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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
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
Normal Changes of Ageing
Older adults have unique physiological,
medical and social requirements that must be
considered during their ED evaluation.
Normal Changes of Ageing
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Happen to 100% of the population
Increase complexity
Increase risk of injury
Contribute to atypical presentation
Increase risk for a negative outcome
Myths & misperceptions?
Normal Changes of Ageing
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
Model of Frailty
De Witte et al, 2013, adapted from Gobbins et al, 2010
Frailty
 Multifaceted syndrome
 Combination of multiple co-morbidity, decreased
physiological reserve & decreased functional
capacity
 It’s the opposite of health, successful ageing
 Physical, social & emotional
 It’s not normal & it’s not a good thing…
Frailty
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Malnutrition; Weight loss
Impaired physical function
Weariness
Low exercise tolerance
Low level of physical activity
Possible cognitive impairment &/or
depression
Geriatric Assessment for the ED
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Medical Hx
Cognition
Mood
Mobility
Pain
 Functional Assessment
(ADL & IADL)
 Medication review
 Nutrition
 Continence
 Social Hx
Cognitive Assessment in the ED?
 Assess acute status
 Medical clearance
 Change to baseline
 Appropriate education &
safe discharge planning
 Opportunity for early
intervention & follow-up
Considerations for the ED
 Goal
 Medical status
 Environment
Considerations for the ED
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Acute Illness
Baseline
Acute change?
Risk Factors
Presenting complaint
Collateral history
Screening Tool
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Pain
Anxiety
Fatigue
Inadequate or missing
sensory aids
 Appropriate space, privacy,
lighting
Spectrum of Cognitive Change
Normal
Changes of
Aging
Mild
Cognitive
Impairment
Dementia
Lee, 2013
Normal Changes of Ageing: Cognition
Normal
Changes of
Aging
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Mild
Cognitive
Impairment
Decreased # brain/nerve cells
Decreased neuron function
Benign forgetfulness
Memory change
Changes to sleep patterns
Dementia
Mild Cognitive Impairment
Normal
Changes of
Aging
Mild
Cognitive
Impairment
Dementia
 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
Dementia
Normal
Changes of
Aging
Mild
Cognitive
Impairment
Dementia
 Gradual but continuous change in cognition that
is seen over time
 Accompanied by a change in function
 Not due to other reversible cause
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.
Clinical Features: ABC
B = Behaviour
A = ADL’s
 Anger
 Bathing, grooming, toileting
 Irritability
 Finances
 Apathy
 Shopping
 Depression
 Driving
 Agitation
 Cooking
 Medication management
 Laundry
C = Cognition
 Forgetfulness
 Repetitive questions/stories
 Word finding problems
 Planning meals/shopping
 Misplacing objects/getting lost
Symptoms of Cognitive Impairment:
ADL/IADLs
 Gets lost in own
neighbourhood & doesn’t
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
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
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
10 Behavioural Flags:
Office, ED or Hospital
1.
2.
Frequent hospitalizations or visits to emergency department
Poor historian, vague, seems “off,” repetitive questions and/or
stories
3. Poor understanding or compliance with medications and/or
instructions
4. Appearance/mood/personality/behaviour
5. Word-finding problems / decreased social interaction
6. Subacute change in function without clear explanation
7. Confusion
8. Weight loss, dwindles, “failure to thrive”
9. Driving: collision/problems/tickets/family concerns
10. + Head-turning sign
Types of Dementia
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Alzheimer’s Type
Vascular
Lewy-Body
Frontal-Temporal
NPH
Alzheimer’s Type
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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
Vascular
 Pure Vascular dementia is relatively uncommon - most are
mixed with AD
 Gait disturbance
 Unsteady, falls, urinary incontinence
 Personality, mood & executive function change
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
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 50’s
Normopressure hydrocephalus
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Triad of symptoms:
Gait difficulties
Urinary incontinence
Mental decline
 wet, wobbly & wacky
 Frequently misdiagnosed as Parkinson's disease
Stage @ Time of Diagnosis
Benefits of Early Diagnosis
Medical
Social
 Social/financial planning
 Early caregiver education
 Safety: driving, cooking,
smoking, compliance
 Advance directives planning
 Right/Need to know
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Reversible cause/component
Risk factor treatment
Compliance strategies
Optimization of
comorbidities
 AChEI treatment
 Crisis avoidance
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Delirium
 A disturbance of consciousness
with inattention that develops
over a short time & fluctuates
Delirium: Specific ED Literature
What do we know?
 Common in ED patients
 We’re 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 it’s missed in the ED the outcomes are poor
(Han, 2010; Kakura 2003)
 Use of a validated tool improves the identification of
delirium
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
Cognitive Screening Toolbox….
 Ottawa 3DY
 CAM
 MMSE
 MoCA
 TICs
 Quick Dementia Screen
 Mini-cog
 Clock Drawing Test
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Screening Confusion in the ED:
The Champlain GEM Algorithm
NO
Evidence of
acute
change
Administer
M ini Cog/Dementia
Quick Screen
NEGATIVE
END SCREEN
ABC
Concerns
ABSENT:
End Screen
Suspicion of
Confusion and/or
Cognitive
Impairment?
Obtain a history
and baseline from
the patient and
collateral source.
Is this confusion
acute, chronic or
acute on chronic?
CAM
POSITIVE
Assess for
presence of
early warning
symptoms:
ABC concerns
ABC
Concerns
PRESENT:
Further
assessment is
indicated.
NEGATIVE
Administer
CAM
CAM POSITIVE:
Delirium
Suspected
YES evidence
of acute
change from
baseline
Consult back with ED
M D and team:
- Identify potential
cause(s) of delirium
- Identify severity
- Identify level of
safe support in the
home
Suggest
admission
for workup
and
treatment
D/C to
supportive
environment
with a clear
follow-up plan
Refer to SGS
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. 2011;13(3): 173-226. (Abstract)
38
Medical Workup
Anyone who presents with a change from their
baseline cognition requires a full medical
evaluation:
 Bloodwork
 Urine R&M, C&S
 ECG
 CXR
 CT head
Also consider:
 O2 sat; ABG
 Blood cultures
 Drug levels
 ETOH
Pre-printed
Delirium
Orders
Nursing Interventions:
Prevention & Treatment
 Provide adequate fluids &
nutrition
 Treat pain on a regular
schedule
 Mobilize
 Remove all unnecessary
tubes
 Give regular medications &
adjust ED meds as
appropriate
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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!
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
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
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