Ms. Nolan is a Nurse Practitioner, Department of Neurocritical Care, and part-time Professor, Lehman College Nursing Program, Columbia University Medical Center/Lehman College, New York, New York.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Margaret R. Nolan, MSN, GNP-C, Department of Neurocritical Care, Columbia University Medical Center/Lehman College, Millstein Hospital Building, 177 Fort Washington Avenue, 8th Floor, Neurocritical Care Division, Room 300, New York, NY 10032; e-mail: firstname.lastname@example.org.
The emergency department (ED) provides initial treatment to patients with a broad spectrum of illnesses and injuries. It is a unique and highly specialized environment for individuals with life-threatening illnesses. Patients in the ED require immediate attention paired with the need for rapid assessment (Hwang & Morrison, 2007). This rapid assessment creates an environment that is loud, fast paced, and orientated to addressing the most emergent case first, using triage techniques. EDs can also be entry points for those without other means of access to medical care.
Older adults make extensive use of the ED (Ballabio et al., 2008). Many difficulties face older adults in every aspect of daily life, but these difficulties become more apparent in the ED. Most EDs are not prepared for older patients (Robinson & Mercer, 2007). Long wait times, hours on hard stretchers, and loud environments can cause older adults even greater discomfort and can put them at risk for complications and adverse outcomes.
Rates of older adult visits to the ED are increasing more rapidly than for any other group; in fact, researchers predict that by 2013 ED visits in the United States for patients ages 65 to 74 could be as high as 11.7 million per year (Lloyd, 2007). By 2030, one in five Americans (approximately 20% of the population) will be older than age 65 (American Geriatrics Society [AGS], n.d.), placing increased burden on already strained EDs (Roberts, McKay, & Shaffer, 2008).
Reasons Older Adults Visit the ED
New onset of illness may bring a younger adult to the ED, but older adults visit the ED for a variety of reasons. While older adults are frequent users of the ED, they do not make inappropriate use of it (Salvi et al., 2007). It has been found that older patients who initiate the ED visit themselves may fare better than those whose visits are prompted by family members or staff (Lazarovici, Somme, Chatellier, Saint-Jean, & Espinoza, 2008). Older adults often visit the ED due to worsening of an existing condition or when the illness affects their functioning or ability to perform activities of daily living (ADLs) (Wilber, Blanda, & Gerson, 2006). Most older patients do not visit the ED unless they are seriously ill. The literature supports that many older adults often wait to visit the ED until late into worsening symptoms so they will not “bother” their physician. For many, a decrease in the ability to be independent can be the trigger that necessitates an admission to the hospital.
Non-emergent admissions can burden the ED as well. Nursing homes follow a protocol when a patient has an event, such as a fall, and often must send the patient to the ED to be seen and cleared. The guidelines of many home care agencies require that home care aides call 911 if older homebound patients experience a minor event, even if this is not necessarily in keeping with the patient’s wishes. Patients with non-emergent blood transfusions, percutaneous endoscopic gastrostomy (PEG) tubes, and peripherally inserted central catheters, as well as presurgical patients, are often sent to the ED for hospital admission.
Some communities may lack primary care providers whom older adults could call at night or during off hours (Salvi et al., 2007) to determine whether going to the ED is appropriate. Problems with medications can also generate visits to the ED (Helfin, 2009).
The most common illnesses for which older adults would visit the ED include fall-related injury (e.g., 50% of patients older than age 80 have had incidences of falls [Helfin, 2009]), respiratory illnesses, chest pain, abdominal pain, urinary tract infection, gastrointestinal bleeding, cerebrovascular accident, and transient ischemic attack (Robinson & Mercer, 2007).
Assessment of Older Adults in the ED
Disease and disability are much more common among older adults. In the United States, 79% of adults older than age 70 have one or more chronic conditions (AGS, n.d.). Common chronic conditions are arthritis, high blood pressure, heart disease, diabetes, lung diseases, stroke, and cancer (AGS, n.d.; Peppe, Mays, Chang, Becker, & DiJulio, 2007).
The older adult population also has unique characteristics that complicate assessment in the ED, including:
- Older patients will consume more time and resources than younger patients (Salvi et al., 2007).
- A higher percentage of older ED patients will be admitted to the hospital (Lloyd, 2007).
- Many older patients have primary care providers and have already been triaged by their provider to go to the ED with an assessment and treatment plan already initiated (Salvi et al., 2007). On average, people age 85 and older see their physician approximately 15 times per year (AGS, n.d.).
