Controversies

Emergency medicine and older adults: continuing challenges and opportunities^B

John G. Schumacher MA, PhD*

Department of Sociology and Anthropology, University of Maryland, Baltimore County, Baltimore, MD 21250, USA

Received 11 December 2004; accepted 22 December 2004

Introduction

The treatment of older adults in the emergency depart- ment (ED) has been a part of emergency medicine (EM) since its inception. Nationwide, older adults represent an important and growing patient population representing about 18% of ED admissions annually [1]. Although geriatric EM has attracted limited clinical and research attention, there continues to be significant challenges, needs, as well as opportunities in pursuit of providing high-quality care to older adults.

Over the next 25 years, the US population of older adults (65 years and older) will double from 34 million in 2000 to more than 69 million by the year 2030 [2]. Because these individuals have already been born and are aging, there is little doubt in the veracity of these projections. This dramatic aging of the US population will significantly affect a range of social institutions from education to health care including hospital EDs. Currently, EDs nationally report an estimated 18.5 million older ED admissions annually [1,3]. Despite the tremendous projected growth of older adults, there are very limited, if any, projections specifically regarding the numbers of older patients EDs can anticipate serving. Nonetheless, it is reasonable to assume any increases in the older adults will likely exacerbate the current overcrowding conditions experienced by many ED

^B This research was supported by a University of Maryland, Baltimore County, Faculty Research Fellowship, 2003.

T Tel.: +1 410 455 3184; fax: +1 410 455 1154.

E-mail address: [email protected].

nationwide [4-6]. At the same time, the size of the older ED population represents just one dimension of the issue, because we also know that older adults (65 years and older) represent a highly heterogeneous population in terms of health status, function, and presenting diagnosis.

Initial efforts in geriatric emergency medicine

Clinical and scholarly attention to geriatric EM has been sporadic during EM’s history. The most recent effort was a 1992 collaboration between the John Hartford Foundation and the Society for Academic Emergency Medicine (SAEM). It was designed to develop a comprehensive educational program for training EM residents and physi- cians. Led by Sanders, the group published a series of journal articles and a textbook and developed an educational training manual distributed by SAEM [7-9]. In addition, a model of geriatric EM was proposed to guide the Clinical approach to treating older adults in the ED [7].

Findings from Sanders and colleagues documented higher ED use rates among older adults compared with younger patients [7-9]. Clinically, older adults were also shown to present with: nonstandard disease presentations, altered laboratory values, multiple comorbid diseases, extensive medical histories, communication problems, and potentially altered mental status [7]. In some cases, Classic symptoms for diagnosis were absent in the older ED patient [10,11]. In addition, 30% to 50% of older adults ED patients were hospitalized, in sharp contrast to just a 12%

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hospitalization rate for younger patients [7]. These issues can make health-care delivery to this population much more challenging and time consuming. The lack of training and educational programs in geriatric EM was documented as part of this project.

The work of Sanders [7] provided a solid foundation for the development of geriatric EM. Unfortunately, since this work of more than a decade ago, there has been only modest evidence of geriatric EM research or new scholarly literature. Aminzadeh and Dalziel [12] recently provided a useful literature review on older adults in the ED. Their review reiterates the distinct pattern of service use and care needs required by older adults. They also note the inadequacy of current approaches to serving this population and call for more research and intervention projects targeting at-risk older adults.

Overall, it appears that clinical and scholarly work in geriatric EM appears to have lost momentum since the efforts of Sanders [7-9]. The early work characterized the population and provided a model, however, the pace of work has diminished despite rapidly increasing older adults ED populations. The research has been dominated by descriptive studies of use rates and issues such as Acuity levels, repeat visits, and 6-month mortality rates [4,12]. Research considering the impact that the older adult population has on the practice of EM is much more limited in scope [13].

Continuing and emerging challenges

Despite the absence of sustained scholarly attention regarding older patients, emergency physicians (EPs) con- tinue to face challenges in providing care to this population. The realities of clinical practice and the existing literature on older adults suggest at least 4 areas that would benefit from renewed attention by EM professionals.

Managing cognitive impairment in the emergency department

Currently, 4.5 million older adult are cognitively impaired, and estimates suggest that by 2050, these numbers could be as high as 16 million [14]. Cognitively impaired older adults are a specific patient population that will continue to demand new and innovative patient care strategies from EM on several levels. First, EPs need the skills and instruments to accurately diagnose and screen this population. Recent findings suggest EPs fail to identify nearly 50% of older patients with cognitive impairment [15]. Second, cognitively impaired patients are a heteroge- neous population presenting with a wide range of diagnoses, impairment levels, comorbidities, and medical histories. Third, cognitively impaired patients in the ED also exhibit a range of challenging behavior patterns including non- responsiveness, combativeness, and/or wandering. Such characteristics complicate rapid diagnosis and patient

management. Fourth, cognitively impaired older adults may present to the ED for evaluation solely because of the unavailability, inadequacy, or failure of other support services, which inappropriately ties up resources [16,17].

