It’s time for an overhaul of emergency department operations for people living with dementia
Emergency departments (EDs) play a vital role in delivering care to an increasing number of older adults, aged 65 years and older. By 2020, this group reached 55.8 million and composed 16.8% of the population in the United States (1). Each day 10,000 people turn 65 years old in the United States with projections that the number of older adults will represent over 20% of the total population by 2050 (2). As this group increases in age so do their medical comorbidities and complexity. Sixty-two percent of Americans over 65 years old have more than one chronic medical condition and the prevalence of multiple comorbid conditions is increasing (3). There are also increases in the number of persons living with dementia.
Currently, it is estimated that dementia affects 2.4 to 5.5 million persons in the United States (4). Gerlach et al. examined over 20 million annual ED visits by older adults and noted nearly 1.4 million persons living with dementia receive care at EDs each year (5). Although persons living with dementia make up nearly 1 in 10 older ED patients, few ED models of care exist that are tailored to persons living with dementias’ unique medical and social needs (5). Caring for persons living with dementia in the ED introduces several unique challenges for ED clinicians including correctly ascertaining the reason for their presentation and the goals of their visit, choosing appropriate medication given their medical complexity, and communicating care plans with caregivers, outpatient clinicians, and facility staff involved in their care. New data by Nothelle et al. suggests a focus on this group is essential not only because persons living with dementia make up a vulnerable group that deserves attention, but also because we have reached crisis levels in ED boarding and persons living with dementia stay on average 3 hours longer in the ED than other patients (6).
Nothelle et al. examined the length of stay of persons living with dementia who visited an ED (6). This retrospective analysis of 1,039,497 ED encounters used the Healthcare Cost and Utilization Project State ED Database including data from four states: Massachusetts, Arkansas, Arizona, and Florida. From 2014–2018 they noted persons living with dementia had a 3-hour longer length of stay on average when compared to those without dementia (6). Even more concerning, persons living with dementia who required transfer to another facility had a length of stay in the ED 4.1 hours longer compared to those without dementia (6).
There were some limitations of this study. First, they only examined the effects of length of stay on patients who were discharged or transferred, and excluded patients who were admitted to the hospital. While a majority of older patients, aged 65 years or greater, who present to the ED are discharged, up to 25% of patients in this age group are admitted (7). Another limitation is how the authors identified persons living with dementia. Nothelle et al. used ICD-9 or -10 codes to determine who had dementia. However, an estimated 25–40% of older adults who present to the ED have cognitive impairment and over half are undiagnosed or unrecognized with no mention of cognitive impairment in their electronic health record (8-10). Nothelle et al. acknowledge that their approach to identifying persons living with dementia via ICD codes could have caused an overestimation of the difference in length of stay by dementia. Additionally, the authors did not explore the clinical and patient centered outcomes that relate to longer length of stay, which is a missed opportunity to highlight downstream consequences of prolonged length of stay such as missed chronic medications, pressure sores, delirium, and mortality (11,12). Finally, reasons for the prolonged length of stay were not elucidated, but are important to understand how to prevent unnecessary and prolonged treatment. We note that a large multisite clinical trial, named Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients (POISED), is currently underway to study the root causes of ED visits in persons living with dementia and whether an intervention that provides tailored care management and referrals could reduce ED utilization (13). While the study does not focus on reducing prolonged ED length of stay, it could reveal reasons for the ED visit and interventions that are useful for persons living with dementia to reduce subsequent ED visits.
While the Nothelle et al. study is the largest to date examining ED length of stay among persons living with dementia, other studies also identified an increased ED length of stay for geriatric patients. Klosiewicz et al. examined the overall length of stay for geriatric patients during their visit to an ED and found that older age correlated with an overall longer length of stay (14). Ogliari et al. noted similar findings in their study showing that adults aged 65 to 74 years, 75 to 84 years, and those over 85 years were at an increased risk for an ED stay greater than 4 hours when compared to adults aged 18 to 64 years (15).
