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The Older Person in the Accident & Emergency Department
(Revised March 2008 )

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1. Introduction
Each year, patients make over 15 million visits to Accident & Emergency (A&E) departments in the United Kingdom, and about 20% are admitted [1]. The demand for emergency care services increases yearly, placing greater pressures on A&E departments, resulting in an increased strain to maintain quality of care.

Older people experience a greater level of morbidity and are relatively frequent users of A&E departments. About one third of these attendances follow trauma (a fall or other accident); most of the remainder being due to illness [2]. Studies have shown a marked increase in the number of A&E attendances by older patients in the winter months when there is a higher risk of falls and respiratory illness [3]. There is no convincing evidence that older people use A&E inappropriately, although social isolation and chronic disease are associated with an increased risk of attendance [4].

2. The clinical challenge
Older people are increasingly frequent users of A&E departments and often have complex medical and social needs over and above the clinical cause of attendance [5]. Accurate history taking may be impeded by cognitive and sensory impairments and presentation may be with classic Geriatric syndromes such as delirium, falls, incontinence and decreased self care due to underlying acute illness [6]. Reduced functional reserve in older people may result in significant impairment of daily living activities following relatively trivial illness or injury. These types of attendance result in 48% of older people being admitted to hospital from A&E compared with 20% of younger patients [1]. Functional impairment may be reversible with diagnosis and treatment of the underlying illness, making rehabilitation during recovery of the patient vital to anticipating and meeting the care needs of older patients, whether they are admitted or returning home.

Important conditions presenting to A&E departments

2.2.1 Falls
Falls are the most common cause of accidents and associated morbidity and mortality in older people. A third of people over 65 in the community fall each year, women more than men, which at least partly reflects their preponderance in the older age groups since the rate of falling increases with age [7-8]. More than 600,000 fall-related A&E attendances occur each year in the United Kingdom for persons over the age of 60 (population approximately 12 million) and of these 66% occur in those over the age of 75. These falls result in over 200,000 admissions to hospital, 78% of which are in those over 75 [9]. In an average A&E department, falls of older people comprise up to 5% of new attendees. 8% of falls in the community result in significant injury requiring acute medical attention and 5% result in fracture (especially fractured neck of femur) [8]. The incidence of fracture, occurring in up to 20% of those presenting to A&E with trauma, is much higher in older than younger patients [10]. Among those discharged from A&E with lesser injury, up to 50% will have significant functional problems, which they may not anticipate at the time [11]. A significant proportion of unexplained falls are associated with cardiovascular syncope that require specialised investigation [12]. Furthermore, multifactorial programmes have been shown to be successful in preventing falls, particularly in those patients with recurrent falls and those who have sustained a femoral neck fracture [7, 13].

Further advice on the assessment and prevention of falls may be obtained from NICE Guidelines [14] and the Cochrane Library [15]

2.2.2 Abuse of older people
Older people may present to A&E departments with signs of abuse which may be wrongly attributed to falls. It is currently estimated that over 300,000 older people are being abused in the United Kingdom at any time [16]. Since abuse may often first come to light in a clinical setting such as an A&E department, it is essential that health care professionals are able to recognise and respond to the crisis [17].

Effective communication and liaison are the keys to the provision of high quality care for the older patient in A&E, especially as the A&E department is at the interface between primary and community care and specialist hospital-based departments. Awareness of local vulnerable adult protection policies in A&E department guidelines and practical inter-agency planning may be considered to help to achieve these aims.

Further advice on this topic may be obtained from the British Geriatrics Society Best Practice Guide on Elder Abuse[18]

2.2.3 Delirium
Delirium (acute confusional state) is a common condition in the elderly, affecting up to 30% of all older patients admitted to hospital [19]. The hospital environment often precipitates or exacerbates episodes of delirium and patients who develop delirium have increased mortality, complication rates and longer lengths of stay. Delirium is often under-recognised by clinicians but improved assessment and understanding of delirium among health professionals and improved attention to the environment around at-risk patients can both prevent its onset and curtail episodes that do arise. Delirium may be the manifestation of a number of serious medical conditions including sepsis, acute coronary syndromes, adverse drug events, metabolic abnormalities and stroke [20]. Many patients with delirium are unable to provide an accurate history and corroboration from carers or other sources is essential for patient management, aimed at identifying and treating the cause [19].

Further advice on this topic may be obtained from the Royal College of Physicians National Guidelines on The prevention, diagnosis and management of delirium in older people [19].

3. Delivering high quality care for older A&E attendees
Building on the principles from ‘Reforming Emergency Care’ [21] that services for older people in A&E should be designed from the patient’s point of view, an accessible, patient-centred, integrated, high-quality service should be delivered without unnecessary delay or loss of dignity [1, 22-24].

