Mary Dawood RN Nurse Consultant in Emergency

Mary Dawood RN
Nurse Consultant in Emergency Care
Imperial College NHS Trust
Management of Emergency Care
for frail older people
Mary Dawood
Nurse Consultant
Imperial College NHS Trust
Definition of Frailty
• Increased vulnerability to
insult or challenges
resulting from impairments
in multiple domains that
compromise compensatory
Frailty Challenges
• Multiple interacting medical and social
• Impaired function
• Altered pharmacokinetics and
• Polypharmacy
• Atypical disease presentations
Context of the Emergency Department
• The Emergency Department is the most common point of
access for frail elderly to the hospital
• Older people particularly those with dementia are heavy
users of emergency services
• A poor ED experience can effect the entire hospital
experience for the person both physically and mentally
• The ED is a very busy place which is frightening and much too
fast for the older patient …..
Emergency Department Attendances
Emergency Data by Age Group
• Try to find a quieter place (sometimes better to
examine in short stay wards)
• Draw curtains/close doors to reduce visual
• Keep lights on – less shadow the better
• Don’t try to compete with loud noises, wait until
they are over before trying to communicate
• Discourage loud chatting outside the cubicle
• If you can find a second person will be easier, or
family member to stay in while examining.
Clear Signposting in the ED
• Signposting needs to
be bold ,visible and
• It should be at eye level
as the older person can
easily loose their
balance if they have to
crane their neck
Communication- What you need to know
(in a short time)
• Used name (often different from given one)
• What the person does/did – helps to connect / helps
with language recognition
• Where the person is originally from – will help with
• Family/ Carers – who’s key and the first names – talk
about ‘Margaret’, not ‘your daughter’
• What is the person’s home situation – who’s caring?
• Who was with the person last?
Nursing Assessment
• In addition to routine
recordings of vital signs the
AMT4 may be useful in the
initial assessment of
cognition in elderly
• Helps early recognition and
documentation of cognitive
• Age,
• Date
• Place (name of the
hospital or building),
• Current year
Key Issues for People with Dementia in the
Unsuitable environment – noise/activity
Fear / anxiety
Illness / pain will make cognition worse
Not good at waiting
Will often struggle to contextualise what is happening
Might react negatively to perceived threats
Will forget injury/incident/reason for admission
High risk of delirium
Will come as a package- family/carer (most people with a
diagnosis of dementia will have some level of care)
Communication - What the Person
with Dementia Needs to know
• You might think it’s
obvious who you are
• No white coats
• Poor vision
• Poor hearing
• Difficulty reading ID
Communicating Context
Every interaction should have:
Who you are (using the word Dr/Nurse)
Where you both are
Why the person is here
That the person is safe / you can be trusted
What’s about to happen (in the next minute)
Repeat it every time.
Delirium Alert
Pain Management
• Inappropriate prescribing is a
common problem in older
• Adverse drug events account
for 6.5%of all admissions but
more in older people leading
significant morbidity and
• Increased pharmacist support
is recommended for the
elderly with medication
Prioritise Medications
Be Alert
• High degree of vulnerability
• Sometimes hard to separate unusual living
situations from abusive ones
• Often involves financial abuse
• Recurrent attendances need to be investigated
• Easy to get it wrong
• “No Secrets Policy”
• All services should have
a nominated lead whilst
accepting that
safeguarding is
Mental Health
• Depression is the
commonest mental
health problem in old
age and is often
• The Geriatric
Depression Score -5 is a
useful screening tool for
Managing Challenging Behaviour
• It should be remembered that the elderly may react
negatively to unfamiliar surroundings
• Unwell older people will not always be able to articulate the
reasons for their distress and it is always important to
establish whether pain, constipation, urinary retention or
psychosis lie behind disturbed behaviour
• Medication should only be used where it is the safest and
least restrictive way of managing behaviour, which is a serious
risk to other patients, the staff or other people in the
emergency setting, or to patients themselves.
National guidance on rapid sedation can be found at:
Discharge Planning
• Early attention to discharge
planning is essential as older
people have complex needs
• They should only be discharged
from hospital with adequate
support and respect for their
• Avoid discharging from the ED at
night unless they are accompanied
by family /carers
Major Incident Planning
• Major incident plans and disaster preparedness plans
need to include explicit contingencies for the
management of multiple casualties of frail older
• Each area/region needs to have up to date lists of
named key clinicians and social care personnel with
contact numbers, who have specific responsibilities
for older people in the event of a major incident
Hurricane Katrina
• It is notable that of the
1,330 people known to
have perished in Hurricane
Katrina in New Orleans in
2005, 71% were over the
age of 60 and 47% were
older than 75 years and at
least 68 people died in
nursing homes.
Simple Recommendations to improve the Emergency
Department Environment
• The assessment area for older people should be located in a quieter area
of the department where observation is possible but noise, interruptions
and over stimulation is minimised.
• Not be close to an exit.
• Cubicle/rooms large enough to accommodate family
• Food and drink should be readily available
• Create an ambience consistent with the age of the patient eg older type
prints on the walls
• Large Clock
• Softer lighting to prevent glare
• Suitable comfortable chairs
• Non shiny /Non slip flooring
• Trolleys with mattresses that are thicker to accommodate the frailty of
the older patient
Ideal vs Reality
Golden Rules for the ED
• Privacy and dignity must be respected
• Carers and/or family members should be involved if possible
• Always consider pain as a cause of agitation/confusion
• Two health care professionals need to be involved in
procedures one to monitor, comfort and distract, and the
other to undertake the procedure;
• Intra and inter-hospital transfers of older people at night,
should be minimised as it increases the risk of delirium
• Keep safeguarding in mind
• Put a name bracelet on patient
• Prioritise assessment if at all possible
• The ED represents a key point in the health and social care
system where older people with health & social crises can
be managed
• Create a “frailty friendly front door” if we get it right for the
elderly it will be right for all
• Focus on the needs of the patient, respond to the needs
• Think creatively – challenges are new, traditional
approaches will not be enough
• Commissioning the right model relevant to the needs of the
local population
It is hoped that the Silver Book
will be a valuable resource
and be the Silver lining in
the care of our frail older
Thank you for listening
Recommended reading !
Medical management of frailty:
confessions of a gnostic
Kenneth Rockwood
CAN MED ASSOC J 1997;157-1081-4

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