Alzheimer's, Dementia & Mental Health
ERs Need Better Support for Senior Citizens with
U.S. seniors visit ERs more than other age groups;
review covers patients from the USA, Canada, Australia, Italy, New
Zealand and Israel
June 6, 2011 - More needs to be done to improve the
care that older adults with cognitive impairment - including dementia
and delirium - receive when they visit hospital emergency departments,
according to a research review in the July issue of the Journal of
Researchers from the University of Alberta reviewed
15 studies published between 1994 and 2009, covering 4,431 patients from
the USA, Canada, Australia, Italy, New Zealand and Israel.
They point out that a large proportion of older
adults over 65 visit emergency departments (EDs) in high-income
countries. For example, in North America, older adults visit EDs more
than any other age group, are more likely to request an ambulance and
receive more acute interventions on arrival.
Similar trends have been observed in New Zealand,
Australia, Great Britain and other European countries.
Despite this, there is little research into how
people with cognitive impairment - who can account for up to 40 per cent
of older ED patients - are assessed, treated or supported during their
"Older patients with cognitive impairment are
unable to make decisions for themselves or function independently when
they visit an emergency department" explains lead author Dr Belinda
Parke, Assistant Professor in the University's Faculty of Nursing.
"They tend to be more helpless, demand special
attention and fail to co-operate, posing many challenges for healthcare
staff during admission, assessment and treatment.
"But, as one of the studies we reviewed rightly
points out, there is a profound difference between saying that a patient
is difficult and realising that patient care is difficult."
Key findings of the review include:
● Most of the studies defined older patients as
65 plus, with the starting point for inclusion varying from 64 to 75
years of age.
● Delirium was the most common cognitive
impairment, but was poorly recognised, difficult to identify and often
overlooked by ED physicians. And when it was identified, it was
● Only one of the 15 studies identified the
significance of dementia in the ED, underlining the need for individual
care tailored to the needs of people with cognitive impairment.
● A wide range of assessment tools for cognitive
impairment featured in the studies, but none were deemed ideal for use
in a busy ED where time is often limited.
● The review also uncovered a debate about
whether the ED was an appropriate setting for screening and detecting
cognitive impairment and questioned the health providers' obligation to
patients once it had been detected.
● It also highlighted questions about who should
carry out cognitive impairment assessments - including physicians,
nurses, social workers and psychologists - and who was proficient to do
● None of the published papers reported
first-hand studies about what people with cognitive impairment or their
carers felt was important when they visited an ED, with some suggestions
that these older patients are excluded from research.
"Although the available research indicates that
older people over 65 with cognitive impairment pay a large number of ED
visits, little is known about what enables or prevents these patients
from receiving safe, meaningful and comprehensive care" says Dr Parke.
"It is very clear that more research is needed into this area, which
will become even more important as our population ages.
"Hospitalised older adults face a greater risk of
adverse outcomes than younger patients and these can have a lasting and
detrimental effect on them. The failure to address the needs of older
patients with cognitive impairment can mean that an ED visit can become
a negative and possibly life-changing event for them."
The authors believe that their research review
highlights three key priorities for clinical practice and/or policy:
● Firstly, healthcare professionals need to know
more about the conditions and processes that influence outcomes for
older people with cognitive impairment in the ED if they are to develop
effective interventions for them.
● Secondly, it is vital to talk to older people
with CI and their carers to ensure that any quality improvements are
appropriate for their often complex and specific needs.
● Last, but not least, a clinically relevant
interdisciplinary cognitive impairment screening tool, appropriate for
use in EDs, is needed.
"Our review exposes a lack of research into this
vital area of healthcare and it is clear that we need a greater
understanding of how this patient group is assessed and treated in ED
departments" concludes Dr Parke. "Without this much-needed research, any
quality improvements could prove an ineffectual use of vital resources."
The Journal of Advanced Nursing (JAN) is an
international, peer-reviewed, scientific journal. JAN contributes to the
advancement of evidence-based nursing, midwifery and healthcare by
disseminating high quality research and scholarship of contemporary
relevance and with potential to advance knowledge for practice,
education, management or policy.
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