Older people in emergency department

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KRISTIINA KARINIEMI-ÖRMÄLÄ

OLDER PEOPLE IN EMERGENCY

DEPARTMENT

Dissertations in Health Sciences

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND

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OLDER PEOPLE IN EMERGENCY

DEPARTMENT

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Kristiina Kariniemi-Örmälä

OLDER PEOPLE IN EMERGENCY DEPARTMENT

To be presented by permission of the

Faculty of Health Sciences, University of Eastern Finland for public examination in MD100 Auditorium, Kuopio

on December 15th, 2020, at 12 o’clock noon Publications of the University of Eastern Finland

Dissertations in Health Sciences No 600

Department of Nursing Science University of Eastern Finland

Kuopio 2020

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Series Editors

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Professor Tarja Kvist, Ph.D.

Department of Nursing Science Faculty of Health Sciences Professor Ville Leinonen, M.D., Ph.D.

Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences

Professor Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D.

School of Pharmacy Faculty of Health Sciences

Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland

www.uef.fi/kirjasto

Name of the printing office/kirjapaino Grano Oy,

Kuopio 2020

ISBN: 978-952-61-3638-7 (nid.) ISBN: 978-952-61-3639-4 (PDF)

ISSNL: 1798-5706 ISSN: 1798-5706 ISSN: 1798-5714 (PDF)

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Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Doctoral programme: Doctoral Programme in Health Sciences Supervisors: Professor Katri Vehviläinen-Julkunen, Ph.D.

Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Associate Professor He Hong-Gu, Ph.D., MD Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore SINGAPORE

Reviewers: Professor Anthony Paul O´Brien, Ph.D.

Faculty of Health and Medicine, School of Nursing and Midwifery University of Newcastle

AUSTRALIA

Heikki Paakkonen, Ph.D., Title of Docent Arcada University of Applied Sciences HELSINKI

FINLAND

Opponent: Docent Satu Elo, Ph.D.

Lapland University of Applied Sciences KEMI

FINLAND

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Kariniemi-Örmälä, Kristiina

Older people in Emergency Department Kuopio: University of Eastern Finland

Publications of the University of Eastern Finland Dissertations in Health Sciences 600. 2020, 229 p.

ISBN: 978-952-61-3638-7 (print) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3639-4 (PDF) ISSN: 1798-5714 (PDF)

ABSTRACT

This study concerns important topics which are seldom studied in nursing sciences;

older peoples´ emergency nursing and care left undone. The aim of the study was to investigate self-medication management, mental status such as symptoms of depression and memory disorders, the ability to self-manage ADLs at home and continuity of care among older people aged 70 years and above who had lived at home before an emergency department visit and returned home immediately after the emergency department visit. The purpose was to identify and examine factors in nursing carried out in emergency department, primary emergency duty or primary care, which lead to omission of certain aspects of required patient care in the care of older people. The data were collected in two phases: At first using a cross-sectional descriptive qualtitative design recruiting a convenience sample of 141 older people over 18 months from 2004 to 2005. Data were collected through structured interviews and by reviewing medical records (n=129). Secondly, data were collected by questionnaire (2019) from nursing managers (n=5) working in Emergency departments and by structured questionnaire (2020) from nursing staff (n=59) working in primary emergency duty and primary care. In the structured interviews of older people, many measurements were used (GDS-15, IADL, MMSE). The questionnaires for nursing managers and for nursing staff were drawn up specially for this study and based on Kalischs´s model of missed nursing. A significant number of home dwelling older people encountered challenges in self-medication management, mental health and ADLs and care. The earlier such a challenge is recognized and found, the earlier the care and rehabilitation can be provided. The main influencing factors contributing to missed nursing care were related to resources (busyness, lack of systematic assessing protocols and lack of measurements) and in the lack of communication between the emergency team and other caregivers of the older people and their relatives. It is very important to prevent missed care in older peoples´ emergency nursing. Unnoticed or overlooked assessment of self-medication management, signs of memory disorders and signs of depression, functional assessment and obscurity in continuity of care might be critical issues and barriers to continue living at home for older people. There is a need

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to develop intervention programmes to improve emergency nursing for older people before their discharge and to provide continuity of care after they are discharged home.

Keywords: Aged; Self Medication; Activities of Daily Living; Memory Disorders; Mental Health; Emergency Service, Hospital; Emergency Nursing, Missed Nursing Care

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Kariniemi-Örmälä, Kristiina Ikääntynyt päivystyksessä Kuopio: Itä-Suomen yliopisto

Publications of the University of Eastern Finland Dissertations in Health Sciences 600. 2020, 229 s.

ISBN: 978-952-61-3638-7 (nid.) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3639-4 (PDF) ISSN: 1798-5714 (PDF)

TIIVISTELMÄ

Tutkimus koskee tärkeää aihetta, josta hoitotieteessä on vähän tutkimustietoa;

ikääntyneen päivystyshoitoa ja huomiotta jäänyttä tarpeellista hoitoa. Tutkimuksen tavoitteena oli selvittää kotona asuvien ikääntyneiden, 70-vuotiaiden ja sitä vanhempien, itsenäistä lääkehoidon hallintaa, orientaatiota ja mielialaa, kykyä selviytyä kotona päivittäisissä toiminnoissa sekä jatkohoitoa yliopistosairaalan päivystyskäynnin jälkeen. Tutkimuksen tarkoituksena oli tunnistaa niitä hoitotyöhön liittyviä tekijöitä, jotka johtavat päivystyksessä, kiirevastaanotoilla tai vastaanotoilla ikääntyneen hoidossa keskeisen ja tarpeellisen asian huomiotta jäämiseen. Poikkileikkaustutkimukseen osallistui 141 ikääntynyttä ja yli vuoden kestänyt aineistonkeruu ajoittui vuosiin 2004-2005. Tiedot kerättiin strukturoidun haastattelun avulla sekä potilaiden sairaskertomustiedoista (n=129). Lisäksi tietoa kerättiin kyselyllä hoitotyön esimiehille (v.2019/n=5) sekä strukturoidulla kyselyllä (v.2020/n=59) perusterveydenhuollon vastaanotoilla (akuutti/kiire- ja ajanvarausvastaanotoilla) työskenteleviltä hoitotyön tekijöiltä. Ikääntyneiden strukturoiduissa haastatteluissa käytettiin monia mittareita (GDS-15, IADL, MMSE).

