Quality Geriatric Emergency Care II: Preparing for the Future Functional Assessment

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Quality Geriatric EmergencyCare II Preparing
for the FutureFunctional Assessment

• Scott T. Wilber, MD, MPH
• Summa Health System / NEOUCOM

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Geriatric Emergency Care Model
From SAEM ECEP Instructors Manual
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Principles of Geriatric Emergency Medicine

• 1. The patients presentation is frequently
  complex
• 2. Common diseases present atypically in this age
  group
• 3. The confounding effects of co-morbid diseases
  must be considered

From SAEM ECEP Instructors Manual
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Principles of Geriatric Emergency Medicine

• 4. Polypharmacy is common and may be a factor in
  presentation, diagnosis, and management
• 5. Recognition of the possibility for cognitive
  impairment is important.
• 6. Some diagnostic tests may have different
  normal values

From SAEM ECEP Instructors Manual
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Principles of Geriatric Emergency Medicine

• 7. The likelihood of decreased functional reserve
  must be anticipated
• 8. Social support systems may not be adequate,
  and patients may need to rely on caregivers
• 9. A knowledge of baseline functional status is
  essential for evaluating new complaints

From SAEM ECEP Instructors Manual
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Principles of Geriatric Emergency Medicine

• 10. Health problems must be evaluated for
  associated psychosocial adjustment
• 11. The emergency department encounter is an
  opportunity to assess important conditions in the
  patients personal life

From SAEM ECEP Instructors Manual
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ED Assessment of Elderly Patients
From SAEM ECEP Instructors Manual
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Summary Points

• 1. The elderly person has a unique physiology,
  patter and incidence of disease and psychosocial
  needs.
• 2. The optimal emergency care of elderly
  patients will require a more comprehensive model
  of care.
• 3. The new model of care takes into account the
  elderly persons functional, cognitive,
  emotional status in assessing the patient
  complaint and discharge planning.
• 4. Cognitive impairments are frequently detected
  in elderly patients seeking emergency care.
  Formal mental status testing will help assess
  cognitive impairments and determine the need for
  further work up in an emergency department
  setting.

From SAEM ECEP Instructors Manual
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Summary Points Continued

• 5. Assessment of functional activities is
  important in evaluation and disposition of
  elderly patients in the emergency department.
• 6. Principles of geriatric emergency medicine
  have been defined. Issues such as complexity of
  the chief complaint, atypical disease
  presentation, confounding effects of comorbid
  diseases, polypharmacy, cognitive impairment,
  altered normal values in some diagnostic tests,
  decreased functional reserve, the need for
  psychosocial support and assessment of functional
  status are key factors in optimizing the
  emergency care of the elderly.

From SAEM ECEP Instructors Manual
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Siebens, H. AEM 12(2) 162-8.
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Functional Assessment

• AGS Project Research Agenda Setting Process
• Reviewed EM Literature 1980-2001
• Found little information regarding functional
  assessment or limitation in the emergency
  medicine literature.

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Functional Assessment

• EmergMed 9 (Level B) Development and testing of
  measures for functional assessment that are
  feasible and valid in elderly emergency
  department patients are needed.
• EmergMed 10 (Level B) Case-control or cohort
  studies are needed to determine whether older
  emergency department patients with functional
  impairment have worse outcomes than do those
  without impairment.
• EmergMed 11 (Level A) Controlled intervention
  trials are needed to determine whether the
  detection and management of functional impairment
  in older emergency department patients have an
  effect on these outcomes.

http//www.americangeriatrics.org/specialists/NewF
rontiers/
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Functional Assessment

• New Horizons
• Reviewed EM Literature 2000-2005
• New Research Addressing These Questions
• No new research addressing these questions was
  found.
• Modification of These Questions in Light of New
  Research
• Since the publication of New Frontiers no
  evidence has emerged to prompt a modification of
  the original questions.

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Literature Search

• "Activities of Daily Living"Mesh AND
  ("Emergency Service, Hospital"Mesh OR
  "Emergency Medical Services"Mesh OR "Emergency
  Treatment"Mesh OR "Emergency Medicine"Mesh)
• 305 Articles 1978-2008
• 20 Pertinent

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Potential Quality Indicator 1

• If an older patient presents with functional
  decline, then the ED evaluation should include an
  evaluation for serious medical problems, because
  these serious medical conditions may present with
  functional decline.
• Measure Comprehensive medical evaluation
  documented in the medical record.

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Potential Quality Indicator 2

• If an older patient presents with subacute
  medical symptoms, then the patient should be
  assessed for functional decline, because
  functional decline commonly prompts ED visits in
  older patients.
• Measure Functional assessment documented in the
  medical record if patient presents with symptoms
  gt 48 hours old.

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Potential Quality Indicator 3

• If an older patient has functional decline or a
  new injury identified in the ED and the patient
  is considered for discharge, then the patient
  should be assessed for the ability to transfer
  and ambulate prior to discharge, because these
  activities of daily living are necessary unless
  24 care is available.
• Measure Documentation of the ability to transfer
  and ambulate in the medical record for discharged
  patients with functional decline.
• Exclusion Patients who have 24 hour care
  available.

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Group Discussion

• Accept
• Reject
• Modify

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Potential Quality Indicator 1Accept, Reject,
Modify

• If an older patient presents with functional
  decline, then the ED evaluation should include an
  evaluation for serious medical problems, because
  these serious medical conditions may present with
  functional decline.

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Potential Quality Indicator 2Accept, Reject,
Modify

• If an older patient presents with subacute
  medical symptoms, then the patient should be
  assessed for functional decline, because
  functional decline commonly prompts ED visits in
  older patients.

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Potential Quality Indicator 3Accept, Reject,
Modify

• If an older patient has functional decline or a
  new injury identified in the ED and the patient
  is considered for discharge, then the patient
  should be assessed for the ability to transfer
  and ambulate prior to discharge, because these
  activities of daily living are necessary unless
  24 care is available.