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Dementia and the ER—A Toxic Combination
The emergency room (ER) should be the last resort for patient care, especially for a person with dementia. Yet, all too often, that is precisely where a person with dementia ends up. They might be sent there by their medical provider because it is after normal office hours or because there are no urgent appointment slots available. Alternatively, they might be a resident in a facility that does not have access to 24/7 medical care, or they are brought by ambulance after a fall or other acute event that required a phone call to 911.
It is important for nursing and other long-term care facility providers, staff, and caregivers to be aware of how older adults with dementia experience the ER and to educate them on practical strategies, so that they are prepared to deal with, or hopefully avoid, a visit to the emergency department (ED). In general, much attention is still needed to optimize ER care in light of the growing population of older adult, in terms of enhancing the care environment and providing geriatrics-specific training to ER personnel.
How Patients With Dementia Experience the ER
Dementia and mild cognitive impairment are commonly seen among older patients in the ER but are often not recognized.1,2 The patients tend to be medically complex with multiple comorbidities and histories that are often unknown or incomplete. A typical ER is not well-designed for older adults in general and particularly ill-equipped for a person with Alzheimer disease (AD) or another dementia. It is, by nature, a chaotic place. Things happen fast in the ER, and this can make it even more confusing for a person with cognitive impairment. The noises of patients in pain, machines beeping, overhead pages, and the constant movement of people in and out of rooms creates an ideal environment for the expression or exacerbation of behavioral problems of dementia. Then, as happens too often for patients with AD or another dementia, the ER visit devolves into a bout of delirium. Then begins the cascade of hospital admission, overmedication, and institutionalization—all potentially avoidable if care outside the ER was provided or the ER environment was better suited to meet the needs of older adults with dementia.
An individual with dementia may not be able to process what is happening around them. They may be unable to answer questions or have difficulty following even simple directions. Minor procedures like taking blood pressure or drawing blood can be confusing and frightening to a person with dementia in any setting but even more so in the fast-paced and noisy ER environment. There may also be multiple people completing different procedures and tasks, which can intensify anxiety in a person with a dementing illness.
Family Members of Patients With Dementia
An ER visit for a person with dementia can also be a difficult experience for family members. Medical providers need to prepare family members of patients with dementia to have a game plan for when (not if) an ER visit happens. In the course of a disease that lasts a decade or more, an ER visit is extremely likely to occur at least once, if not more. Family or caregivers should be prepared with a notebook or folder with copies of important documents for the patient that are kept updated and readily available. These documents should include copies of medical insurance cards, an updated list of current medications (ie, names and dosages), names and contact numbers for all medical providers, the person’s advance care directive (power of attorney for medical care, POLST/MOLST, etc), and the names and contact numbers for family members.
Caring for Patients With Dementia in the ER
Health care providers working in the ER face unique challenges when caring for someone with dementia. Indeed, patients with cognitive impairment and dementia have been found to be especially difficult for ER providers to assess and treat.3 The inability of the patient to answer questions or follow directions, as well as the associated behavioral disturbances that frequently occur, creates a situation that can be exasperating for all involved. Too often, the emergency medical technicians involved in transporting the patient, the clerical staff who handle paperwork and interface with the patient and family, and the ER providers (eg, physicians, physician assistants (PAs), nurses, social workers) have had little formal training in geriatrics and even less in the unique aspects of caring for a person with dementia.
It is, understandably, difficult for professionals to slow down in the ER, but that is precisely what needs to happen when there is a patient with cognitive impairment. ER personnel should try to adapt their care approach when dealing with someone with a known diagnosis of AD or another dementia. For example, they should approach the patient in a calm and reassuring manner, slow down their pace and speech, and use simple language. Health care providers should consider what a frightening experience the ER is for most people and then imagine how the experience may be intensified for older adults with dementia. Envisioning the ER through their eyes may be helpful when determining how to adjust bedside manner.
Adapting the ER Environment
The medical delivery system overall, particularly in the ER, remains unprepared to meet the needs of the (ever-growing) aging population with dementia. The geriatric ED guidelines published in 2013 provided a first step towards addressing these problems.4 These include evidence-based cognitive screening tools and protocols designed to improve care for older adults. How many places have adopted and instituted these protocols and, more importantly, how effective they are in improving care and outcomes remains to be seen. The recent establishment of the Geriatric Emergency Department Collaborative (GEDC) is another positive sign that we are moving toward improved emergency care for the aging adult population, including those with dementia.5
The development of a geriatric ED designed and staffed to meet the unique needs of older adults, which includes the majority of patients with dementia, is another positive development. The first geriatric ED opened in 2008, and the number has grown steadily in the ensuring decade with over 100 opened by 2016.6 The creation of a quieter space where it is easier for patients to hear and see could go a long way to lessen patients’ confusion that too often is exacerbated in the traditional ER.
ER care is a team sport that requires a well-trained interdisciplinary team to meet the needs of persons with dementia. Geriatric training of all emergency personnel with special attention to unique challenges of patients with cognitive impairment, including dementia and delirium, should be required. Training should include not only ED physicians, nurses, PAs, social workers, and other licensed medical staff, but also physician specialty consultants and clerical and janitorial staff.
Conclusion
Perhaps we need to reconsider whether the ER is an appropriate site of care for patients with dementia. The expansion of house-call practices that bring both providers and technology to the patient, rather than the patient to the provider, may be an alternative to ER care. Providers should also consider earlier initiation of palliative care for patients with dementia. These approaches might better serve patients with dementia, their families, and the health care system.
References
1. LaMantia MA, Stump TE, Messina FC, Miller DK, Callahan CM. Emergency department use among older adults with dementia. Alzheimer Dis Assoc Disord. 2016;30(1):35-40.
2. Carpenter CR, DesPain B, Keeling TK, Shah M, Rothenberger M. The Six-Item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Ann Emerg Med. 2011;57(6):653-661.
3. Terrell KM, Hustey FM, Hwang U, et al. Quality indicators for geriatric emergency care. Acad Emerg Med. 2009;16(5):441-449.
4. American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, Society for Academic Emergency Medicine. Geriatric Emergency Department Guidelines. Acep.org website. https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf. Published 2013. Accessed July 10, 2018.
5. American Geriatrics Society. Geriatrics Emergency Department Collaborative. americangeriatrics.org website. https://www.americangeriatrics.org/programs/geriatrics-emergency-department-collaborative. Accessed July 12, 2018.
6. Gorman A. The rise of geriatrics mergency rooms. Alliance for Retired Americans website. https://retiredamericans.org/rise-geriatric-emergency-rooms/. Published August 23, 2016. Accessed July 13, 2018.
