Treating Older People in the Emergency Department

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In my 16 years in Emergency Medicine in England it has become increasingly common to see people over 85 years of age. This is an experience shared with ED colleagues from several other countries. Even the proud near-centurion awaiting a “letter from the Queen” is a not infrequent visitor to my department.

EDs are increasingly thronged with older people. Our ED has seen a 40% increase in the over-85’s in one year! They are increasingly coming by ambulances and are taking up more and more of our time and hospital beds. Is this a problem or is it a symptom?

Traditionally EDs have been fantastic at managing risk and dealing with trauma and acute illness. These conditions have typically been in younger people with predominantly single complaints or single system disease such as heart failure, asthma, sepsis or trauma. We are familiar with handling “uncertain presentations” such as heart attack presenting as indigestion or stomach bleeds presenting as collapse. These younger patients have largely presented with a single complaint stemming from a single problem masquerading as something else.

Older people also present with “non-specific complaints” like falls, weakness, difficulty mobilizing, confusion, and urinary incontinence. But unlike the situation with younger patients,. these clinical presentations often arise from  a multiplicity of underlying causes. Many older people are on several medications which can add to uncertainty due to their interactions and effects. To make matters more complex, they are sometimes accompanied by spouses who have undiagnosed but obvious memory problems. And I have noticed the reluctance of many older people to “bother the doctors and nurses” as they stoically refuse pain relief for even broken hips! As a result, they are frequently provided with inadequate or no pain relief.

EDs are dealing with a different population, but we have largely not realized it, or are still in denial.

Older peoples’ issues cannot be handled purely with medical knowledge. They also require understanding of psycho-social issues. This is not dissimilar to managing children in the sense that the model of care must be bio-psycho-social.

We ED doctors carry out many tests. Unfortunately, patients are frequently admitted for conditions diagnosed by ostensibly abnormal test results – findings that in the U.S. are called “incidentalomas.”

I believe the high volume of testing we do in the ED is related to our tendency for “reductionism” – the satisfaction of making a single diagnosis that explains all signs and symptoms. Our testing practices may also be related to the ED doctors’ desire to “complete episodes” and move on. We like the “one-problem-one-solution” paradigm that lends itself nicely to our fast paced EDs and our desire to use our hands more than our ears. But older people need time, patient handling and gentleness when it comes to understanding and managing their ill-health.

The skills and competencies in understanding the presentations in older people are not common and frequently missing in the repertoire of the typical ED doctor. I suspect it is similar for doctors practicing in many super and sub- specialties. These competencies were never specifically addressed in traditional emergency medicine training programs – although there is an increasing understanding and efforts underway in several countries including the U.S. and the U.K.

Amidst the tests, decisions, diagnosis, treatment and hospital admission, we frequently miss the person within the process. We forget how the older person is someone’s parent, or grandparent, and frequently have tremendous tales to tell. I have heard some fabulous stories from older people dating back to the 1930’s. Many of them forgot our encounter after 15 minutes and retold the same stories. But they were always wonderful . . . even for the fourth time.

In my experience most older people do not enjoy being in the ED, do not like intrusive interventions, play down their pain and hate being admitted to hospital. I have also noticed how their eyes light up when I say “hopefully home” or “would you like a cup of tea?” I have learned not to order unnecessary tests in frail older people that add to the suffering without adding to their care. I do not carry out any intervention unless I agree with the person or their family that it is necessary for improving their quality of life or decreasing their pain and suffering. I have learned when to stop chasing a diagnosis and start chasing the experience. Respecting the privacy, dignity and autonomy is as important as addressing pain, anxiety and social needs. This has been an experiential, self-directed journey supported by friendly geriatricians and my older patients.

I have discovered fellow enthusiasts across the globe and we have now set up a group: International Consortium for Emergency Geriatrics. We are keen to dedicate our time to developing EDs that provide better care for older people. We are also sharing training tips for our juniors and have Geriatric Emergency Medicine Fellowships – one each in the U.K. and U.S. It is a start, but EDs cannot do this alone. The whole of health and social care services need to participate in the process. Older people are our “core” business – they take up 65% of hospital beds.

Moving on we need to understand how to better capture, address and effectively learn from the experience of older people and their families and loved ones in healthcare. We need every ED to be competent in responding to the needs of older people and improving their experience.

Otherwise I will suffer the consequences in another 40 years time.

Jay Banerjee, 44,  is currently a Health Foundation Quality Improvement Fellow at The Institute for Healthcare Management, Cambridge, MA. He is an Emergency Physician from Leicester, England, with special interest in the care of older people and children and lead author of The Silver Book.

6 Responses to “Treating Older People in the Emergency Department”

  1. Steve Moffic

    What are the finances, the reimbursement, for the kind of most appropriate ER care you want to provide? How does it compare to inpatient care? Are there enough general geriatricians to help avoid unnecessary ER visits? Do you think this has any important influence on caring for these elderly.
    In psychiatry, the outpatient reimbursement is very low, with Medicare paying maybe $25 a visit, a visit which, as you suggest, should be longer than usual. For that reason, and others, geriatric psychiatrists tend to be in short supply.

    • Jay Banerjee

      These are very different in the UK and less complicated compared to the reimbursement policies and procedures in the USA. Also, in the UK healthcare professionals in hospitals get paid the same rate irrespective of specialty. And there are more geriatricians in the UK compraed to the USA. However much of the assessment and management processes can be embedded across the system rather than within specialties or settings. This may be a way to offset against changes in financial arrangements and service deliveries. Ultimately, society needs to make a choice
      on the value of services and the reimbursement

  2. Jay Banerjee

    I suppose the key is to address the care needs of older people and improve the outcomes that matter to them. We could do that in existing EDs or create Geriatric EDs or Clinical Decision Units that have pathways of care for geriatric syndromes. The right model would depend on local feasibility. Each of these have resource and process implications. I am aware of some excellent Geriatric EDs in the USA.

  3. Patricia Gillespie

    Having cared for, and witnessed the long, bumbled decline of my mother’s health in hospital, and observed how her requests to die at home fell on deaf ears, I can reflect that the clinical downstream process and it protocols, highlight pitifully how elder life is barely understood. A whole of life understanding is required, but as long as diagnosis and treatment remains linear, inflexible, and based on satisfying ‘outcomes’, the numbers of elders who suffer functional decline in hospital and are progressively impoverished by the ‘process’ of managing end of life will sadly increase. A more open and responsive approach – the kind that was asked of all of us when we started out researching – and less hubris, would be a better way to learn from elder experiences. And perhaps we should remind ourselves that to die in the presence of strangers, in unfamiliar surroundings, excised of the things we remember and love, is cold comfort. Our obsession with clinical management of dying and death, limits our ability to learn what lessons it can offer in how we can better transition to death.