopnea, and increased bilateral lower extremity edema. He had a history of congestive heart failure (CHF), with an ejection fraction of 40%, and had been on 40 mg of furosemide daily at home; there were no recent changes to his medication. The patient was independent of ADL at baseline, living with his wife in a home with stairs.
His vital signs at presentation were: temperature, afebrile; HR, 86 beats/minute; BP, 160/90 mm hg; RR 30 breaths/minute; O2 saturation was 92% on room air. The patient had increased work of breathing and was speaking in four- to five-word sentences. Pulmonary examination revealed crackles half way up bilaterally. He also had 2+ pitting edema bilaterally in his lower extremities. He was otherwise alert and oriented.
On 4 L O2 via nasal cannula, the patient’s O2 saturation was 98%. Laboratory analysis revealed a BNP of 600 pg/mL, negative troponin, and normal creatinine level. Urinalysis was negative for evidence of infection. An ECG showed no changes, and chest X-ray revealed mild pulmonary congestion without an infiltrate. In the ED, an indwelling urinary catheter (IUC) was placed to monitor urinary output before the patient was given 40 mg of IV furosemide for diuresis. The patient was then admitted for management of exacerbation of CHF. As the medical team was preparing to discharge him on hospital day 2, his wife noticed that he was confused and not acting “like himself.” An investigation for causes of delirium included evaluation for infectious disease, which revealed an elevated WBC of 14.0 K/uL, stable creatinine; and urinalysis positive for bacteria, WBCs, leukocyte esterase, and nitrites. Since chest X-ray showed resolution of the vascular congestion, the patient no longer required supplemental O2.
The IUC was removed, and the patient was started on IV antibiotics for a urinary tract infection (UTI) secondary to IUC placement. The inpatient stay was prolonged for an additional 3 days until his delirium cleared and he could be continued on oral antibiotics as an outpatient.
Discussion
There is nothing extraordinary about these two cases. Every day elderly adults present to EDs throughout the country with confusion caused by pneumonia and dehydration that is sometimes initially attributed to worsening dementia and then complicated or prolonged by overuse of powerful sedating medications. Also, complications resulting from IUCs inserted in the ED all too often prolong hospitalizations. But by using protocols designed for better, more efficient emergency care of elderly patients, their ED care can be substantially improved and any subsequent inpatient care shortened.
The older adult population (ages 65 years and older) often presents to the ED with similar complaints to their younger counterparts—eg, chest pain, abdominal pain, dyspnea. However, the history, physical examination, and social assessment of elderly patients usually lead to a more comprehensive work-up, as older adults tend to present in an atypical fashion for both illness and trauma, thus necessitating a broader differential. In addition, they are more susceptible to adverse reactions from medications and procedures.
Regardless of the ultimate diagnosis, simply presenting to an ED as a patient (and sometimes spending many hours there) places older adults at elevated risk of morbidity and mortality. The challenge is to develop reliable tools to streamline the management of this population in order to increase diagnostic accuracy, decrease adverse events, and improve patient outcomes.
Clinical Protocols
Clinical protocols are one way in which we can educate and standardize the practice of multiple levels of provider, including nurses, midlevel providers, and physicians. Adopting protocols is natural for EPs—the key is to make sure the clinical protocol to be implemented is designed or modified for the ED setting in which it will be implemented.
In our ED, we have recently implemented the following two protocols for common scenarios in older adults: (1) assessment and management of delirium; and (2) decreased use of IUCs. These protocols employ the following stepwise project plan:
- Focus groups involving nurses, midlevels, residents, and attendings to assess ED provider knowledge, attitudes, and practice patterns regarding the clinical issue in older adult patients, and to guide development of the clinical protocol by understanding needs and constraints of the current ED environment;
- An extensive literature review of the clinical topic;
- Development of the clinical protocol by the workgroup;
- Implementation of protocol after multiple educational sessions using a scripted slide presentation to ensure all providers receive the same information; and
- Subsequent data analysis from the electronic medical record to assess the impact (ie, outcome) of the protocol.
