Frailty: A Slow Burning…Emergency? A Resident review on Advanced Care Planning in the ED

 

Robert Hanlon PGY1

Dalhousie Family Medicine

Saint John NB

Reviewed by Dr. Fraser MacKay

Copyedited by Dr. Mandy Peach

Chart: 95 year old male arrived by ambulance for generalized weakness…

PMHx: Mild Dementia, left hip arthroplasty 5 years ago from a fall at home (which also broke his left wrist), hypertension, atrial fibrillation, GERD, hearing loss, and anxiety/depression.

Social Hx: Lives with his daughter. Has a son. No admissions in the past 2.5 years.

Patient is lying supine on the stretcher and appears disheveled and  in emotional distress. He looks pale and emaciated with sunken facial features. He is staring at the ceiling and is slightly startled when you speak.

The patient is alert and oriented only to person. He answers questions with short sentences. His voice is shaky and anxious. He does not understand why he is in hospital or how he got here. He says he lives with his daughter. It seems he was living independently with some assistance, but recently requires more help. He claims he doesn’t walk much and really cannot bath, dress, or feed himself without his daughter. He, however, feels that he is still managing at home. He is afraid to be admitted to hospital.

 

Physical exam reveals pupils 3mm, equal and reactive to light. No RAPD, CN 2-12 are intact. Muscle bulk is reduced, but tone is normal.  Strength is 4/5 for both upper and lower limbs. There is normal ROM of his neck and limbs. Lungs have decreased air entry bilaterally but are clear. Cardiac exam reveals normal S1 and S2 with a systolic ejection murmur over the aortic valve area. Abdomen is soft, nondistended and non-tender. No pressure sores are noted at the coccyx or heels.

 

You call the daughter for some collateral. She says she is too distressed and not able to talk at this time. You call the son, and he identifies himself as the POA and his sister as the SDM. He lives in another city. He informs you that his father’s health has steadily declined since his fall 5 years ago. They have known about the dementia diagnosis for 8 years now and that his father first showed symptoms of declining memory after their mother died 9 years ago. Up until 5 years ago he had been living on his own with some assistance from family. After the fall, his family decided to have him come live with them. He says his sister has been taking care of their father, but that in the past 2 years the demands are out-weighing her abilities. He confirms that the patient is not able to complete their ADLs without assistance and that IADLs are impossible for his father. He had previously been using a walker to ambulate, but now he is unable to walk more than 2-3 steps. Despite this struggle, both the daughter and father do not want anyone in the house to help.

 

You ask when was the last time he saw his family physician – it was about 2.5 years ago right before the pandemic hit. He has had no in-person visits since, only phone calls for prescription refills. Although living with his daughter, he retains his family physician from his previous home when he lived independently. It has become increasingly difficult to get the patient to appointments of any kind.

 

You inquire about a code status: The son states that the discussion about SDM and POA had just occurred last week. The patient has been talking with both the daughter and son and often says that he is ‘ready to die and just wants this over with’. Together the son and daughter feel that a DNR order was appropriate, but the patient has not been asked outright what his wishes are.

This scenario is a common occurrence in Emergency Department’s across Canada and North America.

However, reading the scenario there is a sense that it is not a sudden acute emergency, but rather a slow burning issue that has reached a breaking point. You may ask yourself: why is this patient presenting to the Emergency Department? Is it appropriate? And, what does this type of presentation tell us about our care system and the experiences of frail patients?

 

There are many potential factors that have led to this patient’s current presentation. The main health issue being he is a 95 year old frail elderly male presenting with failure to thrive due to worsening dementia and physical decline.

However, I would like to focus on two specific areas of geriatric care. Advanced Care Planning and Local Resources for Caregivers

Advanced Care Planning

Looking at the scenario, there were multiple opportunities for this family, along with their health care providers, to discuss advanced care planning. This is in no way intended to place blame on any individual, group, or provider; yet, because there was a lack of communication/planning, the patient and their caregiver suffered a preventable crisis. Discussing advanced care plans is awkward; it can be unpleasant to discuss one’s end-of-life course or to cause family members distress. Nevertheless, the end-of-life experience is inevitable and the evidence shows that planning can help improve satisfaction with care and allow families to cope with loss (1,2). It is well established that being a care-giver for a complex-elderly patient is both mentally and physically demanding (3). Knowing this as care-providers, it is prudent to encourage elderly patients and their families to seek advanced planning early in a disease course or, better yet, before an illness. This way the individual is able to begin to reflect on their values and what they would like to prioritize in terms of their health and end-of-life experience. As well, starting early allows the conversation to be on-going over many years, which helps all those involved commit to the plan (1,2). Family physicians are best suited to encourage these early conversations.

But what can be done in the emergency department?

 

The reason this patient has presented to the emergency department is that his level of need surpassed his caregiver’s abilities; today just happened to be the day the caregiver could not function anymore in their role. Because of the poor access to primary care and little follow-up, this family had little choice but to choose the hospital as their point of entry.

 

The number of people over the age of 65 visiting emergency departments has been steadily increasing for decades, and older adults typically require more tests, stay longer, and are more frequently admitted to the hospitals (4,5,6). They are at greater risk of revisits, hospitalization, functional decline, and death after an emergency department visit (4). In elderly patients, an emergency visit is often a sign for declining health, which should prompt opportunities to change the clinical course of older patients.

