The Life Cycle of the Banana: Rethinking Geriatric Falls in the ED

Aging ED patients can be likened to the life cycle of a banana. When you buy a bunch of bananas they are green and hard and if you drop them, nothing happens. As time goes on, they become more yellow and if you drop one of these, you might get some bruising on the skin, but once you open the peal the inside of the banana is intact. As time goes on the banana starts to accumulate brown spots very similar to aging spots. When one of these gets dropped on the floor, the amount of damage is impressive.

When I began to do quality and risk management work about 12 years ago, I realized two things very quickly: 20% of my quality reviews were on geriatric patients who were discharged from the emergency department and 24% of all my ED visits were patients older than 70. There was one particular case, however, that tipped me off that we were doing something wrong with regards to our care for the elderly.

He was an 80-year-old man who presented with a fairly extensive laceration to his arm after a fall. I took care of him and sat at his bedside for more than an hour while repairing the laceration. We talked about politics, sports teams, family, and the world at large. He was a very interesting and intelligent individual. I discharged him home.
He fell again six days later and also presented to our emergency department. He fell at night walking to the bathroom, but was able to make his way back to bed. The next morning, he found that his face was bruised and covered in dried blood. He proceeded to shower, dress in a seersucker suit, and drove himself to the emergency department. One of my colleagues took care of him and got a CT scan of his head and cervical spine, which were negative. He was again discharged home. He fell two days later and broke his hip. This case was referred by the hospitalist who felt that the emergency department had somehow dropped the ball. The patient died of complications from pneumonia three weeks later. I went through all of phases of grief with this case, from anger to denial, and finally acceptance. This was a vital, older man, not somebody who was holding onto life by the tips of his fingers. His pneumonia was present on admission for his hip fracture. He had a BUN of 84 and a creatinine of 4.2. He had developed leg edema a couple of weeks earlier and was started on a diuretic by his primary care physician.

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What went wrong? We treated his injuries, but we never figured out why he was falling. We never did gait testing. Nobody thought to get labs or even ask about medical or social issues. He should have at least been screened for fall risks after the second visit.

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Aging ED patients can be likened to the life cycle of a banana. When you buy a bunch of bananas they are green and hard and if you drop them, nothing happens. As time goes on, they become more yellow and if you drop one of these, you might get some bruising on the skin, but once you open the peal the inside of the banana is intact. As time goes on the banana starts to accumulate brown spots very similar to aging spots. When one of these gets dropped on the floor, the amount of damage is impressive. Then you go on vacation. When you get back, you find these greasy, black bananas with fruit flies circling. The frail elderly are the black bananas. Even with minimal trauma, they tend to have extensive damage.

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Facts About Falls
Falls represent 16% of all emergency department visits. This number is 15% to 30% in the elderly. Some high risk items for future falls include:

• Inability to remember the fall or circumstances
• Fall recurrence
• Inability to get up at the scene
• Inability to get out of bed and walk in the ED

Up to 10% of falls in the elderly require hospitalization or prolonged immobility. They have a much higher mortality than their younger cohorts. Premature mortality after a hip fracture is 25% at one year.

Chairing the ACEP Geriatrics Section for more than five years, I am still amazed at the impact that the elderly have on our health care system.

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• The elderly are the most rapidly growing demographic in healthcare.
• Baby boomers reached age 65 in 2011
• The population is increasing
• People are living longer
• They are much sicker than the younger counterparts
• They utilize more healthcare resources
• 35 million people will be older than 70 in 2011
• 70 million will be older than 70 in 2030
• The elderly represent 13% of the population now
• They will be 20% of the population by 2030
• Those older than 85 are the largest growing demographic and according to the CDC represent 20% of ED visits

With the Affordable Care Act and ACOs, this is the perfect storm. We will be asked to take care of the sickest members of society more quickly, with less hospital admissions, and for less money. The number of primary care physicians in America is decreasing. Fifty-three percent of family practice residents are going into primary care. Twenty-three percent of graduating internal medicine residents are going into primary care. We will have a shortage of 25,000 gerontologists in 2030. Historically, Medicare pays less than most traditional insurers. As a result, many primary care physicians are not taking new Medicare patients. The impact on the emergency department should be obvious. If patients can’t access primary care, they will present to the emergency department much sicker and more often.

