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For Elder Health, Trips To The ER Are Often A Tipping Point

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't go out often, his congestive heart failure worsened, and he ended up in a nursing home a year later, where he eventually passed away.

"Just because someone in their 70s or 80s isn't admitted to a hospital doesn't mean that everything is fine," said Dr. Timothy Platt-Mills, 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's trip to the ER often signals a serious health challenge and should serve as a wake-up call for caregivers and relatives.

Research published last year in the Annals of Emergency Medicine underscores the risks. Six months after visiting the ER, seniors were 14 percent more likely to have acquired a disability — an inability to independently bathe, dress, climb down a flight of stairs, shop, manage finances or carry a package, for instance — than older adults of the same age, with a similar illness, who didn't end up in the ER.

These older adults weren't 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 "a fairly vulnerable period of time for older persons" and "we should consider new initiatives to address patients' care needs and challenges after such visits," said one of the study's co-authors, Dr. Thomas Gill, a professor of medicine (geriatrics), epidemiology and investigative medicine at Yale University.

Research by Dr. Cynthia Brown, a professor and division director of gerontology, geriatrics and palliative care at the University of Alabama at Birmingham, confirms this vulnerability. In a 2016 report, she found sharp declines in older adults' "life-space mobility" (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.

"We know that when people have a decline of this sort, it's associated with a lot of bad outcomes — a poorer quality of life, nursing home placement and mortality," Brown said.

Other research 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 "I can't handle this any longer" 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's available, and their health may spiral downward.

Other possibilities: Seniors who fall and injure themselves — a leading cause of ER visits — may become afraid of falling again and limit their activities, leading to deterioration. Or, underlying vulnerabilities that led to an ER visit — for instance, depression, dementia or delirium (a state of acute, sudden onset confusion and disorientation) — 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 endorsed guidelines 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, "our traditional model of emergency medicine has to shift its paradigm," 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 — another effort to improve care and outcomes for older adults. Three levels of accreditation — basic, intermediate and advanced — 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.

"My 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," said Dr. Kathleen Unroe, associate professor of medicine at Indiana University School of Medicine.

Dr. Kevin Biese, chair of the board of governors for ACEP's geriatric ER accreditation initiative, offers these recommendations: