FOREWORD: Elderly Patients in the Emergency Department

Elderly adults 65 years and older make more than 20 million emergency department (ED) visits each year, accounting for over 15% of all visits (Shenvi & Platts-Mills, 2019, p. 302). The ED plays a significant role in determining health care paths of older adults: “60% of hospitalized Medicare patients are admitted through the ED” (Biese et al., 2018, pg. a). Older adults on average have more medical problems, are taking more medications, and are more likely to experience social isolation, malnutrition, abuse, or neglect. All of these characteristics create three main challenges in emergency care of geriatric patients: efficiency at the expense of treatment, honoring the patient’s desire for discharge when possible, and recognizing non-medical problems (e.g., social isolation) that influence health outcomes (Shenvi & Platts-Mills, 2019, pg. 302).

In recognition of these challenges, the American College of Emergency Physicians (ACEP) created guidelines to improve ED care for older adults and a Geriatric ED Accreditation Program (Shenvi & Platts-Mills, 2019, pg. 304). The guidelines describe several conditions in which providers should be aware of the inherent diagnostic challenges. Some of the conditions listed are an acute coronary syndrome, abdominal pain, trauma, and adverse drug reactions. ACEP also created a list of goals of care that doctors should assess during patient evaluations. For example, doctors should obtain confirmation from patients who have documented preferences of care because patients can change their goals over time. Additionally, since hospitalizations account for one-third of US health care expenditures, reducing them should be a significant focus on efforts to control health care costs for older adults. Dr. Shenvi and Platts-Mills suggest that there should be consequences for readmissions to help enforce efforts to reduce hospitalizations. Other suggestions are that bundled payments be available for patients after an episode of care, and the use of ED care managers by accountable care organizations should become more frequent.

However, for health care providers, overcoming these challenges will become more of a problem over the upcoming years. According to the United States Census Bureau’s 2017 National Population Projections, by the year 2030, all baby boomers (individuals born in the United States between mid-1946 and mid-1964) will be older than the age of 65. The elderly population that is at retirement age will increase to every 1 in 5 residents. For the first time in history, older people are projected to outnumber children. By the year 2035, there will be 78 million people 65 years and older (US Census Bureau, 2018), and by the year 2050, the number will rise to 83.7 million (US Census Bureau, 2014). The increase in the population will also cause a strain within assisted living.

With the enactment of Medicare and Medicaid in 1965, residential settings for older people with health problems, ranging from boarding homes to funded organizations (homes for the aged), rose in popularity. Medicare is a federal health insurance program for people who are 65 or older, certain younger people with disabilities, or people with End-Stage Renal Disease. Three parts make up Medicare: hospital insurance, medical insurance, and prescription drug coverage (Medicare.gov, n.d.). On the other hand, Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities (Medicaid.gov, n.d.). Both programs are funded jointly by states and the federal government.

However, over the next few years, state governments encouraged many homes for the aged to convert to nursing facilities. This introduced the matching of federal funds to help state and local governments finance long-term care for low-income people. Over time, nursing facilities became more hospital-like in their design and physical operation. Nevertheless, not all homes for the aged convert to certified nursing facilities due to not being able to meet the regulatory standards; many of these homes then became known as retirement homes (Wilson & Keren, 2007, pg. 9).

Retirement homes were advertised as a lifestyle choice to the older population seeking companionship, meals, and housekeeping. The houses typically served those at the lowest end of the economic spectrum, including Supplemental Security Income recipients, people with mental health issues, or developmental disabilities (Wilson & Keren, 2007, pg. 9). Assisted living developed on an as-needed basis–it responded to the current condition. A study was conducted in Oregon in 1986 to see how practical and financially viable assisted living was to Medicaid-eligible clients (Wilson & Keren, 2007, pg. 13-14). The study focused mainly on a 142-unit setting, licensed as a residential care facility called Regency Park. The study finds that health conditions of Medicaid clients remained stable, whereas the activity of daily living and instrumental activity of daily living functioning improved for the majority of the clients and measures of depression, cognition, and life satisfaction for clients also showed improvement. The influx of the elderly population using assisted living at this time was at a steady demand and retirement homes were able to maintain a quality living. However, in today’s time, the population of older adults has suddenly increased placing a strain on assisted living resources. The pressure on retirement homes resources will only become worse with the aging baby boomer generation causing more trips to the ED. Nonetheless, geriatric emergency departments are hard to come by in the U.S.

ACEP launched an accreditation program in 2018 to improve and standardize emergency care for older adults (UNC Health Care and UNC School of Medicine, 2018). According to the ACEP, there are currently only 43 accredited geriatric emergency departments in the nation since the launch of the program in 2018. The purpose of geriatric emergency departments “is ensuring geriatric-focused education and interdisciplinary staffing, providing standardized approaches to care that address common geriatric issues, ensuring optimal transitions of care from the ED to other settings (inpatient, home, community-based care, rehabilitation, long-term care), and promoting geriatric-focused quality improvement and enhancements of the physical environment and supplies”(ACEP Geriatric Emergency Department Accreditation Program, n.d.). When an ED becomes a geriatric accredited ED, the care provided to older adults improves and the resources needed to provide that care is available. Furthermore, this signals to the public that the local institution is focused on the developing the standard of care for the community’s older citizens and that the institution wants to give them the highest quality of care.

