US Pharmacist. 2014(5):18-21.

In the United States, patients admitted through the emergency department (ED) represent over one-half of hospital admissions.1 Of importance to pharmacists, nearly 70% of those admitted receive a nonsurgical diagnosis.1 According to the CDC, adverse drug events cause over 700,000 ED visits per year.2 Additionally, approximately 120,000 patients each year need to be hospitalized for further treatment after emergency visits for adverse drug events.2 Older adults ( > 65 years) typically take more medicines than younger persons; they are twice as likely to present to EDs owing to adverse drug events (over 177,000 ED visits per year); and are almost seven times more likely to be hospitalized after an emergency visit.2  

Population studies have indicated that 40% of patients >65 years of age take five to nine medications daily, and 18% take more than 10.3 In light of the fact that there is a 50% to 60% chance of a drug-drug interaction when taking five medications and a 90% chance of a drug-drug interaction when taking 10 or more medications, it is abundantly clear that in the care of seniors, medication is a burden that requires evaluation.3 Pharmacists understand, and can appropriately address, the challenge of polypharmacy, which in older adults is especially problematic.4,5 Prompt, multidimensional assessment is critical to addressing the challenges presented by geriatric patients. Pharmacists’ involvement in the geriatric ED setting and during discharge transitions is an important, evolving, and expanding area of practice.

Multidimensional Assessment: Avoiding Inaccurate Labels

The scenario of an elderly person left unattended in an ED, confused, disoriented, and unable to advocate for himself or herself regarding the acute situation, current difficulties, and medical and medication history, is a potential safety hazard and may also result in inaccurate clinical labels (e.g., incontinent, having dementia) that may put the patient on track for nursing home placement prior to careful evaluation. Dizziness, mobile instability, pain, and sensory impairments (e.g., hearing, visual) may contribute to communication difficulties, uncertainty, fear, and confusion in the ED setting. A physical condition such as a urinary tract infection (UTI) or dehydration can cause a cascade of physical and cognitive symptoms that progress into a serious and misleading presentation.  

The need for proper geriatric assessment is essential, for example, to differentiate between a reversible, physical cause of mental status changes—such as a UTI in an elderly female requiring treatment—and an underlying dementia (e.g., vascular, Alzheimer) requiring a different management approach. The geriatric assessment is a multidimensional, multidisciplinary tool developed to evaluate a senior’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances.6,7 It includes an extensive review of prescription and OTC medications, vitamins, and herbal products, in addition to a review of immunization status. It assists with determining diagnoses of medical conditions; development of treatment and follow-up plans; coordination of management of care; and evaluation of long-term care needs and optimal placement.7  

By emphasizing the patient’s functional capacity and quality of life, while at the same time utilizing a multidisciplinary team approach, this type of assessment is capable of yielding a more complete and relevant list of medical problems, functional problems, and psychosocial issues, some of which may or may not be medication-related.8

Functional Ability Matters  

Maintenance of independence and prevention of disability are primary goals in the clinical care of persons > 65 years.9 It is imperative for ED healthcare professionals to understand the concept of functional status as a proxy measure of a patient’s ability to live independently.10,11 To fully assess functional status, inquiry into the two types of functional measurements, basic activities of daily living (ADLs) and the more complex, instrumental ADLs, must be considered in addition to psychological state, financial resources, physical function, and social circumstances.6 Furthermore, care coordination programs, blended with technologies (e.g., telemedicine applications) could prevent or limit hospitalizations and ED visits (TABLE 1) of frail elderly patients with chronic diseases.12 Recognizing and managing conditions frequently seen in older adults (e.g., geriatric syndromes, TABLE 2 and RESOURCES) is not only the key to maintaining and improving functional status in geriatric individuals, but also one of the true challenges.9 These conditions are often the result of underlying disease processes that may or may not be diagnosed.13

 

Geriatric ED Guidelines

The Geriatric Emergency Department Guidelines document is a consensus-based project that included representatives from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.3 The document provides a standardized set of guidelines that can effectively improve the care of the geriatric population and is feasible to implement in the ED. Ultimately, it creates a template for staffing (e.g., board-certified emergency physician with training in geriatrics, geriatric-appropriate CME, ancillary services including pharmacists), equipment (e.g., use of reclining chairs in the ED instead of ED gurney beds, nonslip fall mats and bedside commodes to minimize fall risk), education (atypical presentation of disease, medication management, effect of comorbid conditions, palliative care), policies and procedures, follow-up care, and performance improvement measures.  

Sample policies and procedures include The Screening of Geriatric Patients, Guidelines for the Use of Urinary Catheters, Geriatric Medication Management, Geriatric Fall Assessment, Delirium and Dementia, and Palliative Care. The document, in its entirety, is available online (see Reference 3). Ultimately, these guidelines support the notion that pharmacists can lead and participate in integrated coordinated care programs aimed at improving patient health outcomes.

