Concepts in Practice: Geriatric Emergency Departments.

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

Geriatric emergency medicine service: a novel approach to an emerging trend.

Many studies have described benefits to patients from geriatric care in the emergency department (ED), yet few geriatric emergency departments exist nationally. As our nation ages and health care financing for these patients becomes more complex, it will be crucial for hospitals to develop ED services that address the needs of our sickest and frailest patients. In this article, we report on our experiences using advanced practice registered nurses (APRNs) embedded in an established ED. Our geriatric emergency medicine service (GEMS(SM)) model has improved patient satisfaction rates and decreased time spent in the ED. It has increased volume of geriatric patients in our hospital by 6%. Strong executive support for geriatric services has established our hospital as a local leader in geriatric emergency medicine. The program is fiscally neutral and serves a frail vulnerable population. We have improved healthcare for our seniors and believe this model of geriatric emergency care can easily be replicated nationally.

Obesity-associated abdominal elephantiasis.

Abdominal elephantiasis is a rare entity. Abdominal elephantiasis is an uncommon, but deformative and progressive cutaneous disease caused by chronic lymphedema and recurrent streptococcal or Staphylococcus infections of the abdominal wall. We present 3 cases of patients with morbid obesity who presented to our hospital with abdominal wall swelling, thickening, erythema, and pain. The abdominal wall and legs were edematous, with cobblestone-like, thickened, hyperpigmented, and fissured plaques on the abdomen. Two patients had localised areas of skin erythema, tenderness, and increased warmth. There was purulent drainage from the abdominal wall in one patient. They were managed with antibiotics with some initial improvement. Meticulous skin care and local keratolytic treatment for the lesions were initiated with limited success due to their late presentation. All three patients refused surgical therapy. Conclusion. Early diagnosis is important for the treatment of abdominal elephantiasis and prevention of complications.

Thyrotoxic Dysphagia in an 82-year-old male.

Dysphagia is a common problem in elderly patients and a rare manifestation of Graves' disease. We report a case of an 82-year-old male who presented with a 4-week history of dysphagia and weight loss. Workup for his dysphagia with upper endoscopy, MRI brain, electromyography, acetyl-cholinesterase receptor antibodies, and voltage-gated calcium channel antibodies were negative. Modified Barium swallow test showed oropharyngeal dysphagia. Thyroid function tests that revealed hyperthyroidism and antibodies to TSH-receptor were positive. Based on the above findings, we considered Graves' disease as the most likely diagnosis. Patient was treated with methimazole and beta-blockers and subsequently his dysphagia resolved. This paper highlights the importance to clinicians of considering thyrotoxicosis as possible diagnosis in an elderly patient presenting with unexplained dysphagia.

Elders' environs and their end-of-life preferences.

HYPOTHESIS: Elders' predilections regarding end-of-life interventions vary with their living environs. METHODS: Patients in 3 settings--assisted living/outpatient, skilled nursing facility (SNF), and acute hospitalization--were asked to complete a brief questionnaire. RESULTS: A total of 269 patients who averaged 80.0 ± (SD) 8.1 years, 44% male, 70% white were studied. Eighty-five patients were outpatient elderly, 101 were hospitalized for acute illnesses, and 83 were interviewed in SNFs. Outpatients (44/85; 52%) and acutely ill inpatients (40/101; 40%) were more likely than patients residing in SNFs (19/81; 23%) to choose comfort care only (P = .047) for acute pneumonia requiring endotracheal intubation (ETI). Overall, 32% changed their choice for ETI, opting for comfort care only if acute pneumonia was followed by disposition to an SNF. However, ambulatory and acutely ill elderly patients were 3 times as likely as SNF patients to change from aggressive to comfort care if the most likely outcome was disposition to an SNF (P < .001). In multivariate regression models, age (>80), gender, number of lost ADLs (>2), and self-described quality of life were not associated with choosing comfort care instead of ETI, whereas place of residence (SNF versus home) was independently associated with choosing ETI (odds ratio = 3.5; 95%CI = 1.9-6.4). Similarly, those already living in an SNF were more likely to opt for remaining there for advancing dementia (odds ratio = 7.7; 95%CI = 3.8-15.8). However, choices for ETI did not coincide with choosing an SNF for advancing dementia. CONCLUSIONS: Elders residing in nursing homes were more likely than ambulatory patients to request invasive end-of-life care, a difference that was more pronounced when outcome required disposition to an SNF. These preferences were not dependent on patients' self-described disability or quality of life. This study suggests that qualitative outcomes matter to patients and their choices are associated with their place of residence.

Physician preferences for medical interventions in elderly patients.

PURPOSE: To identify factors influencing medical decision making in the elderly based on differences in age, cognition, and function. MEASUREMENTS: Physicians were given a clinical scenario and asked to select from three management options based on the patients' characteristics. RESULTS: Eighty-six percent would offer aggressive management to patients less than 85 years of age, whereas only 47.2% would offer similar care to those over 85 years of age (RR 0.5; 95% CI: 0.4-0.7). Physicians were less likely to offer aggressive management for patients with dementia (RR 0.2; 95% CI: 0.1-0.6), and for those requiring home assistance (RR: 0.2; 95% CI: 0.1-0.6) compared to those without dementia or functional limitations. CONCLUSION: Physicians are more likely to deny aggressive management to functionally active adults over 85 years of age, and to those with dementia or functional impairment irrespective of age.

Anemia prevalence in a home visit geriatric population.

OBJECTIVES: Ascertain anemia prevalence in the home visit geriatric population. DESIGN: Retrospective chart review. SETTING: A geriatric home visit program of a community-based teaching hospital. PARTICIPANTS: Non-institutionalized elderly patients referred to the geriatric home visit program from March 1, 2003, through October 1, 2006. MEASUREMENTS: Demographic, diagnostic, and hemoglobin data were abstracted. Anemia was defined using the WHO criteria of hemoglobin (Hb) less than 13 g/dL in men and less than 12 g/dL in women. RESULTS: The cohort consisted of 244 patients, predominantly white (88%), women (77%), and with a median age of 85 years. Anemia prevalence was 39.6% (95% CI: 32.6-46.9): 44.7% (95% CI: 30.2-59.9) in the men and 37.9% (95% CI: 30.0-46.4%) in the women. There was no statistically significant difference in anemia prevalence by race, known diagnosis of dementia, or by any other comorbidity. Majorities (86.8%) of the anemias were normocytic, 10.5% were microcytic, and 2.6% had macrocytosis. About 36.4% had nutrient deficiencies, 13.6% had anemia of chronic disease, 9.1% had myelodysplastic syndrome, and the etiology remained unknown for 40.9%. CONCLUSION: Anemia prevalence in the homebound geriatric population is high, about 4 times the National Health and Nutrition Examination Survey (NHANES III) estimate for the free-living, community-dwelling elderly. It mirrors the high prevalence in the nursing home population.