Kysely hoitotyön esimiehille sekä hoitotyöntekijöille laadittiin tätä tutkimusta varten, viimeksi mainittu perustui Kalischsin malliin huomiotta jääneestä hoitotyöstä (Missed nursing care model). Huomattava osa tutkimukseen osallistuneista ikääntyneistä kärsi haasteista itsenäisessä lääkehoidon hallinnassa, orientaatiossa ja mielialassa, kyvyssä selviytyä päivittäisissä toiminnoissa sekä jatkohoidossa. Keskeisimmät vaikuttavat tekijät, jotka johtivat huomiotta jääneeseen hoitoon, liittyivät resursseihin (kiire, puuttuvat arviointikäytännöt ja -mittarit) sekä hoitavan tiimin ja muiden ikääntynyttä hoitavien tahojen sekä ikääntyneen läheisten väliseen vuorovaikutukseen. Tutkimuksen tulokset osoittavat päivystyksessä ikääntyneiden hoitotyön haasteita, jotka vaativat terveydenhuollon ammattilaisten huomion. Mitä aiemmin tällaiset jokapäiväisen elämän haasteet ikääntyneen elämässä tunnistetaan ja löydetään, sitä aiemmin voidaan myöskin kuntoutus ja tarpeiden mukainen tuki aloittaa. Hoitotyön interventiot, erityisesti ikääntyneen

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itsenäisen lääkehoidon hallinnan, toimintakyvyn kotona ja mielialan arvioinnissa, ikääntyneiden päivystyshoitotyön parantamiseksi ovat tarpeen, varmistaaksemme ikääntyneen kotona selviytymisen, ja tarpeiden mukaisen jatkohoidon päivystyksestä kotiutumisen jälkeen. Hoitotyön keinoin sekä moniammatillisella yhteistyöllä on mahdollista tukea ja parantaa ikääntyneiden itsenäistä, turvallista ja laadukasta asumista kotona.

Avainsanat: ikääntyneet; vanhukset; lääkehoito; itsehoito; koti; avohoito; itsenäinen selviytyminen; toimintakyky; muistihäiriöt; mieliala; päivystys; hoitotyö; laiminlyönti

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To:

Arttu-Kalle, Iiris and Kare

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ACKNOWLEDGEMENTS

The study was conducted in the Department of Nursing Science at the University of Eastern Finland, in the Doctoral Programme of Nursing Science. I wish to thank several people who enabled and supported my study process. This work has been supported by many individuals who have provided their valuable contributions during these study years.

First and foremost, I express my deepest gratitude and thank to my main supervisor, Professor Katri Vehviläinen-Julkunen, for her excellent guidance and essential support throughout these years. I would like to especially thank my second supervisors, Associate Professor He Hong-Gu, for carefully instructing me with patience and support, and Chief of Service, Matti Halinen, MD, for his advices and support in the beginning of my study process.

I would like to thank the reviewers, Professor Anthony O´Brian and Docent Heikki Paakkonen, for their valuable and constructive comments on the thesis. I thank Aku-Ville Lehtimäki for statistical advice. I am thankful to Docent Pirjo Laitinen-Parkkonen for the support she provided especially during the end of this research journey.

I am deeply to thankful to all my participants who consented to take part in this study. Without their time and commitment, this study could not have been possible.

I would like to thank my collaborators at work and networks, nationally and internationally, for your encouraging support and interesting discussion about my study topics and everything else.

I am deeply thankful to all my friends for caring, joy and support. Especially for Ruija for weekly runnings together, ventilating lungs and minds, and for Johanna for long walks and talks.

My warmest thanks belong to my family. My dear parents Marja-Leena and Matti, my sister Pauliina and her family, brothers Jukka and Matti and their families, I am very lucky to have you all in my life. I am thankful to Anni, Nuutti and Jaakko for being part of my life. Finally, my depest thanks go to my wonderful children Arttu- Kalle, Iiris and Kare for bringing all this happiness and love in my life, and to Timo for his patience, support and love during these years. Thank you for sharing your life with me.

Helsinki, 24 October 2020 Kristiina Kariniemi-Örmälä

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ABBREVIATIONS

ADL Activities of Daily Living DRP Drug related problem ED Emergency department ER Emergency room EP Emergency practitioner GDS Geriatric Depression Scale GDS-15 Geriatric Depression Scale 15

–item shortened form

GP General practitioner

IADL Instrumental Activities of Daily living MMSE Mini-Mental State

Examination MNC Missed nursing care NSC Non-specific-complaint OTC- Over the Counter-medication PC Primary care

PCP Primary care practitioner

PIM Potentially inappropriate medication UCC Urgent Care Clinic

UN United Nations

WHO World Health Organization

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1 INTRODUCTION

This study addresses a phenomenon that has been the subject of public conversations for several decades: older people and emergency department care. Due to the aging of the population and the demographic shift towards older people in the health care system, emergency departments are increasingly challenged by the complexities of providing care to an increasing amount of geriatric patients (e.g., Lowthian et al., 2016.) Older people with multiple health problems are an ever-increasing population in emergency departments in many countries (e.g., Salvi et al., 2007; Yim et al., 2009;

Lowthian et al., 2013a,b; Mylläri 2017). Although advanced practice nurses within acute care settings, like emergency departments, are responsible for providing healthcare to a rapidly expanding population of older people, it is an infrequently studied area in nursing sciences. Older people themselves are seldom recruited to participate as informants in acute care nursing studies.

Aging is usually seen as a complex issue not only from the individual’s viewpoint but also from society’s viewpoint. The latter view is mostly connected with national economics. Aging has been a topic around the world during the last decade because of the huge growth in the number of older people, especially in Asia and Europe (e.g., Pew Research Centre, 2014). The proportion of people older than 65 years in the Finnish population is expected to increase from 17% at present to 27% by 2040 and to 29% by 2060 (Official Statistics of Finland, 2018). The number of those over 80 years will double during that same time. The national aging policy goal in Finland is for every older person to live in their own home for as long as possible and to remain intependent. The aim of the aging policy is to further older people's functional capacity, independent living and active involvement in society (Ministry of Social Affairs and Health in Finland, 2013a, 2017.) Such targets require the early recognition of possible threats to older peoples lives. These threats include impaired activities in daily living (ADL), memory disorders or signs of depression, and problems with handling medicines. The earlier the problems are recognized and found, the earlier the care and rehabilitation can be provided.

