Emergency care for elderly can be dangerous
In 2005, when physician Kevin Biese was a medical resident in Boston, a 92-year-old woman with a urinary tract infection arrived by ambulance at a hospital emergency room. Her behavior — confusion and lethargy — suggested she also was suffering from hypoactive delirium, a cognitive disorder.
She was alone, without family or friends. The doctors decided to admit her, but a bed wasn’t yet available. So she had to wait. “She spent 24 hours on a cot in the hallway,” Biese recalls. “She came in during the day on a Thursday and was still there Friday morning. I got mad.”
The emergency care system should “not allow that to happen to those who deserve the most respect in our society,” he says.
Nobody enjoys a trip to the ER. But it can be especially difficult — sometimes even dangerous — for the elderly. Many emergency health-care settings are frenzied and noisy, with glaring lights and slippery floors, often without handrails. Cots and gurneys are hard on fragile bodies. Privacy is scarce.
“The emergency department is not a great place to hang out for anyone, but it can be especially tough if you are older,” says Denise Nassisi, director of the geriatric emergency department at the Mount Sinai Hospital in New York. “Many older patients are frail and have difficulty getting up and down from a gurney, or getting to a restroom. Some have cognitive dysfunction and don’t know their medical history. Some may have impaired vision or hearing. A crowded chaotic environment is not the best for them.”
In recent years, recognition has been growing that older patients need a better ER environment and specialized care than the rest of the population. This has prompted many hospitals to introduce structural changes and new procedures to make their ERs age-friendly. The American College of Emergency Physicians launched an accreditation program last spring for the nation’s emergency departments to encourage them to adopt a more comprehensive and standardized approach for geriatric patients.
The percentage of Americans 65 or older is growing. It was 14 percent in 2012 and is projected to be 20 percent by 2030, according to the Centers for Disease Control and Prevention. About 49.2 million older adults live in the United States today, according to the American Geriatrics Society.
During 2012-2013, the incidence of adults older than 65 who sought emergency care was 12 per 100 persons for injury and 36 per 100 for illness, according to the CDC. The most common complaints that bring elderly patients to emergency departments are falls, abdominal pain, difficulty breathing, fever, chest pain, confusion or other cognitive issues, according to experts.
“Older adults are more vulnerable and have less reserve,” says Susan Zieman, a medical officer in the geriatrics and clinical gerontology division at the National Institute on Aging. “Somebody might fall and just plunk down on the floor, a ‘low mechanism’ fall for someone younger. But an older person can do serious damage — break a hip, for example. Also, sometimes they feel less pain, or show up with atypical symptoms, such as nausea, rather than chest pain, when they are having a heart attack. When people get into their 70s and 80s, there are some clear differences, [and] it takes specialty training to pick up these things.”
Moreover, many emergency departments, while effective in dealing with acute problems, don’t always look at the big picture when it comes to older patients. This means comprehensive screening procedures to check all medications and health history, as well as conditions at home, with the aim of not having to admit them to the hospital. Hospitalizing the elderly brings its own risks, and many of these patients have difficulty returning to their earlier functioning state.
“We want to look at all their needs and problems, including medical and social problems,” says Zia Agha, chief medical officer at the West Health Institute in San Diego, which has a special geriatric emergency care unit. “We need to be aware of their risk of falls, unexpected complications from patients taking multiple medications, cognition and mental status, among other things. Is the person getting the food they need? Is their home safe from basic fall hazards?”
This also means ensuring that patients aren’t showing up “with an acute problem with a chronic basis that keeps them coming back to the emergency room,” says Ula Hwang, an emergency medicine researcher at Mount Sinai, which has introduced numerous “age-friendly” practices. “We need to make sure we aren’t just treating [the emergency], but treating it well enough so the patient doesn’t have to come in with the same problem once a month.”
The new voluntary accreditation includes certain requirements, such as having both doctors and nurses with specialized geriatric training, and environmental criteria, such as mobility aids and easy access to water. The new program so far has accredited 22 hospital emergency departments, but Biese, who manages the program, predicts more of the nation’s estimated 5,000 emergency departments will apply and receive geriatric certification.“We have conversations with health-care systems every week anxious to get theirs online,” he says, pointing out that numerous health-care systems not yet accredited provide geriatric-appropriate emergency care. “Just because a department doesn’t yet have accreditation doesn’t mean it isn’t doing a great job.”
Holy Cross Hospital in Silver Spring is one of them.
It established its seniors emergency center in 2008 and is considering applying for accreditation. Believed to be the first such center in the nation, it was the idea of Kevin J. Sexton, the former chief executive whose mother had a bad ER experience at a hospital outside Maryland.
“It was created to reduce anxiety and confusion in [older] patients and their loved ones,” says James DelVecchio, the center’s medical director, adding that its focus is on “quality care, dignity, safety and comfort.”The Holy Cross center has installed walls to separate its treatment bays, rather than curtains, to ensure added privacy and quiet. Older patients are assigned cots with thicker mattresses and given heated blankets, and have access to special speakers that make it easier to listen to music or watch TV, and telephones and remotes with large buttons. The area features softer lighting, handrails and nonslip floors.
Upon arrival, patients receive a thorough screening that extends beyond their acute emergency. A centrally located nursing station monitors each patient, and later — after discharge — checks up on them by phone to make sure everything is going well.
The latter is especially key, experts say.
“Not everyone can change their lighting and flooring,” Hwang says. “Structural changes are great, but the approach is even more important — checking their medications, looking for cognitive risk, looking at transitions after discharge. You can splash on some paint, change your lighting and flooring, but if the clinicians and staff don’t change their approach, you won’t be making a real difference for these patients.”
At Mount Sinai, one of the nation’s first hospital emergency departments to be accredited, nurses and social workers assess patients’ cognitive function, medications, at-home risk for falls, and the stress level on their caregivers.
“They talk to the patient and make sure there is good follow-up,” Hwang says. “We don’t target every patient older than 65, but those in the ‘gray zone,’ who are not a clear discharge or a clear admission.”
She conducted a study released this year that found geriatric patients seen by ER transitional care teams in three hospitals — Mount Sinai among them — were less likely to be admitted to the hospital and less likely to return during the month following treatment. “They were safely discharged,” Hwang says.
Biese says he believes that such a program could have made a difference for his elderly patient of 13 years ago. Today, her urinary tract infection would have been treated quickly with intravenous antibiotics, and she would have undergone further evaluation with the aim of discharging her with follow-up care at home, he says.“Today, emergency departments are instituting processes and enhancements to address older patients’ vulnerabilities, and make them more comfortable,” Biese says. “These programs matter. They matter to the patient and to the community. When our loved ones have an emergency, we deserve to know that there is a [geriatric] emergency department ready to take care of them.”