So what is the impact of the elderly on emergency department operations?

• They have much higher rates of testing
• 20% longer lengths of stay
• 2.5 to 4.6 times higher rate of hospitalization
• Five times higher rates of admission to ICU
• They are more likely to be misdiagnosed (atypical presentations)
• They are more frequently discharged with unrecognized or untreated health problems
• They represent 15 to 20% of all ED patients
• Seven times more usage of ED services
• 40 to 80% of all ED admissions
• 50% more laboratory use
• 50% more radiology use
• 400% more social service use

My early attempts to solve this problem with my group of physicians and nurses was to teach them the “get up and go test.” This meant watching elderly patients ambulate prior to discharge. I then instituted The Frail Elderly Pathway. It involved historical factors, assessment, diagnostic testing, referrals/consults/community services, and admission guidelines.
Admission guidelines:

• Abnormal vital signs
• An admittable diagnosis (pneumonia, dehydration, etc.)
• Inability to walk
• IV fluid requirements
• Off hours if a patient who lives alone

We retooled the emergency department. It helped us focus on the specific needs of the geriatric patient in front of us. Everyone in the department had permission to question the disposition of their patient. Our medical assistants were quite comfortable bringing issues to our attention such as family concerns, difficulty getting in and out of bed, or walking, and concerns about the patient’s ability to follow-up. We assembled a group of individuals in the hospital and community to discuss our concerns about the management of the elderly. Representatives from EMS, VNA, discharge planning, volunteer services, and some geriatric patients in the community participated. We developed a comprehensive in-home screen for the elderly within 24 hours, including weekends and
holidays. Despite all of our efforts, many geriatric patients still fell through the cracks.

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The Elderly Patient: A Clinical Primer
The elderly often don’t give you that opportunity to easily make a diagnosis and frequently can’t effectively communicate their symptoms They present with general weakness, altered mental status, weak and dizzy, and syncope or near syncope. They often have atypical presentations for common diseases. In the patient over 80 years they often present with shortness of breath instead of chest pain when they are having myocardial ischemia. Acute cholecystitis often presents without pain, fever, or increased WBC count. Infectious diseases, which rarely present typically, are pneumonia 25%, UTI 22%, and sepsis with bacteremia 18%.

Cognitive impairment plays a significant role in geriatric emergency department visits. 25% of geriatric patients present with delirium, dementia, or both. 50% of patients with delirium have dementia. Chronic cognitive impairment affects the following:

• Medication compliance
• Adverse drug events (ADE)
• Adherence to discharge instructions
• Repeated emergency department visits
• Your threshold should be low to order a head CT in geriatric patients.

Adverse Drug Events
Adverse Drug Events (ADEs) account for about 11% of all emergency department visits in the elderly. The average number of medications for the elderly presenting to the emergency department is 4.2. Four or more medications in a geriatric patient is an independent fall risk. When the elderly were screened in the emergency department, 11% were found to be on inappropriate medication according to the Beers criteria. Usually they have no medication list or an inaccurate one. Many have cognitive impairment, making any meaningful decision about medications difficult.

There are three medication classes that cause 48% of ADEs. These include anticoagulant/antiplatelet medications, anti-diabetic agents, and agents with narrow therapeutic windows. Insulin, Coumadin, and digoxin cause one-third of all ADEs in the elderly. The term “medication reconciliation” often puts fear in the hearts emergency physicians, nurses, and administrators. As you can see, there is a reason why the Joint Commission has targeted this area. Of note, many of the ADEs presenting to the ED are credited to the ED. In other words, the US pharmacopeia has determined that the emergency department is second only to the intensive care unit in terms of medication errors. So, the next time you take care of a patient on insulin that presents with hypoglycemia, or a patient with an INR of seven that is bleeding, these cases are being attributed to the emergency department even though we never prescribed the medications and are treating the complications. There is now a national database for patient’s medications that should be accessible to emergency departments 24/7.

