Normal Aging, Frailty

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Normal Aging, Frailty Cognition Considerations
for the ED

• Laura J. Y. Wilding RN BScN MHS ENC(C)
• Advanced Practice Nurse
• Geriatric Emergency Management
• The Ottawa Hospital
• The Regional Geriatric Program of Eastern Ontario
• September 2013

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Geriatric Emergency Management
What are we trying to accomplish?

• Target high-risk seniors discharged home from the
  ED
• Advocate for age-appropriate care
• Improve the quality sustainability of ED
  discharges through early referral to specialized
  geriatric services community support services
• Integration of acute care, primary care
  community care
• Support the capacity for older adults to remain
  safely in their own home

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Normal Changes of Ageing

• Older adults have unique physiological, medical
  and social requirements that must be considered
  during their ED evaluation.

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Normal Changes of Ageing

• Happen to 100 of the population
• Increase complexity
• Increase risk of injury
• Contribute to atypical presentation
• Increase risk for a negative outcome
• Myths misperceptions?

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Normal Changes of Ageing
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Frailty
A physiologic syndrome characterized by decreased
reserve resistance to stressors, resulting from
cumulative decline across multiple physiologic
systems, causing increased vulnerability to
adverse outcomes.
Fried et al. 2001
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Model of Frailty
De Witte et al, 2013, adapted from Gobbins et al,
2010
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Frailty

• Multifaceted syndrome
• Combination of multiple co-morbidity, decreased
  physiological reserve decreased functional
  capacity
• Its the opposite of health, successful ageing
• Physical, social emotional
• Its not normal its not a good thing

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Frailty

• Malnutrition Weight loss
• Impaired physical function
• Weariness
• Low exercise tolerance
• Low level of physical activity
• Possible cognitive impairment /or depression

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Geriatric Assessment for the ED

• Functional Assessment (ADL IADL)
• Medication review
• Nutrition
• Continence
• Social Hx

• Medical Hx
• Cognition
• Mood
• Mobility
• Pain

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Cognitive Assessment in the ED?

• Assess acute status
• Medical clearance
• Change to baseline
• Appropriate education safe discharge planning
• Opportunity for early intervention follow-up

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Considerations for the ED

• Goal
• Medical status
• Environment

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Considerations for the ED

• Acute Illness
• Baseline
• Acute change?
• Risk Factors
• Presenting complaint
• Collateral history
• Screening Tool

• Pain
• Anxiety
• Fatigue
• Inadequate or missing sensory aids
• Appropriate space, privacy, lighting

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Spectrum of Cognitive Change
Lee, 2013
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Normal Changes of Ageing Cognition

• Decreased brain/nerve cells
• Decreased neuron function
• Benign forgetfulness
• Memory change
• Changes to sleep patterns

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Mild Cognitive Impairment

• 10 - 15 of seniors
• Impaired memory when compared to others of same
  age education but function well
• Borderline
• Many convert to dementia
• Must r/o other cause such as depression, drugs,
  disease
• Need close follow-up

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Dementia

• Gradual but continuous change in cognition that
  is seen over time
• Accompanied by a change in function
• Not due to other reversible cause

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BC Guidelines Recommendation 1 - Recognition
1 (b) Cognitive impairment should be suspected
when there is a history that suggests a decline
in occupational, social or day-to-day functional
status. This may be directly observed or
reported by the patient, concerned family
members, friends and/or caregivers.
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Clinical Features ABC

• A ADLs
• Bathing, grooming, toileting
• Finances
• Shopping
• Driving
• Cooking
• Medication management
• Laundry

• B Behaviour
• Anger
• Irritability
• Apathy
• Depression
• Agitation

• C Cognition
• Forgetfulness
• Repetitive questions/stories
• Word finding problems
• Planning meals/shopping
• Misplacing objects/getting lost

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Symptoms of Cognitive Impairment ADL/IADLs

• Gets lost in own neighbourhood doesnt know how
  to get home
• Dresses inappropriately (e.g. may wear summer
  clothing on a winter day)
• Trouble managing finances
• Computer telephone use

• Food preparation/cooking
• Ability to deal with emergencies
• Medication management
• Transportation
• Home maintenance
• Housekeeping/laundry
• Ability to carry out hobbies

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Symptoms of Cognitive Impairment Behaviour

• Repeatedly forgets where things are left put
  things in inappropriate places
• Has mood swings for no apparent reason
  especially without prior psychiatric history
• Has dramatic personality changes may become
  suspicious, withdrawn, apathetic, fearful or
  inappropriately intrusive, over familiar or
  disinhibited
• Becomes very passive requires prompting to
  become involved

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Symptoms of Cognitive Impairment Cognition

• Asks the same question repeatedly
• Cannot remember recent events
• Cannot prepare any part of a meal or may forget
  that they have eaten
• Forgets simple words, or forgets what certain
  objects are called

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10 Behavioural Flags Office, ED or Hospital

• Frequent hospitalizations or visits to emergency
  department
• Poor historian, vague, seems off, repetitive
  questions and/or stories
• Poor understanding or compliance with medications
  and/or instructions
• Appearance/mood/personality/behaviour
• Word-finding problems / decreased social
  interaction
• Subacute change in function without clear
  explanation
• Confusion
• Weight loss, dwindles, failure to thrive
• Driving collision/problems/tickets/family
  concerns
• 10. Head-turning sign