An aging population is a phenomenon resulting from declines in fertility and increases in longevity: two trends usually are associated with social and economic development. Aging is connected with the national economy and the need for social and healthcare services (WHO, 2011.) Medical advances have contributed to longevity, resulting in an increase in such age-related challenges as functional decline, chronic conditions and cognitive impairment. Older people are more likely to have chronic illnesses and impaired functions. Thus issues connected to aging are common topics of conversation, such as the already mentioned treatment and care, lack of personal care (Finnback et al., 2012) and, especially in Finland, feelings of loneliness (Golden et al., 2009; Tilvis et al., 2011; Eloranta et al., 2015.)

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At the same time, aging policy goals emphasize older peoples´ own involvement and active role both in society and in their nursing processes. Active ageing, defined by the WHO, means “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age” (WHO, 2002). The European Union is also following active and healthy ageing (active aging index/AAI) in Europe, and Finland was at the top of five countries in this latest study (Zaidi et al., 2017). Older people themselves also have new expectations of and demands for social and healthcare services. This phenomenon is recognized worldwide: Older people wish not only to spend their later years in good health but also aim to achieve great accomplishments (Arai et al., 2012.)

However, older people are not a homogenous group, and aging is an individual process for each person. There is also evidence from empirical studies that patients who can participate in their own care have better health and social wellbeing outcomes compared to those who aren´t (Wetzels et al., 2007). Regarding older people’s own involvement in their care and rehabilitation processes in emergency settings there is a lack of research about into nursing processes in emergency departments.

It is important that acute care nurses are familiar with the most common threats to older people who live at home if we are to ensure the best care for older people and their families. They also are on the front line of recognizing possible threats to older people´s lives. Such threats include a lack of assistance with daily living tasks, medication mistakes, loneliness, memory disorders and depressive symptoms (Hartikainen et al., 2007; Ahonen 2011; Ekwall et al., 2012; Tsai-Yun & Ke-Hsin, 2011;

Steinmiller et al., 2015). However, there is evidence about access to the right supports and prevention’s effectiveness connected with aging and aging problems (Pitkälä et al., 2009; Routasalo et al., 2009; Pitkälä et al., 2013; Maloney et al., 2017). In addition, it is found that when older patients are discharged home, family members have a significant role to play in providing aftercare (Deminenko, 2018), therefore it is always important to pay attention to older peoples´family members also in emergency nursing.

Turning aging into an opportunity means that older people need to be listened to more and to become more involved. Involvement is an ambiguous concept in nursing that needs more study. It has been found that older people, 70 years and above, are interested in to take part in their own care, but their definition of involvement is more focused on the “caring relationship,” a “person-centred approach” and “receiving information” than on “active participation in decision making” (Bastiaens et al., 2007). It is also found that nurses and other health care professionals don’t necessarily know how to facilitate older peoples greater participation to make possible their involvement in their own care (Lyttle & Ryan, 2010).

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This study’s purpose was to investigate self-medication management, mental status, the ability to self-manage ADLs and continuity of care among older people aged 70 or older, who lived at home before an emergency department visit and who returned home immediately after an emergency department visit. The purpose was to identify and examine factors in nursing carried out in emergency department, primary emergency duty or primary care, which lead to omission of certain aspects of required patient care in the care of older people. The study took place at university hospital emergency departments and in primary emergency duty and primary care in Finland.

The terms, concepts and euphemisms for "older people" exist in many languages and cultures. This study chose the concept “older people” because of its worldwide usage and neutrality. The study venue is called “emergency department (ED)” and

“primary emergency duty” which also has many synonyms -emergency room (ER), accident and emergency department (A&E) ect., and are a part of acute care. Based on the Merriam-Webster-dictionary, the medical definition of acute care means

“providing or concerned with the short-term usually immediate medical care as for serious illness or traumatic injury”. In other words, patients might receive active but short-term treatment for example for a severe or life-threatening injury, illness, routine health problems, recovery from surgery, or acute exacerbation of chronic illnesses. Typically, the goal of acute care is to restore the health and stability of the patient. The proposed definition of acute care by Hirshon et al. (2013) comprises the health system parts, or care delivery environments, “used to deal with sudden, unexpected, urgent or emergent episodes of injury and illness that can lead to death or disability without rapid intervention.” In their definition the term “acute care”

includes a range of clinical health-care functions, including emergency medicine, trauma care, pre-hospital emergency care, acute care surgery, critical care, urgent care and short-term inpatient stabilization (Figure 1). These environments include also pscychiatric acute care and the care of people of all ages.

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Figure 1. Domains in acute care (Hirshorn et al., 2013)

Despite this acute care role definition, it is also regognized that emergency departments have become important entry points for those without other means of access to medical care (e.g. Faulkner&Law, 2015; Malmström et. al., 2017).

This thesis is based on two research phases and comprises several parts. First, the literature review carefully examines the phenomena of interest. Then the study’s aims, objectives and methods are described. The final part presents the study’s results and conclusions.

Trauma care &

acute care surgery

Critical care

Pre-hospital emergency care

Short-term inpatient stabilization Urgent care Emergency

medicine care

Acute care

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2 REVIEW OF THE LITERATURE

2.1 AN AGING POPULATION

The world´s population of people aged 60 or over is growing faster than all younger age groups. In 2019, it was an estimated 703 million people aged 65 or over in the world, comprising 9% of the global population. The number of older persons is projected to double to 1.5 billion in 2050 (United Nations, 2019). The population aged 60 or above is growing at a rate of about 3% per year and Europe has the greatest percentage (25%) of population aged 60 or over (United Nations, 2017.)

Europe was the first region to enter the demographic transition, having begun the shift to lower fertility and increasing longevity in the late 19th and early 20th centuries (United Nations 2015). As a result, today’s European population is the most aged in the world, with 25% of the population aged 60 or over. Europe is projected to remain the most aged region in the coming decades, with 34% of the population aged 60 or over in 2050, followed by North America (27%), Latin America and the Caribbean (25%), Asia (24% ) and Oceania (23%). Compared to other regions, including many parts of Africa, the proportion of the world´s population reaching older ages is predicted to grow for several decades (United Nations 2015, WHO 2018.) Older people are a growing demographic group in society (Table 1).