Dr. Christina Shenvi states:

“The heightened focus on geriatric-specific emergency care comes at a time when research increasingly shows that everything about the ER experience is more challenging for elderly patients, who make up nearly 20 percent of emergency room visits. The aging population is also expected to double in the next 30 years” (UNC Health Care and UNC School of Medicine, 2018).

She reemphasizes the need for hospitals to adjust due to the booming elderly population. Shenvi also says that by 2030, hospitals can expect every other ambulance coming to the ED to be carrying an older adult.

An example of a hospital jumping into action is located close by. Earning its accreditation in October 2018, University of North Carolina Medical Center Hillsborough (Carolina) is the first and only geriatric emergency department in the state of North Carolina (UNC Health Care and UNC School of Medicine, 2018). Carolina earned a level 2 “Silver” GED accreditation from the ACEP. Kevin Biese, MD, MAT, associate professor of emergency medicine and geriatrics, and co-director of the geriatric emergency medicine service, was one of the main leaders of this transition. He states the reason for the shift was due to the traditional model of acute care emergency medicine was no longer sufficient for the elderly population. The traditional model resulted in many unwanted and unneeded hospitalizations and frequent readmission. He furthermore says “[t]he traditional system is not aligned with the needs and care wishes of elderly patients, even though many wonderful physicians, nurses, and other care providers are dedicated to providing the best care that they can” (UNC Health Care and UNC School of Medicine, 2018). Older adults often require more time, lab work, and have more complicated medical and social needs; many of them often end up being admitted more often to the hospital.

Hospitals like Carolina are not only being challenged to handle the problems mentioned previously, but they are also being challenged to improve identification and reporting victims of elder abuse, neglect, and self-neglect. Emergency Medical Services (EMS) providers, who are the first to perform assessments of patients, can identify potential victims of elder abuse, neglect, or self-neglect (Rosen et al., 2017). EMS providers are also able to observe inappropriate behaviors between the caregiver or family and the patient. Unfortunately, with all the chaos that occurs within EDs, EMS concerns are sometimes lost in communication and are not conveyed further by other health care providers, social workers, or authorities. Usually, the loss of critical information occurs during the handoff between EMS and ED personnel, and the consequences can be grave.

ED providers are not likely to be able to identify elder mistreatment during their medical evaluation (Rosen et al., 2017). Consequently, this typically leads to a vulnerable geriatric patient being discharged into an unsafe environment or into the care of the abuser. Therefore, ensuring that EMS concerns are effectively passed on is vital for these patients. Other barriers that prevent efficient identification of patients who may be elderly mistreatment victims is lack of existing protocols, time constraints, and absence of feedback.

In 2017, a study was conducted that focused on EMS providers and their perspectives on identifying and reporting victims of elder abuse, neglect, and self-neglect (Rosen et al., 2017). The EMS providers who participated in the study reported solutions to some of the barriers effecting efficient identification of mistreated patients. One of the solutions participants suggested is “improving direct communication with ED social workers who may further evaluate for elder mistreatment while the patient receives care in the ED” (Rosen et al., 2017). EMS providers also suggested “adding a section within the Ambulance Report to record concerns about mistreatment or a separate form to report their concerns” (Rosen et al., 2017). By adding an increase of use of electronic data, this can help improve the communication issue between providers. Another solution participant’s proposed is dependence on protocols in the care provision.

Protocols provide guidance to healthcare providers in their management of victims of mistreatment. “Analogous protocols should be developed for elder mistreatment, and their efficacy should be evaluated” (Rosen et al., 2017). Participants also highlighted that “[t]hese protocols should include provisions to optimize care and safety for patients who refuse transport and to manage hazards in the home environment” (Rosen et al., 2017). By disseminating these protocols, an opportunity is presented for additional training for EMS providers. However, time constraints make dependence on new assessment protocols challenging.

Nonetheless, increasing the anticipated time EMS providers spend responding to calls may be worth it given the potential value of additional in-home evaluation (Rosen et al., 2017). EMS providers should be highly encouraged to directly correspond with ED personnel if they have any worries concerning elderly mistreatment and should not be chastised for any delays. The research conduct in this study support these claims and also “identifies the power of negative feedback in discouraging EMS providers and thereby suppressing reporting” (Rosen et al., 2017). An additional way to improve older adult health care is by capitalizing on EMS providers’ unique role within the community. Community paramedicine can help ensure the safety of vulnerable geriatric patients and help the ones who need the services the most.

There are three main challenges the ED faces concerning geriatric patients. First, to improve efficiency without overlooking any serious medical conditions. Second, to honor the patient’s desire for discharge when possible. Third, to recognize and address nonmedical problems (e.g., social isolation) that may influence health outcomes (Shenvi & Platts-Mills, 2019, pg. 302). An additional challenge the geriatric population in the U.S. faces is the lack of identification and clear communication of their mistreatment. Overcoming these obstacles will become increasingly difficult as the baby boomer generation rapidly ages. Not only will the aging population put pressure on ED resources, but also on assisted living and care facilities. In the stories by Arendas and Joyner, first-hand accounts are told of issues elderly patients face within the ED. One way that our communities can conquer these obstacles is by having a local ED become certified in geriatric emergency care. Our treatment of the elderly population is one that is overlooked and that needs to be changed. We all deserve equal quality in healthcare and that should not change dependent on age. The geriatric population should receive just as much care and attention has any other population.