Emergency Department Pain Management in the Older Adult.

Pain assessment and management in older adults is complex and requires evaluation and consideration of the type of pain, the acuity of the condition, comorbidities, and medications. Many older adults do not receive appropriate therapy for painful conditions in the emergency department (ED). This brief review article is focused on pharmacologic agents, drug-drug interactions, drug-disease interactions, and approaches in the management of painful conditions seen in older adults in the emergency department. Recommendations for specific painful conditions such as fragility fractures are discussed.

Emergency Department Length of Stay Is Associated with Delirium in Older Adults.

INTRODUCTION: Incident delirium in older patients is associated with prolonged hospitalization and mortality. A recent study suggested an association between emergency department (ED) length of stay (LOS), time in ED hallways, and incident delirium. In this study we further evaluated the emerging association between incident delirium with ED LOS, time in ED hallways, and number of non-clinical patient moves in the ED. METHODS: We performed this retrospective cohort study at a single, urban, academic medical center. All data were extracted from the electronic health record. We included patients aged ≥65 years presenting to the ED and admitted to family or internal medicine services over a two-year period. Patients admitted to any other service, transferred from another hospital, discharged from the ED, or who underwent procedural sedation were excluded. The primary outcome was incident delirium, defined as a positive delirium screen, receipt of sedative medications, or use of physical restraints. Multivariable logistic regression models including age, gender, language, history of dementia, Elixhauser Comorbidity Index, number of non-clinical patient moves within the ED, total time spent in the ED hallway, and ED LOS were fitted. RESULTS: We studied 5,886 patients ≥65 years of age; median age was 77 (69-83) years; 3,031 (52%) were female, and 1,361 (23%) reported a history of dementia. Overall, 1,408 (24%) patients experienced incident delirium. In multivariable models, ED LOS was associated with development of delirium (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03, per hour), while non-clinical patient moves [OR 0.97, (95% CI 0.91-1.04) and ED hallway time [OR 0.99, 95% CI 0.98-1.01, per hour) was not associated with development of delirium. CONCLUSION: In this single-center study, ED length of stay was associated with incident delirium in older adults, while non-clinical patient moves and ED hallway time in the ED were not. Health systems should systemically limit time in the ED for admitted older adults.

Geriatric Emergency Medicine Fellowships: Current State of Specialized Training for Emergency Physicians in Optimizing Care for Older Adults.

Improving emergency department (ED) care for older adults is a critical issue in emergency medicine. Institutions throughout the United States and Canada have recognized the growing need for a workforce of emergency physician (EP) leaders focused on clinical innovation, education, and research and have developed specialized fellowship training in geriatric emergency medicine (GEM). We describe here the overview, structure, and curricula of these fellowships as well as successes and challenges they have encountered. Seven GEM fellowships are active in the United States and Canada, with five offering postresidency training only, one offering fellowship training during residency only, and one offering both. The backbone of the curriculum for all fellowships is the achievement of core competencies in various aspects of GEM, and each includes clinical rotations, teaching, and a research project. Evaluation strategies and feedback have allowed for significant curricular changes as well as customization of the fellowship experience for individual fellows. Key successes include an improved collaborative relationship with geriatrics faculty that has led to additional initiatives and projects and former fellows already becoming regional and national leaders in GEM. The most critical challenges have been ensuring adequate funding and recruiting new fellows each year who are interested in this clinical area. We believe that interest in GEM fellowships will grow and that opportunities exist to combine GEM fellowship training with a focus in research, administration, or health policy to create unique new types of highly impactful specialized training. Future research may include exploring former fellows' postfellowship experiences, careers, accomplishments, and contributions to GEM to better understand the impact of GEM fellowships.

Observations of urinary oxycodone and metabolite distributions in pain patients.

Oxycodone is an opioid analgesic metabolized to oxymorphone and noroxycodone by cytochrome P450 (CYP) 2D6 and 3A4/5, respectively. This was a retrospective study to evaluate sex, age, urinary pH and concurrent medication use on oxycodone, oxymorphone and noroxycodone distributions. Urine specimens obtained from patients on chronic opioid therapy were analyzed by LC-MS-MS. There were 108,923 specimens from a subject's first or single visit, who were at least 18 years of age, and had documented physician-reported oxycodone use. The majority of specimens had detectable oxycodone urine concentrations (n = 106,852) resulting in oxycodone mole fractions (arithmetic mean ± SD) of 0.44 ± 0.27. Ninety-eight percent (n = 106,229) and 49% (n = 53,394) had detectable oxymorphone and noroxycodone, respectively. Oxycodone and oxymorphone mole fractions were lower in women compared with men (P < 0.0001). Mean ± SD age was 49.1 ± 12.9 years. Noroxycodone mole fractions were highest in the 65 years and older age group. Concurrent use of a CYP2D6 inhibitor, but not a CYP3A4/5 inhibitor, altered oxycodone and oxymorphone mole fractions. Dual inhibition of CYP2D6 and CYP3A4/5 did not result in a statistical difference upon comparison with CYP2D6 inhibitor or CYP3A4/5 inhibitor use. Patient factors affect oxycodone and metabolite mole fractions and suggest increased awareness of each contribution when attempting to monitor therapy with urine drug testing.