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connection“Transitions of care” has become a hot topic in the care of older adults. It is usually applied to the transition from the hospital to home or the hospital to a nursing facility. But what about the transition from the ED to an inpatient service? It turns out there are plenty of things we could be doing (or not doing) to help smooth that transition and improve patient care. Here are some thoughts from admitting physicians with geriatrics training.

10. Don’t lose important belongings.

Dentures, glasses, and hearing aids are all expensive items for patients, and they frequently seem to go missing in the ED. Whether the items are put somewhere for safekeeping and then lost, or removed to facilitate care in the case of dentures and intubation, this is a set up for a troublesome admission. Making an effort to keep the items with the patient or a family member will help the patient down the line. Without glasses or hearing aids, a hospital stay can become more confusing, overwhelming, and contribute to delirium. Plus it makes it harder for doctors and nurses to communicate with a patient who can’t hear. Without dentures, the patient may be condemned to a soft diet and the cost of replacement dentures. Help make sure these items stay with the patient or a responsible family member.

9. Tell the admitting doctor if you have any concerns about alcohol and substance abuse.

Though the typical 70-year-old does not usually appear suspicious for having an alcohol or substance abuse problem, the prevalence is higher than you might suspect (screening for alcohol misuse). In a study of primary care patients aged 66-75, 29% of men and 10.8% of women consumed more than the currently recommended limits [1]. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends no more than 7 drinks per week, and no more than 3 in one day for older men and women [2].

Patients are often unaware they are drinking at hazardous levels. Of men over age 60 who were drinking more than 14 drinks per week, almost 60% were not aware of the guidelines [3]. For your patient who presents with a hip fracture, worsening CHF exacerbation, syncope, or delirium, ask about alcohol and substance use. The admitting physicians should also ask about this, but if you have any suspicion for regular alcohol use, communicate it to the admitting doc, so they can keep their eyes out for it, and treat it early rather than 2 days into a hospital stay when the patient is hallucinating from withdrawal. In these patients, if an alcohol level will be checked, it should be sent early on, and may help identify patients who are at higher risk of experiencing withdrawal.

8. Give the patient their home medications.

Give home medications unless contraindicated by their illness or presentation. Clearly, if the patient in septic shock, do not give them their home doses of Lisinopril and Hydralazine. However, often home meds for hypertension, diabetes, and chronic pain can be safely administered. When a patient’s home medications are not ordered, patients tend to hit the floors with very high blood pressures, pain, and elevated sugars. Especially in elderly patients, this can make their inpatient management more difficult and potentially prolong their hospitalization.

7. Keep checking in with the patient.

It is easy in a busy ED to forget about our admitted patients as we have a constant stream of new people to see. If an older adult is boarding in your ED for an extended period of time waiting for a bed, the admitting team will do their best to check in, but they will not be able to lay eyes on the patient as often as you can. Older adults who are sedated, septic, quietly demented, or have hypoactive delirium may be easy to forget about. They may need simple things like food, water, help to the bathroom, or reorientation. They may not know how to ask for help or be able to push the nurse call button. If you can position them where you can see them, glance at their vitals when you walk by, or check in with them, that can help make sure their medical condition has not significantly deteriorated while they board with you.

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6. Hold on to the records that come with patients.

Hold on to records, medication lists, and DNR forms. If the patient has dementia, is delirious, or has some other barrier to clear communication, lacking records can lead to more unnecessary testing. It may also result in treatment beyond the scope of the patient’s wishes. If he or she comes with records from another hospital or a nursing facility, do your best to make sure they stay with the patient or in a safe place to hand off to the admitting physician.

5. Avoid medications that could ‘snow’ the patient for days.

Diphenhydramine, antipsychotics, and benzodiazepines are frequently used for combative patients. However, they can have prolonged effects in older adults, and also can be deliriogenic. Giving a combative older adult a ‘B52′ (50 mg of benadryl, 5 mg of haldol, and 2 mg of lorazepam) could put them down for one or two days, making inpatient assessment and management challenging, and leading to a prolonged recovery time. Instead, first try behavioral modifications. Some EDs and hospitals have activity aprons that can help distract the patient. Or you can encourage family members or a sitter to help with redirection and reorientation. If medications are needed, try a small dose of an antipsychotic, such as 0.5 mg or 1 mg of haldol IV or IM, 2.5-5 mg of PO rapidly-dissolving olanzapine (Zydis), or 5-10 mg IM ziprasidone (Geodon).

