This document discusses acute care of elderly patients in emergency departments. It notes that elderly patients make up a large proportion of emergency department visits, often arriving by ambulance. Elderly patients are more likely to have unnecessary emergency department visits and longer lengths of stay. The document advocates for improved pre-hospital interventions to prevent emergency department visits for falls in elderly patients. It also suggests implementing comprehensive geriatric assessments and observation units in emergency departments to help determine if admissions are necessary and reduce admissions, readmissions, and return visits for elderly patients.

1. Acute Care of the Elderly
or…. Learning to love frailty
Suzanne Mason
Professor of Emergency Medicine
University of Sheffield, UK

2. • Not sexy
• No gizmos / gadgets
• No targets
• Where is Scott Weingart
when we need him???
……………
• Toenails, tottering and
toileting

3. • How many
• When
• Do they need to come
• How
• Admissions
• Experiences
• Making it better

4. ED attendances by age
Av. 25.9%
Based on analysis of 16 EDs and 1.03 million patient visits (HSCIC data 2011-2014)

5. Arriving by ambulance
Av. 64.2%

6. Unnecessary Attendance
Unnecessary, N (%) Necessary, N (%) Total, N (%)
16 – 24 145,413 (21.0) 529,738 (76.4) 693,747 (100.0)
25 – 34 124,876 (19.9) 483,426 (77.2) 626,587 (100.0)
35 – 44 97,032 (18.5) 414,753(79.0) 525,192 (100.0)
45 – 54 81,471 (16.5) 401,104 (81.4) 492,837 (100.0)
55 – 64 48,207 (13.0) 316,317 (85.3) 370,626 (100.0)
65 – 74 30,034 (8.8) 306,718 (90.1) 340,457 (100.0)
75 – 84 20,543 (5.6) 341,306 (93.6) 364,453 (100.0)
85+ 9,715 (3.8) 242,666 (95.7) 253,702 (100.0)
Total 557,291 (15.2) 3,036,028 (82.8) 3,667,601 (100.0)
Missing data excluded for this presentation

7. Admitted patients by age
Av. 52.3%

8. Older people’s experience of ED
2006
Total time in department
0 60 120 180 240 300 360
Percentageofattendanceepisodes
0
2
4
6
8
10
12
Under 65
65+
Spike accounted for 6.3% <65yrs and 17.3% of those >65 yrs
Total time in ED for older people ↓47 mins
Older people likely to stay >1hr longer than younger patients
05/09/2016 © The University of Sheffield 8
Patient level data for 15 EDs

9. Is it changing?
• Attendances 65+ ↑by 234/ year (95% CI: 148 to 320,
P<0.001) approx. 5960 per week (25%) in 2011 to
6661 per week (27%) in 2014
• Admissions 65+ attendances increased by 122
per year (95% CI: 78 to 166, P<0.001) approx. 3115 per
week in 2011 to 3482 per week in 2014
• 42.5% patients age 65+ stay for ≤ 48h
(n=203,432)
• What are we trying to do?
• Will a hospital admission help this patient?

10. Lets watch a short film

11. What could we have done
differently?
• Was the admission avoidable?

12. Prevalence of falls
• Each year 30% of those aged over 65y, 40%
over 80y living in the community and 60% of
nursing home residents will fall (Shaw 1996)
• 400,000 older people attend ED in England
because of an accident (DTI 1997, O’Loughlin 1993)
• We can’t cure these patients
• They will fall again and possibly die
• So what are we trying to do???

13. Pre-hospital care interventions
• Prevent attendance
• Evidence these can work
for elderly fallers. 25% ↓
ED attendance (RR=0.72 (0.68 to
0.75) ; 6% ↓ hospital
admission (RR=0.87 (0.81 to 0.94).
Costs saved @£150 per
patient Mason, 2007

14. Evidence from the hospital
• CGA approach is beneficial in ward settings
Ellis G, Whitehead M, O'Neill D, Robinson D, Langhorne P. Comprehensive geriatric
assessment for older adults admitted to hospital. Cochrane Library: Cochrane
collaboration, 2011.
• Various models of CGA might be initiated in the
ED – traditional geriatrician-led models, nurse
specialist models or referral onwards. No good
evidence
Conroy SP, Stevens T, Parker SG, Gladman JRF. A systematic review of comprehensive
geriatric assessment to improve outcomes for frail older people being rapidly
discharged from acute hospital: ‘interface geriatrics’. Age and Ageing
2011;40(4):436-43

15. ED Interventions
• Within ED: One study of ED pharmacist, trends to
reduced admissions Mortimer
• ED discharge to assess / follow up: included CGA,
falls assessment, specialist nurses, telephone
follow up Mion, McCusker, Caplan, Arendts, Foo, Shaw, Davison,
Hegney, Lee, Biese, Guttman. Two studies had impact on
reattendances / readmissions
• Observation / assessment wards: CGA-type
assessment. Two studies found reduced
admission, readmission, reattendance rates. Foo,
Conroy, Ong

16. ED or specialist teams?
• Should we all be trained?
• The sub-specialist Geriatric Emergency
Physician
• Should we leave to others?

17. Simple strategies
• Was anything about this patient preventing us
from trying to discharge her from ED?
• Trolleys – medicalising patients
• Dehydration – give them fluids!
• Thorough history and examination
• ECG, Temperature
• L/S BP – let them eat and drink first
• UTIs – are they really??
• Assessment areas - use them
• What can be reasonably be achieved??

18. What to do about the DNAR
order?• Patients coming in with
DNARs should not be in
resuscitation room
• Set / agree a ceiling of
treatment
• Symptom control is crucial
• Please don’t investigate
• Communicate with family
• Put yourself and your family
in their shoes

19. s.mason@sheffield.ac.uk
© the University of Sheffield 2016, a partner of the NIHR Collaboration for Leadership
in Applied Health Research and Care, Yorkshire and Humber (NIHR CLAHRC YH).
Disclaimer:
The research was funded by the NIHR CLAHRC Yorkshire and Humber. www.clahrc-yh.nihr.ac.uk.
The views expressed are those of the author(s), and not necessarily those of the NHS, the NIHR or
the Department of Health.