These challenges are illustrated in the case of a 79-year-old female patient transferred to a large county ED from a local nursing home for evaluation of increased temperature and increasing Lower extremity edema. She had a history of moderate dementia and was not oriented to person or place. She was unaccompanied and transported via private ambu- lance. In the ED, she resisted lying down and continuously attempted to get down from the cart in an attempt to exit the area. After a few minutes of persistent struggle and combativeness with several ED nurses, the patient was loosely tied to the cart with a bedsheet across her chest. In addition, the cart was strategically placed near the nursing station so she could be closely observed. Within minutes she used a bHoudiniQ maneuver to release herself and climbed down from the cart. The staff returned her to the cart; however, she immediately set about the task of struggling to free herself, oblivious to the pleadings of the staff. Again, she freed herself and the frustrated staff applied soft Velcro restraints. Her examination continued, with some difficulty, as she was combative and uncooperative. Her care required additional staff support during every phase of the examina- tion. Eventually, the patient was diagnosed with an acute urinary tract infection and was transferred to a medical ward for continued therapy.

Appropriate management of cognitive impairment in the ED requires substantial staff time, training, resources, and commitment. Despite the increasing prevalence of cognitive impairment, it is widely recognized that the training, policies, and resources for handling this population remain inadequate [17].

Assisted-living facilities and emergency departments

Assisted-living facilities (ALFs) are a residential envi- ronment broadly guided by a social model of care designed to maximize the independence of older adults by providing assistance and services to maintain an individual’s ability to age-in-place. Although regulations vary by state, in general, these facilities generally house 3 or more unrelated adults (although some purpose-built facilities have over 200 units); provide shelter (room), food (board), and 24-hour supervi- sion/protective oversight and personal care services; and can respond to unscheduled needs for assistance. There are as many as 35000 AL facilities nationwide [18], and the total number of residents is as high as 1.5 million. ALFs are considered an intermediate between home and nursing home care [19-22].

The rapid expansion and saturation by the ALF industry presents a number of challenges to EDs. First, ALFs typically do not employ trained medical staff and conse- quently rely on community physicians and EDs for medical

Physician satisfaction treatin”>care. Second, older adults typically move into an ALF because of some health, functional, or cognitive decline that compromises their ability to live independently and increases their likelihood of ED use. Third, residents of ALFs may lack family involvement or other caregivers to provide health histories and support, which may make emergency care more challenging. On a structural level, the presence of multiple large ALFs (N100 units) in a catchment area has the potential to overwhelm the resources of an ED particularly during a public health epidemic (eg, influenza outbreak).

In response to the rise of ALFs as a living environment for older adults, EDs may consider taking proactive steps to address some of the challenges ALF present. EDs may want to assess the number and type of ALFs and nursing homes that fall into their catchment area. Based on this evaluation, EDs may encourage large ALFs to develop primary medical coverage for their residents to avoid overreliance on area EDs. In addition, EDs could encourage ALFs to use consistent medical records in the event their residents are transferred to an ED. An ED may also wish to initiate a dialogue with area ALFs to educate them about the appropriate use of EDs and the services that can and cannot be offered.

Emergency physician satisfaction treating older patients

Examining EPs attitudes about their patients is important because patient encounters have been identified as a key source of professional satisfaction and dissatisfaction across specialties [23]. EP practice dissatisfaction has been associated with abusive and demanding patients, anger on the part of patients or relatives, and difficult or violent patients [24]. Considering these dimensions of EP satisfac- tion and dissatisfaction, older adult patients admitted from long-term care settings or presenting with cognitive impairment overlays are at risk of being considered particularly unsatisfying patients. Research comparing satisfaction between EPs and internists reported EPs were less satisfied than internists regarding current and preferred conditions of their practice. A source of this gap was suggested to be the discontinuity for EPs between being trained to treat urgent, emergently ill patients while frequently treating patients with nonurgent problems [25]. Issues of practice satisfaction/dissatisfaction among EPs are important because low levels of satisfaction are predictive of decisions to leave the field [24]. In addition, leaving the field is also associated with work-related stress and burden. EM has been described as a high-stress work environ- ment due to its unpredictability and the need for rapid action and decision making [25]. Increasing numbers of encounters with older ED patients has the potential to add to physician stress because these patients may be more time-consuming, perceived as less satisfying, and EPs report less confidence in their treatment [8]. Research indicates that EPs agreed

that older adults required more time and resources than other patients and that their training in geriatric EM was not sufficient [8]. EPs have also been shown to highly overestimate the percentage of older patients they treat in the ED. In one study, EPs estimated the mean percent- age of older adults they treated was near 40%, which is more than double the actual national average of 18% (J Schumacher, unpublished manuscript, 2004). Such overestimation may indicate feelings of burden, particularly, if these patients also are considered to be unsatisfying and/ or time-consuming cases. Despite a decade-old call for research into factors associated with occupational stress among EPs, few studies examine this issue and none has focused on the impact of older adult patients [25].