Delirium
Delirium is a common syndrome in older adults, but is often unrecognized despite its clinical importance. Although 7% to 17% of older adults who present to the ED suffer from delirium,1-6 emergency physicians (EPs) miss 64% to 83% of cases, and 12% to 38% of patients with unrecognized delirium are actually discharged from the ED.1,6-8 Unfortunately, patients discharged from the ED with undetected delirium are three times more likely to die within 3 months than those whose delirium was recognized.
Life-threatening causes are more apt to be recognized early on in the ED. With this in mind, we developed a new, comprehensive, evidence-based protocol for recognition, diagnosis, management, and disposition of agitated delirium in older adults in the ED, with a focus on identifying and treating the commonly missed contributing causes: analgesia, bladder-urine retention, constipation, dehydration, environment, and medications.9
IUC Placement in the ED
The second protocol implemented at our institution is a new, evidence-based protocol for the placement, management, and reassessment of IUCs. As emphasized by the National American College of Emergency Physicians (ACEP) 2013 Choosing Wisely Campaign,10 inserting an IUC is a procedure that should be undertaken judiciously as it is associated with an elevated risk of infection, delirium, falls, and other adverse events. As of 2008, the Centers for Medicare and Medicaid Services no longer reimburses for hospital-acquired catheter-associated UTIs.11
After conducting focus groups of our ED providers, we learned that IUCs are placed more frequently than needed—often for reasons of convenience—and are rarely reassessed or removed if the patient is admitted to the hospital. Thus, our protocol highlights appropriate, possibly appropriate, and inappropriate indications for IUC placement, with an emphasis on trying alternative modes of urine collection, communicating among healthcare providers regarding the necessity of an IUC, and reassessment of the patient for IUC removal.
Our protocols have yielded early promising results, but further research is underway to determine their specific impact. The goal is to create a protocol that is feasible and effective for the specific institution and department to which it is applied. By ensuring all members of the healthcare team are involved in the development and design of a protocol, there is ownership of its implementation and use, with the overarching goal of improving patient care.
Geriatric ED Guidelines
In the beginning of 2014, new consensus-based Geriatric Emergency Department (GED) guidelines were published in order to “provide a standardized set of guidelines that can effectively improve the care of the geriatric population and are feasible to implement in the ED.”12 These guidelines are the result of a 2-year effort by representatives from ACEP, the American Geriatrics Society, the Society of Academic Emergency Medicine, and the Emergency Nurses Association, who were committed to optimizing the emergency-care delivery model for geriatrics. The participants encompassed both academic and community providers and included clinicians and researchers. These guidelines were formulated based on an 80% consensus among the representatives and, when possible, validated using existing literature at the time.
The genesis of the GED guidelines was multifactorial. In addition to the formation and rapid growth of geriatric interest groups and sections within EM academic organizations over the last 14 years, as well as the development of geriatric core competencies for EM residents in training, the 2010 Census Data results sharply outlined the details of the rapidly growing population of older adults in the United States. This acted as an alarm highlighting the need for a structured document containing best practice recommendations from geriatric emergency healthcare providers, researchers, and advocates. “The subsequent increased need for healthcare for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American healthcare system as a whole and to emergency departments specifically,” the authors of the GED guidelines noted.
In response to a growing national interest in geriatric ED patients and an ever-increasing competition to attract patients from this demographic by EDs across the country, there has been a surge of self-designated GEDs during the last few years. Currently, more than 70 hospitals claim to have GEDs, raising the question of what sort of geriatric patient care is actually being delivered in these EDs. The question is of increased importance because very few of these “GEDs” are in academic centers or are associated with thought leaders in EM. In fact, when 30 self-designated GEDs that were snowball sampled in 2013 by researchers who asked what specific changes they had made toward the goal of improving care for the elderly, several rescinded this self-designation.