The ED Pharmacist and Geriatric Medication Management

One of the overwhelming challenges to the U.S. healthcare system, and with specific regard to EDs, is the unprecedented and rapidly expanding geriatric population: those > 65 years and especially seniors > 85 years and older (growing at a rate almost three times that of the general population).14-17 To begin to address this challenge, geriatric EDs began appearing in the U.S. in 2008 and have become increasingly more common.18 In light of the problems with polypharmacy in the elderly, the pharmacist has been playing a significant role in this expansion effort as well.3-5 The Geriatric Emergency Department Guidelines recommend the following3:

Accurate and current medication list: Developing a medication-reconciliation tool will involve patients, caregivers, and medical record resources; patients taking more than five medications, taking high-risk medications ( TABLE 3 ), or presenting with signs or symptoms of adverse drug events will be managed with a multidisciplinary approach, including a pharmacist, that is focused on improving patient outcomes. Regardless of presenting complaint, all geriatric patients coming to the ED will have a medication list completed. When patients or caregivers are not able to provide the information, computer-based resources can be effective for obtaining accurate medication lists; further, pharmacy leadership and/or involvement as part of a multidisciplinary team, including geriatric specialists, is suggested for maintenance of a high-risk medication list. Medication assessment should be performed on all patients at risk or who have experienced a fall, especially those currently taking any of the following classes of medications: vasodilators, diuretics, antipsychotics, sedative hypnotics, and other high-risk medications.19 In the event that a senior patient requires hospital admission and is noted to have either polypharmacy concerns or the presence of one or more high-risk medications, a referral will be made to a multidisciplinary team to include a pharmacist. This approach, which involves interacting with the attending physician, has several goals: minimizing drug-drug interactions, minimizing polypharmacy, and minimizing the use of high-risk medications—not only during hospitalization but also upon discharge.

Transitions: The patient transition process (e.g., admissions, transfers, discharges) presents many challenges. In an era of daily ED crowding, providing effective, reliable discharge instructions for all patient populations is demanding; it is particularly so for the geriatric population.3,20 Older ED patients identify misinformation as a primary cause of dissatisfaction with their emergency care, a problem confounded and magnified by ongoing underrecognition of cognitive dysfunction, lower health literacy, and financial impediments for prescriptions and recommended outpatient follow-up.21-23 When pharmacists encounter patients during a transition, in addition to identifying the use of unnecessary medication and the presence of undertreated/untreated conditions, there is an opportunity to observe for signs of elder mistreatment and neglect. For other recommendations for pharmacists’ roles in the ED setting, including involvement in distinguishing between features of delirium and dementia, see Reference 3.

Benefits of Geriatric Pharmacists: Supportive Evidence

Lee et al published a systematic review and meta-analysis of the performance of U.S. geriatric pharmacists on healthcare teams.24 The final analysis included 20 studies, conducted mostly in ambulatory clinics and inpatient hospital settings. The authors concluded that pharmacist intervention has favorable effects on therapeutic, safety, hospitalization, and adherence outcomes in older adults and also suggested that pharmacists should be involved in team-based care of older adults.24

Credentialing

According to the Council on Credentialing in Pharmacy (CCP), there is variability in complexity of care and increasing differentiation of pharmacy practice. CCP believes that “pharmacists—like many other patient care providers—should be expected to participate in credentialing and privileging processes to ensure they attain and maintain competency to provide the scope of services and quality of care that are required in their respective practices.”25 The vision of CCP is that all credentialing programs in pharmacy will meet established standards of quality and contribute to improvement in patient care and the overall public health.25

Quality Assessment Instrument: The Dashboard  

The Geriatric Emergency Department Guidelines indicate that the geriatric quality improvement program will include identification of indicators, methods to collect data, results and conclusions, recognition of improvement, actions taken, and assessment of effectiveness of the actions and communication process for participants. In addition to other mechanisms to document and measure quality, pharmacy-related, disease-specific entities that facilities may monitor include3:

• Falls in the geriatric adult (polypharmacy screening in patients with falls)

• Medication reconciliation/pharmacy oversight (documentation of high-risk medications, usage of high-risk medication in ED, percentage of revisits for medication adverse reaction or nonadherence).

An example of a geriatric ED quality assessment instrument, generically referred to as a dashboard, is found in Reference 3. Of note, it is imperative that knowledgeable and skillful professionals become involved in the evaluation of results from assessment instruments; left to the inexperienced individual, these tools may be nothing more than a paper device compiling measurables that overlooks the intended goal of quality services delivered to and outcomes for an actual human being—the patient.

Interorganizational Collaboration  

In addition to efforts by pharmacists and physicians to improve care of elders in the ED, nurses are also playing an active role. Nurses Improving the Care of Healthsystem Elders (NICHE) is collaborating with organizations to build consumer advocacy and drive system-wide initiatives in the care of seniors. In one such collaboration, NICHE is working with the Catholic Health Association to improve integration of care within their member institutions, including 600 hospitals across the U.S. Further, NICHE is a supporter of the efforts of the Emergency Nurses Association with regard to the development of an emergency department core curriculum.26

Conclusion

Medication-related problems in older adults are common and cause considerable morbidity. A growing number of pharmacists are playing a significant role in identifying, preventing, and resolving medication-related problems in older adults, while at the same time optimizing drug therapy and using their training, skills, clinical judgment, and compassion in the ED setting for the benefit of vulnerable seniors.  