Ideas, concerns and expectations of older people
• When older people become ill many of their concerns, anxieties and fears over loss of independence may be heightened because of frailty and other problems associated with ageing.
• Patients who come to A&E will want to be seen promptly and have the opportunity to be assessed by a doctor in private, in surroundings which take account of their hearing as well as their physical, emotional and cognitive states [25].
• There should be an understanding of the particular health problems of elderly patients from ethnic minority groups, particularly with reference to linguistic, cultural and religious differences.
• If admission is to be arranged, patients and their carers should be informed of their management plan and prognosis.
• Where applicable, advance directives and lasting powers of attorney should be respected and in cases where patients lack capacity, carers, next of kin, friends and independent mental capacity advocates may be consulted as outlined in the Mental Capacity Act [26].

4. Newer models of emergency care
Current trends are towards closer integration of A&E departments and acute medical units to ensure a prompt response to patient needs and ‘four-hour’ A&E operational standards. ‘Fast-track’ systems for older patients with fractured neck of femur and stroke are examples of beneficial developments [27-29]. No single model of care has been shown to be the most effective and in general, local priorities and availability of resources determine which method of care for older people is established [30]. However, early involvement of old age specialist teams has been shown to improve outcome, reduce length of stay and reduce inappropriate admission, in addition to being preferred by patients [1, 27, 31]. Therefore, a clear focus on comprehensive multidisciplinary assessment and care planning is essential to the successful management of the older patient in and following admission or discharge from A&E. This involves communication and collaboration between health professionals from a variety of disciplines to achieve effective patient assessment and treatment [31, 33-4].

Policies and procedures

Local policies and procedures should ensure:

• minimal delays in A&E prior to assessment
• adequate facilities available to make patients feel comfortable in A&E e.g. food, drink, appropriate chairs/beds available for the elderly
• adequate toilet facilities
• timely transfer from A&E directly to acute geriatric medicine wards, acute medicine units, geriatric medicine rehabilitation or specialist stroke beds
• appropriate admission of patients with acute mental health problems
• admission areas for overnight observation where discharge may be unsafe
• referral from A&E for urgent multi-disciplinary assessment to provide care support, based on level of need, either at home or in residential home, nursing home or interim care facilities
• that responsibilities for meeting the needs of older patients are clear and comprehensive so that individuals do not fall between services

5. Clinical practice
Clinicians should ensure that the clinical care provided for older patients is based on clinical need and not arbitrary age-defined criteria. There should be equity of access to the full range of investigation and treatment facilities whatever the local agreements defining clinical responsibilities. Inter-departmental and multi-disciplinary guidelines should be developed or adopted to guide clinical practice in the following common and important areas, ensuring that they are in line with national guidance:

• Assessment of pressure sore risk and implementation of preventative measures
• Assessment of pain and need for analgesia (particularly in those with communication difficulties)
• Assessment, management and appropriate referral strategy for patients with mental health needs
• Identification and response to suspected elder abuse and protection of vulnerable adults
• Assessment of patients who have fallen, with or without injury, to identify those who need specialist investigation, treatment or rehabilitation
• Management of hip fractures
• Management of acute stroke
• Assessment and management of hypothermia
• Assessment and management of continence
• Assessment and management of social care needs e.g. awareness of local provisions available in the community to support independent living
• Discharge planning and procedures

6. Identifying frailty and referring for comprehensive assessment
Older people have complex needs and multiple conditions and it is important to identify those individuals who need specialist involvement as a result of frailty. Specialist involvement is known to improve outcome, reduce length of stay and identify those who would benefit from intermediate care rather than hospital admission. The key markers of frailty during emergency response are the presence of confusion or a history of recent falls and/or loss of mobility. For this reason, it is important that these frailty markers are identified. Whilst an in-depth assessment in A&E may be unrealistic, routine screening for the emergency being related to a fall or blackout, and routine assessment of gait and balance, and confusion using a cognitive assessment instrument should always be considered [35].

Each A&E department needs its own system, but there is considerable efficiency in siting staff within A&E who can provide initial assessment for frail elderly patients. This may be a physiotherapist, occupational therapist, social worker, specialist nurse or any combination of these individuals who can then access/pass the referral on to further assessment in the appropriate setting including:

• Primary care
• Falls clinic
• TIA clinic
• Day Hospital
• Rapid assessment Geriatric clinic
• Intermediate care and social care to provide urgent support and/or rehabilitation when indicated
The use of simple screening tools for older people presenting with falls or confusion may provide the basis for audit of practice, facilitating the adaptation of A&E departments to identify and manage frail patients optimally.

Further advice on this topic may be obtained from Urgent care pathways for older people with complex needs [35].

7. Training
A&E departments should ensure that senior staff regularly update their skills in aspects of care of older patients. One senior clinician with appropriate training should have specific responsibility for maintaining standards of practice in these areas, maintain close liaison with other relevant departments, and lead or facilitate audit of the care given against local and national standards.

