The Silver Tsunami: Are You Ready?

America is aging. Between 2010 and 2030, the number of older Americans is expected to double, to 72.1 million. This will mean that for the first time in history, people over 65 will outnumber children under the age of 5.

The geriatric population, defined as persons 65 years or older, numbered 44.7 million in 2013 (the latest year for which data is available). This represents 14.1% of the population, or about one in every seven Americans. This will grow to 21.7% of the population by 2040.¹ This means by 2040, one out of every five persons in the U.S. will be over 65.

The older population itself is also increasingly older—we are seeing more adults in the age categories above 65, specifically the 65–74, 75–84 and 85+ age groups.

EMS Specifics

Is your EMS agency ready for this paradigmatic shift and what it means for utilization of your service, the types of calls you will see, the need for greater interaction with social services and even potential changes to clinical protocols?

Patients 65 and older utilize EMS twice as often as younger populations.² Americans over 85 use it three times as much.³ That both these population groups are increasing will have significant impact on your call volume. 

The increasing geriatric population will also translate into a need for geriatric-specific training programs, understanding how the facilities that typically house geriatric patients operate and even studying utilization patterns for geriatric residents. One study called attention to the minimal training EMS providers receive specific to geriatrics and revealed that many EMS providers do not understand geriatric-specific needs regarding communication and psychosocial issues.⁴

The aforementioned increase in overall population numbers could potentially impact the number of calls received and amount of time your units spend on scene, as these calls for chronic medical issues are more clinically intricate. One statewide study showed the proportion of patients using EMS to reach emergency departments increased steadily with age and estimated, by the year 2030, older patients will account for approximately half of all EMS transports to North Carolina’s EDs.⁵ These trends were further confirmed by the CDC’s National Hospital Ambulatory Medical Care Survey from 2009–2010, which showed the percentage of ED visits made by nursing home residents, patients arriving by ambulance and patients admitted to the hospital increased with age.

Most Common Emergencies

Elders report using EMS because of immobility, perceived medical needs or requests by others. Similarly, the presence of acute illness symptoms, older age and poor social and physical function, rather than health beliefs, predicts EMS use among elders. These factors must be considered when managing the demand for EMS services.

A review of the most common traumatic and medical emergencies this population encounters is in order. Per the National EMS Information Systems (NEMSIS), in 2014, 45% of all calls for EMS were from patients 65 or older, and females comprised 54% of these patients. NEMSIS also identified the most common geriatric emergencies, based on provider impression, that year as follows:

• Traumatic injury: 10%
• Respiratory distress: 8%
• Syncope/fainting: 6%
• Abdominal pain/problems: 6%
• Altered level of consciousness: 5%.

Geriatric patients are at increased risk of morbidity and mortality when experiencing trauma. Although they currently account for just 12.5% of the population, they account for one-third of all traumatic deaths.⁶ The types of trauma seen most frequently in the elderly are blunt trauma from falls, motor vehicle crashes and pedestrians struck by automobiles.

Falls are responsible for half of all accidental deaths in the elderly and are a common cause of head injuries. There are various reasons why the elderly fall. Environmental factors may include stairways without handrails, slippery bathtubs, slipping rugs, steep steps or improperly fitting footwear. There are also a number of medical reasons why the elderly fall. The most common are dizziness, side effects from medications, heart rhythm problems, spinal weakness, syncope, transient ischemic attacks, low blood pressure, internal bleeding and poor vision.

Since falls have been shown to be a major issue for geriatrics, it is incumbent on your EMS agency to either develop a fall prevention program or join with your local/regional public health partners to develop one. As the typical mobile integrated healthcare/community paramedicine program is geared toward patients with chronic health problems not defined by age, patients with mental health issues and/or patients with severe social problems (the homeless, etc.), CP programs could potentially play a big role in identifying issues in the home.

