Why Older Adults Have Poor Outcomes in Emergency Departments

June 2020Milenko Martinovich

Adults age 65 and older visit emergency departments (EDs) more than any other age group except infants. Yet the ED’s physical environment and acute nature often conflict with the type of care this population requires, a disparity that has become more pronounced during the COVID-19 pandemic that has disproportionately affected older adults. 

Faculty at the UCSF School of Nursing are formulating solutions to help this vulnerable group, while also incorporating it into the academic training for future nurse specialists to help care for this fast-growing population.  

Aligning Care With a Patient’s Goals

So why are older adults more vulnerable to poor outcomes during ED visits?

The ED’s linoleum floors are unforgiving to older patients who are more prone to falls. Numerous clinicians walking in and out of a patient’s room can cause Lauren Hunt confusion. Beeping machines and bright fluorescent lights can cause delirium. These can be even more challenging for older adults who are confronting additional medical issues, such as dementia.

“It’s a big transition in care and change in environment,” said Lauren Hunt, an assistant professor in the UCSF School of Nursing, who describes challenges older adults face in EDs in a recently published article in Geriatric Nursing. “It’s uncomfortable. There’s pain associated with it. They’re being poked with needles, undergoing procedures and getting other treatments that might make them feel worse.”

Rosalie Bravo, an associate clinical professor at the School of Nursing who teaches acute care, explains that even basic communication can be challenging for older adults.

Rosalie Bravo “It’s the changes that occur in all of us as we age: hearing impairment, loss of social networks,” Bravo said. “If an elderly patient arrives in the emergency room via ambulance and there are no family members present, sometimes it can be very challenging to obtain an accurate history.” 

As a result of the disparity between care delivery in the ED and the needs of older adults, older adults often experience poor outcomes from ED visits, including falls, delirium, functional decline and increased mortality, Hunt said.

Hunt suggests providing older adults with options other than visiting the ED. She said existing home-based primary and palliative care models, like the Program for All-Inclusive Care for the Elderly, a national program that provides integrated preventative, acute care and long-term care services, are better alternatives. 

If an ED visit is unavoidable, then EDs should work to cater to the needs of older adults.

“We need to make sure the care they’re receiving is aligned with their goals and values,” Hunt said. “People may not be interested in pursuing aggressive treatments and would prefer to have their care focus more on comfort. Especially for people with advanced dementia and nursing home residents, the cost of an acute care visit could really outweigh the benefits.”

Some progress has been made over the years. The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association led the effort to create the Multidisciplinary Geriatric Emergency Department Guidelines, approved in 2013-2014, that provides standardized guidance on treating older adults in EDs. 

But these guidelines are recommendations, not directives. Some health care facilities have adopted many of the recommendations, including the creation of stand-alone geriatric units in EDs, which Hunt calls the “gold standard” of geriatric emergency department interventions and innovations (GEDIs). Others have not, which may explain disparities in care for older adults. Only 137 of the more than 5,000 EDs in the U.S. have geriatric units accredited by the ACEP.

Hunt believes nurses can and should continue to be the source of future innovations.

“It’s important for nurses to lead these efforts because nurses are the ones on the front lines and understand what the day-to-day processes and structures and interactions with patients are like and the obstacles that can get in the way,” she said. “There needs to be more emphasis on nurse-led interventions in the ED and hospital for helping older adults and improving outcomes. Of course, it has to be interdisciplinary as well, but a nurse’s vantage point offers a lot in how to deal with these problems.”

Hunt suggests institutions implement a “geriatric practitioner model” where nurses specializing in geriatrics can provide consultations and also train ED nursing staffs on best practices when treating older adults. She also advocates for increasing funding to support nurse-led GEDIs, increasing the number of geriatric nurses and ensuring all nurses are exposed to geriatrics in their education and training. The Gerontological Advanced Practice Nursing Association (GAPNA) developed a new APRN gerontology certification to better prepare APRNs to manage the care of older adults.  

Keeping Geriatrics Education Alive

Preparing the next generation of nurses to aid this growing population has become more arduous. In the last decade, U.S. nursing schools adapted their curriculum to align with the APRN regulatory model set by the Advanced Practice Nursing Consensus Work Group and the National Council of State Boards of Nursing (NCSBN) APRN Committee. The change resulted in geriatrics transitioning from a stand-alone discipline to being included within adult gerontology. 

“We have to align our curriculum with the certification exams that our students need to be prepared to take upon graduation,” said Lynda Mackin, Lynda Mackin clinical professor at the School of Nursing. 

Mackin, coordinator of the School’s Adult-Gerontology Clinical Nurse Specialist specialty, has played a key role in maintaining geriatrics’ presence in the School’s curriculum. She reconfigured courses on cancer and cardiovascular care in older adults to include more geriatrics content, and teaches an adult-gerontology mental health seminar elective that enrolls about 60 students every year.

The School of Nursing also has the distinction of housing the John A. Hartford Center of Gerontological Nursing Excellence, directed by professor Margaret Wallhagen and founded by professor emerita Jeanie Kayser-Jones, which provides research and educational experiences for nurse scientists. The School also has the only Adult-Gerontology Acute Care Nurse Practitioner specialty in northern California.

Bravo, who was an acute care nurse practitioner at UCSF for 12 years, will transition to lead the School’s Adult-Gerontology Acute Care Nurse Practitioner specialty on July 1.

“Our graduates are managing adult and older adult patients in all of the large ICUs, emergency departments and sub-specialty units in the Bay Area — UCSF, Stanford, San Francisco General [Hospital],” Bravo said. “They’re accomplishing amazing things and we are very proud of our graduates.”