At least one senior doctor should have responsibility for ensuring that the training needs of A&E junior doctors are described in their educational contracts and met. Training of nurses and doctors should include skills, attitudes and knowledge about:

• Assessment, particularly of mental state, cognitive impairment and functional abilities
• Clinical practice guidelines in local use
• Operational policies and procedures in local use

8. References

1. Department of Health. Transforming emergency care in England , 2004 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4091775

2. Downing A, Wilson R. Older people's use of Accident and Emergency services. Age Ageing. 2005; 34: 24-30

3. Downing A, Wilson R. Temporal and demographic variations in attendance at accident and emergency departments. Emerg Med J. 2002; 19: 531-5

4. Coast J, Peters TJ, Inglis A. Factors associated with inappropriate emergency hospital admission in the UK . Int J Qual Health Care. 1996; 8: 31 -9

5. Bentley J, Meyer J. Repeat attendance by older people at accident and emergency departments. J Adv Nurs. 2004; 48: 149-56

6. Schumacher JG. Emergency medicine and older adults: continuing challenges and opportunities. Am J Emerg Med. 2005; 23: 556-60

7. Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with recurrent falls attending Accident & Emergency benefit from multifactorial intervention – a randomised controlled trial. Age Ageing. 2005; 34: 162-8

8. Pasapula C, Katta S. Falls : implications in old age. Geriatric Medicine. 2005; 35: 73

9. Scuffham P, Chaplin S, Legood R. Incidence and cost of unintentional falls in older people in the United Kingdom . J Epidemiol Community Health. 2003; 57: 740-4

10. Davies AJ, Kenny RA. Falls presenting to the accident and emergency department: types of presentation and risk factor profile. Age Ageing. 1996; 25: 362-6

11. Farnworth TA, Waine S, McEvoy A. Subjective assessment of additional support requirements of elderly patients discharged from an accident and emergency departments. J Accid Emerg Med. 1995; 12: 107-10  

12. Kerr SR, Pearce MS, Brayne C, Davis RJ, Kenny RA. Carotid sinus hypersensitivity in asymptomatic older persons: implications for diagnosis of syncope and falls. Arch Intern Med. 2006; 166: 515-20

13. Stenvall M , Olofsson B , Nyberg L , Lundström M , Gustafson Y . Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up. J Rehabil Med. 2007; 39: 232-8

14. National Institute of Clinical Excellence. The assessment and prevention of falls in older people. 2004 http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10956

15. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD000340. ttp://www.cochrane.org/reviews/en/ab000340.html

16. O’Keefe M, Hills A, Doyle M, McCreadie C, Scholes S, Constantine R, Tinker A, Manthorpe J, Biggs S, Erens B. UK study of abuse and neglect of older people. Prevalence Survey Report. 2007

17. Clarke ME, Pierson W. Management of elder abuse in the emergency department. Emerg Med Clin North Am. 1999; 17: 631-44

18. British Geriatrics Society. Abuse of older people. 2005 http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-10.htm

19. British Geriatrics Society. The Prevention, Diagnosis and Management of Delirium in Older People. 2006 http://www.bgs.org.uk/Publications/Clinical%20Guidelines/clinical_1-2_fulldelirium.htm

20. Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. 2002; 39: 338-41

21. Department of Health. Reforming emergency care - first steps to a new approach. 2001. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4092955

22. Borrill Z, Harrison B, Organisational issues in acute medical care. Clin Med JRCPL. 2002; 2: 161-4

23. Department of Health. National Service Framework for Older Persons. 2001 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4010161

24. Department of Health: About dignity in care. 2007 http://www.dh.gov.uk/en/Policyandguidance/SocialCare/Socialcarereform/Dignityincare/DH_065407

25. Bridges J, Meyer J, Dethick L, Griffiths P. Older people in accident and emergency: implications for UK policy and practice. Reviews in Clinical Gerontology. 2005; 14: 15 -24

26. Mental Capacity Act. 2005 http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1

27. Department of Health. National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/06-2007/08. 2004 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/Browsable/DH_4096173

28. Charalambous CP, Yarwood S, Paschalides C, Siddique I, Paul A, Hirst P. Reduced delays in A&E for elderly patients with hip fractures. Ann R Coll Surg Engl. 2003; 85: 200-3

29. Fitzpatrick M, Birns J. Thrombolysis for acute ischaemic stroke and the role of the nurse. Br J Nurs. 2004; 13: 1170-4

30. Royal College of Physicians. Management of the older medical patient. 2000 http://www.rcplondon.ac.uk/pubs/books/momp/wp_momp_appen1.htm

31. Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet. 1999; 353: 93-7

32. Bene J, Solomon SA, The attitudes of patients to integrated medical care. Age Ageing. 1999; 28: 271-3

33. Hendriksen H, Harrison RA. Occupational therapy in accident and emergency departments: a randomized controlled trial. J Adv Nurs. 2001; 36: 727-32

34. Mcleod E, Bywaters P, Cooke M. Social work in accident and emergency departments: a better deal for older patinets’ health? Br J Soc Work. 2003; 33: 787-802

35. Department of Health. Urgent care pathways for older people with complex needs. 2007 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080135

Review date: May 2010

Author: Dr J Birns and Dr D Beaumont for BGS Policy Committee

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