Because of heightened concerns for the needs of the increasing geriatric population overall, and the rise in the proportion of ED visits by this demographic, the authors of the GED guidelines state that “the contemporary emergency medicine management model may not be adequate for geriatric adults,” and offer the new GED guidelines as a basis on which EDs can consider ways to improve care for older adults while addressing the unique needs of this population. The GED guidelines propose specific methods and processes by which ED care of the elderly can be optimized. The authors note that “similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved the care both in individual EDs and system-wide, resulting in better, more cost-effective care and ultimately better patient outcomes.”
The GED guidelines consist of 40 specific recommendations in six general categories: (1) staffing/administration; (2) equipment/supplies; (3) education; (4) policies/procedures/protocols; (5) follow-up/transitions of care; and (6) quality-improvement measures. This template outlines how to construct an effective GED program. The following highlights recommendations for each of these categories:
Staffing/Administration. Set qualifications and responsibilities for the medical director, nurse manager, staff physicians, nurses, and specialists, as well as accessibility to specialist ancillary services, with the goal of establishing hospital site-specific staff and coordination of local resources.
Equipment/Supplies. Develop potential physical and structural enhancements that address issues of mobility, comfort, safety, and behavioral needs (including memory cues and sensorial perception) while decreasing iatrogenic complications, such as the development of pressure ulcers (eg, the use of reclining chairs and pressure-redistributing foam mattresses).
Education. Provide nurse and clinical provider education and specialty-specific training focusing on contemporary, research-based geriatric-specific material, with regular assessment for interdisciplinary core competencies.
Policies/Procedures/Protocols. Implement a directed, comprehensive approach to facilitate screening and assessment of geriatric patients for added needs/post-ED adverse outcomes, as well as validated, ED-feasible screening tools/instruments for delirium and dementia, medication management, falls, use of urinary catheters, and the provision of palliative care.
Follow-up/Transitions of Care. Design discharge processes best suited for older patients (eg, large-font instructions), as well as collaborate with community resources to provide home-health services and home safety assessment in order to facilitate care following discharge.
Quality Improvement. Implement a system to collect and monitor pertinent and prevalent geriatric emergency care indicators (eg, incidence of injurious falls and documentation of fall risk assessment) designed to increase staff education and program success.
The authors clearly state that the GED guidelines represent recommendations. They are not a mandate for every ED, nor are they a list that requires 100% compliance. Instead, the document provides the potential steps to be taken, the rationale for these recommendations, and an outline of the resources available to aid in the transition from theory to implementation in any ED. The goal is to ensure better, safer, and age-appropriate treatment. In summary, these guidelines represent an effort to improve and even transform emergency care for older adults on the brink of one of the most significant challenges facing our healthcare system both in and beyond the ED.
Moving forward, the authors of the GED guidelines have defined a plan that “includes dissemination, implementation, adaptation, and refinement.” In addition to approval by each of the organization’s board of directors and the copyright of the material in 2013, the ED guidelines have now been widely disseminated through publication in numerous news articles (including international publications) and discussions on satellite radio. Tracking of new GEDs is planned. In addition, the prioritization of the guidelines is underway using a modified Delphi method, with the express purpose of assessing the relative potential benefits and harms associated with each recommendation by providing a weighted list from most important to least important.
A “Geriatric Emergency Department Boot Camp” is being developed to bring the recommendations to hospitals interested in “geriatricizing” their EDs. Geriatric EM leaders will act as consultants, providing training and a toolbox of resources. Specific reviews and revisions of the GED guidelines will take place in a 4- to 5-year cycle. Clearly, a next important step is the development of a GED certification system based on outcome studies of the individual components.
Criticisms of the GED guidelines have already been voiced among some EM providers. Specific concerns include a fear of partitioning the ED (as has occurred with pediatrics); an increase in cost and decreased efficiency; the need to maintain general expertise among EM physicians; the lack of evidence-based data upon which the recommendations were made; the fact that some guidelines were extrapolated from other clinical settings; and the belief that these changes will be too logistically difficult and take too much time.
