Nobody loves an emergency room visit, least of all older patients. Everything about the ER experience can be more challenging for older adults. Time in the waiting room is harder to tolerate: You’re cold and…
Nobody loves an emergency room visit, least of all older patients. Everything about the ER experience can be more challenging for older adults. Time in the waiting room is harder to tolerate: You’re cold and they’ve run out of blankets. If you’re confused or disoriented, the harsh lighting, bursts of yelling and constant noise make it worse. If you’re unsteady on your feet and need the bathroom, navigating cramped ER quarters is difficult. If your joints are painful or your skin is thin and delicate, “resting” on a cot or stretcher is tough. If you’re alone, without a friend or family member, it’s frightening.
When older patients are admitted to the emergency department, vague-sounding symptoms (“I feel dizzy.” Or “I just don’t feel right.”) may actually be more serious than for someone younger. Common conditions like urinary tract infections can present themselves quite differently depending on age, and treatments may vary. For these reasons and more, some emergency departments are making changes to tailor their care and better meet the needs of older adults.
Geriatric emergency departments incorporate specially trained staff, assess older patients in a more comprehensive way and take steps to make the experience more comfortable and less intimidating. However, not all geriatric EDs are the same. Below, clinical experts spell out basic criteria for geriatric emergency departments and describe what patients and families should look for and expect.
People ages 65 and older are the most likely to visit U.S. emergency departments. According to an Agency for Healthcare Research and Quality report on hospital ED trends, rates for older patients were the highest among all age groups every year covered from 2006 through 2015.
Over time, EDs will increasingly serve older patients. “The population is aging,” says Dr. Denise Nassisi, an associate professor in the emergency medicine department at the Icahn School of Medicine and director of the geriatric emergency department at Mount Sinai Hospital in New York City. “We are doing a better job of taking care of patients, and people are living longer so it’s not uncommon to see multiple patients on a given day that are in their 90s or that even have reached 100.”
Complexity of care rises with age. Older patients are more likely to have several conditions such as heart disorders and chronic obstructive pulmonary disease, or COPD. Many patients who are on multiple prescribed medications might benefit most from having their drug regimens trimmed. Instead, they may receive new drugs in the ER that can cause side effects and possibly interact with drugs they’re already taking.
In the past, the tendency in emergency medicine was to admit older patients to the hospital in an abundance of caution, Nassisi says. Today, she says, “We’re really trying to stay away from that for a number of reasons.” First of all, she points out, patients don’t want to be in the hospital. “Actually, for older patients, coming to the hospital is risky,” she says. Older adults may not see or hear as well and are more likely to develop delirium (an acute state of confusion), have a drug reaction or lose some of their functional ability. They’re more vulnerable to infections and other hospital complications.
“Over 60 percent of hospital admissions for patients over the age of 65 come through the emergency department,” says Dr. Kevin Biese, an emergency medicine physician with University of North Carolina Hospitals who has a focus in geriatrics.
In 2014, the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association and the Society for Academic Emergency Medicine created geriatric emergency department guidelines.
These are four basic components that set apart geriatric emergency departments:
— Structure. This feature will be most obvious to patients and family members entering an emergency department. “It should be quieter,” Biese says. “You shouldn’t be in the hallway. You should be in a more comfortable bed or cot, not a thin cot that’s going to cause skin breakdown in older adults. The lights should dim at night. There should be some nonstick flooring to minimize falls within the department.”
— Screening processes. A variety of screening tools can quickly uncover physical or mental health risks that are more common in older adults. When ER clinicians screen older patients to determine their frailty, risks of falls or delirium, or check prescriptions against criteria for potentially inappropriate medication use in older adults, it’s a chance to safeguard their health in the moment and later at home.
— Staff education. Nurses and doctors receive additional education in geriatrics, above and beyond what they learned about caring for older adults during emergency medical training. “We need to know something about their physiology, polypharmacy [taking multiple medications] and the risks they face,” Biese says.
— Community connections. “The geriatrics emergency department isn’t just the front door of the hospital,” Biese says. “It’s the front porch of the health care system.” You don’t necessarily have to stay in the house when you drop in on a neighbor and chat on the porch, he says, and an emergency department visit needn’t always lead to hospitalization for older patients. “Rather, you might have an opportunity to connect with your community, figure out what your needs are and see whether those can be met at your house,” he says. Team members can reach out to the local Agency on Aging, services like Meals on Wheels, physical therapy providers and home health agencies.
Volunteers provide an extra human touch to patients when they’re feeling most isolated and vulnerable. At Mount Sinai, through a “robust” volunteer program called Care and Respect for Elders, or CARE, specially trained volunteers particularly try to focus on anyone who comes in unaccompanied, Nassisi says: “We found a lot of our older patients are coming in by themselves.” Volunteers provide one-on-one comfort care, such as offering pillows, reading glasses, generic hearing amplifiers and other amenities.
Geriatric emergency departments are needed to fill substantial gaps in care for older adults, says Dr. Christopher Carpenter, an associate professor of emergency medicine with Washington University School of Medicine in St. Louis.
“Unprecedented growth in aging demographics — with 10,000 baby boomers turning 65 every day — yet a health care system that is not adapting to address unique geriatric needs” are contributing factors to these gaps, according to Carpenter, who is also deputy editor in chief of Academic Emergency Medicine and associate editor of the Journal of the American Geriatrics Society.
Too few geriatricians, a shrinking primary care safety net, inadequate exposure to geriatric health issues in medical schools and a lack of related guidelines for family and internal medicine practitioners are part of the problem, Carpenter says.
Carpenter points to “numerous examples of suboptimal emergency care,” including emergency department clinicians failing to diagnose dementia and delirium in a significant number of patients, and lack of adherence to guidelines for fall prevention.
The decision by hospitals to pursue accreditation and meet higher standards may serve “as a motivator and facilitator of local geriatric emergency medicine quality-improvement efforts,” Carpenter suggests.
“There are 140 self-declared geriatric emergency departments across the country as of about six months ago,” Biese says. “However, I have visited some of them and there’s a wide variation of quality.”
In May 2018, ACEP, with support from the Gary and Mary West Health Institute and the John A. Hartford Foundation, launched an accreditation program for geriatric emergency departments that have met certain quality standards. Biese is chair of the project.
Three levels of accreditation are offered, with increased recognition dependent on multiple factors including policies, outcomes and staff. One quality indicator is the availability of a geriatric assessment team including physical therapists, occupational therapists and social workers, for instance, or having a pharmacy within the ED.
Mount Sinai Hospital, St. Joseph’s University Medical Center in New Jersey and UC San Diego Health are among participating hospitals. Soon, Biese says, there will be 20 such accredited geriatric EDs in 10 states across the country, with many other hospitals expressing interest.