Nowadays in 17 countries more than one fifth of the population are older people and it is estimated that this will be the case for 155 countries in the end of the century (year 2100), covering a majority (61%) of the world´s population (United Nations, 2019).

Table 1. Proportion of older ages (percent) in the world (United Nations, 2015)

Age 2015 2030 2050

60+ 12.3 16.5 21.5

65+ 8.3 11.7 16.0

80+ 1.7 2.4 4.5

The goal in Finland, one of the fastest aging countries in Europe, is for all older persons to live in their own home for as long as possible and to do so as independently as possible. The aim of the aging policy is to further older people's functional capacity, independent living and active involvement in society (Ministry of Social Affairs and Health in Finland, 2017.) The aim is for older people to become motivated to be responsible for their own health and for preserving their functional capacity through exercise, healthy nutrition, rehabilitation and by using other social and health services when needed. Although an increasing number of older people

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enjoy good health longer than previously, live independently and need no assistance or care, the aging of the population will still increase the pressure on social and health services. Most older people do not need regular health and social services; however, many diseases and functional limitations tend to increase with age. The oldest age groups are growing, which increases the need for services. There is, nevertheless, little evidence to suggest that older people today are experiencing their later years in better health than their parents. While rates of severe disability have declined in high- income countries over the past 30 years, there has been no significant change in mild to moderate disability over the same period (WHO, 2011, 2018.)

The Ministry of Social Affairs and Health in Finland has established national objectives concerning services for older people in the form of its National Framework for High Quality Services for Older People (Ministry of Social Affairs and Health in Finland, 2013a, 2017). One of its most important strategic goals is to improve the welfare of the older people and to promote health. The nationwide aim was that by 2017, 91% to 92% of 75-year-olds would live at home independently, or under the protection of appropriate social and health services provided on the basis of a comprehensive service needs assessment (Ministry of Social Affairs and Health in Finland, 2013a). The latest form of the National Framework for High Quality Services for Older People (2017) encouraged society to build an economically and socially sustainable service system and to guarantee, as much as possible, the good health and functional capacity of the older population. The most recent quality recommendation emphasizes five thematic areas and provides recommendations for each of them. The thematic areas dealt with are: guaranteeing the functional capacity of older people, arranging service counselling for clients, the personnel performing the services, the structure of the age-friendly services, and technology (Ministry of Social Affairs and Health in Finland, 2017.)

In 2015, most of Finland's population over the age of 65 (almost 1000 000 people) lived their daily lives independently. The social and health care services were used regularly by about 150,000 of those people. In these ages about 95,000 people received regular home services, home care and family care support. Outside private homes, more than 50,000 people over the age of 65 received round-the-clock care and nursing care. From year 2008 to year 2018 the outpatient visits to special medical care have almost doubled (visits/1000 citizens); from 254 visits to 420 visits in the age of 65 to 79 years old, and from 89 visits to 162 visits in the age of 80 years and older (Ikatalo.fi/2019; Finnish Institute for Health and Welfare, 2019.)

It is found that about 20% of emergency department patients in special medical care are 75 years old and older in Finland (Malmström et al., 2017). On the other hand, there is a big variation in the use of emergency department of older people between Finnish cities and municipalities. The number of emergency department visits (in 2014) per 1000 older people in large cities ranged from less than 300 visits to more

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than 900 visits and were influenced by the entire social and health care services available in the area for older people (Malmström et al., 2017.)

Younger retirees are now in better shape than before, and older people are still active and able to function. However, the average health status and functional capacity of people over the age of 85 have remained the same over the last 15 years. In old age, men are in better shape than women. Women, on the other hand, live longer than men (Ikatalo.fi/2019; Finnish Institute for Health and Welfare, 2019.)

The aging of the population has brought with it a new public disease, memory disorders. It is currently estimated that there are more than 190,000 people with memory problems in Finland. The majority of those affected are over 80 years of age, although memory disorders also occur in working-age people. Three out of four older people in long-term care suffer from memory disease (ikatalo.fi/2019; Finnish Institute for Health and Welfare, 2019.)

2.2 EMERGENCY SERVICES IN FINLAND

Emergency departments, as part of acute “on duty” health care services, have their own special role in social and health care services. Their branch of activity and the arrangement of duties in Finland are defined by many laws and regulations including the Act of Specialized Medical Care (1062/1989), the Health Care Act (1326/2010), the Primary Health Care Act (66/1972), the Act on the Status and Rights of Patients (785/1992), and the latest being “Valtioneuvoston asetus kiireellisen hoidon perusteista ja päivystyksen erikoisalakohtaisista edellytyksistä (583/2017)”

(unofficially translation: Decree of the Government on principles of urgent care and requirements of emergency care specialties 583/2017). (STM, 2010, 2014, 2017.) In Finland, Hospital Districts are responsible for arranging the medical emergency services in their respective areas, based on the Health Care Act (1326/2010). Hospital districts plan and develop the provision of specialized medical care to ensure that primary health care and specialized medical care form an effective whole. Mainland Finland has 20 hospital districts. Health care services on the autonomous Åland Islands are provided based on the Act on the autonomy of Åland. Every municipality must belong to a hospital district. Municipalities (or joint municipalities) have the responsibility to organinize the primary care, social and healthcare services of their own area. Each hospital district belongs to one of the five university hospitals catchment areas. These coordinate the provision of specialised medical care, information systems, medical rehabilitation and procurement (Ministry of Social Affairs and Health in Finland, 2013b.)

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Urgent cases, like emergency department patients, are defined as “cases involving an injury, a sudden onset of illness, an exacerbation of a long-term illness, or the deterioration of a general functional capacity where immediate intervention is required and where treatment cannot be postponed without risking the worsening of the condition or further injury” (Ministry of Social Affairs and Health in Finland, 2013b, p. 29).

The role of an acute care setting is to quickly, adjustably and effectively address a patient´s primary problem, that is, the specific reason why they need acute care.

Emergency department services are generally delivered by teams of health care professionals from a range of medical and surgical specialties. In addition to different kinds of speciliaze doctors and nurses, other healthcare professionals like physiotherapists and pharmacists are also involved. Hospital-based acute inpatient care typically has the goal of discharging patients as soon as they are deemed healthy and/or stable.

