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News: Caring for Alzheimer's Patients in the ED

Vann, Allan S.

doi: 10.1097/01.EEM.0000462522.71387.50
News

Mr. Vann is a retired public school principal. His wife, Clare, was diagnosed with young-onset Alzheimer's in 2009 at age 63. Mr. Vann has published articles in peer-reviewed medical journals, caregiver magazines, on national Alzheimer's organization websites, and in newspapers to increase awareness. A collection of his work is available on his blog, www.allansvann.blogspot.com.

My wife has Alzheimer's disease and lives in the dementia unit of an assisted living residential facility. She has been treated in a hospital emergency department several times over the past year. The ambulance ride alone can be very unsettling for an Alzheimer's patient, but it can be even scarier for patients when they're transferred to a gurney, changed into a gown, and put beneath fluorescent lights, on top of hearing people screaming, machines beeping, and being poked and prodded by unfamiliar faces. 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 more confusion.

All of this sensory overload, overstimulation, and confusion may easily exacerbate whatever condition initially led to ED care. Already very confused and emotionally fragile, often so cognitively impaired that nothing said by a physician, nurse, or technician makes any sense, a person with Alzheimer's disease must be treated with extra care by ED personnel.

They often ask patients to tell them their name and date of birth, to describe the intensity of their pain on a 1-10 scale, or to describe the pain as sharp, moderate, or dull. But asking someone with Alzheimer's such questions will usually be futile and lead to greater anxiety and even more confusion. Asking Alzheimer's 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 area while asking the 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.

If the patient's primary caregiver is present, ED staff 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 light on the reason for the visit, provide valuable patient health history and a list of all of the patient's medications, and note whether the patient has had food or daily medication by the time of the visit. The latter information can be crucial because if an Alzheimer's patient has not yet taken his daily medication or has not eaten in a long time, more confusion may develop that can complicate a diagnosis.

ED staff also needs to learn that many patients will sundown as the day wears on, growing even more confused about where they are and why. The longer it takes a staff to administer and analyze tests for someone with Alzheimer's, the greater the chance for sundowning. During my wife's visits, she was not allowed to eat, drink, or take her daily medication until all testing was completed and results were interpreted. This often took many hours, however, and the lengthy wait time made my wife 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 IV from her arm. But each time I told the staff 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.

More than five million people in this country are already dealing with Alzheimer's disease, and that number is expected to increase to 15 million by 2050. That means ED staff will be treating increasing numbers of fragile elderly patients who are confused and unable to communicate effectively. They must become more aware of the characteristics of people with Alzheimer's disease to be able to diagnose and treat the causes for their ED visits more quickly and effectively.

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