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Types of Dementia

• Alzheimers Type
• Vascular
• Lewy-Body
• Frontal-Temporal
• NPH

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Alzheimers Type

• Gradual onset
• Slow progression
• Dominated by problems with memory orientation
• Aphasia, apraxia, agnosia
• If your patient has an abrupt onset, rapid
  progression and is not dominated by problems with
  memory orientation this is a red flag for other
  dementias

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Vascular

• Pure Vascular dementia is relatively uncommon -
  most are mixed with AD
• Gait disturbance
• Unsteady, falls, urinary incontinence
• Personality, mood executive function change

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Lewy Body

• Triad of symptoms
• Fluctuation in cognition
• Recurrent visual hallucinations - well formed
  detailed non threatening
• Motor features of parkinsonism appears at the
  time of dementia

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Frontotemporal

• Neurodegenerative disease primarily affecting the
  temporal frontal lobes
• Early decline in social interpersonal conduct
• Social disinhibition, loss of insight
• Impulsive
• Emotional blunting loss of warmth
• Men in 50s

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Normopressure hydrocephalus

• Triad of symptoms
• Gait difficulties
• Urinary incontinence
• Mental decline
• wet, wobbly wacky
• Frequently misdiagnosed as Parkinson's disease

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Stage _at_ Time of Diagnosis
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Benefits of Early Diagnosis

• Medical
• Reversible cause/component
• Risk factor treatment
• Compliance strategies
• Optimization of comorbidities
• AChEI treatment
• Crisis avoidance

• Social
• Social/financial planning
• Early caregiver education
• Safety driving, cooking, smoking, compliance
• Advance directives planning
• Right/Need to know

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Delirium

• A disturbance of consciousness with inattention
  that develops over a short time fluctuates

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Delirium Specific ED Literature

• What do we know?
• Common in ED patients
• Were not very good at identifying patients with
  delirium (Lewis et al 1995 Eelie el al. 2000)
• May not get recognized even when the patient is
  admitted (Han, 2009)
• When its missed in the ED the outcomes are poor
• (Han, 2010 Kakura 2003)
• Use of a validated tool improves the
  identification of delirium

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Delirium vs. Dementia
Delirium Dementia
Onset Abrupt confusional state that is different than their baseline acute, potentially reversible Gradual progressive decline over time chronic, irreversible
Awareness Reduced awareness of their environment Clear
Alertness Fluctuates can be hyper vigilant or lethargic Generally normal
Attention Impaired unfocussed Generally normal, may progress over time
Orientation May fluctuate but can be A O x 3 Decreases over time
Delusions, Hallucinations New onset of delusions or hallucinations common Generally with late stage disease
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Cognitive Screening Toolbox.

• Ottawa 3DY
• CAM
• Quick Dementia Screen
• Mini-cog
• Clock Drawing Test

• MMSE
• MoCA
• TICs

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Screening Confusion in the ED The Champlain GEM
Algorithm
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Confusion Assessment Method

• Acute onset of a change in normal mental status
  fluctuating course?
• AND
• Inattention?
• AND EITHER
• Disorganized thinking?
• OR
• Altered Level of Consciousness?

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Ottawa 3DY
Question Score
What is the date? 1
What day of the week is it? 1
Spell the word WORLD backwards DLROW 1 (if all correct)
What year is it? 1
Total 4

• Molnar, F.J., Wells, G.A., McDowell, I. The
  derivation and validation of the Ottawa 3D and
  3DY three and four question screens for cognitive
  impairment. Clinical Medicine Geriatrics. 2008
  2 1 -11.
• Wilding, L., Stiell, I., Molnar, F., O'Brien, J.,
  Moors, J., Dalziel, W.B. Assessing cognition in
  the emergency department Prospective validation
  of the Ottawa 3DY case finding tool with animal
  fluency test. CJEM. 201113(3) 173-226.
  (Abstract)

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Medical Workup

• Anyone who presents with a change from their
  baseline cognition requires a full medical
  evaluation
• Bloodwork
• Urine RM, CS
• ECG
• CXR
• CT head

• Also consider
• O2 sat ABG
• Blood cultures
• Drug levels
• ETOH

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Pre-printed Delirium Orders
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Nursing InterventionsPrevention Treatment

• Provide adequate fluids nutrition
• Treat pain on a regular schedule
• Mobilize
• Remove all unnecessary tubes
• Give regular medications adjust ED meds as
  appropriate

• Avoid restraints
• Regular toileting
• Offer eyeglasses, hearing aids
• Orient the patient
• Speak slowly clearly, use short simple
  instructions
• Comfort reassurance
• Family presence

Good Nursing Care is Key!
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Behavioural Psychological Symptoms of Dementia
(BPSD)

• 2/3 of people living with dementia will have
  clinically significant behavioural issues
• Addressing behaviour depends on the
  characteristic (what are they doing?), context
  (when?), frequency, severity impact
• Behavioural issues significantly impact caregiver
  burden

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Managing Behaviour

• What is triggering the behaviour?
• Decrease stimulii
• Speak in a calm reassuring voice speak slowly,
  clearly allow time for the person to respond
• Use reassurance distraction
• Gentle physical touch
• Do not reason with the person
• For repetitive movements provide something for
  the patient to do

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Discharge?

• Assess for home safety
• Driving, smoking, cooking on the stove
• Managing medications
• Behaviour
• Adequate supervision
• Extra Supports?
• Consider SW, CCAC, PT, BSO
• Education patient family
• Appropriate follow-up GP, SGS

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