Friday, March 6, 2015

Caring for Alzheimer's Patients in the ED

(Author's note:  The editor changed all ER references to ED, referring to Emergency Department instead of Emergency Room, in the actual published version.)

What ER staff should know about people with Alzheimer’s
My wife has Alzheimer’s disease (AD) and lives in the dementia unit of an assisted living residential facility.  She has been admitted to a hospital Emergency Room (ER) several times within the past year.  For a person with AD, the ambulance ride itself can be very unsettling.  But then being transferred to a hospital gurney, changed into a hospital gown, lying beneath bright lights and hearing the sounds of nearby people screaming and the sounds of machines beeping, being poked and prodded by many different and unfamiliar doctors and nurses ... all of this can be very scary to a person with Alzheimer’s.  In addition to these disorienting and frightening experiences, painful needles for requisite blood work or injections, and being wheeled into other rooms for various testing procedures, often cause additional confusion for the Alzheimer’s patient.

All of this sensory overload, overstimulation, and confusion may easily exacerbate whatever condition initially led to ER admittance.  Already very confused and emotionally fragile, often so cognitively impaired that nothing that is happening and nothing that is being said by a doctor, nurse or technician makes any sense, a person with AD must be treated with extra care by ER personnel.

ER staff must modify their techniques to gain helpful information
ER personnel often ask patients to tell them their name and date of birth, and to describe the intensity of their pain on a 1-10 scale, or to describe the pain as sharp, moderate, or dull.  But asking such questions to someone with AD will usually be futile and lead to greater anxiety and even more confusion.  Asking AD patients to place a hand on the part of the body that is hurting, for example, is more effective than asking the patient where it hurts.  After learning where the pain is located, the doctor may then apply pressure around that identified area while asking the AD patient if it hurts more or less, here or there.  Simply observing the patient’s face when applying pressure to a painful area will often let a doctor know just where the pain is most intense.

Don’t forget the caregiver ... and be aware of sundowning
If the AD patient’s primary caregiver is present, ER personnel should immediately ask that caregiver for information.  Aside from giving the patient’s complete name and date of birth, the caregiver may be able shed more light on the reason for ER admittance, provide valuable patient health history along with a list of all of the patient’s medications, and note whether or not the patient has had food or daily medication by the time of admittance.  This latter information can be crucial because if AD patients have not yet taken their daily medication or have not eaten in a long time, more confusion may develop that can complicate a diagnosis. 

ER personnel also need to learn that many AD patients will “sundown” as the day wears on, growing even more confused about where they are and why.  The longer it takes ER personnel to administer and analyze tests for someone with Alzheimer’s, the greater the chance for sundowning.  During my wife’s ER visits, she was not allowed to eat, drink, or take her daily medication until all testing was completed and results were interpreted.  However, this often took many hours and the lengthy “wait time” led to my wife becoming more fatigued, confused, anxious, and disoriented.  She refused to use a bed pan and I had to restrain her from leaving her gurney to go to the bathroom.  She also kept trying to remove the needles and IV hook-up from her arm.  But each time I told ER personnel that my wife was sundowning and they needed to complete and analyze testing quickly so she could at least take her medications and eat, I was told that I needed to continue to wait patiently.  I was able to wait patiently ... but my wife was not!

Preparing for the future
With more than 5 million people in this country already dealing with AD, and with that number expected to increase to 15 million by 2050, ER personnel will be treating increasing numbers of fragile elderly patients who are confused and unable to communicate effectively.  ER personnel must become more aware of the characteristics of people with AD to be able to diagnose and treat the causes for their ER visits more quickly and effectively. 

When ER personnel diagnose an Alzheimer’s patient, chances of making a proper diagnosis will increase if ER staff modify their patient questioning techniques and seek assistance of caregivers if they are present.  And if additional testing is ordered, ER staff must make a greater effort to minimize the wait time for such testing and test analysis.

Published on website of  Emergency Medicine News on March 5, 2015 in advance of publication in Emergency Medical enews on 3/25/15.  Access online only at:

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