2.3 THE PURPOSE OF THE LITERATURE REVIEW

The purpose of the literature review was to examine what is known about older people in acute care settings, such as emergency departments and nursing. The special interests were in home-dwelling older people of 70 or over, their self- medication management, mental status, ability to self-manage ADLs at home and the continuity of care they receive. The first literature review was made in 2004 and finally completed in 2020. In the 2020 the special interest was in the missed nursing care model. The university´s information specialist´s help was asked from time to time to search and find references. The search was finally limited to the years 2006 to 2020; as a result there were thousands of references, many connected with medication and dementia. After a more refined search, such as “acute care nursing”,

“self-medication management,” the results decreased. It was important to accept a broader view in the literature review of older people in order to deepen understanding about the study phenomena, as well as the theoretical perspectives in the branch of science, especially if it was connected with the study’s interests in older people’s self-medication management, mental status, activities in daily living, continuity of care or in missed nursing care model. Duplicate references were excluded. All the papers included in the review are in English, Swedish or Finnish (Table 2).

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Table 2. Inclusion and exclusion criteria for studies included in the literature review

Inclusion criteria Exclusion criteria

Required home-dwelling older people age 65 years or above

Living in institutions and receiving institutional care

Reporting self-medication, mental status, ADLs, and/or continuity of care

With psychiatric disorders Having dementia Having end-stage illnesses Acute care settings

Nursing study, or medicine, pharmacology, social study

Finnish, English, Swedish

Additionally, national and international statistics and laws concerning the study’s interest were also used in the literature review, as were nine Finnish dissertation studies.

This literature review searched the electronic database of CINAHL, Medic, PsycINFO and PubMed. A manual search was performed on all the Finnish Nursing dissertation studies that had been electronically published and made available in university databases. Some of their reference lists were also studied carefully to find further studies relevant for this review.

At the first study phase the keywords used in the literature review (Figure 2) included older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living; connected with:

1. Acute care OR accident and emergency (department, room) care OR A&E, OR emergency (department, room) OR/AND nursing (especially chapters 2.2)

2. Self-medication OR/AND self-medication management OR/AND nursing (especially chapters 2.3.)

3. Orientation OR confusion OR mental status OR depression OR dementia OR loneliness OR apathy OR/AND nursing (especially chapters 2.4.)

4. Social activity OR ADL OR IADL OR continuity of care OR/AND nursing (especially chapters 2.5)

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Figure 2. The first study phase keywords in the literature review

A total of 2079 abstracts were evaluated, and 125 articles were included in the literature review (Table 3).

Table 3. Search databases and included studies in the literature review in the first study phase (2006-2020)

_____________________________________________________________________

Databases Search result (2079) Included studies (125)

______________________________________________________________________________

CINAHL 277 52

Medic 10 2

PsycINFO 66 5

PubMed 1726 66

______________________________________________________________________________________

The included articles (Appendix 1-4) used mostly quantitative approaches (n=79);

qualitative approaches (n=21), or literature reviews (n=24). The United States of America (USA) was the country of origin for most of the included articles, but nearly all continents were represented. A total of 42 were from Nordic Countries, with 29 from Finland (Table 4).

2.4 Orientation OR confusion OR mental status OR depression OR

dementia OR loneliness OR

apathy

OR/AND NURSING 2.3

Self-medication OR/AND self-medication management

OR/AND NURSING 2.2

Acute care OR accident and emergency (department, room) care OR A&E OR Emergency (department, room)

OR/AND NURSING

Older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living

2.5 Social activity

OR ADL OR IADL OR continuity

of care

OR/AND NURSING

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Table 4. Summary of the articles included in the literature review in the first study phase (n=125)

Study design and methods n Country of origin n

Quantitative 79 Asia 9

Qualitative 21 Australia 16

Mixed methods 1 Canada 6

Literature review 24 Europe (other than Nordic countries) 19

Finland 29

Other Nordic countries 13

Middle-East 2

USA 31

At the second study phase keywords used in literature review concerning Missed nursing care model (Figure 3) included missed nursing care AND/OR missed nursing care model AND/OR older people OR elder OR older adults OR old aged OR older aged OR aged AND/OR acute care OR accident and emergency (department, room) care OR A&E OR emergency OR ED OR/AND nursing.

Figure 3. The second study phase keywords in the literature review

In the second study phase a total of 107 abstracts were evaluated, and 16 articles (Appendix 5) were included in the literature review. The included articles used mostly quantitative approaches (n=11), qualitative approaches were 1 (n=1) and four (n=4) literature review/reviews. The United States of America (USA) was the country of origin for most of the included articles (n=8), two were from Australia (n=2) and three from Asia (n=3) and Europe (n=3).

2.4 OLDER PEOPLE AND NURSING IN ACUTE CARE SETTINGS

The literature review for home-dwelling older people and nursing in acute care settings was performed using the following keywords: older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living connected with acute care OR accident and emergency

Missed nursing care model AND/OR missed nursing care

AND/OR older people OR elder OR older adults OR old aged OR older

aged OR aged AND/OR nursing

AND/OR acute care OR accident and emergency (department, room) care

OR A&E OR emergency OR ED AND/OR nursing

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(department, room) care OR A&E OR Emergency OR ED OR/AND nursing (Figure 4).

Figure 4. Keywords in the literature review of home-dwelling older people and acute care settings nursing

2.4.1 Complex needs and multiple health conditions

The acute hospital sector today has the largest health care system expenditure in developed countries. Older people are said to be an increasingly frequent user group in emergency departments (ED) (Yim et al., 2009; Lowthian et al., 2013a,b; Salvi et al., 2013; Legramente et al., 2016; Mylläri, 2017). Older people are found to often have complex needs over and above the clinical cause of attendance, along with repeat attendance and health and non-health factors associated with that cause (Courtney et al., 2009; Naughton et al., 2010; Faulkner & Law, 2015). It is also suggested that the fast-paced ED environment is unsuitable for meeting the older population’s care needs and can cause negative outcomes and adverse events for older people (Schnitker et al., 2011; Bolz et al., 2013; Skar et al. 2015). (Figure 5).