- Older adults may have reduced cognitive function (Prückner et al., 2008).
- Nearly 75% of all deaths in the United States are older adults, making the outcome less than optimal for hospitalized older adults (AGS, n.d.).
- Older adults take a disproportionate number of prescription medications daily—on average, seven per day (Orwig, Brandt, & Gruber-Baldini, 2006; Yee, Hasson, & Schreiber, 2005).
- Many older adults have baseline functional impairment and receive some assistance at home (AGS, n.d.).
- Older adults usually have comorbid conditions, which may require more tests to determine the need for hospitalization. Often, the existence of past medical history changes the very nature of triage. A patient may come in with a new injury or concern, but a preexisting condition may lead the triage nurse and physician in another direction (Lloyd, 2007).
- Symptoms may be less specific or atypical in older adults (Helfin, 2009).
Older adults’ ED visits may be further complicated by aging-related changes. Many older adults have significant hearing and vision loss that increases their difficulty in adjusting to the ED environment (Helfin, 2009). They also have slower response rates, making triage difficult (AGS, n.d.). Special needs of older adults related to these conditions are not aligned with the ED: Space is tight and overcrowded, with little privacy and bright lights on 24 hours per day (Hwang & Morrison, 2007). Long wait times and lack of medical history information may be the biggest problems for older adults in the ED (Shapiro, 2009); communication difficulties can also arise, as older adults are often brought to the ED without their eyeglasses, hearing aids, dentures, and/or canes.
The ED can also create new problems for older adults. Skin breakdown often begins in the ED if older adults spend hours on stretchers, unable to reposition themselves (Baumgarten et al., 2006). ADLs, which may already be decreased, can be further threatened by hours of immobility and restraint use. Many older adults risk developing a hospital-acquired illness, such as a secondary line infection. Indwelling urinary catheters, often used to obtain urine specimens when older adults are in the ED, may be left in for most of their hospitalization, leading to urinary tract infections and incontinence (Robinson & Mercer, 2007). Older men with indwelling catheters may experience problems when the catheter is removed due to retention secondary to a large prostate.
The more frail the older patient is in the ED, the greater the risk of adverse outcomes (Hastings, Purser, Johnson, Sloane, & Whitson, 2008). Older adults frequently have problems with memory and may have difficulty providing an accurate history, which can create great disparities in the medical histories obtained (Cohen et al., 2008). Cognitive impairment may make caring for older patients in the ED difficult and increase the risks described above (Voyer & Sych-Norrena, 2003). It may be helpful for nurses to review patients’ prior hospitalization records to obtain complete histories. Other tactics for gathering relevant histories may involve calling the patient’s primary health care provider, family members, pharmacy staff, nurses aides, and visiting nurses.
An ED visit can worsen older adults’ pain issues, such as back pain, with prolonged time spent on stretchers and underuse of pain management strategies (Robinson & Mercer, 2007). Use of chemical (i.e., pharmacological) and mechanical restraints may be necessary due to the increased confusion for which older adults are at risk in the ED (Chen et al., 2009; Robinson & Mercer, 2007). Pressure ulcers may develop, secondary to immobility, hard stretchers, undertreated pain, and use of chemical and mechanical restraints. Undiagnosed delirium, which often occurs among hospitalized older adults, has been associated with increased mortality and needs to be assessed (Press et al., 2009). Falls, which are the reason many older adults are brought to the ED, often occur secondary to orthostatic hypotension and, if identified, may be preventable (Mussi et al., 2009).
Avoiding the ED: Alternative Options
The ED should not be relied on as a substitute for primary care for older adults, and health care professionals need to consider options other than the ED (Lloyd, 2007). For example, could necessary laboratory tests be done on an outpatient basis? It may be possible to discharge the older patient from the ED, and the patient can follow up from home.
To prevent future ED visits, it is important to use screening tools with older adults in the ED, such as functional assessment, cognitive assessments, inquiry about falls, and ambulation testing. Screening for depression is also recommended: Suicide rates are high among older adults (twice that of the general population), with rates highest for White men older than age 85 (Helfin, 2009).
Considerations Related to Hospital Admission
More than half of all older ED patients are admitted to the hospital. It is unknown how many patients discharged from the ED follow up with their primary care provider, need to return to the ED with the same or worsening condition, or die at home (Roberts et al., 2008).
