US Pharmacist. 2014(5):18-21.
In the United States, patients admitted through the emergency department (ED) represent over one-half of hospital admissions.1 Of importance to pharmacists, nearly 70% of those admitted receive a nonsurgical diagnosis.1 According to the CDC, adverse drug events cause over 700,000 ED visits per year.2
Additionally, approximately 120,000 patients each year need to be
hospitalized for further treatment after emergency visits for adverse
drug events.2 Older adults (
years) typically take more medicines than younger persons; they are
twice as likely to present to EDs owing to adverse drug events (over
177,000 ED visits per year); and are almost seven times more likely to
be hospitalized after an emergency visit.2
Population studies have indicated that
40% of patients >65 years of age take five to nine medications daily,
and 18% take more than 10.3 In light of the fact that there
is a 50% to 60% chance of a drug-drug interaction when taking five
medications and a 90% chance of a drug-drug interaction when taking 10
or more medications, it is abundantly clear that in the care of seniors,
medication is a burden that requires evaluation.3 Pharmacists understand, and can appropriately address, the challenge of polypharmacy, which in older adults is especially problematic.4,5
Prompt, multidimensional assessment is critical to addressing the
challenges presented by geriatric patients. Pharmacists’ involvement in
the geriatric ED setting and during discharge transitions is an
important, evolving, and expanding area of practice.
Multidimensional Assessment: Avoiding Inaccurate Labels
The scenario of an elderly person left
unattended in an ED, confused, disoriented, and unable to advocate for
himself or herself regarding the acute situation, current difficulties,
and medical and medication history, is a potential safety hazard and may
also result in inaccurate clinical labels (e.g., incontinent, having
dementia) that may put the patient on track for nursing home placement
prior to careful evaluation. Dizziness, mobile instability, pain, and
sensory impairments (e.g., hearing, visual) may contribute to
communication difficulties, uncertainty, fear, and confusion in the ED
setting. A physical condition such as a urinary tract infection (UTI) or
dehydration can cause a cascade of physical and cognitive symptoms that
progress into a serious and misleading presentation.
The need for proper geriatric assessment
is essential, for example, to differentiate between a reversible,
physical cause of mental status changes—such as a UTI in an elderly
female requiring treatment—and an underlying dementia (e.g., vascular,
Alzheimer) requiring a different management approach. The geriatric
assessment is a multidimensional, multidisciplinary tool developed to
evaluate a senior’s functional ability, physical health, cognition and
mental health, and socioenvironmental circumstances.6,7 It
includes an extensive review of prescription and OTC medications,
vitamins, and herbal products, in addition to a review of immunization
status. It assists with determining diagnoses of medical conditions;
development of treatment and follow-up plans; coordination of management
of care; and evaluation of long-term care needs and optimal placement.7
By emphasizing the patient’s functional
capacity and quality of life, while at the same time utilizing a
multidisciplinary team approach, this type of assessment is capable of
yielding a more complete and relevant list of medical problems,
functional problems, and psychosocial issues, some of which may or may
not be medication-related.8
Functional Ability Matters
Maintenance of independence and prevention of disability are primary goals in the clinical care of persons
65 years.9 It
is imperative for ED healthcare professionals to understand the concept
of functional status as a proxy measure of a patient’s ability to live
independently.10,11 To fully assess functional status,
inquiry into the two types of functional measurements, basic activities
of daily living (ADLs) and the more complex, instrumental ADLs, must be
considered in addition to psychological state, financial resources,
physical function, and social circumstances.6 Furthermore,
care coordination programs, blended with technologies (e.g.,
telemedicine applications) could prevent or limit hospitalizations and
ED visits (TABLE 1) of frail elderly patients with chronic diseases.12 Recognizing and managing conditions frequently seen in older adults (e.g., geriatric syndromes, TABLE 2 and RESOURCES)
is not only the key to maintaining and improving functional status in
geriatric individuals, but also one of the true challenges.9 These conditions are often the result of underlying disease processes that may or may not be diagnosed.13
Geriatric ED Guidelines
The Geriatric Emergency Department
Guidelines document is a consensus-based project that included
representatives from the American College of Emergency Physicians,
American Geriatrics Society, Emergency Nurses Association, and Society
for Academic Emergency Medicine.3 The document provides a
standardized set of guidelines that can effectively improve the care of
the geriatric population and is feasible to implement in the ED.
Ultimately, it creates a template for staffing (e.g., board-certified
emergency physician with training in geriatrics, geriatric-appropriate
CME, ancillary services including pharmacists), equipment (e.g., use of
reclining chairs in the ED instead of ED gurney beds, nonslip fall mats
and bedside commodes to minimize fall risk), education (atypical
presentation of disease, medication management, effect of comorbid
conditions, palliative care), policies and procedures, follow-up care,
and performance improvement measures.
