The opening paragraph of the AGS Viewpoint article1
in the September/October 2017 issue of Annals of Long-Term Care: Clinical
Care and Aging® states, “Four national medical societies and
nine leading health systems recently announced that they have established a new
national Geriatric Emergency Department Collaborative (GEDC) to help improve
emergency care for our nation’s older adults.” Toward the end of that article,
the American Geriatrics Society (AGS) notes, “The GEDC will continue to add
more health centers and partners, contributing to an alliance of national
stakeholders who will help promote national adoption of geriatric emergency care
best practices.”
This is wonderful news,
but I see no mention of the GEDC’s real stakeholders: geriatric patients. To
improve hospital emergency department (ED) practices for older adults, the GEDC
may want to consult with those who have been in EDs, such as those caring for
and speaking for older adults. And with the rapidly increasing number of older
adults, who are also living longer with Alzheimer disease (AD) dementia,
special attention is needed for this population. The GEDC should consult with
current and former caregivers of persons with dementia who have direct
experience with ED practices and often serve as patients’ spokespersons. As a
former AD caregiver whose late wife was a patient in several EDs, I would
suggest the following:
Treat patients with AD as a higher triage priority.
Some of my wife’s
ED visits lasted more than 9 hours. She would begin sundowning as time went on
and became increasingly confused, anxious, and aggressive. I continued to
remind ED personnel that my wife had not eaten or taken her anti-anxiety
medication in many hours, but each time I received the same response: “Until
her test results are analyzed by the doctors, she may not eat or take any
medication.” That would have been fine had she been a high priority, but she was
a low priority.
On too many ED visits, my
wife sat there for well over an hour just waiting for blood to be drawn then
had to wait as long as 2 hours for doctors to analyze the blood work. It was
the same with radiographs or other testing—long waits for tests and long waits
for results. During all of this time, I served as a human bed restraint to keep
my wife on the gurney.
I understand the wisdom of
ED policies dictating withholding a patient’s medication and food until testing
has been completed. However, withholding anxiety medication and food for 9
hours or more for a patient with AD is, in my opinion, almost medical
malpractice. My wife was screaming louder and louder, repeatedly ripping
painful IV needles out of her arm, constantly trying to get up, trying to
remove her uncomfortable diaper, and refusing to use a bedpan and soiling her
clothing. We waited and waited for tests to be ordered or analyzed so that she
could be admitted or discharged. Only afterward would she be given medication
and food.
Direct all questions to the
caregiver.
If a caregiver is present whenever a person with AD
comes into the ED, directing medically specific questions to the caregiver
rather than the patient is much more helpful. Often, I would tell medical staff
that my wife had moderate- or late-stage AD and that I was her caregiver, yet
doctors continued to ignore me while wasting valuable time asking my wife
questions she could not possibly understand or answer. Asking patients for
reliable information is fruitless if they are in the moderate or severe stages
of AD. In addition, I was completely familiar with my wife’s medication, her
medical history, etc, but too often I was told in no uncertain terms to remain
quiet.
Asking my wife what part
of her body hurt, or to describe her pain on a 1 to 10 scale, was both
ridiculous and fruitless. I told doctors that she did not understand anything
they were saying to her, but doctors continued asking her one question after
another. Doctors should consider simply placing their hands gently on different
parts of the patient’s body; the patient with AD will usually let the doctor
know very clearly where it hurts.
Provide dementia training for all doctors, nurses, and medical
technicians.
As the number of older adults with dementia grows,
supplemental training on dementia care for all ED providers would allow them to
better understand how a person with AD experiences the ED. Because of her AD
symptoms, my wife was thoroughly confused well before arriving in the ED, but
once she got there she became even more confused and also fearful. She was in a
totally unfamiliar setting with strangers asking her questions she did not
understand and saying things she could not comprehend. She was quickly
undressed by a total stranger, even her absorbent underwear were removed, and
she was placed in a diaper and paper gown. That bothered her tremendously. Then
she was forced to lie down on an uncomfortable gurney, stare at extremely
bright overhead lights, listen to very loud and strange machine sounds, and
watch strangers walking all around her and poking her all over while needles
were painfully placed in her arms. Her chronic back pain made her very
uncomfortable on that hard gurney. The combination of all of these
environmental factors made her terrified, and she began screaming and crying.
