Preventing Adverse Events in Hospitalized Elderly

Aka: Preventing Adverse Events in Hospitalized Elderly, Geriatric Emergency Care, Acute Care in Older Adults, Emergency Care of the Elderly

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II. Epidemiology

  1. Adverse events occur in 6% of hospitalized patients over age 65
    1. Twice the rate of all patients
    2. Brennan (2004) Qual Saf Health Care 13:145 [PubMed]
  2. Adverse events in the hospitalized elderly
    1. Drug event (15%)
    2. Pressure Ulcer (13-23%)
    3. Functional loss (33%)
    4. Delirium (9-56%)
    5. Malnutrition (75%)
    6. Hospital Infections (CAUTI, Wound Infections)
    7. Rothschild (2000) Arch Intern Med 160:2717 [PubMed]

III. Precautions

  1. Every emergency visit and hospitalization are high risk events

IV. Evaluation: Emergency Department Triage

  1. Elderly evaluation and management is delayed overall (in addition to triage process) more than younger patients
  2. Even apparently minor injuries on presentation are associated with increased morbidity and mortality
  3. Delirium is often missed on initial emergency department triage and on medical provider evaluation
    1. Standardized tools are recommended (e.g. B-CAM)
  4. Elderly are undertriaged in at least one third of cases in the Emergency Department (esp. in age over 90 years old)
    1. Emergency Severity Index (ESI) Vital Sign and mental status criteria have poor Test Sensitivity in elderly
    2. Proposed abnormal criteria for older adults
      1. Heart Rate >90
      2. Systolic Blood Pressure <110 mmHg
      3. Temperature >99.3 F (37.4 C)

V. Evaluation: Factors that affect poor outcome

  1. Precautions for those over age 75 years
    1. Activities of Daily Living dependence on others in 75% of patients after Emergency Department visit
    2. Unable to walk without assistance in 50% of emergency department patients
  2. Cognitive Function
    1. See Brief Confusion Assessment Method (bCAM)
    2. Clock Drawing Test with 3 item recall
  3. Mobility
    1. Get Up and Go Test
  4. Activities of Daily Living
    1. See Activities of Daily Living
  5. Nutrition (involve dietician early)
    1. BMI <20
    2. Weight loss >10 pounds in 6 months
    3. Cachexia
    4. Albumin <3.0 mg/dl

VI. Disposition: Safety for Discharge Home from Emergency Department or Hospital

  1. Functional
    1. Assess independent mobility before discharge
      1. Consider Get Up and Go Test
    2. Activities of Daily Living (ADLs)
    3. Fall Risk
    4. Medication Compliance
  2. Social
    1. See Community Services for the Elderly
    2. Community support
    3. Chain of emergency contacts and support
  3. Cognitive
    1. Dementia or Delirium
    2. Confusion Assessment Method
  4. Medical
    1. Seriousness of acute complaint
    2. Risk of short-term decompensation of chronic comorbidity
  5. Pain Control (undertreated in older patients)
    1. Risk for Delirium, functional loss and falls
    2. See Emergency Department Transition to Palliative Care (distinguish from Hospice)
    3. Consider Non-Opioid Analgesics
      1. Acetaminophen
      2. Topical Anesthetic (e.g. Lidoderm, Diclofenac Gel)
  6. References
    1. http://boringem.org/2015/01/12/approach-to-geriatric-patients/

VII. Prevention: Improve safety and quality for individual patients

  1. Address Advance Directives
  2. Careful drug prescribing
    1. See Medications to Avoid in Older Adults (STOPP, Beer's List)
    2. See Polypharmacy
    3. See Drug-Drug Interactions in the Elderly
    4. See Medication Causes of Delirium in the Elderly
    5. Use alternatives to Opioids or lower doses when possible, but avoid under-treating pain
  3. Reconcile medications
    1. Verify admission list for accuracy
    2. Assess medication doses, indications, stop dates
    3. Discharge summary clearly reconcile medications
      1. See Transitions of Care
      2. Admitting medications listed in PMH
      3. Discharge medication list should be clear
        1. Was the drug new, continued, stopped, changed?
        2. Date for re-evaluation or stopping
        3. Medication indication
  4. Assess for Delirium
    1. See Delirium
    2. See Brief Confusion Assessment Method (bCAM)
    3. Manage baseline Dementia related problems typically exacerbated in the hospital
      1. See No-fail Environment in Dementia
      2. See Dementia Related Malnutrition
      3. See Agitation in Dementia
      4. See Sleep Problems in Dementia
  5. Minimize functional loss
    1. Reduce use of restraints and catheters
    2. Keep patients moving
      1. Consult occupational and physical therapy early
      2. Muscle Strength loss is 5% per day with non-use
    3. Reduce use of psychoactive drugs
      1. See Medications to Avoid in Older Adults
  6. Follow-up
    1. Consider Referrals
      1. See Community Services for the Elderly
      2. See Palliative Care
    2. Communicate with provider in primary care or at accepting facility
      1. See Transitions of Care
    3. Follow-up phone call at 3 days (and consider at 10-14 days)
      1. Prevents bounce backs and readmissions
      2. Aldeen (2014) J Am Geriatr Soc 62(9): 1781-5 [PubMed]

VIII. Prevention: Emergency Department Environment Changes

  1. Fall Prevention
    1. Handrails in the hallway
    2. Keep hallways clutter free
    3. Even walking surfaces
    4. Avoid bed rails (paradoxically increase Fall Risk)
    5. Keep bed at lowest level
    6. Well-lit hallways
    7. Limit tethers (cords, catheters)
    8. Eliminate uneven walking surfaces and avoid textured tiles, carpets or rugs
  2. Delirium Prevention and Reorientation Cues
    1. Large clock faces
    2. Room signs with current date and day of the week
    3. Large, well placed signs for bathroom and exits
    4. Bedside testing is optimal (over transfer to and from multiple departments such as imaging)
    5. Encourage use of glasses and Hearing Aids
    6. Family and sitters may help to reorient and engage the patient throughout the visit
  3. Skin breakdown prevention
    1. See Pressure Sore Prevention
    2. Thick, soft mattresses or soft reclining chairs (if extended emergency department duration)
    3. Limit medical tape and adhesive use (Skin Tear risk)
  4. Multi-Disciplinary Consultation
    1. Pharmacy medication reconciliation and review adverse medication risks (Polypharmacy, Beers List, STOPP)
    2. Social workers and case managers
    3. Physical therapists

IX. References

  1. AA Borrud (Fall, 2005) Mayo Geriatric Update Lecture
  2. Cimino-Fiallos and Khoujas (2018) Crit Dec Emerg Med 12(9): 3-11
  3. Cimino-Fiallos and Khoujas (2022) Crit Dec Emerg Med 36(9): 23-9

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