If hospitalization is deemed necessary, it is important to determine patients’ wishes regarding advanced care planning. For example, has the patient appointed a health care proxy? Do they have a living will? The answers are essential when discussing the treatment plan and goals of care. The nurse should notify the older patient that he or she is going to be admitted and offer to call a family member, close friend, or neighbor to relay information about the admission. If home care agencies are involved, the nurse should also call and inform them of the admission. If the patient is admitted from a nursing home, the nursing home’s nursing supervisor should be advised of the patient’s admission. Finally, the patient’s primary care provider should be informed of the admission, even if the provider does not have admitting privileges at the hospital. The primary care provider often has a wealth of information about the patient, which can help with assessment (Roberts et al., 2008).
Many hospitals have direct admissions for services such as day surgery for PEG tube placement and outpatient transfusion services, which enable primary care providers or specialists to call ahead and book an inpatient bed directly; this enables older patients to bypass the ED entirely. Often, when an older patient is brought to the hospital by transport services, the ED triage nurse needs to confirm the correct destination of the patient, as such services routinely drop off the patient at the ED regardless of where the patient is expected.
Discharging Older Adults from the ED
If discharge from the ED to the patient’s home is possible, certain steps can ensure a safer transition for the older patient. The nurse should evaluate the medication the patient takes at home and determine whether the patient will continue that regimen. In addition, many older adults with advanced cognitive or physical decline have their medication pre-poured weekly by family members or a visiting nurse.
If any medications need to be stopped, the discharging nurse must be sure to explain this to the patient in the patient’s primary language and in writing. The nurse should call the patient’s primary care provider and/or visiting nurse to inform them of changes to the patient’s status and medications. This communication is necessary, for example, to prevent the patient from returning home and taking a medication that was supposed to be discontinued. Great disparities have been found between the medications older adults say they take and those they actually take (Belknap, 2009). It may also be necessary for the nurse to call the patient’s pharmacy to decrease such disparities and reduce the risk.
The discharging nurse should reach out to the patient’s primary care provider and offer an update regarding the patient’s care. Planning follow up is essential in reducing repeat visits to the ED (Kirchhoff, Bregnbak, Backe, Hendriksen, & Obel, 2008). Using comprehensive geriatric evaluation tools and following up after discharge from ED have been found to reduce adverse outcomes, repeat visits to the ED, hospitalizations, and deaths (Ballabio et al., 2008). Family members should also be notified so they can follow up with their loved one when the patient is home.
Transportation for the patient should be ordered early, and social work services may need to be involved. If the older patient uses a nursing agency, the agency will need information about the plan for discharge so the patient’s services will not be discontinued.
Summary and Clinical Implications
Hospitals and ED staff can develop strategies, techniques, and care plans for older patients who visit the ED to decrease the risks described in this article. For example:
- Hospitals need to provide education for staff regarding care of older patients (Robinson & Mercer, 2007). EDs need to be equipped with special communication aids, such as listening devices and magnifying glasses, to help older patients (Robinson & Mercer, 2007). Routine use of geriatric assessments related to ADLs, mental status, depression, and functioning are important when evaluating older adults (Hare, Wynaden, McGowan, & Speed, 2008; Maaravi & Stessman, 2008; Veillette, Demers, Dutil, & McCusker, 2009).
- Hospitals may consider developing a waiting unit with beds that are more user friendly for older adults, creating geriatric-specific ED areas for higher specialization (Hwang & Morrison, 2007; Shapiro, 2009; Stern & Flomenbaum, 2008; Takun, Der Sahakian, Bloch, Kansao, & Dhainaut, 2006), and building bathrooms that are easier for older adults to use while waiting for an inpatient bed.
- An interdisciplinary team that includes a full-time social worker or a specialist in geriatrics can help better address the needs of older patients (Shapiro, 2009; Shoham et al., 2005).
- EDs can provide more assistance, such as nurse aides, while older patients are waiting for an inpatient bed.
- ED staff should always practice good communication so older patients understand what is happening at each step of their evaluation and hospitalization.
- Hospitals should try to minimize the wait times for inpatient beds for older patients who are very ill (Gilligan et al., 2008).
- ED staff need to better manage care specific to older patients to improve care delivery to this population (Rossille, Cuggia, Arnault, Bouget, & Le Beux, 2008). Providing geriatric-specific triage at the door can assist in proper evaluation and decrease delays (Rutschmann et al., 2005).
As the number of older adults continues to grow, preparing ED staff and the ED environment for these patients makes practical sense and may, in fact, be mandatory to appropriately care for this population.
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