Do you sigh and think you're in for the long haul trying to figure out the myriad things that are wrong with your older patient?
You aren't alone. Ageist attitudes aren't easily overcome, said Stephen Katz, a professor of sociology at Trent University in Peterborough, Ontario. When he shows his students a picture of a fit but elderly woman in a skimpy swimsuit, their reaction most often is disgust, even revulsion. “Well, if the older body has become so disgusting ... then I doubt it will ever be seen in any other way,” he said. “I do know that geriatrics is not a popular specialty, and, as a result, we have nowhere near the number of geriatricians we need now and into the future,” said Professor Katz, also the author of Cultural Aging: Life Course, Lifestyle and Senior Worlds. (Ontario, Canada: Broadview Press; 2005.)
Yet, he holds out hope that a cultural shift could change the collective viewpoint, just as when physicians themselves pass middle age and recalibrate their own perception of what it means to be elderly. “As our population is aging, led by more liberated and self-interested boomers, the culture will surely change as well,” Professor Katz said.
Professor Katz isn't the only one with stories that made a lasting impression. A new intern was deep in sleep when his resident rousted him with a bark: “I've got an old GOMER with your name on it down here, Phil!” Scurrying into the emergency department, the recent medical graduate found himself face to face with an elderly man, who was gasping for breath.
And, sure enough, stuck to the top of the patient's head was a piece of masking tape with the letters P-h-i-l. “He was, quite literally, a patient with my name on him,” the young physician recalled.
That incident troubled him so much that “Phil” continued to recount it over the years. And when he shared it with Mark Lachs, MD, it stuck with him, too, prompting him to label it “odious bigotry” in his book, Treat Me, Not My Age: A Doctor's Guide to Getting the Best Care as You or Your Loved One Gets Older. (New York, NY: Penguin Books; 2010.) As the director of geriatrics at New York Presbyterian Health System, he has seen the health system become trickier to navigate “the older you get,” as he put it.
The nation's 65-and-older population is projected to reach 83.7 million in the year 2050, almost double the 2012 level, according to the U.S. Census Bureau. Data from 1980 to 2010 show that the number of people aged 90 and older is projected to more than quadruple from 2010 to 2050, compared with a doubling of the population aged 65 to 89. (“65+ in the United States: 2010,” U.S. Census Bureau, June 2014; http://1.usa.gov/1Lsd2x6.) The sheer number of elderly may reduce some of the discrimination against the aged that has been documented in the U.S. medical literature, especially as health care providers who started their careers in the 1980s find themselves in “snowtop territory.”
Perhaps the field of medicine has itself to blame for ageism. When Pierre-Charles-Alexandre Louis proposed the numerical method to govern medical decision-making, the individual patient was presumed to require comprehensive care and evaluation to address a malady. But the French physician-scientist changed this, demonstrating how hard data and epidemiologic reasoning should be applied to patient care.
As Dr. Louis's statistical model was embraced, the time-intensive approach to illness was replaced with reliance on identifying disease and determining the best clinically-proven treatments for a specific condition. This had the depersonalizing effect of putting the sick into a classification system.
Patients have routinely been stratified because of chronological age for decades, prompting the late Robert Butler, MD, the founding director of the National Institute on Aging, to call out the medical community for using such an imprecise marker. British researchers have been honing in on how this labeling might affect elderly health. The 10-year-old English Longitudinal Study on Aging (ELSA) at University College London showed that a low sense of psychological well-being can be used to predict onset of disability, and they suggested that assessing such a mental state requires effective interaction with elderly patients. A group of U.S. academic emergency physicians found roughly the same thing, that adverse outcomes are likelier in older and sicker patients largely because of communication lapses. (Ann Emerg Med 2009;54:89.)
Federal legislation prohibits age discrimination, but it doesn't carry much weight in health care delivery. The Age Discrimination Act, passed in 1975, addresses medical care but in broad language. “The regulations don't advise the public how they can remedy this,” said Phoebe Weaver Williams, JD, an associate professor of law emeritus at Marquette University in Milwaukee.
“Even in clear-cut situations of age discrimination, most persons will experience considerable difficulties when accessing the Age Act's protections,” said Professor Williams, who wrote a treatise on age discrimination in the delivery of health care. (Marquette Elder's Adviser 2009;11:3.)
The Civil Rights Act of 1964 makes no mention of age, though the Age Discrimination in Employment Act of 1967 does prohibit age discrimination, but its aim is the workplace. Perhaps the best approach is for institutions to provide policies in which there is an expectation that there will be zero tolerance for disparaging remarks, even in the privacy of colleague conversations, Professor Williams said. It is likely, after all, that such attitudes can eventually lead to poor outcomes.