The fact remains that the wave of geriatric patients (the “silver tsunami”) is already beginning to hit the shores of our hospitals. And GEDs are already here to help absorb the impact. The lack of iron-clad evidence for many of the recommendations should not be an absolute obstacle, but rather part of the natural evolution and improvement of similar endeavors. Nor should GEDs contain empty beds while younger adults sit in the waiting room, or conversely, force the elderly to wait for space in the GED when there are empty beds in the main ED. Ideally, the GED should be the location where the ED staff can implement these guidelines, which they can afterwards utilize in any part of the ED. These guidelines are designed to provide the best available expert opinion on how to deliver better geriatric care in the ED. The imperative for this goal is clear and necessitates this educated “leap-of-faith.” Change is never easy and often comes with an upfront cost of time, resources, and money. Moreover, there is nothing in a well-designed GED that may not also benefit, or at least will not adversely affect care of a younger adult as well. Therefore, flexibility and optimal utilization of space in a busy ED need not be sacrificed.
Conclusion
To improve diagnostic evaluation and care of the increasing number of geriatric patients presenting to the ED, reliable tools, protocols, and guidelines must be developed and implemented to ensure diagnostic accuracy, decrease adverse events, and improve patient outcomes. Fortunately, the new GED consensus guidelines are flexible and do not need to be wholly embraced—lending themselves to modifications and institution-specific adoptions. The “protocolization” and implementation of the guidelines may improve patient flow, operational efficiency, and, most importantly, the quality of care delivered. And likely, these guidelines will provide the foundation for future education and research into the improved emergency care of older adults.
The GED guidelines can be accessed at http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2.
Dr Stern is an assistant professor of medicine and codirector, geriatric emergency medicine fellowship, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York; and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital.
Dr Mulcare is an instructor of medicine and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York. She is a former fellow of geriatric emergency medicine.
Case 1
An 82-year-old man presented to the ED accompanied by his son, who stated that his father “had not been acting right” for the past 2 days. The patient was combative, yelling “Go away,” and was intermittently more confused than his baseline; he was also eating and drinking less than usual. He had a history of mild dementia, noninsulin-dependent diabetes, hypertension, and arthritis; there were no recent changes in his medication. The patient lived alone in an apartment across the hall from his son and had home healthcare aide 4 hours a day, 3 days a week. He was independent of activities of daily living (ADL), but needed help with shopping and cooking.
At presentation, the patient’s vital signs were: temperature, afebrile; heart rate (HR), 94 beats/minute; blood pressure (BP), 146/92 mm hg; respiratory rate (RR), 22 breaths/minute. Oxygen (O2) saturation was 96% on room air. A finger-stick glucose test was 103 mg/dL. He was hyperalert and agitated, and did not appear oriented to place or time. There were no focal neurological deficits; mucous membranes were mildly dry; and faint crackles were heard at the right base of the lungs. The patient was placed on a monitor in a curtained room in the ED, and was given 2 L O2 via nasal cannula, which improved O2 saturation to 99%. With his son present, an intravenous (IV) line was placed and blood was drawn. An electrocardiogram (ECG) showed a sinus rhythm without ischemic findings.
During evaluation, the patient continued to pull at the monitor lines and attempted to get off the stretcher. To calm his agitation, he was given haloperidol 2.5 mg and lorazepam 1 mg; 10 minutes after administration, he became sedated and difficult to arouse. His vital signs remained stable.
Laboratory analysis revealed a white blood cell count (WBC) of 12.5 K/uL, a negative troponin, a brain natriuretic peptide (BNP) of 80 pg/mL, and normal blood urea nitrogen (BUN) and creatinine levels. Urinalysis was negative for infection, but chest X-ray showed a right lower lobe infiltrate. Blood cultures were drawn, and the patient was continued on maintenance fluids and started on IV antibiotics to cover community-acquired pneumonia. He was admitted to the hospital for pneumonia and altered mental status.