Five to 14% of all emergency department visits pertain to substance abuse in the geriatric population. Thirty-six percent are intoxicated, 21% are delirious from withdrawal, and 15% are for mood disorders. All of these groups have the potential for falls. Only 21% of current abusers are identified in the emergency department. Beware of prescription drugs such as opioids, benzodiazepines, and sedative hypnotics. Consider them in all cases of agitation, delirium, and falls.

We are often presented with social admissions in the elderly. The patients or caregivers can no longer provide care for the patient in the home. Many have an occult illness causing this functional decline 78% of elderly patients admit to having a functional decline as the reason for their visit to the emergency department. Among social admissions, 51% have an underlying medical problem. The one-year mortality for social admissions in the elderly is 34%.

Screening Tools
Many screening tools have been suggested for the emergency department to assess the patient for future falls, emergency department visits, and admissions to the hospital. Only a couple have shown to be valid. This could be due to the fact that we have time constraints in the emergency department and a limited ability to train staff. The best tool so far is the Identification of Seniors at Risk tool. It was developed for the emergency department. Some risk factors include:

• A decline in the Activities of Daily Living (ADLs)
• Visual and cognitive impairment
• Hospitalization history
• Polypharmacy

Identification of “Seniors at Risk” includes the following questions:

• Before the illness or injury, did you need someone to help you on a regular basis?
• Since the illness or injury, have you needed more help than usual?
• Have you been hospitalized for one or more nights in the past six months?
• In general, do you see well?
• In general do you have serious problems with your memory?
• Do you take more than three different medications every day?

The patient is considered high risk with two or more positive answers. The identification of” Seniors at Risk” screening tool was found to have validity for detecting impaired functional status and depression. It predicts:

• Revisits to the emergency department
• Mortality
• Admissions to nursing homes
• Use of community services
• Decrease in functional status

This was all validated with 4 to 6 month follow-up. Older patients benefit from a more thorough geriatric evaluation after being screened as high risk. The components of this evaluation include mood, cognition, and functional status. When we consider the limitations of quality geriatric care in the emergency department, one of our weaknesses is not having the time and staff to screen them. In addition, once we have screened them, who provides the referral for a more thorough geriatric evaluation and where does it take place? Comprehensive geriatric assessments have all shown essentially the same thing:

• They detect geriatric syndromes
• They increase referrals to community service providers
• They avoid hospital admissions
• They decrease the number of emergency department revisits
• They decrease the occurrence of functional decline

Canadian Test Case
I attended the Third Annual Geriatric Emergency Medicine Conference in Toronto. Training nurse practitioners how to screen, do functional assessments, and provide services for geriatric patients presenting to the emergency department was studied. They were able to demonstrate all of the above and the return on investment for training these providers was more than offset by the cost savings. As a result, they implemented the program throughout Ottawa. It has been demonstrated that social workers, mid-level providers, and case managers could effectively perform these assessment .

The American Geriatric Society and British Geriatrics Society drafted clinical practice guidelines: Prevention of Falls in Older Persons about 10 years ago and were revised two years ago. Only a multidisciplinary approach has ever been demonstrated to be effective in reducing the number of falls. In other words, no single intervention was successful in decreasing falls in the elderly. The multidisciplinary approaches all involved exercise and balance training. For some strange reason, vitamin D replacement has been shown to be effective. I recently found out that vitamin D actually increases leg strength in the elderly. No interventions have ever been shown to be effective in patients with cognitive impairment.

David P John M.D. FACEP, is the Chair of the Geriatric Emergency Medicine Section for the American College of Emergency Physicians.

Bibliography

• Fitzgerald, Robert T. Report on: “The Future of Geriatric Care in our Nation’s Eme
  rgency Departments: Impact and Implications.” American College of Emergency Physicians October 2008.
• 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons
• Hayward, Alison MD. “Vulnerable Populations.”
• Samaras, N, Chevalley,T, Samaras, D, Gold, G. “Older Patients in the Emergency Department: A Review.” Annals of Emergency Medicine 2010
• Green, Adrienne MD. “Acute and Post-Acute