1. Partner with emergency medical services (EMS), nursing facilities, and community resources to prepare for a comprehensive, efficient ED evaluation.
Working together as a team is essential in creating both the environment and processes which will maximize best patient outcomes and avoid harm to older patients in the ED.
- Create an EMS protocol for gathering and directly reporting specific information about the home environment, nursing facility report, caregivers, medications (including bringing bottles to the ED), and advance directives.
- Establish an efficient, reliable transfer process by partnering with referring nursing facilities. This includes a concise transfer form and direct provider-to-provider report. The American Medical Directors Association (AMDA) “Universal Transfer Form” and INTERACT II “Nursing Home to Hospital Transfer Form and Acute Care Document Checklist” are examples of forms to consider. Concise, accurate and full information is essential in both transfer to the ED as well as transfers back to the community (home, nursing facility or other).
2. Consider the unique needs of patients with dementia in constructing a “Dementia Friendly” ED process and environment.
Dementia produces changes in cognition, perception, mood, and behavior that alter the way patients interact with their environment, lowering their “stress threshold”.
- Implement processes to decrease distress, discomfort, and the risk of developing delirium for this vulnerable population, including:
- Insure the presence and comfort of caregivers in the ED.
- Assign trained staff or volunteers to engage and orient unaccompanied patients.
- Insure comfortable temperature and proper lighting. Minimize noise.
- Avoid use of cardiac monitoring, IVs, and urinary catheters unless necessary.
- Treat pain promptly and minimize painful procedures.
- Offer food and fluids frequently unless contraindicated.
- Offer frequent toileting. Avoid nighttime diuretics and IV fluids if possible.
- Display eye-level signage and orienting cues.
- Insure the patient has access to their glasses and/or hearing aids.
- Assist patients in mobility (up in chair, ambulate) as able.
- Provide a preferred activity and distraction aids.
- See GFF #63 “Acute Management of Behavioral Changes in Hospitalized Patients with Dementia’ for more information.
3. Contextualize the acute presentation with a comprehensive history from ancillary sources.
Document baseline cognitive and functional status and recent accelerated decline.
- Seek first to understand “What has changed today?” and the caregiver’s “Biggest Worry”.
- Construct an accurate history. This often requires that members of the ED team contact the nursing facility, caregivers, referring providers, and pharmacies.
- Understand the level of assistance a patient requires in their current living environment whether at home, assisted living, personal care at home, or skilled nursing facility.
- Obtain a “Caregiver History”, asking caregivers about changes in their ability to provide care in the current arrangement. Nationally, 50% of family members providing live-in care are over 65 years.
- Screen for neglect, self-neglect, and abuse as cognitive impairment and functional dependence are major risk factors for neglect and abuse.
4. Begin to coordinate subsequent care during the ED evaluation.
Consider hospital admission for patients requiring inpatient resources only when necessary, and work to effectively implement outpatient care for others.
- A visit to the ED may signal the need for more support, either in the home or in a higher level of institutional care.
- Construct a workable plan for subsequent outpatient care, insuring that the caregiver demonstrates understanding of discharge instructions and is able to readily follow the plan.
- Improve communication with outpatient and inpatient teams.
- Develop a “hand-off” protocol for patients discharged to facilities or returning home. Ideally, this involves a provider-to-provider conversation.
- Clearly communicate with the admitting team the patient’s cognitive and functional status, caregiver information, and challenges encountered during the ED evaluation.