Geriatric emergency medicine education and training

The EM training curriculum is overfilled and consistently challenged to incorporate new and emerging information. Geriatric EM content represents another curriculum pres- sure. To date, it has not been a formal part of the residency training with core competencies or explicit skills testing. However, with the projected demographic transition fueled by Baby boomers, geriatric instruction may rapidly need to become a core part of training. In a recent survey, EM residents reported lower levels of confidence treating older adults (N65 years) compared with adults (age 18-64 years) (J. Schumacher, unpublished manuscript, 2004). One quarter of these residents indicated that their training experience bavoided Q instruction in geriatric EM. At the same time, three quarters agreed that more training in geriatric EM is necessary to provide better care to older adults. These results suggest that efforts by professional organizations to develop and disseminate educational programs in geriatric medicine are warranted.

Innovations and future directions of geriatric emergency medicine

Several challenges have been described above regarding older adults and EM. In response to these challenges, the following subsections suggest 3 thematic areas to renew attention to issues of older adults in the ED.

Emergency department case finding, assessment, and referral projects

In response to the complexity of older adult cases presenting to the ED, several innovative case finding, assessment, and community referral projects have been implemented. The case finding and assessment projects are designed to screen older patients to identify at-risk older adults who would benefit from comprehensive geriatric assessment by a geriatric nurse specialist [26-28]. Early identification of these at-risk patients also facilitates their

management because appropriate ED resources can be directed earlier in the admission. Some programs extend the screening function into the prehospital setting by training paramedics in intermediate care and assessment of older patients [29]. These programs are frequently coordinated with a referral network comprised of a coalition of community-based service providers. Evaluations of the programs find high levels of support from staff; however, improvements in reported outcomes such as repeat ED visits, hospitalizations, nursing home admissions, and costs have been modest [30]. Such programs are one way to begin to address the challenges of cognitive impairment, ALF, and EP provider burden by providing EPs with information and resources to improve their management of this patient population.

Evaluating the structure and process of emergency department care

Responsive ED management requires continuous evalu- ation of their structure and Processes of care to appropriately accommodate the needs of older patients. Structurally, the typical design/layout of EDs with many open bays, curtain dividers, and extraneous noise may interfere with the clinical examination of older patients with hearing loss. Tracking these patients to quieter examination rooms may be good clinical practice as well as a priority in future ED architectural design and renovations. ED Observation Units or 23-hour beds represent another structural resource in the appropriate clinical evaluation of older patients [31].

Processes of care issues in the ED include evaluating patient flow and supportive services. Older adults waiting for hours, without food/fluids, and sitting in hard chairs are poor processes that may lead to the patients’ diminished physi- ological capacity. Cognitively impaired older adults may require innovative support services and Treatment protocols that accommodate their needs. Some EDs have partnered with local Alzheimer disease associations to develop collaborative arrangements providing staffing or volunteer support for cognitively impaired patients. In addition, EDs could work more closely with nursing facilities to develop procedures for handling cognitively impaired patients. Many nursing homes have developed bspecial care unitsQ specif- ically designed to accommodate cognitively impaired patients. The techniques and treatment protocols developed for use in these special care units may be successfully applied in the ED setting. One thing remains clear-the population of cognitively impaired older adults presenting to EDs will increase in the future. An organized response by EM would benefit the patients, families, and ED staff.

Focusing national efforts regarding geriatric emergency medicine

Educating EPs at all training levels about geriatric EM remains a critical need. Leadership by professional organ- izations (eg, American College of Emergency Physicians,

SAEM) and national health agencies and organizations (eg, Agency for Healthcare Research and Quality, the National Institute on Aging) is needed to promote geriatric EM as an educational and research priority. Despite the growing older population, a lack of geriatric EM educational opportunities persists, particularly on the national level (eg, few national conferences). In addition, funded research opportunities in the area have been limited or nonexistent. The professional EM societies need to provide critical leadership and advocacy in establishing priorities, convening workgroups, developing position statements, setting and funding research goals, and fostering the growth of the area of geriatric EM.

Conclusions

Older adults are a heterogeneous and rapidly growing population in the ED. Responding to their unique care needs requires a sustained, focused effort by the EM profession. Consistent clinical and scholarly themes suggest the need for innovation, increased geriatric education, and systematic research about older adults. The challenges facing EM related to older adults will continue building particularly in the areas of cognitive impairment and ALFs. EM has the opportunity to prepare and respond to these challenges if it takes the initiative to address the issues associated with providing quality care to older adults in the ED.

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