I would be willing to bet
that if the GEDC approached such national organizations as the Alzheimer’s
Association or the Alzheimer’s Foundation of America, these organizations would
be able to design a program and provide knowledgeable staff to bring effective
in-service training to medical personnel. A 2010 study on hospitals’ approach
to patients with dementia, “Dementia-Friendly Hospitals: Care Not Crisis,”2
supported in part by a grant from the National Institutes of Health, noted that
“The greatest unmet need was in-service training to increase the staff’s
understanding of dementia and strategies to improve the hospital environment
for the patient with dementia.” The study found that staff themselves recognized
that they needed to improve their communication skills with patients with
dementia.
Current and former AD
caregivers can provide valuable insights based on experiences with their loved
ones and patients in EDs. I am so pleased to read that the GEDC hopes to
improve current practices for AD patients in hospital EDs. To truly gain a
better understanding of how current practices may be improved, however, GEDC
should ask for suggestions from AD caregivers who have dealt with or are
dealing with current ED practices. Current and former AD caregivers can provide
valuable insights based on their actual experiences with their loved ones in
hospital EDs, offering a unique perspective that cannot be gained from anyone
else.
Allan S
Vann, EdD
Dementia
care advocate
Former spouse caregiver
References
1. American
Geriatrics Society. Four national medical societies and nine leading health
systems collaborate to improve geriatric emergency care. Ann Longterm Care.
2017;25(5):13.
2. Galvin JE,
Kuntemeier B, Al-Hammadi N, Germino J, Murphy-White M, McGillick J.
“Dementia-friendly hospitals: care not crisis” an educational program designed
to improve the care of the hospitalized patient with dementia. Alzheimer Dis
Assoc Disord. 2010;24(4):372-379.
A response from the Geriatric Emergency Department
Collaborative (GEDC)
As leaders and
interprofessional advisors for the GEDC, we commend the author for reinforcing
one of the hallmarks of geriatrics expertise and of the GEDC: a
person-centered approach to care.1,2 The GEDC aspires to improve the
process and outcomes of older adult emergency care in addition to the patient
and caregiver experiences of care. As the author rightly notes, that includes
forging a better sensitivity for older adults and caregivers with unique needs,
ensuring that caregivers are included in care planning in the ED and beyond,
and building a better system for training health care professionals in best
practices for a range of older patients and caregivers, particularly those
living with AD.
People living with dementia
are among the most vulnerable individuals in emergencies. Their experiences
represent a litmus test for creating efficient and compassionate health care
systems. If high-quality care can be delivered to people living with dementia
and their families during times of acute illness or injury, access to efficient
ED care will improve for all populations. Importantly, geriatric emergency
medicine had to learn to crawl before walking, which means the specialty needed
first to acknowledge that, historically, dementia was usually unrecognized
because case findings were rare and screening instruments untested.3,4
Of course, screening is unnecessary when family members inform providers of a
person’s dementia diagnosis and baseline cognitive capacity.
As part of the GEDC
infrastructure, we established a Geriatric Emergency Medicine Advisory Council
earlier this year not only to lay the framework for our plans with initial
health system partners, but also to help shape a broader alliance of
stakeholders to promote improved emergency care for us all as we age. The voice
and perspective of the patient are contributed by stakeholder organizations
such as Patient and Family Centered Care Partners, which is active and essential
in our work. Caregivers and patients have presented their experiences at GEDC
conferences and boot camps through speaker panels, video testimonies, and case
discussions. We need this representation to ensure that our best practices
reflect the lives (both real and ideal) of older people and their caregivers
who benefit from enhanced ED care. As researchers and educators, we value
further still what these perspectives provide as we develop training materials
and a repository of data for changing clinical practice from the textbook to
the bedside. The geriatric ED guidelines developed in 2013 and endorsed by the
American College of Emergency Physicians, the American Geriatrics Society, the
Emergency Nurses Association, and the Society for Academic Emergency Medicine
offer a compelling case in point.5 Among several salient examples,
the guidelines provide evidence-based and feasible cognitive screening tools
for older adults with protocols to ensure more geriatric-focused evaluations
for current and future ED or other care visits.5
Beyond the Geriatric
Medicine Advisory Council, we also have worked to catalyze a culture of
person-centered care across the GEDC. The institutional, organizational, and
individual partners with whom we already work—as well as those we hope to
recruit—have demonstrated a unique sensitivity to patient perspective. Many
have their own important links to patient advocacy champions, and all have
multiple stakeholders, including patients and administrators, who are aware of
the high-priority institutional need for improved care of older people. They
all now are working to ensure those voices are integrated into their own health
system’s GEDC-based plans. Those attributes must remain at the heart of
who we are and what we do through the work of the GEDC nationwide.