Older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living

Acute care OR accident and emergency (department, room) care OR A&E OR Emergency

OR ED OR/AND NURSING

A TOTAL OF 82 abstracts were evaluated and 35

articles were included in the literature review

(Appendix 1)

2.2.1

Complex needs and multiple health conditions

2.2.2

Acute care settings and nursing

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Figure 5. Phenomena connected with older people´s emergency department care

Most of the phenomena connected with older peoples´emergency department care (Figure 5) are often considered and have mostly been researched by organizational view and how it looks from the service providers’ view. Less is known from the older peoples´own view from patient-centered instead of use of primary outcome.

Increasingly frequent user group

Many studies indicate that older peoples are an increasingly frequent user group in EDs, and the number of visits is only rising year by year (Foo et al., 2009; Yim et al., 2009; Lowthian et al., 2013a; Legramente et al., 2016). This is partly related to a demographic shift that has resulted in a rapid increase in a number of older people in general, but according to the literature review many other reasons are affecting too. Similar perceptions were made about the ED duration of stay, it´s longer with older people and increasing with growing age, and hospital admissions which are

WHY OLDER PEOPLE CHOOSE ED THEIR OWN EXPERIENCE

Access to primary care blocked, including phone system and staff Lack of more specialized care and

available appointments Expectations of more timely and

specialized care Lack of primary physician Desire to avoid burdening friends

and family Low or medium levels of continuity of care with a primary

physician

Previous experience from care

RECOGNISED PHENOMENONS WITH OLDER PEOPLE AND ED

Incresingly frequent user group Repeat attendance Complex needs over and above

clinical cause of attendance Health and non-health factors associated with attendance and

repeat attendance More likely to have atypical

presentations

Fast pace ED environment is unsuitable to meet the older

peoples´s care needs Hospital admission is common Attends more likely than other age

groups for non urgent conditions to ED

Interventions reduce ED utilization

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more common with older people. Also, the amount of ED hospital admissions of older people has doubled over the last decade, and older patients are disproportionately represented among ED attendance (Lowthian et al., 2013a; Yim et al., 2009.) (Figure 5).

It is found that older people, when compared to younger patiets in ED and the general population, have a greater presentation and more likely present atypically too (Foo et al., 2009). The older people also had the highest rates of comorbidities and higher resource utilization rates (Foo et al., 2009, Salvi et al., 2013).

Legramente et al. (2016) studied the older people’s frequent use of emergency departments by evaluating and profiling patients’ age 65 and above hospital visits to the emergency department. Their study’s aim was to recognise clinical and social characteristics possibly connected with "older frequent users.” The older people in this study represented 25% of the total ED population. At the same time older people had an increased risk of common use of ED, diagnostic complexity and hospitalization. Legramente et al. (2016) suggest that older people presented clinical and social characteristics connected to the definition of "elderly frail frequent users”.

They also noticed that the fact that a larger number of hospitalizations took place with such patients is indirect evidence of frailty in this specific population.

Also, many reasons behind the increased rate of emergency department use of older people are recognized. Repeat attendance and “unnecessary use” of emergency departments by older people are also phenomenon´s behind the increasing rates of older peoples´ visits to ED. “Unnecessary use” of ED by older people is a contradictory concept and usually means that older people are more likely than other age groups to attend to emergency department repeatly for non-urgent conditions.

Early return or nonscheduled early return to the emergency department is also a phenomenon behind the increasing rates of older peoples´visits to ED.

Repeat attendance

Repeat attendance is a widely recognized phenomenon connected to older peoples´

ED visits (Nauhgton et al., 2010; Faulkner & Law, 2015;

š

teinmiller et al., 2015). It is also found that both, health- and non-health factors have a role in the repeat ED attendance of older people. Independent risk factors of a repeat ED attendance by older people have found to be previous hospital visit, anxiety, being part of a vulnerable social network and other health-related variables (Naughton et al., 2010;

Faulkner & Law, 2015.)

In fact, independent risk factors for early return to ED of older people have recognized many, like symptoms of depression, cognitive impairment, co-morbidity,

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triaged as less urgent and attendance in the previous 12 months, with a decline in risk after 85 years of age. Some specific reasons, like chronic obstructive pulmonary disease, moderate cognitive impairment, previous ED visit and triaged as less urgent, are also mentioned. (Lowthian et al., 2016.)

“Unnecessary use” of ED is not widely studied area of older people’s acute care even if it is very commonly used. Faulkner and Law’s (2015) research studied the

“unnecessary” use of emergency departments by older people. Researchers used three data sources from two emergency departments: hospital data for the financial year 2010–2011 for patients aged 65 years and over that were identified as triage category four or five (gategory 5 = non urgent) three focus groups with medical, nursing and allied staff from these two hospitals; and interviews with 58 older people who presented at the two emergency departments over a two-week period (Faulkner

& Law, 2015.) They learned that, other than the medical diagnosis, the hospital administrative data provided a very limited insight into why older people attended the emergency department. Professional staff identified individual determinants, societal determinants and the health-services system as explanations. Important is that the researchers (Faulkner & Law, 2015) suggested that older people attended the emergency department for a range of reasons that may not necessarily reflect the opinions of health professionals.

In literature review by Šteinmiller et al. (2015) factors associated with repeat emergency department visits of older people were also many and connected with complex needs and multiple health connections like sociodemographic characteristics, social problems, health problems, demand for systematic health estimation, health-care service use and the deficiency of care provided (Figure 5).

Health and non-health factors associated with attendance and repeat attendance.Complex needs over and above clinical cause of attendance.

Nemec et al. (2010) studied prospective patients who presented to the emergency department with non-specific complaints (NSC). They discovered that a severe state of health was diagnosed for 59% of those patients during their thirty-day follow-up period. The 30-day mortality rate was 6%. Finally, it was suggested that patients with NSC presenting to the emergency department were actually at high risk of suffering from severe conditions (Nemec et al., 2010.)

Hunt et al. (2006) tried to identify frequent users of EDs and determine those patients’

characteristics by using the 2000-2001 population-based, nationally presentable Community Tracking Study Household Survey (CTS). Characteristics independently associated with frequent use included poor physical health, poor mental health, greater than or equal to five outpatient visits annually, and family income below the poverty threshold (reasons related both to health and non-health

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related factors). The researchers (Hunt et al., 2006) suggested that supplementary support systems and better access to alternative sites of care would have the benefit of improving these individuals’ health and social wellbeing and help to reduce emergency department use.

