GERI FRIENDLY ED Dr Guruprasad ( Guru) Nagaraj ED Physician with sp interest in GEM Liverpool Hospital. @geminaustralia

Geriatric ED presentations • 20% of all presentations to ED • 40 % of > 65 get admitted • 80% of > 85 get admitted • Numbers are increasing • Often have multiple co morbidities • Different physiology

Triage

Triage

An acute medical problem was identified in 129 of those patients (51%).

All these patients were triaged in lower acuity categories.

33 (26%) were undertriaged due to 1. absence of vital signs measurement, 2. poor recognition of neurological symptoms, 3. atypical clinical presentation.

Triage Things to consider

Atypical presentations Altered physiology Vitals can be deceiving May be over triage might be better

Structure

Structure

• Location • Access • Lighting: • Dual monitors • Toilet • Electric point

• Bedside • Distraction/Entertainment

• Physio/ OT assessment equipment

Evaluation • Social issues • Psychological issues • Financial issues • Vision and hearing issues

Functional assessment Basic (self-care)(“DEATH”)

Dressing Eating Ambulating Toileting Hygiene

Instrumental (community interactions)

(“SHAFT”) Shopping Housework Accounting Food preparation Transportation

Goals of care

• Patients point of view • Doctors point of view

Delirium and Dementia

End Of Life Care ( EOLC)

Capacity • needs to be assessed every

time • Is specific for the question and

the situation

Consent • Is specific for the given situation • Implied cosent in ED for life

saving situations only • ? End of life care Substitute decision makers • Often difficult to identify • Have a clear idea

Depression • 3% elderly have major depression in community • in GP 10% • medical inpatients – 30% • RACF 50% • Often no subjective symptoms

• Insomnia /agitation/being worried or somatic symptoms might be only

clue

Very high incidence of suicide in >85 esp males • Ratio of suicide attempts to completed • Age 20 :1 • >85 4:1

Admit if you are worried but definitely if they have attempted suicide

Polypharmacy

• Too many • Too much • Too long

• Often un necessary

• What are the common drugs implicated in ADEs ?

Polypharmacy • Anti-hypertensive and diuretics • Opioids and benzodiazepines • Antineoplastic agents, • Anti-thromboitcs • Anti-bacterials

• Know common interactions • Use IT solutions • Avoid prescribing cascade • Transcribe correctly • Use IIMS or other adverse event notification system • Develop and implement QA projects • Notify If you change meds in ED

Abuse and Neglect

• Pattern of behaviour by a person that results in physical

or psychological harm to an older person. (McCallum, Matiasz and Graycar 1990)

• .

• Neglect, by comparison, is used as a general label for acts of omission, namely those with only a passive involvement of the abuser (McCallum, Matiasz and Graycar 1990).

Some stats • Incidence 2%–10%. • Only around 5% get reported • Most occur in the home. • A household member (89.7%) • A paid caregiver (4.2%). • Although there are extreme cases of elder abuse, the

abuse is often subtle.

EASI

Falls • Commonest form of trauma • Why did they fall • Is this one of many • Does the fracture match the mechanism • Osteoporosis can be treated • Use OT / Physio

Resources available • Geri-ED.com • Geri ED guideline (ACEP) • Silver book (UK) • GEMSIG of ACEM and IFEM • Geri EM podcast • EMA acute geriatrics series

•Thank you

• @geminaustralia • GEMinAustralia@gmail.com