Proactive health systems
such as our GEDC partners know that the future of health care requires bold
approaches to (1) valuing older adults as individuals, (2) addressing our
unique needs as we age, and (3) providing the best care and support possible.
Regardless of the space, place, or context for delivering that care, it can
only begin by recognizing patients as people, including and perhaps most
especially when those people live with multifaceted conditions such as AD and
dementia. The reward for that person-centered approach is a health system that
can be responsive to individual needs and priorities, ideally while also
helping to improve our care quality and reduce our care costs.6
That promise
notwithstanding, the devil remains in the details. The National Academy of
Medicine, formerly the Institute of Medicine, estimates a 17-year delay before
just 14% of research or guidelines are incorporated into routine bedside care.7
GEDC leaders developed geriatric core competencies for emergency medicine
trainees that now appear on credentialing examinations, but research and
traditional medical education alone are inadequate strategies to improve care.8,9
The GEDC approach incorporates implementation science to accelerate the uptake
of the geriatric ED guidelines by health care systems, an approach that depends
upon representative patient and family voices.10,11 AD advocacy
groups have already expressed interest in helping to improve emergency care as
a broad strategic priority, but linking that enthusiasm institutionally
to patient perspective individually is a challenge not limited to the
ED. Engaging patients and families as sustained partners in the GEDC with the
deployment of geriatric emergency care models remains a core objective—one we
continue to explore as we bring the principles of person- and family-centered
care into the GEDC design.
There are, indeed, as many questions as answers in this early
stage of our work, but coalescing experts (and we count patients and caregivers
among that cohort) is an important first step, and one we are heartened to see
expressed so thoughtfully by a reader vested in our efforts.
Daniel E
Trucil, MA, MPH
Assistant Director of Communication,
American Geriatrics Society,
New York, NY
Libby Hoy
Founder,
Patient and Family Centered Care Partners,
Long
Beach, CA
Kevin
Biese, MD, MAT
University of North
Carolina at
Chapel Hill School of Medicine,
Chapel Hill, NC
Ula Hwang,
MD, MPH
Icahn School of Medicine
at Mount Sinai,
New York, NY
Christopher R Carpenter, MD, MSc
Washington
University School of Medicine in St. Louis
St.
Louis, MO
References
1. American
Geriatrics Society. Four national medical societies and nine leading health
systems collaborate to improve geriatric emergency care. Ann Longterm Care. 2017;25(5):13.
2. American
Geriatrics Society Expert Panel on Person-Centered Care. Person-centered care:
a definition and essential elements. J Am Geriatr
Soc. 2016;64(1):15-18.
3. Carpenter CR,
Griffey RT, Stark S, Coopersmith CM, Gage BF. Physician and nurse acceptance of
technicians to screen for geriatric syndromes in the emergency department. West J Emerg Med. 2011;12(4):489-495.
4. Carpenter CR,
Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four sensitive
screening tools to detect cognitive dysfunction in geriatric emergency
department patients: Brief Alzheimer’s Screen, Short Blessed Test, Ottawa 3DY,
and the caregiver-completed AD8. Acad Emerg Med. 2011;18(4):374-384.
5. American
College of Emergency Physicians, American Geriatrics Society, Emergency Nurses
Association, Society for Academic Emergency Medicine. Geriatric emergency
department guidelines.
http://www.acep.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=95365.
Published 2013. Accessed January 22, 2018.
6. Hwang U, Shah
MN, Han JH, Carpenter CR, Siu AL, Adams JG. Transforming emergency care for
older adults. Health Aff (Millwood).
2013;32(12):2116-2121.
7. Balas EA. From
appropriate care to evidence-based medicine. Pediatr
Ann. 1998;27(9):581-584.
8. Hogan TM,
Losman ED, Carpenter CR, et al. Development of geriatric competencies for
emergency medicine residents using an expert consensus process. Acad Emerg Med. 2010;7(3):316-324.
9. Neta G,
Glasgow RE, Carpenter CR, et al. A framework for enhancing the value of
research for dissemination and implementation. Am J
Public Health. 2015;105(1):49-57.
10. Carpenter CR,
Pinnock H. StaRI aims to overcome knowledge translation inertia: the Standards
for Reporting Implementation Studies guidelines. J
Am Geriatr Soc. 2017;65(8):1664-1666.
11. Hogan TM,
Richmond NL, Carpenter CR, et al. Shared decision making to improve the
emergency care of older adults: a research agenda. Acad
Emerg Med. 2016;23(12):1368-1379.
Published as a Letter to the Editor in Annals of Long-Term Care, March/April, 2018, pp.11-13. Access at www.annalsoflongtermcare.com
