Twice a day, the 86-year-old man went for long walks and visited with neighbors along the way. Then, one afternoon he fell while mowing his lawn. In the emergency room, doctors diagnosed a break in his upper arm and put him in a sling.
Back at home, this former World War II Navy pilot found it hard to manage on his own but stubbornly declined help. Soon overwhelmed, he didn鈥檛 go out often, his congestive heart failure worsened, and he ended up in a nursing home a year later, where he eventually passed away.
鈥淛ust because someone in their 70s or 80s isn鈥檛 admitted to a hospital doesn鈥檛 mean that everything is fine,鈥� said , co-director of geriatric emergency medicine at the University of North Carolina School of Medicine, who recounted the story of his former neighbor in Chapel Hill.
Quite the contrary: An older person鈥檚 trip to the ER often signals a serious health challenge and should serve as a wake-up call for caregivers and relatives.
underscores the risks. Six months after visiting the ER, seniors were 14 percent more likely to have acquired a disability 鈥� an inability to independently bathe, dress, climb down a flight of stairs, shop, manage finances or carry a package, for instance 鈥� than older adults of the same age, with a similar set of illnesses, who didn鈥檛 end up in the ER.
These older adults weren鈥檛 admitted to the hospital from the ER; they returned home after their visits, as do about two-thirds of seniors who go to ERs, nationally.
The takeaway: Illnesses or injuries that lead to ER visits can initiate 鈥渁 fairly vulnerable period of time for older persons鈥� and 鈥渨e should consider new initiatives to address patients鈥� care needs and challenges after such visits,鈥� said one of the study鈥檚 co-authors, , a professor of medicine (geriatrics), epidemiology and investigative medicine at Yale University.
Research by , a professor and division director of gerontology, geriatrics and palliative care at the University of Alabama at Birmingham, confirms this vulnerability. In a , she found sharp declines in older adults鈥� 鈥渓ife-space mobility鈥� (the extent to which they get up and about and out of the house) after an emergency room visit, which lasted for at least a year without full recovery.
鈥淲e know that when people have a decline of this sort, it鈥檚 associated with a lot of bad outcomes 鈥� a poorer quality of life, nursing home placement and mortality,鈥� Brown said.
suggests that seniors who are struggling with self-care (bathing, dressing, toileting, transferring from the bed to a chair) or with activities such as cooking, cleaning and managing medications are especially vulnerable to the aftereffects of an ER visit.
Why would seeking help in an ER often become a sentinel event, with potential adverse consequences for older adults?
Experts offer various suggestions: Seniors who were previously coping adequately may be tipped into an 鈥淚 can鈥檛 handle this any longer鈥� state by an injury or the exacerbation of a chronic illness, such as diabetes or heart failure. They now may need more help at home than what鈥檚 available, and their health may spiral downward.
Other possibilities: Seniors who fall and injure themselves 鈥� a leading cause of ER visits 鈥� may become afraid of falling again and limit their activities, leading to deterioration. Or, underlying vulnerabilities that led to an ER visit 鈥� for instance, depression, dementia or delirium (a state of acute, sudden onset confusion and disorientation) 鈥� may go undetected and unaddressed by emergency room staff, leaving older adults susceptible to the ongoing impact of these conditions.
In response to concerns about the care older adults are receiving, the field of emergency medicine has designed to make ERs more senior-friendly. With the rapid expansion of the aging population, which accounts for more than 20 million ER visits each year, 鈥渙ur traditional model of emergency medicine has to shift its paradigm,鈥� said Dr. Christopher Carpenter, associate professor of emergency medicine at Washington University School of Medicine in St. Louis.
The guidelines call for educating medical staff in the principles and practice of geriatric care; assessing seniors to determine their degree of risk; screening older adults deemed at risk for cognitive concerns, falls and functional limitations; performing a comprehensive medication review; making referrals to community resources such as Meals on Wheels; and supplying an easily understood discharge plan.
Starting in February, the American College of Emergency Physicians (ACEP) is launching an accreditation program for emergency rooms, certifying at least a minimal level of geriatric competence 鈥� another effort to improve care and outcomes for older adults. Three levels of accreditation 鈥� basic, intermediate and advanced 鈥� will be offered.
For each of these levels, ERs will be required to provide walkers, canes, food and drink, and reading glasses to older patients. For intermediate and advanced accreditation, physicians will have to oversee improvement initiatives, such as limiting the use of urinary catheters in older patients. Also, changes to the ER environment such as nonslip floors and enhanced lighting will be required, along with amenities such as hearing devices, thicker mattresses and warm blankets.
Family members can also help older adults during and after a visit to the ER.
鈥淢y biggest piece of advice is get there and stay by their side throughout the experience, because things happen very quickly in emergency rooms, and these are difficult environments to navigate under the best of circumstances,鈥� said , associate professor of medicine at Indiana University School of Medicine.
Dr. Kevin Biese, chair of the board of governors for ACEP鈥檚 geriatric ER accreditation initiative, offers these recommendations:
- Escape the crowd. 鈥淎sk for a room, instead of letting your loved one stay out in the hallway 鈥� a horrible place for seniors at risk of delirium. Tell staff, who may have put Mom in the hallway because she鈥檚 a fall risk and they want to keep an eye on her, 鈥業鈥檒l watch Mom and make sure she doesn鈥檛 get out of bed.鈥欌��
- Supply a full list of medications. 鈥淎nd ask the doctor or nurse to make sure that your list is the same as what鈥檚 in [the hospital鈥檚] computer. If not, have them update the computer list. Don鈥檛 leave without knowing which medications have been stopped or changed, if any, and why.鈥�
- Focus on comfort. 鈥淏ring eyeglasses and any hearing-assist devices that can help keep your loved one oriented. If you think Mom is in pain, encourage her pain to be treated.鈥�
- Educate yourself. 鈥淜now what happened in the ER. What tests were done? What diagnoses did the staff arrive at? What treatments were given? What kind of follow-up is being recommended?鈥�
- Communicate effectively. 鈥淯tilize teach-back. When the nurse or doctor says, 鈥極K, you鈥檙e supposed to do this when you get back home,鈥� say, 鈥楲et me see if I understand. I hear you say take this medication on this schedule. Did I get that right?鈥欌��
- Follow through. 鈥淎sk 鈥楬ow is Mom鈥檚 regular doctor going to know what happened here? Who鈥檚 responsible for telling him 鈥� do you make that call or do I? And how soon should we try to get in for a follow-up appointment?鈥欌��
- Keep tabs on your loved one. Finally, 鈥測ou need to see the few days after a visit to the ER as a time of critical importance, when increased vigilance is required. Arrange for some extra help if you can鈥檛 be around, even if only for a few days. Check in frequently on Mom and make sure her needs are being met, her pain is being adequately controlled and she鈥檚 not getting delirious. Does the plan of care that she left the ER with seem to be working?鈥�
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