Elder Abuse

One of the not-well-understood but frightening realities for this aging population is the surge in cases of elder abuse. According to the best available estimates, between 1 and 2 million Americans 65 or older have been injured, exploited or otherwise mistreated by someone they depended on for care or protection.⁷ Additional statistics show that more than 9.5% of the geriatric population will suffer some form of abuse annually.⁸ Elder abuse can affect both men and women of all ethnic backgrounds and social statuses. The following are commonly defined as the major categories of elder mistreatment:

• Physical abuse—Inflicting, or threatening to inflict, physical pain or injury on a vulnerable elder, or depriving them of a basic need.
• Emotional abuse—Inflicting mental pain, anguish or distress on an elder person through verbal or nonverbal acts.
• Sexual abuse—Nonconsensual sexual contact of any kind, or coercing an elder to witness sexual behaviors.
• Exploitation—Illegal taking, misuse or concealment of funds, property or assets of a vulnerable elder.
• Neglect—Refusal or failure by those responsible to provide food, shelter, healthcare or protection for a vulnerable elder.
• Abandonment—Desertion of a vulnerable elder by anyone who has assumed the responsibility for their care or custody.

While there is much we don’t know about elder abuse, we do know that female elders are abused at a higher rate than males and that the older one is, the more likely one is to be abused.⁹ Signs of elder abuse may be missed by professionals who work with older Americans due to lack of training on detecting abuse. The elderly may be reluctant to report abuse themselves because of fear of retaliation, lack of physical and/or cognitive ability to report, or because they don’t want to get the abuser (90% of whom are family members) in trouble.

Many states have designated EMS providers as mandated reporters of elder abuse, and this designation comes with the need to understand your role in reporting, to whom you should report, any additional requirements related to reporting and any protections you are afforded as a reporter. EMS agencies need to develop and promulgate policies that take into account all the elements of mandated reporting mentioned above married with their system/agency specifics.

Additional Challenges

Additional challenges associated with this population that are not EMS-specific can impact how you treat and access these patients.

According to the National Council on Aging, more than 23 million Americans 60 or older are economically insecure, which is defined as living at or below 250% of the federal poverty level. According to the American Association of Retired Persons (AARP), from 2001–09, the number of Americans 50 or older threatened by hunger increased by 79%, to nearly 9 million people. This translates into a population that cannot afford basic nutrition, necessary medications and even basic healthcare.

There is also increasing evidence that hoarding is a problem affecting the geriatric population more than others. This phenomenon, clinically categorized as hoarding disorder (HD) and defined as “a psychiatric condition that produces symptoms such as the compulsive urge to acquire unusually large amounts of possessions and an inability to voluntarily get rid of those possessions, even when they have no practical usefulness or monetary value,” is associated with increased risk for fire, falling, poor sanitary conditions, disability and health risks. Hoarding symptoms and the resulting clutter may exacerbate existing health conditions and lead to improper management of medical illnesses.¹⁰ Results from a Johns Hopkins study show that hoarding behavior is more prevalent among older adults,¹¹ and a study of hoarding complaints to a Massachusetts health department found that 40% of individuals referred were elderly.¹² As our aging population rapidly increases, so will the number of older adults for whom hoarding is a problem. Hoarding can result in extremely cluttered living spaces as well as blocked access to toilets, refrigerators, and routes of ingress and egress—all concerns for EMS providers.

Another issue that’s not specific to but has significant implications for the geriatric population is alcoholism. Alcohol overuse is associated with poor mental health functioning, as well as increased risk of suicide, liver disease, cancer and falls. Some medical conditions, such as high blood pressure, ulcers and diabetes, can worsen with alcohol use. Many medications—prescription, over-the-counter and herbal—can be dangerous or even deadly when mixed with alcohol. This is a special concern for older people because the average person over 65 takes at least two medicines a day.

What You Should Be Doing

The most time-consuming, resource-consuming, medically challenged population in your service area is about to explode in the next 10–20 years, and chances are, you are not ready. Your EMS agency must develop and implement a plan to handle the demands this upsurge will place on your agency. Such a plan should include:

• Understanding how the aging population will impact the operational aspects of your EMS system. Plan accordingly with analysis of what time of day these calls typically occur, the most common treatment modalities/interventions needed, and whether staffing patterns should change to reflect these realities. Your dispatch center should have this information available. Additionally, your state EMS office could potentially provide statistics regarding geriatric use of EMS for both your agency and your state.
• Spearheading a working group of stakeholders that includes local hospitals, public health agencies, assisted living facilities and anyone else with an interest in delivering services to the geriatric population. This group should be proactive in understanding the growing population and needs of the geriatric, informing governmental decision-makers about these changes, ensuring services are in place for these patients, and educating geriatrics on what services are available as well as when to call 9-1-1.
• Reviewing what other EMS agencies around the United States, and even internationally, are doing to deal with this booming population.