Evidence also suggests that older patients with dementia have longer lengths of stay once admitted to the hospital compared to those with normal cognition. Möllers et al. completed a systematic review which examined hospital length of stay in persons living with dementia. They noted that in 52 out of the 60 studies analyzed persons living with dementia had increased hospital length of stay compared to those without dementia (16). They also noted that persons living with dementia were more than twice as likely to experience an in-hospital complication, which can further prolong their length of stay (16). These studies demonstrate that dementia is associated with longer length of stay in the ED as well as the inpatient units. The etiologies underlying prolonged length of stay in this population may be different in the ED and inpatient unit, and need further study. However, a long stay in the ED increases a patient’s hospitalization period, thus care improvements for persons living with dementia in the ED may be useful to avoid downstream delays (17).
We think the key factors that prolong ED length of stay in persons living with dementia include that these patients have (I) challenges in succinctly recalling and reporting their reasons for the ED visit, (II) they often receive more testing, (III) they have increased vulnerability to ED treatments (e.g., psychoactive medication may lead to over sedation), (IV) they are more likely to present with nonspecific symptoms or geriatric syndromes which can lead to missed or delayed ED diagnosis, and (V) they have unaddressed social needs which require lengthy care coordination and often specialized staff, such as ED case managers or social workers. We summarize these reasons and potential solutions in Table 1.
Table 1
| ED timeline | Reasons for prolonged length of stay | Solutions for prolonged length of stay |
|---|---|---|
| Registration | Patient registered as “Jane Doe” due to inability to confirm identity, thus caregivers can’t “find” patient in ED | Apply medical band that indicates caregiver name and contact information |
| ED clinician initial encounter | History taking challenging; history missing at first encounter leads to prolonged ED length of stay | Involve caregiver early by staff education that caregivers are permitted 24/7 for persons living with dementia; ensure visitor policies encourage caregiver presence |
| Disposition plan not addressed | ED clinician education to assess patient’s current home safety, suitability of current living situation, desire to get assistance with new residence, facility, home based services, skilled nursing facility placement | |
| Waiting for disposition | Geriatric syndromes not assessed | Clinical pathways and clinician education targeting diagnosis and management of geriatric syndromes (falls, frailty, delirium, etc.) |
| Concern about mobility of patient at home | Engage physical therapy/occupational therapy evaluation in the ED | |
| Goals of care inconsistent with current ED management | Multidisciplinary team can include social worker or palliative care team, who clarify patient preferences for hospitalization vs. home care vs. hospice | |
| Complex care needs of persons living with dementia not addressed | Assign roles to nursing assistant to promote patient mobility, regular toileting, turning, hydration and nutrition | |
| Adverse events—in-ED falls, procedure related adverse events, medication adverse events | Robust quality improvement processes identify adverse events and develop tailored responses (e.g., fall prevention programs, avoidance of sedative medication, avoidance of unnecessary procedures) | |
| Sedating medication increase ED length of stay | Delirium protocols to reduce unnecessary tethers (foley catheter, bed alarms), promote caregivers, treat pain, avoid unnecessary sedation | |
| Admission decision | Boarding increases ED length of stay | Avoid hospitalization, when possible, use multidisciplinary team to coordinate discharge care, set guidelines for admission for persons living with dementia |
| Discharge | Transportation to facility can take hours to arrange | Communicate early with facility to coordinate transportation, arrange family member transport |
| Concern for delayed timeframe to outpatient follow up | Partner with outpatient clinicians and geriatricians to avoid admissions and allow for close follow up |
ED, emergency department.
Here, we highlight a few of these reasons and the evidence that supports them. Gerlach et al. noted that persons living with dementia were more likely to receive a urinalysis and head computed tomography (CT) compared to those without dementia (5). Because persons living with dementia may be unable to provide a complete history and fully participate in an exam clinicians may feel compelled to order more testing which can ultimately increase length of stay. Ideally, caregivers could provide additional history. But only 32% of older ED patients report having a caregiver, and rates of caregiver availability in the ED are not known for persons living with dementia (18).
Persons living with dementia may also be unable to share key information needed for patient registration. Prior to being able to perform a chart review or enter orders patients need to be registered in the electronic health record. This exact process varies between institutions, but typically patients confirm multiple demographic aspects such as: name, date of birth, and social security number. When patients cannot recall these personal details, clinicians cannot access critical past information such as their medical history and medications and family members who later arrive in the ED may not be able to locate the patient.