 

Predicting the course or progression of disease in elderly patients is challenging. However, close monitoring of a patients’ experiences are likely to help clarify disease severity and drive better care. This provides Emergency Physicians with an opportunity to screen for frequent visitors and assess the level of frailty in patients. Frailty is a condition that occurs from multisystem decline and it compromises a person’s ability to recover from stressors (7).

 

The gold standard for assessing frailty is the comprehensive geriatric assessment (7). However, this is typically done through a geriatric service or as an in-patient assessment. There are streamlined tools that look to stratify risks for elderly patients visiting the emergency department. The Identification of Seniors at Risk (ISAR) and the Silver Code (SC) tools have been found to be useful in stratifying risk in both acute and long-term hospitalization, revisits, and death (8).

As score increases as does the risk of return visits, hospital admission and death.

 

One systematic review, suggested that the ISAR alone was not suitable for identifying seniors at risk (9). There are also the Clinical Frailty Scale (CFS), which was found to be strong at predicting in-patient death and admission to geriatrics (10,11). As well as the Study of Osteoporotic Fracture frailty index (SOF), which was strong at predicting functional decline (11).

Whatever tool that is used, it is important to remember it is a tool; used only to guide and inform care, but it is also important to consider the physical exam and clinical gestalt in assessing frailty.

 

If emergency physicians are able to help risk stratify frail patients, then the conversation at the end of a visit is an opportunity to shape expectations and suggest options for the prevention or early recognition of decline, and to encourage them to follow-up with their primary care physician (if they have one). This information can be used to help facilitate/motivate patients and their families to discuss and plan the future of their care.

 

Local Resources in NB

As providers at any entry point to the healthcare system, both primary care and emergency physicians ought to be familiar with local resources that can help patients in the community. The Government of New Brunswick has created an excellent guide for caregivers of older adults.

https://www2.gnb.ca/content/dam/gnb/Departments/sd-ds/pdf/Seniors/CaregiversGuide.pdf

 

As well there is a program called Social Supports NB, which can either be accessed via website or by telephone at 211.  https://socialsupportsnb.ca/en/

 

There is also the NB Home Support Association http://nbhsa.ca/english/about-us

 

 

References:

 

1. Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am. 2015 Mar;99(2):391-403. doi: 10.1016/j.mcna.2014.11.010. Epub 2014 Dec 23. PMID: 25700590.
2. Detering K M, Hancock A D, Reade M C, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial BMJ 2010; 340 :c1345 doi:10.1136/bmj.c1345
3. Hawken T, Turner-Cobb J, Barnett J. Coping and adjustment in caregivers: A systematic review. Health Psychol Open. 2018;5(2):2055102918810659. Published 2018 Nov 9. doi:10.1177/2055102918810659
4. Frumkin K. Toppling Oranges: Death, Disability, Decline, and Readmission of Community-Dwelling Elderly Patients After an Emergency Department Visit. J Emerg Med. 2020 Feb;58(2):339-345. doi: 10.1016/j.jemermed.2019.12.014. Epub 2020 Jan 28. PMID: 32005609.
5. Latham LP, Ackroyd-Stolarz S. Emergency department utilization by older adults: a descriptive study. Can Geriatr J. 2014 Dec 2;17(4):118-25. doi: 10.5770/cgj.17.108. PMID: 25452824; PMCID: PMC4244125.
6. Shenvi CL, Platts-Mills TF. Managing the Elderly Emergency Department Patient. Ann Emerg Med. 2019 Mar;73(3):302-307. doi: 10.1016/j.annemergmed.2018.08.426. Epub 2018 Oct 2. PMID: 30287120.
7. Theou O, Searle SD. Using frailty tools as prognostic markers in patients who are acutely ill. CMAJ. 2018 Feb 20;190(7):E182-E183. doi: 10.1503/cmaj.170902. PMID: 29565017; PMCID: PMC5828888.
8. Di Bari M, Salvi F, Roberts AT, Balzi D, Lorenzetti B, Morichi V, Rossi L, Lattanzio F, Marchionni N. Prognostic stratification of elderly patients in the emergency department: a comparison between the “Identification of Seniors at Risk” and the “Silver Code”. J Gerontol A Biol Sci Med Sci. 2012
9. Yao JL, Fang J, Lou QQ, Anderson RM. A systematic review of the identification of seniors at risk (ISAR) tool for the prediction of adverse outcome in elderly patients seen in the emergency department. Int J Clin Exp Med. 2015;8(4):4778-4786. Published 2015 Apr 15.
10. Wallis SJ, Wall J, Biram RW, Romero-Ortuno R. Association of the clinical frailty scale with hospital outcomes. QJM. 2015 Dec;108(12):943-9. doi: 10.1093/qjmed/hcv066. Epub 2015 Mar 15. PMID: 25778109.
11. Jørgensen R, Brabrand M. Screening of the frail patient in the emergency department: A systematic review. Eur J Intern Med. 2017 Nov;45:71-73. doi: 10.1016/j.ejim.2017.09.036. Epub 2017 Oct 3. PMID: 28986161.