Even without serious legal consequences, prejudice against the aged comes at a high price. This demographic sees a high percentage of readmission — 11 to 18 percent — costing more than $17 billion for the return trips, according to a Medicare-based study by Dartmouth College and the Robert Wood Johnson Foundation. (The Revolving Door: 2013 Report on Hospital Readmissions; http://bit.ly/1AsSGi8.)
“The resistance to using the ER is very low. You dial 911, and you get delivered right to the doctor's stretcher,” said one emergency physician in the study, contrasting the benefits of the ED to a primary care physician's office that requires an appointment and doesn't provide transportation. How can an ED address such a situation? Christopher Carpenter, MD, an associate professor of emergency medicine and the director of evidence-based medicine at the Washington University School of Medicine in St. Louis, discussed just that in an editorial that called for geriatric EDs. (J Am Geriatr Soc 2013;61:1806.)
Dr. Carpenter performed a meta-analysis on risk factors and screening tools for predicting adverse outcomes in the ED with colleagues from several academic medical centers. (Acad Emerg Med 2015:22:1.) “Unfortunately, none of the current instruments works well,” he said. The review and analysis, however, provide some ideas on where researchers, clinicians, and policymakers should focus next, he added.
A couple of years ago, the American College of Emergency Physicians released guidelines for geriatric EDs in the hope that it will be used by EDs to move toward a more geriatric-friendly environment, Dr. Carpenter said.
So far, about 150 geriatric EDs are scattered across the country, many with features such as softer lighting, private rooms, and non-skid flooring.
Though the comparative effectiveness of geriatric emergency care hasn't been studied, findings from other investigations indicate that healthy self-perception in aged patients is a good predictor of general well-being. (J Gerontol B Psychol Sci Soc Sci 2014;69:168.) Evidence also suggests that the more responsibility older patients take for their own health care, the better off they are in quality-of-life measures. (Psychol Aging 2013;28:1088.)
That kind of instruction and assessment takes time and one-on-one interaction, however. That's the reason Dr. Carpenter and others suggest that a geriatric emergency nurse on shifts may be a solution for some EDs, particularly those without the resources for a full-scale conversion.
Others who have studied the issue have similar ideas. “I think that, generally, a specialized care for elderly patients should be implemented in emergency departments,” said Nikolaos Samaras, MD, a geriatrician at the Hôpitaux Universitaires de Genève in Switzerland. He and other Swiss researchers conducted a review of ED care in the elderly for the same reason that Dr. Carpenter and his group undertook their analysis. (Ann Emerg Med 2010;56:261.) “In my opinion, particular measures will be necessary mostly because of their high numbers, not because they are different from others,” he said.
That's what Mary Lou Kelley, PhD, found when she and several others from Ontario, Canada, looked at an ED to see how it could be improved for meeting the needs of the elderly. Not surprisingly, they found it to be a chaotic environment for older patients and so fast-paced that it could be disorienting. (J Health Serv Res Policy 2011;16:6.)
These and other studies by Canadian investigators have prompted EDs in the provinces to become more senior friendly, including adding geriatric emergency nurses. It isn't seen as a case of battling ageism but a logical next step. “Recognizing the unique needs of older people is the rationale behind the need for age-friendly hospitals and the prevalence of elder programs in hospitals now,” said Dr. Kelley, a professor of social work and gerontology at Lakehead University and a professor at the Northern Ontario School of Medicine in Thunder Bay, Ontario.
A dozen years ago, a pair of Boston researchers examined the issue, recommending a return to the historic benevolent doctor with complete information as a possible part of the solution for gaps in care, though racial disparity was actually the focus of their study. (J Health Econ 2003;22:89.)
The benevolent doctor concept is being carried out in nearly 60 Ontario EDs by more than 100 geriatric nurses. Known as the Regional Geriatric Program of Toronto, it is a nursing network that generally provides geriatric emergency management to the older old — patients who are at least 75.
Nurses designated for this role in geriatric emergency management have proven to be cost-effective, essentially saving at least the same expense as would have been incurred without such special placements, and in many cases, a lot more. This kind of program also increases recognition of elderly needs. By making this a goal of care, the program has been found to facilitate safe and durable discharge and identify older patients who are at risk for clinical issues that might have been missed, such as falls, according to David Ryan, PhD, the director of education for the program and an assistant professor of medicine at the University of Toronto.
The Regional Geriatric Program has come up with clever ways to make older patients feel special while helping to ensure their safety. Frail elderly patients at risk for a fall, for example, are given a pair of red socks to wear. Some of the geriatric nurses were originally trained in the care of elderly, but others were not. Once they spend time assigned to geriatric emergency care, they typically allocate part of their time to mentoring other staff members about this special patient population.
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Alzheimer's Patients in the ED
More than five million people in the United States have Alzheimer's disease; one of them is Allan Vann's wife. Read Mr. Vann's article about how confusing the ED can be for Alzheimer's patients and why the ED staff has to be able to treat them more quickly: http://bit.ly/1JHnJOO.