As the patient’s sedative state was followed by periods of agitation, he was treated with additional haloperidol and lorazepam by the inpatient medical team, which resulted in further sedation. On hospital day 3, his urinary output decreased. He was given an IV bolus of 3 L normal saline over 6 hours, after which his mental status began to improve, and he was switched to oral antibiotics. His mental status returned to baseline and O2 saturation was 99% on room air. He was discharged home on hospital day 5 accompanied by his son.
Case 2
A 75-year-old man was brought to the ED with a 3-day history of worsening dyspnea on exertion, increased orthopnea, and increased bilateral lower extremity edema. He had a history of congestive heart failure (CHF), with an ejection fraction of 40%, and had been on 40 mg of furosemide daily at home; there were no recent changes to his medication. The patient was independent of ADL at baseline, living with his wife in a home with stairs.
His vital signs at presentation were: temperature, afebrile; HR, 86 beats/minute; BP, 160/90 mm hg; RR 30 breaths/minute; O2 saturation was 92% on room air. The patient had increased work of breathing and was speaking in four- to five-word sentences. Pulmonary examination revealed crackles half way up bilaterally. He also had 2+ pitting edema bilaterally in his lower extremities. He was otherwise alert and oriented.
On 4 L O2 via nasal cannula, the patient’s O2 saturation was 98%. Laboratory analysis revealed a BNP of 600 pg/mL, negative troponin, and normal creatinine level. Urinalysis was negative for evidence of infection. An ECG showed no changes, and chest X-ray revealed mild pulmonary congestion without an infiltrate. In the ED, an indwelling urinary catheter (IUC) was placed to monitor urinary output before the patient was given 40 mg of IV furosemide for diuresis. The patient was then admitted for management of exacerbation of CHF. As the medical team was preparing to discharge him on hospital day 2, his wife noticed that he was confused and not acting “like himself.” An investigation for causes of delirium included evaluation for infectious disease, which revealed an elevated WBC of 14.0 K/uL, stable creatinine; and urinalysis positive for bacteria, WBCs, leukocyte esterase, and nitrites. Since chest X-ray showed resolution of the vascular congestion, the patient no longer required supplemental O2.
The IUC was removed, and the patient was started on IV antibiotics for a urinary tract infection (UTI) secondary to IUC placement. The inpatient stay was prolonged for an additional 3 days until his delirium cleared and he could be continued on oral antibiotics as an outpatient.
Discussion
There is nothing extraordinary about these two cases. Every day elderly adults present to EDs throughout the country with confusion caused by pneumonia and dehydration that is sometimes initially attributed to worsening dementia and then complicated or prolonged by overuse of powerful sedating medications. Also, complications resulting from IUCs inserted in the ED all too often prolong hospitalizations. But by using protocols designed for better, more efficient emergency care of elderly patients, their ED care can be substantially improved and any subsequent inpatient care shortened.
The older adult population (ages 65 years and older) often presents to the ED with similar complaints to their younger counterparts—eg, chest pain, abdominal pain, dyspnea. However, the history, physical examination, and social assessment of elderly patients usually lead to a more comprehensive work-up, as older adults tend to present in an atypical fashion for both illness and trauma, thus necessitating a broader differential. In addition, they are more susceptible to adverse reactions from medications and procedures.
Regardless of the ultimate diagnosis, simply presenting to an ED as a patient (and sometimes spending many hours there) places older adults at elevated risk of morbidity and mortality. The challenge is to develop reliable tools to streamline the management of this population in order to increase diagnostic accuracy, decrease adverse events, and improve patient outcomes.
Clinical Protocols
Clinical protocols are one way in which we can educate and standardize the practice of multiple levels of provider, including nurses, midlevel providers, and physicians. Adopting protocols is natural for EPs—the key is to make sure the clinical protocol to be implemented is designed or modified for the ED setting in which it will be implemented.