Sample policies and procedures include
The Screening of Geriatric Patients, Guidelines for the Use of Urinary
Catheters, Geriatric Medication Management, Geriatric Fall Assessment,
Delirium and Dementia, and Palliative Care. The document, in its
entirety, is available online (see Reference 3). Ultimately, these
guidelines support the notion that pharmacists can lead and participate
in integrated coordinated care programs aimed at improving patient
The ED Pharmacist and Geriatric Medication Management
One of the overwhelming challenges to the
U.S. healthcare system, and with specific regard to EDs, is the
unprecedented and rapidly expanding geriatric population: those
65 years and especially seniors
85 years and older (growing at a rate almost three times that of the general population).14-17 To begin to address this challenge, geriatric EDs began appearing in the U.S. in 2008 and have become increasingly more common.18
In light of the problems with polypharmacy in the elderly, the
pharmacist has been playing a significant role in this expansion effort
as well.3-5 The Geriatric Emergency Department Guidelines recommend the following3:
Accurate and current medication list:
a medication-reconciliation tool will involve patients, caregivers, and
medical record resources; patients taking more than five medications,
taking high-risk medications (
or presenting with signs or symptoms of adverse drug events will be
managed with a multidisciplinary approach, including a pharmacist, that
is focused on improving patient outcomes. Regardless of presenting
complaint, all geriatric patients coming to the ED will have a
medication list completed. When patients or caregivers are not able to
provide the information, computer-based resources can be effective for
obtaining accurate medication lists; further, pharmacy leadership and/or
involvement as part of a multidisciplinary team, including geriatric
specialists, is suggested for maintenance of a high-risk medication
list. Medication assessment should be performed on all patients at risk
or who have experienced a fall, especially those currently taking any of
the following classes of medications: vasodilators, diuretics,
antipsychotics, sedative hypnotics, and other high-risk medications.19 In the event that a senior patient requires
hospital admission and is noted
to have either polypharmacy concerns or the presence of one or more
high-risk medications, a referral will be made to a multidisciplinary
team to include a pharmacist. This approach, which involves interacting
with the attending physician, has several goals: minimizing drug-drug
interactions, minimizing polypharmacy, and minimizing the use of
high-risk medications—not only during hospitalization but also upon
patient transition process (e.g., admissions, transfers, discharges)
presents many challenges. In an era of daily ED crowding, providing
effective, reliable discharge instructions for all patient populations
is demanding; it is particularly so for the geriatric population.3,20
Older ED patients identify misinformation as a primary cause of
dissatisfaction with their emergency care, a problem confounded and
magnified by ongoing underrecognition of cognitive dysfunction, lower
health literacy, and financial impediments for prescriptions and
recommended outpatient follow-up.21-23 When pharmacists
encounter patients during a transition, in addition to identifying the
use of unnecessary medication and the presence of undertreated/untreated
conditions, there is an opportunity to observe for signs of elder
mistreatment and neglect. For other recommendations for pharmacists’
roles in the ED setting, including involvement in distinguishing between
features of delirium and dementia, see Reference 3.
Benefits of Geriatric Pharmacists: Supportive Evidence
Lee et al published a systematic review and meta-analysis of the performance of U.S. geriatric pharmacists on healthcare teams.24
The final analysis included 20 studies, conducted mostly in ambulatory
clinics and inpatient hospital settings. The authors concluded that
pharmacist intervention has favorable effects on therapeutic, safety,
hospitalization, and adherence outcomes in older adults and also
suggested that pharmacists should be involved in team-based care of
According to the Council on Credentialing
in Pharmacy (CCP), there is variability in complexity of care and
increasing differentiation of pharmacy practice. CCP believes that
“pharmacists—like many other patient care providers—should be expected
to participate in credentialing and privileging processes to ensure they
attain and maintain competency to provide the scope of services and
quality of care that are required in their respective practices.”25
The vision of CCP is that all credentialing programs in pharmacy will
meet established standards of quality and contribute to improvement in
patient care and the overall public health.25
Quality Assessment Instrument: The Dashboard
The Geriatric Emergency Department
Guidelines indicate that the geriatric quality improvement program will
include identification of indicators, methods to collect data, results
and conclusions, recognition of improvement, actions taken, and
assessment of effectiveness of the actions and communication process for
participants. In addition to other mechanisms to document and measure
quality, pharmacy-related, disease-specific entities that facilities may
Falls in the geriatric adult (polypharmacy screening in patients with falls)
reconciliation/pharmacy oversight (documentation of high-risk
medications, usage of high-risk medication in ED, percentage of revisits
for medication adverse reaction or nonadherence).
An example of a geriatric ED quality assessment instrument, generically referred to as a dashboard,
is found in Reference 3. Of note, it is imperative that knowledgeable
and skillful professionals become involved in the evaluation of results
from assessment instruments; left to the inexperienced individual, these
tools may be nothing more than a paper device compiling measurables
that overlooks the intended goal of quality services delivered to and
outcomes for an actual human being—the patient.
In addition to efforts by pharmacists and
physicians to improve care of elders in the ED, nurses are also playing
an active role. Nurses Improving the Care of Healthsystem Elders
(NICHE) is collaborating with organizations to build consumer advocacy
and drive system-wide initiatives in the care of seniors. In one such
collaboration, NICHE is working with the Catholic Health Association to
improve integration of care within their member institutions, including
600 hospitals across the U.S. Further, NICHE is a supporter of the
efforts of the Emergency Nurses Association with regard to the
development of an emergency department core curriculum.26
Medication-related problems in older
adults are common and cause considerable morbidity. A growing number of
pharmacists are playing a significant role in identifying, preventing,
and resolving medication-related problems in older adults, while at the
same time optimizing drug therapy and using their training, skills,
clinical judgment, and compassion in the ED setting for the benefit of
Disclaimer: Dr. Zagaria is
Chair-elect, Board of Commissioners, 2013-2014, of the Commission for
Certification in Geriatric Pharmacy.
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