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'Senior-friendly' emergency rooms for an aging population

This article first appeared in the St. Louis Beacon, April 12, 2012 - In a few years, baby boomers who get care in hospital emergency rooms might find the experience more pleasant than expected. That's the goal of Dr. Christopher Carpenter, assistant professor of emergency medicine at Washington University and president-elect of the geriatric section of theAmerican College of Emergency Physicians. He's part of a movement to encourage hospitals to create "geriatric friendly" ERs that offer both comfort and expertise for health problems unique to an increasingly aging population.

"Why is this important? Because the baby boomers are coming our way. The demographic tsunami that we are seeing is unprecedented in the history of mankind," Carpenter says.

Adults over age 65 already are creating quite a splash. They are big consumers of ER care, with about 1 in 4 getting treatment once or more in 2009, according to the Health U.S. 2010 report. The challenge as people grow older, Carpenter says, is: "How do we care for these patients, keep them alive and healthy and not just alive with no quality of life?"

A few hospital ERs already have begun to cater to the elderly. In other states, some hospitals have opened ERs tailored solely to seniors. Others, like Tenet-owned Des Peres Hospital in west St. Louis County, have set up separate ER sections, offering geriatric services within general emergency departments. Des Peres was the first area hospital to make this change when it set up its geriatric section in 2009.

Carpenter says incorporating geriatric principles into existing emergency departments is likely to embraced by most hospitals. He thinks it will take about two years for the idea to gain wide acceptance. The change has to happen, he argues, because general ERs are overlooking some conditions  common among the elderly.

For four years, Carpenter and a team of medical school students tracked geriatric symptoms among about 1,200 older patients who took part in a survey. All were patients treated in the ER at Barnes-Jewish Hospital.

The conditions included dementia, affecting 35 percent of the patients.  

"I wasn't terribly surprised (it went undiagnosed) because I felt that we weren't recognizing the condition because we weren't testing for it," he says.

What did surprise him were his findings after following the 60 percent of the patients who were admitted and treated for other health conditions. The team found that dementia often wasn't identified among those hospitalized.

"Not only are the emergency doctors and nurses missing it, but the in-patient physicians are missing it as well. If we don't do a better job in capturing it, there is a big chance it won't get captured for some period of time."

Complicating the problem, he says, is that medical students aren't exactly breaking down the door to become geriatricians. "Their numbers are shrinking each year. The reason is because (geriatrics require) another couple of years of training after your residency and they don't get paid for that."

Still another challenge, he says, is that many providers are trying to apply a traditional adult ER model to an older adult population with unique needs.

"The first thing we need to do is establish a minimum baseline of care that has to be met by emergency departments caring for older adults," he says.  Establishing the baseline will be part of his mission as the leader of the American College of Emergency Physicians' geriatric section.

The problem isn't just treatment but the ER environment that poses challenges for the elderly, he says. ERs tend to have bright lights, noisy machines and occasional chaos while doctors and nurses are in constant motion to keep up with whatever emergency comes through the door. 

Carpenter and others say the elderly need to be removed from that busy environment and placed in locations where lights can dimmed or brightened to help the elderly keep track of time. He adds that if the patients are in the emergency department for several hours, it would help to have comfortable armchairs so they could sit and rise without assistance, rails along the walls if the elderly want to walk around, and comfortable observation rooms, separate from the main ER, when patients are not sick enough to be admitted but aren't well enough to leave the ER area immediately.

Carpenter says his career choice was influenced by less-than-ideal care for his grandfather, who suffered from Alzheimer's.  Physicians who cared for his grandfather lacked the background to provide more help. Worse, Carpenter said, was their seeming indifference.

"I didn't appreciate what I guess is best to say was lack of empathy among (the) doctors," Carpenter said. "He went into the emergency room several times with falls. And my grandmother aged several years faster than she should have trying to deal with my grandfather."

Carpenter felt the physicians had looked upon his grandparents as "part of the old and frail who had lived a full life and you just had to let them go."

But he has good memories of his grandparents, too, such as reports about his grandfather as a young athlete, fit enough to compete against world-class sprinter Jesse Owens. Never mind who won.

In any case, he believes there is a "unique opportunity for people to age gracefully and have a high quality of life into retirement and even till the end, so we don't have years of dementia."

He adds, "We can start recognizing the challenges and be proactive rather than reactive."