In our ED, we have recently implemented the following two protocols for common scenarios in older adults: (1) assessment and management of delirium; and (2) decreased use of IUCs. These protocols employ the following stepwise project plan:
- Focus groups involving nurses, midlevels, residents, and attendings to assess ED provider knowledge, attitudes, and practice patterns regarding the clinical issue in older adult patients, and to guide development of the clinical protocol by understanding needs and constraints of the current ED environment;
- An extensive literature review of the clinical topic;
- Development of the clinical protocol by the workgroup;
- Implementation of protocol after multiple educational sessions using a scripted slide presentation to ensure all providers receive the same information; and
- Subsequent data analysis from the electronic medical record to assess the impact (ie, outcome) of the protocol.
Delirium
Delirium is a common syndrome in older adults, but is often unrecognized despite its clinical importance. Although 7% to 17% of older adults who present to the ED suffer from delirium,1-6 emergency physicians (EPs) miss 64% to 83% of cases, and 12% to 38% of patients with unrecognized delirium are actually discharged from the ED.1,6-8 Unfortunately, patients discharged from the ED with undetected delirium are three times more likely to die within 3 months than those whose delirium was recognized.
Life-threatening causes are more apt to be recognized early on in the ED. With this in mind, we developed a new, comprehensive, evidence-based protocol for recognition, diagnosis, management, and disposition of agitated delirium in older adults in the ED, with a focus on identifying and treating the commonly missed contributing causes: analgesia, bladder-urine retention, constipation, dehydration, environment, and medications.9
IUC Placement in the ED
The second protocol implemented at our institution is a new, evidence-based protocol for the placement, management, and reassessment of IUCs. As emphasized by the National American College of Emergency Physicians (ACEP) 2013 Choosing Wisely Campaign,10 inserting an IUC is a procedure that should be undertaken judiciously as it is associated with an elevated risk of infection, delirium, falls, and other adverse events. As of 2008, the Centers for Medicare and Medicaid Services no longer reimburses for hospital-acquired catheter-associated UTIs.11
After conducting focus groups of our ED providers, we learned that IUCs are placed more frequently than needed—often for reasons of convenience—and are rarely reassessed or removed if the patient is admitted to the hospital. Thus, our protocol highlights appropriate, possibly appropriate, and inappropriate indications for IUC placement, with an emphasis on trying alternative modes of urine collection, communicating among healthcare providers regarding the necessity of an IUC, and reassessment of the patient for IUC removal.
Our protocols have yielded early promising results, but further research is underway to determine their specific impact. The goal is to create a protocol that is feasible and effective for the specific institution and department to which it is applied. By ensuring all members of the healthcare team are involved in the development and design of a protocol, there is ownership of its implementation and use, with the overarching goal of improving patient care.
Geriatric ED Guidelines
In the beginning of 2014, new consensus-based Geriatric Emergency Department (GED) guidelines were published in order to “provide a standardized set of guidelines that can effectively improve the care of the geriatric population and are feasible to implement in the ED.”12 These guidelines are the result of a 2-year effort by representatives from ACEP, the American Geriatrics Society, the Society of Academic Emergency Medicine, and the Emergency Nurses Association, who were committed to optimizing the emergency-care delivery model for geriatrics. The participants encompassed both academic and community providers and included clinicians and researchers. These guidelines were formulated based on an 80% consensus among the representatives and, when possible, validated using existing literature at the time.
The genesis of the GED guidelines was multifactorial. In addition to the formation and rapid growth of geriatric interest groups and sections within EM academic organizations over the last 14 years, as well as the development of geriatric core competencies for EM residents in training, the 2010 Census Data results sharply outlined the details of the rapidly growing population of older adults in the United States. This acted as an alarm highlighting the need for a structured document containing best practice recommendations from geriatric emergency healthcare providers, researchers, and advocates. “The subsequent increased need for healthcare for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American healthcare system as a whole and to emergency departments specifically,” the authors of the GED guidelines noted.