Many studies exist regarding older people’s repeat attendance with health and non- health factors associated with it (e.g. Hunt et al., 2006; Naughton et al., 2010;

Lowthian et al., 2016). The phenomenon is international and identified in studies as being partly connected with older patients’ unmet needs (Muntlin et al., 2006;

Gordon et al, 2010), discharge (Palonen et al., 2015), the lack of continuity of care (Legramente et al., 2016) and a lack of geriatric and/or gerontological nursing skills (Nemec et al., 2010; Peters, 2010).

However, few crucial points are known about why older people themselves choose ED for non-urgent care (Figure 5). For example, in study by D´Avolio et al. (2013) nearly all their study participants reported barriers to primary care, including difficulty with the phone system and a lack of available appointments and, as a result, turned to the ED for their primary care needs. Older people can face barriers accessing primary care for example because of limited availability of practioner based primary care and the continuity of care with primary physician or nurses, and limited transportation for illness care and variable interactions with health-care providers and systems. The reason to choose ED for non-urgent care can also be a desire to avoid burdening friends and family, or previous experiences with illnesses.

(Ionescu-Ittu et al., 2007; Finta et al., 2017).

Older people’s own experiences when accessing emergency care were described also in an Australian qualitative study of emergency department care (Considine et al., 2010). In this study researchers found four major themes related to access to emergency care: variation in ED use by older people, reluctance to access ED care, mixed experienced of waiting, and perceived factors influencing access to emergency care (Considine et al., 2010).

Different kinds of reasons and expectations are found to be behind the reasons why older people with lower clinical urgency present to the ED. For example, due to a perceived block on access to primary or specialist services, beside an expectancy of more timely and specialized care and quick entry to specialist care (Lowthian et al., 2013b). In this study it was also discovered that 56% of these older people described feelings of loneliness. (Lowthian et al., 2013b).

On the other hand, it is also found that mostly older people visit the emergency department for a variety of health conditions. According to the Šteinmillers´ et al.

(2015) literature review, the causes for the visits were urgent and non urgent among other things; cardiovascular, mental health, musculoskeletal and abdominal

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conditions, adverse drug reactions, dermatological, neurological and respiratory conditions, poor health status, accidents, and connected with time factors such as time of day, week or season. Šteinmiller et al. (2015) also regocnized factors that influenced the discharge process like unsolved troubles, health risk identification, after care instructions, medication prescribed at discharge and a patient's residence before the emergency department visit (Figure 5).

Interventions reduce ED utilization

It is found that older people also have higher rates of hospital admissions than the general population and higher rates of readmission due to complications and falls (Cortney et.al. 2009; Salvi et al., 2013). These issues could be influenced by interventions. Courtney et al. (2009) conducted a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up programme for older people at risk of emergency or hospital revisit. The intervention group required significantly fewer emergency hospital readmissions and also emergency GP visits. The intervention group also described significantly bigger improvements in quality of life than the control group (Courtney et al., 2009.) In qualitative interviews with older veterans in the USA, Claver (2011), asked about their decision to use emergency rooms (ERs). His suggestions were that more appropriate interventions by social work personnel might reduce inappropriate ER use and enhance the care of this vulnerable population (Figure 5).

The discharge process (from the hospital ward) itself has also been often studied in nursing (Walker et al., 2007; Watkins et al., 2012), partly because it is usually seen to be a vital part of the nurse’s role. Older people are generally viewed as a vulnerable group during discharge, especially those who live alone at home without any family members. There are also findings that suggest even adverse health outcomes after an ED discharge, especially when connected with a diagnosis such as a chronic condition (Hastings et al., 2009; McCusker et al., 2009). Effective communication and multiprofessional liaisons have been found to be key to successful discharges and the providing of continuity of care for older people (Olsen et al., 2014).

Communication among hospital personnel, patients, family members and community caregivers, as well as individualized, comprehensive discharge plans for patients, were topics during the hospitals’ discharge of older people in the study in USA (Walker et al., 2007). Paavilainen et al. (2009) was interested in the importance of family participation in counseling in the emergency department. They found that patients´ family members were important partners in counseling situations. Those patients with family members were more pleased with counselling and felt that it improved their involvement in their own care (Paavilainen et al., 2009.)

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In a Finnish dissertation study of “Older Patients and Their Families´ Wellness and Social Support in Emergency Departments” (Deminenko, 2018) was found that when older patients are discharged home, family members have a significant role to play in providing aftercare. In another Finnish study (Palonen et al., 2015), discharge education was organized for older people and family members in the emergency department in order to examine the level of discharge education and to see how discharge education was associated with discharge readiness. Palonen et al. (2015) suggest that discharge education was associated with a higher level of discharge readiness among both patients and family members. (Figure 5).

According to the studies mentioned in this chapter, older peoples´ emergency care is challenging and complicated in many ways. At worst it can lead to situation where appropriate care in the emergency department is hard to ensure (Figure 6).

Figure 6. Circle of complexity regarding emergency department care for older people

• e.g. Yim et al.

2009; Lowthian et al. 2013a; Foo et al.

2009

• e.g. Courtney et al.

2009; Šteinmiller et al. 2015;

Legramente et al.

2016

• e.g. Naughton et al.

2010; Šteinmiller et al. 2015;Lowthian et al. 2016

• e.g. Lowthian et al.

2013b; D´Avolio et al. 2013; Finta et al.

2017; Nemec et al.

2010; Peters 2010

Unmet needs, barriers to primary

care, lack of geriatrics/geronto

logical nursing skills

Atypical presentations,

serious and multiple health

conditions, complex needs

Unnecessary use, repeat attendance,

higher resource utilization Negative

outcomes, adverse events,

complications, hospitalizations

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2.4.2 Acute care setting and nursing

It is said that emergency departments have a medical technical character and that they require advanced clinical skills from nurses. Paakkonen (2008) found out in his Finnish study of the contemporary and future clinical skills of emergency department nurses that the very core of ED nurses’ professional competence is related to their skill in controlling both the clinical situation of each patient and the overall situation in the ED (Paakkonen, 2008). This seems to be true in nowadays too.

After the patient’s primary needs are met, cooperation with the older person’s family or relatives and the other sectors of the social and health-care services are important for guaranteeing continuity of care. Emergency departments have a medical technical character that demands medical technical tasks from their nurses, who also need to, at the same time, provide safe and quality care to older people.