Training Realities

In the early 1990s, Acadian Ambulance in Louisiana analyzed its customer base and took the initiative to develop a highly interactive course known as “Carpe Diem,” which focuses on the geriatric patient’s distinct social, physical and cognitive needs. Class participants utilize training aids to mimic hearing loss, vision loss and even muscular degeneration and then have classmates assist them in daily functions such as walking and eating.

Similarly, the National Association of Emergency Medical Technicians (NAEMT) offers the Geriatric Education for Emergency Medical Services (GEMS) course. While maintaining a scenario-based approach with emphasis on the uniqueness of the geriatric population, GEMS lectures include slides that highlight geriatric-specific content that EMS providers must know, such as fall prevention, epidemiology, polypharmacy and more. According to NAEMT, future geriatric-specific initiatives include an all-scenario-based class to supplement the one-day GEMS class, a lecture on unique geriatric challenges in a disaster, and a lecture on mobile integrated healthcare-community paramedicine (MIH-CP) and the opportunity to make a difference with older patients.

EMS agencies should ensure classes like these are mandatory for personnel.

Conclusion

There is clearly a silver tsunami coming. Between 2010 and 2030, the number of older Americans will double to 72.1 million. These geriatric patients will utilize your services for a variety of calls with unique needs that require unique communication and unique training. This population will also have social services needs that could potentially be unrealized and, combined with the aforementioned increase in elder abuse, will put your EMS agency and its providers into new, unique roles for which they should be trained.

Be proactive in understanding these elements and how this unique population will impact your EMS system, or you will get hit by the tsunami.

References

1. Administration for Community Living. Administration on Aging (AoA): Aging Statistics, https://www.aoa.acl.gov/Aging_Statistics/index.aspx.

2. Snyder DR, Christmas D (eds.). Rate of Aging and Older People and the Health Care System, 2003 Geriatric Education for Emergency Medical Services.

3. Blanda M. Geriatric Trauma: Current Problems, Future Directions. www.saem.org/download/02blanda.pdf.

4. Peterson LN, Fairbanks RJ, Hettinger AZ, Shah MN. EMS attitudes towards geriatric prehospital care and continuing medical education in geriatrics. J Am Geriatr Soc, 2009 Mar; 57(3): 530–5.

5. Platts-Mills TF, Leacock B, Cabanas JG, Shofer FS, McLean SA. Emergency medical services use by the elderly: analysis of a statewide database. Prehosp Emerg Care, 2010 Jul–Sep; 14(3): 329–33.

6. Hannan EL, Waller CH, Farrell LS, Rosati C. Elderly trauma inpatients in New York state: 1994–1998. J Trauma, 2004 Jun; 56(6): 1,297–304.

7. Bonnie RJ, Wallace RB, eds. Elder Mistreatment: Abuse, Neglect and Exploitation in Aging America. National Academies Press, www.nap.edu/read/10406/chapter/1#ii.

8. Statistic Brain. Elderly Abuse Statistics, www.statisticbrain.com/elderly-abuse-statistics/.

9. National Center on Elder Abuse. Statistics/Data, www.ncea.aoa.gov/Library/Data/index.aspx.

10. Ayers CR, Iqbal Y, Strickland K. Medical conditions in geriatric hoarding disorder patients. Aging Ment Health, 2014 Mar; 18(2): 148–51.

11. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther, 2008 Jul; 46(7): 836–44.

12. Kim HJ, Steketee G, Frost RO. Hoarding by elderly people. Health Soc Work, 2001 Aug; 26(3): 176–84.

Raphael M. Barishansky, MPH, MS, CPM, is a solutions-driven consultant working with EMS agencies, emergency management and public health organizations on complex issues including leadership development, strategic planning, policy implementation and regulatory compliance. He previously served as director of the Office of Emergency Medical Services (OEMS) at the Connecticut Department of Public Health (2012–15), as well as chief of public health emergency preparedness at the Prince George’s County (MD) Health Department (2008–12). A frequent contributor to and editorial advisory board member for EMS World, he can be reached at rbarishansky@gmail.com.