In response to a growing national interest in geriatric ED patients and an ever-increasing competition to attract patients from this demographic by EDs across the country, there has been a surge of self-designated GEDs during the last few years. Currently, more than 70 hospitals claim to have GEDs, raising the question of what sort of geriatric patient care is actually being delivered in these EDs. The question is of increased importance because very few of these “GEDs” are in academic centers or are associated with thought leaders in EM. In fact, when 30 self-designated GEDs that were snowball sampled in 2013 by researchers who asked what specific changes they had made toward the goal of improving care for the elderly, several rescinded this self-designation.
Because of heightened concerns for the needs of the increasing geriatric population overall, and the rise in the proportion of ED visits by this demographic, the authors of the GED guidelines state that “the contemporary emergency medicine management model may not be adequate for geriatric adults,” and offer the new GED guidelines as a basis on which EDs can consider ways to improve care for older adults while addressing the unique needs of this population. The GED guidelines propose specific methods and processes by which ED care of the elderly can be optimized. The authors note that “similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved the care both in individual EDs and system-wide, resulting in better, more cost-effective care and ultimately better patient outcomes.”
The GED guidelines consist of 40 specific recommendations in six general categories: (1) staffing/administration; (2) equipment/supplies; (3) education; (4) policies/procedures/protocols; (5) follow-up/transitions of care; and (6) quality-improvement measures. This template outlines how to construct an effective GED program. The following highlights recommendations for each of these categories:
Staffing/Administration. Set qualifications and responsibilities for the medical director, nurse manager, staff physicians, nurses, and specialists, as well as accessibility to specialist ancillary services, with the goal of establishing hospital site-specific staff and coordination of local resources.
Equipment/Supplies. Develop potential physical and structural enhancements that address issues of mobility, comfort, safety, and behavioral needs (including memory cues and sensorial perception) while decreasing iatrogenic complications, such as the development of pressure ulcers (eg, the use of reclining chairs and pressure-redistributing foam mattresses).
Education. Provide nurse and clinical provider education and specialty-specific training focusing on contemporary, research-based geriatric-specific material, with regular assessment for interdisciplinary core competencies.
Policies/Procedures/Protocols. Implement a directed, comprehensive approach to facilitate screening and assessment of geriatric patients for added needs/post-ED adverse outcomes, as well as validated, ED-feasible screening tools/instruments for delirium and dementia, medication management, falls, use of urinary catheters, and the provision of palliative care.
Follow-up/Transitions of Care. Design discharge processes best suited for older patients (eg, large-font instructions), as well as collaborate with community resources to provide home-health services and home safety assessment in order to facilitate care following discharge.
Quality Improvement. Implement a system to collect and monitor pertinent and prevalent geriatric emergency care indicators (eg, incidence of injurious falls and documentation of fall risk assessment) designed to increase staff education and program success.
The authors clearly state that the GED guidelines represent recommendations. They are not a mandate for every ED, nor are they a list that requires 100% compliance. Instead, the document provides the potential steps to be taken, the rationale for these recommendations, and an outline of the resources available to aid in the transition from theory to implementation in any ED. The goal is to ensure better, safer, and age-appropriate treatment. In summary, these guidelines represent an effort to improve and even transform emergency care for older adults on the brink of one of the most significant challenges facing our healthcare system both in and beyond the ED.
Moving forward, the authors of the GED guidelines have defined a plan that “includes dissemination, implementation, adaptation, and refinement.” In addition to approval by each of the organization’s board of directors and the copyright of the material in 2013, the ED guidelines have now been widely disseminated through publication in numerous news articles (including international publications) and discussions on satellite radio. Tracking of new GEDs is planned. In addition, the prioritization of the guidelines is underway using a modified Delphi method, with the express purpose of assessing the relative potential benefits and harms associated with each recommendation by providing a weighted list from most important to least important.
A “Geriatric Emergency Department Boot Camp” is being developed to bring the recommendations to hospitals interested in “geriatricizing” their EDs. Geriatric EM leaders will act as consultants, providing training and a toolbox of resources. Specific reviews and revisions of the GED guidelines will take place in a 4- to 5-year cycle. Clearly, a next important step is the development of a GED certification system based on outcome studies of the individual components.