Disclaimer: Dr. Zagaria is Chair-elect, Board of Commissioners, 2013-2014, of the Commission for Certification in Geriatric Pharmacy.  

REFERENCES

1. Fitzgerald RT. White paper: the future of geriatric care in our nation’s emergency departments: impact and implications. Dallas, TX: American College of Emergency Physicians; 2008.
2. Centers for Disease Control and Prevention. Medication Safety Program. Adults and older adult adverse drug events. Updated October 2, 2012. www.cdc.gov/medicationsafety/adult_adversedrugevents.html. Accessed April 16, 2014.
3. American College of Emergency Physicians. Geriatric emergency department guidelines 2013. www.acep.org/geriEDguidelines/. Accessed April 14, 2014.
4. Hustey FM, Wallis N, Miller J. Inappropriate prescribing in an older ED population. Am J Emerg Med. 2007;25:804-807.
5. Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:755-765.
6. Rubenstein LZ, Rubenstein LV. Multidimensional geriatric assessment. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:211-217.
7. Elsawy B, Higgins K. The geriatric assessment. Am Fam Physician. 2011;83:48-56.
8.Landefeld CS. Improving health care for older persons. Ann Intern Med. 2003;139:421-424.
9. Hajjar ER, Gray SL, Guay DR, et al. Geriatrics. In DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: McGraw-Hill Inc; 2011.
10. Wernevik LC, Nystrom P, Andersson M, et al. Comparable pharmacokinetics and pharmacodynamics of melagatran in Japanese and caucasian volunteers after oral administration of the direct thrombin inhibitor ximelagatran. Clin Pharmacokinet. 2006;45:85-94.
11. Fillenbaum GG. Screening the elderly: a brief instrumental ADL measure. J Am Geriatr Soc. 1985;33:698-706.
12. Dang S, Golden AG, Cheung HS, et al. Telemedicine applications in geriatrics. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:1064-1069.
13. Kane Rl, Ouslander JG, Abrass IB. Clinical implications of the aging process. In: Essentials of Clinical Geriatrics. 5th ed. New York,NY: McGraw-Hill Inc; 2004:3-15.
14. Roberts DC, McKay MP, Shaffer A. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med. 2008;51:769-774.
15. Pines JM, Mullins PM, Cooper JK, et al. National trends in emergency department use, care patterns, and quality of care of older adults in the United States. J Am Geriatr Soc. 2013;61:12-17.
16. Schumacher JG, Deimling GT, Meldon S, et al. Older adults in the Emergency Department: predicting physicians’ burden levels. J Emerg Med. 2006;30:455-460.
17. Samaras N, Chevalley T, Samaras D, et al. Older patients in the emergency department: a review. Ann Emerg Med. 2010;56:261-269.
18. Hogan TM, Olade TO, Carpenter CR. A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013. Acad Emerg Med. 2014; 21:337-346.
19. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.
20. Engel KG, Heisler M, Smith DM, et al. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009;53:454-461.
21. Baraff LJ, Bernstein E, Bradley K, et al. Perceptions of emergency care by the elderly: results of multicenter focus group interviews. Ann Emerg Med. 1992;21:814-818.
22. Han JH, Bryce SN, Ely EW, et al. The effect of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients. Ann Emerg Med. 2011;57:662-671.
23. Carpenter CR, DesPain B, Keeling TN, et al. The Six-item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Ann Emerg Med. 2011;57:653-661.
24. Lee JK, Slack MK, Martin J, et al. Geriatric patient care by U.S. pharmacists in healthcare teams: systematic review and meta-analysis. J Am Geriatr Soc. 2013;61:1119-1127.
25. Council on Credentialing in Pharmacy, Washington, DC. CCP guiding principles for post-licensure credentialing of pharmacists. Published February 2011. www.pharmacycredentialing.org. Accessed April 24, 2014.
26. Capezuti EA, Briccoli B, Boltz MP. Nurses improving the care of healthsystem elders: creating a sustainable business model to improve care of hospitalized older adults. J Am Geriatric Soc. 2013;61:1387-1393.
27. Wilbur ST, Gerson LW. Emergency department care. In: Halter JB, Ouslander JG, Tinetti ME, et al, eds. Hazzard’s Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill Inc; 2009:221-227.
28. Health In Aging Foundation. American Geriatrics Association. A guide to geriatric syndromes: common and often related medical conditions in older adults. September 2012. www.healthinaging.org/files/documents/tipsheets/geri_syndromes1.pdf. Accessed April 21, 2014.

To comment on this article, contact rdavidson@uspharmacist.com.