It is found that patients, especially older people, are not all the time pleased with the care they get in emergency departments (Muntlin et al., 2006; Mylläri 2017), mostly because professionals, like nurses’ and physicians’, visions about high quality services do not always agree with the patients’ perceptions. Frail older people are high users of services but at the same time claim that services are not responsive to their main concerns, such as meeting their individual needs, maximizing independence and helping them to live fulfilled lives (Themessis-Huber et al., 2007).

A study by Gordon et al. (2010), a systematic synthesis of qualitative research about the patient experience in emergency departments was intended to describe what factors influence patient experience. Several categories were developed, like the emotional impact of the emergency, staff-patient interactions, waiting, having family in the emergency department, and the emergency department environment. The patient experience issue given most emphasis by the articles under that review was the care or lack of care, regarding their psychosocial and emotional needs (Gordon et al., 2010.)

Similar experiences were found in a Finnish dissertation study. Mylläri (2017), studied the perceived quality of emergency department care of older adults aged 74- 94 years. This qualitative study found five main criteria for high-quality emergency care. Those were accessibility of care, care that proceeds in a meaningful way and results in a desirable outcome, the patient’s well-being during the ED visit, positive interaction between patient and staff and ED users’ different needs being taken into account. The study interviewees believed that the medical aspect of care was high quality, but at the same time they were uncertain of whether or not they would receive help that corresponded to their needs. A larger proportion of time was spent waiting than being examined and receiving treatment. Some of the interviewees felt they received extremely good care, but at the same time, others had negative experiences concerning a lack of information, being left alone, uncomfortable circumstances, inadequate symptom relief and insufficient consideration of feelings of thirst and hunger (Mylläri, 2017.)

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It is also found that the involvement of family members’ in acute care matters is especially important for older people. It is also important for health care professionals because family members are well aware of an older patient's previous level of functional capacity and their medications, which is decisive information when planning further care and thinking about patients coping at home (Paavilainen et al., 2009; Nikki et al., 2012,; Deminenko, 2018.)

In a study by Nikki et al. (2012), the family members of older patients perceived themselves as satisfied participants, invisible participants, or disappointed outsiders in ED. Family members accompanying an older patient also wanted to be active participants i.e. not excluded, but this was possible only because of their own active attitude. Nikki et al. (2012) suggested that broader educational initiatives for ED staff about family presence and involvement in care in EDs are needed, because the family members' experiences showed that they were left as outsiders. Deminenko (2018) examined associations between family wellness and social support. She recommendeds that the nursing care provided for older people and their families in emergency departments should be more supportive and family-centered (Demineko, 2018). Themessis-Huber et al. (2007) suggested that care providers need more to adopt older people's priorities in order to provide them with responsive patient- centered care.

Normal aging changes and multiple co-morbidities, in combination with multifactorial conditions and multiple etiologies and adverse effects arising from therapeutic interventions are common in older patients (e.g., Hartikainen et al., 2007).

Older people themselves also report a lack of autonomy in their care process when their health problems are not consistently identified at a timely stage and that care systems often require better coordination between health-care professionals (Muntinga et al., 2012). Older patients experienced a diminished sense of their individual significance, in Bridges and Nugus’s (2010) study about older people's experiences of dignity and significance in urgent care. The three key features of this diminished significance were the primacy of technical medical care, an imbalance of power and the subordination of the non-medical needs of patients. The researchers suggest that interventions to enhance care delivery that promote a sense of significance should target practitioners and the wider organizational culture (Bridges

& Nugus, 2010.)

Stein-Parbury et al. (2015) studied the expectations and experiences of older people and their carers in relation to ED arrival and care. The results of this qualitative Australian study discovered that the older people were presenting to the emergency department as a result of increasing symptoms and their general practitioner´s advice. According to the study results, participants felt uninformed about ED procedures; therefore, families and carers felt the need to advocate for information

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and basic services. The participants were thankful for the care received and aware of the busy environment. The researchers suggest that to meet older people’s expectations, nurses need to provide timely information and advise carers how they can assist (Stein-Parbury et al., 2015.)

In summary, according to the litterature review, there were many circumstances important to older people in acute care nursing settings. These factors included family members accompanying them and becoming involved, meeting older patients´ psychosocial and emotional needs in addition to their physical ailments, better coordination between health care professionals, better information about acute care procedures and better communication and a desire to experience more autonomy, dignity and significance (Table 5).

Table 5. Important issues for older people in acute care nursing settings

Important for older people Study

Family members accompanying involvement Paavilainen et al., 2009; Gordon et al., 2010; Nikki et al., 2012; Deminenko, 2018

“Caring”, meeting psychosocial and emotional needs in addition to physical ailments

Muntlin et al., 2006; Themessis-Huber et al., 2007; Gordon et al., 2010; Mylläri, 2017

Better coordination between healthcare professional’s, better information about acute care procedures, better communication

Muntinga et al., 2012; Bridges & Nugus, 2010;

Stein-Parbury et al., 2015; Mylläri, 2017

Experiences of autonomy, dignity and

significance. Bridges & Nugus, 2010

2.5 SELF-MEDICATION MANAGEMENT BY OLDER PEOPLE

The literature review for this topic was performed using the key words older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living connected with self-medication OR/AND self- medication management, OR/AND nursing (Figure 7).

Older people in emergency department

KRISTIINA KARINIEMI-ÖRMÄLÄ

OLDER PEOPLE IN EMERGENCY

DEPARTMENT

Dissertations in Health Sciences

OLDER PEOPLE IN EMERGENCY

DEPARTMENT

Kristiina Kariniemi-Örmälä

OLDER PEOPLE IN EMERGENCY DEPARTMENT

ABSTRACT

TIIVISTELMÄ

ACKNOWLEDGEMENTS

CONTENTS

ABBREVIATIONS

1 INTRODUCTION

2 REVIEW OF THE LITERATURE

2.1 AN AGING POPULATION

2.2 EMERGENCY SERVICES IN FINLAND

2.3 THE PURPOSE OF THE LITERATURE REVIEW

2.4 OLDER PEOPLE AND NURSING IN ACUTE CARE SETTINGS

š

2.5 SELF-MEDICATION MANAGEMENT BY OLDER PEOPLE