Criticisms of the GED guidelines have already been voiced among some EM providers. Specific concerns include a fear of partitioning the ED (as has occurred with pediatrics); an increase in cost and decreased efficiency; the need to maintain general expertise among EM physicians; the lack of evidence-based data upon which the recommendations were made; the fact that some guidelines were extrapolated from other clinical settings; and the belief that these changes will be too logistically difficult and take too much time.
The fact remains that the wave of geriatric patients (the “silver tsunami”) is already beginning to hit the shores of our hospitals. And GEDs are already here to help absorb the impact. The lack of iron-clad evidence for many of the recommendations should not be an absolute obstacle, but rather part of the natural evolution and improvement of similar endeavors. Nor should GEDs contain empty beds while younger adults sit in the waiting room, or conversely, force the elderly to wait for space in the GED when there are empty beds in the main ED. Ideally, the GED should be the location where the ED staff can implement these guidelines, which they can afterwards utilize in any part of the ED. These guidelines are designed to provide the best available expert opinion on how to deliver better geriatric care in the ED. The imperative for this goal is clear and necessitates this educated “leap-of-faith.” Change is never easy and often comes with an upfront cost of time, resources, and money. Moreover, there is nothing in a well-designed GED that may not also benefit, or at least will not adversely affect care of a younger adult as well. Therefore, flexibility and optimal utilization of space in a busy ED need not be sacrificed.
Conclusion
To improve diagnostic evaluation and care of the increasing number of geriatric patients presenting to the ED, reliable tools, protocols, and guidelines must be developed and implemented to ensure diagnostic accuracy, decrease adverse events, and improve patient outcomes. Fortunately, the new GED consensus guidelines are flexible and do not need to be wholly embraced—lending themselves to modifications and institution-specific adoptions. The “protocolization” and implementation of the guidelines may improve patient flow, operational efficiency, and, most importantly, the quality of care delivered. And likely, these guidelines will provide the foundation for future education and research into the improved emergency care of older adults.
The GED guidelines can be accessed at http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2.
Dr Stern is an assistant professor of medicine and codirector, geriatric emergency medicine fellowship, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York; and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital.
Dr Mulcare is an instructor of medicine and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York. She is a former fellow of geriatric emergency medicine.
- Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13(2):142-145.
- Naughton BJ, Moran M, Ghaly Y, Michalakes C. Computed tomography scanning and delirium in elder patients. Acad Emerg Med. 1997;4(12):1107-1110.
- Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med. 1995;25(6):751-755.
- Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39(3):248-253.
- Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5):678-684.
- Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163(8):977-981.
- Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200.
- Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. 2002;39(3):338-341.
- Rosen T, Connors S, Halpern A, et al. Improving emergency department identification and management of agitated delirium in older adults: implementation and impact assessment of a comprehensive clinical protocol emphasizing commonly missed contributing causes using an A-B-C-D-E-F mnemonic. Sys Qual Rev J. 2013;11(special issue):203,204. http://www.nypsystem.org/pdf/System-Quality-Review-2013.pdf. Accessed June 4, 2014.
- Choosing Wisely: ACEP Lists 5 Tests to Question. Medscape Web site. http://www.medscape.com/viewarticle/812600. Accessed June 4, 2014.
- Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA. 2007;298(23):2782-2784.
- American College of Emergency Physicians; American Geriatrics Society; Emergency Nurses Association; Society for Academic Emergency Medicine. Geriatric Emergency Department Guidelines. http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2. Accessed June 4, 2014.
- Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13(2):142-145.
- Naughton BJ, Moran M, Ghaly Y, Michalakes C. Computed tomography scanning and delirium in elder patients. Acad Emerg Med. 1997;4(12):1107-1110.
- Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med. 1995;25(6):751-755.
- Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39(3):248-253.
- Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5):678-684.
- Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163(8):977-981.
- Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200.
- Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. 2002;39(3):338-341.
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