4. Be careful with pain medication dosing in older patients.

There are age-associated differences in effectiveness, sensitivity, and toxicity that put older adults at risk for side effects and adverse drug events. The American Geriatrics Society recommends Tylenol as the first line agent for pain control in older adults. If Tylenol is not sufficient or the patient has severe pain, it is reasonable to give opioids. “Start low and go slow” is an axiom among geriatricians. This works well as long as you reassess frequently to ensure adequate pain control [4]. That means, for example, in an opiate-naive, frail, older patient consider starting with 2 mg of morphine IV, 2.5 or 5 mg of oxycodone PO, or 5 mg of hydrocodone PO. Reassess every 15 minutes (for IV medication), and re-dose until adequate pain control is achieved. NSAIDs should also be used with caution. Many older adults have reduced creatinine clearance, and NSAIDs can worsen this leading to acute renal failure and hyperkalemia. Also use with caution in those with gastropathy, cardiovascular disease, or congestive heart failure [5]. It is important, however, to adequately treat pain and relieve suffering. While you may be worried that the medication could cause delirium, pain itself can be deliriogenic!

3. Write down the contact information for family members who bring the patient and then leave.

Demented or severely ill patients may not be able to tell you their family members’ phone numbers (without our cell phones, most of us couldn’t recite our family’s phone numbers), leaving the admitting physician unable to obtain much history. Better yet, encourage the family to stay until the admitting team can see the patient. Not only is their input extremely valuable, their presence can help prevent confusion for the patient. Family members can also act as patient advocates, to help call a nurse or physician when they need help.

2. If there is no clear indication to investigate the patient’s urine, do not send a UA.

When screened, around 50% of institutionalized older women have asymptomatic bacteruria[6]. Many asymptomatic older adults also have pyuria [7]. In a cognitively intact older adult, asymptomatic bacteriuria does not require treatment. Over-treatment brings the usual risks of increasing antibiotic resistance, as well as the risk of medication side effects and polypharmacy. To read more on the importance of not treating asymptomatic bacteruria, see the AMDA Choosing Wisely Guidelines and prior blogposts on diagnosis and treatment of UTIs in older adults.

1. Contact the sending facility.

If a patient comes from a skilled nursing facility (SNF) contact the facility early. A patient may come in for a reported fall, but after talking to the person who witnessed it, you may conclude that they actually had syncope, a seizure, or stroke-like symptoms. The only way to find out these critical details is to call the facility. Often by the time the patient is admitted, the staff member at the SNF who witnessed the episode will have gone, leaving no one who can say what actually happened to help guide the workup.

 

Summary

Treat older adults in the ED the way you would want your older family members to be treated.

The ED is a busy place. We are pulled in dozens of directions taking care of existing patients, seeing new patients, and supervising residents or medical students. Some of the tips suggested here will take an extra minute or two during your shift, but they can pay huge dividends both for the patient’s well-being and for your relationship with the admitting physician.

MalloryIf you have other suggestions, leave a comment!

 

This post was written in collaboration with University of North Carolina Geriatrics/Family Medicine fellow, Dr. Mallory McClester Brown.

References

  1. W.L. Adams, K.L. Barry, and M.F. Fleming, "Screening for problem drinking in older primary care patients.", JAMA, 1996. http://www.ncbi.nlm.nih.gov/pubmed/8971065
  2. R. Saitz, "Clinical practice. Unhealthy alcohol use.", The New England journal of medicine, 2005. http://www.ncbi.nlm.nih.gov/pubmed/15703424
  3. K. Gilson, C. Bryant, and F. Judd, "Exploring risky drinking and knowledge of safe drinking guidelines in older adults.", Substance use & misuse, 2014. http://www.ncbi.nlm.nih.gov/pubmed/24827868
  4. U. Hwang, and T.F. Platts-Mills, "Acute pain management in older adults in the emergency department.", Clinics in geriatric medicine, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23177605
  5. E.M. Antman, J.S. Bennett, A. Daugherty, C. Furberg, H. Roberts, K.A. Taubert, and . , "Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association.", Circulation, 2007. http://www.ncbi.nlm.nih.gov/pubmed/17325246
  6. T.A. Rowe, and M. Juthani-Mehta, "Diagnosis and management of urinary tract infection in older adults.", Infectious disease clinics of North America, 2013. http://www.ncbi.nlm.nih.gov/pubmed/24484576
  7. J.G. Ouslander, M. Schapira, J.F. Schnelle, and S. Fingold, "Pyuria among chronically incontinent but otherwise asymptomatic nursing home residents.", Journal of the American Geriatrics Society, 1996. http://www.ncbi.nlm.nih.gov/pubmed/8636589
Christina Shenvi, MD PhD

Christina Shenvi, MD PhD

Assistant Professor
Assistant Residency Director
University of North Carolina
Christina Shenvi, MD PhD

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