Gerlach et al. also noted that persons living with dementia were more likely to receive anti-psychotic medication in the ED (5). Although there are clinical situations such as acute agitation when other safer alternative medications are not available, these medications are known to be harmful to older patients, and the resulting sedation can prolong the ED stay and sometimes require hospitalization (19,20).
There are a lack of published interventions that have successfully reduced length of stay among persons living with dementia, but here we share potential solutions our academic medical center, the University of Colorado Hospital, has implemented. While they require rigorous evaluation, they may provide a starting point for ED staff and researchers who want to tackle this important problem. First, we have developed a multidisciplinary team including social workers and care managers to help care for these patients and help clinicians address their social needs. Additionally, we have 24/7 ED pharmacists to help provide medication review and guide clinicians in selecting medications that are preferable for this patient population. Each medication ordered by an ED clinician is verified in real time by an ED pharmacist. This allows them to check for potential interactions, adjust dosing for renal impairment, and reach out to clinicians in real time to suggest safer alternatives, if indicated. This process can prevent medication errors and adverse events. Our pharmacists also can analyze patients’ home medications and look for opportunities to reduce unnecessary polypharmacy. Only one in four older patients without cognitive impairment correctly report their medication during the ED encounter, thus the use of lists, caregivers, and dispense records are essential to identifying potential adverse medication events before prescribing new medication (21).
Another key partner in this multidisciplinary team is the patient’s primary care physician (PCP). Contacting PCPs while the patient is still in the ED can provide the ED clinician with insights into the patient’s baseline functional or cognitive status, and goals of care which could reduce unnecessary testing. We recently initiated a geriatric consult service which provides a means for geriatricians to assess patients who have an existing relationship with their seniors clinic with the goal of improving care transitions and reducing unnecessary admissions. They provide real time recommendations and help determine the safest ED disposition for their patients.
One final solution is increasing the use of ED led observation units in lieu of typical inpatient admissions. Hospital inpatient capacity is at an all-time high across the US, so it is essential to consider alternative dispositions for these patients, e.g., home with home care services or facility-based care. Older patients who spend even one night boarding in the ED while waiting for an inpatient bed have increased mortality (12) and there is ample evidence suggesting that persons living with dementia who are admitted have longer lengths of stay, more complications, and higher mortality (15,22,23). By utilizing ED led observation units patients’ care can start immediately upon arrival (vs. waiting for an inpatient bed). There is ample literature that suggests that ED led observation units have lower costs and shorter lengths of stay while demonstrating similar outcomes when compared to patients admitted to inpatient services (24).
Key implications of this work on ED policy and practice include that there is a need for EDs to develop protocols for the care of persons living with dementia. To successfully implement these protocols additional training of ED staff in dementia care is essential, and ED medical directors may consider partnering with geriatric colleagues or emergency medicine colleagues who have received additional training in geriatrics. Some EDs have taken the approach of obtaining certification from the American College of Emergency Physicians as a Geriatric ED or co-locating their ED with geriatric assessment units, to achieve improved care for older patients with and without dementia. More research on the patient outcomes of these approaches and interventions to reduce ED length of stay for priority groups, such as persons living with dementia, is underway and needed to provide the best possible care for all patients who present to EDs (25). Providing safe, expeditious care to persons living with dementia is difficult, but essential to meet patient and care partners’ expectations and reduce harm. Models of care that address partners’ living with dementias’ unique needs and vulnerabilities—falls, delirium, adverse medication effects, functional decline, frailty, increasing social needs—are critical to meet this goal. Still, the ED cannot work in isolation, and we will achieve the best outcomes for this important group if we work with staff at facilities, our outpatient and inpatient clinicians, policy makers, and advocacy groups to develop, test, and disseminate interventions that improve how we deliver care to persons living with dementia.
Acknowledgments
Funding: This work was supported by
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency. The article has undergone external peer review.
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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-44/coif). E.M.G. reported funding from National Institutes of Health (National Institute on Aging; K76 AG059983). E.M.G. serves as President of the Academy for Geriatric Emergency Medicine, Society of Academic Emergency Medicine, and Medical Executive Committee Member at Large, University of Colorado Hospital. The other authors have no conflicts of interest to declare.
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Cite this article as: Adams G, Hoffman JW, Goldberg EM. It’s time for an overhaul of emergency department operations for people living with dementia. J Public Health Emerg 2024;8:12.
