Seniors With Dementia Need an Advocate in the ER; Indy Doctor Provides Tips

Going to the emergency room is stressful in the best of circumstances. For older adults – especially those with dementia – a trip to the ER can lead to confusion, extra medical tests and often longer hospital stays.

Considering that 30 percent of seniors need emergency treatment annually, families need to prepare for the inevitable and determine who will be the advocate for their aging parents, which could help reduce the need for some tests and help doctors make the correct diagnosis, said Dr. Tochukwu Iloabuchi, an assistant professor of clinical medicine at the IU School of Medicine and a geriatrics physician at Roudebush VA Medical Center Indianapolis. He provided insights and tips to CICOA Aging & In-Home Solutions on what family members can do to help.

Opposites collide

When something happens, whether Mom or Dad fall or are experiencing shortness of breath and they need to go to the emergency room, it is a disruption to their routine. Plus, the environment isn’t always conducive to the needs of people with dementia. This isn’t a regular doctor’s appointment with a comfortable waiting room, soft music and magazines to read. The ER is a fast-paced, often chaotic, loud, crowded environment. That can cause confusion for older adults, whose senses change as they age. The noises may seem more pronounced, lights can seem even brighter, or their hearing may be muffled as they are experiencing so many sounds around them.

While it’s important to understand how the ER can impact seniors, it’s also important to understand the mindset of emergency department workers, Dr. Iloabuchi said. The medical team is focused on stabilizing patients who arrive with life-threatening conditions. ER care teams often don’t have the luxury of time to perform a detailed review of charts; rather, obtaining reliable history from patients or their loved ones is very important to the evaluation process.

“The doctor and care teams are looking at what we call triage,” Dr. Iloabuchi said. “We are listening to the story and examining the individual, trying to sort out what may be most life threatening. That’s the common mindset. Why are they here? How severe is the problem? Is it something we can fix here? The care team does not want to miss anything that can hurt that individual. If the person is unable to speak for themselves and provide reliable information, this leaves a lot of unanswered questions with regards to not only the symptoms, but also the goals of care. This may lead to extensive medical testing in an attempt to resolve some of the unanswered questions, and it plays a role in why older adults may get more tests than others.”

The role of an advocate

Some of those tests may be prevented if an advocate is present to help answer questions and provide more insights on what’s typical and what’s not for the older adult, who may be confused or disoriented in the ER, Dr. Iloabuchi said.

“They need an advocate who knows the medications they are taking, someone who can explain what’s typical for Mom or Dad, or what’s unusual,” Dr. Iloabuchi said. “We know that sometimes for people with dementia, noise will bother them, or they get upset when hungry. They may be missing their dentures and not want to eat, or not have their hearing aid and may not understand what’s being said to them. That’s why advocates need to be there.”

Prepare for an ER visit

Simple things families can do in advance to save time and expense in the ER, Dr. Iloabuchi said, are to have the following information readily available:

• List of names and contact information of all your loved one’s doctors
• List of all medications, doses and times of day they are taken
• List of all diagnoses and any recent tests or changes
• List of allergies

In addition, if the senior is in an assisted living facility or goes to an adult day care, make sure the facility knows whom to call in an emergency. Also, ask the facility for its protocol when someone needs emergency care. Most facilities do not send a staff member to accompany the patient in the ambulance.

When a loved one goes to the ER, if time permits, make sure they are able to take items such as dentures, hearing aids, eyeglasses and any other assistive device that aids their function.

Family members need to have these talks and be prepared on the roles each will play in an emergency situation.

Questions to ask medical teams

While advocates are there to answer questions and provide comfort for their loved one, they also should ask doctors questions, such as “What are you worried about? What are you trying to address?”

There are times a doctor may be thinking one thing, but then a test comes back, and a shift occurs in what is suspected.

“Keep asking, ‘Are you still thinking the same thing? Have you found anything or reached a conclusion?’” Dr. Iloabuchi said.

When systems fail

When families are prepared and proactive, it helps prevent system failures. Complications can occur when a patient is taken to the emergency room and there is little or no information and no advocate to speak on behalf of the patient.

“Some may go into an emergency room and end up worse than they were, because it doesn’t take long for an older adult to become dehydrated, for sugars to go low, for medications to be missed, for skin to break down. These are common things that can happen,” Dr. Iloabuchi said. “I’ve seen older adults put on restraints in the emergency department because they were trying to get out of bed, but maybe it was their way of saying, ‘I’m hungry,’ or ‘I am uncomfortable,’ or ‘I need to use the bathroom.’ If we don’t know, it causes the wrong type of treatment,” he said.

“That is a system failure, because the hospital may not have any way of reaching out to find out how aggressive to be,” Dr. Iloabuchi said. “Is there a way to prevent that? I’d say yes.”

If a family member is there who can provide information and tell the care team what they know, that will help the care team to best evaluate, diagnose and treat the patient.

Efforts are being made to make emergency departments older-adult friendly, he said, but it’s not yet widespread.

For example, emergency departments could let an older adult speak on a mobile handset with a loved one to help bridge the gap until a family member arrives. It can be a simple conversation, Dr. Iloabuchi said.

“Mom, you are in the hospital; I am aware you are there. They are trying to help you,” he scripted. “That can go a long way to reassure an individual who is overwhelmed and in a strange environment and not aware of what is going on.”

That’s a step in the right direction. More can be done, though, by making sure medical teams have specialized geriatric training and making environmental changes.  Dr. Iloabuchi is advocating for more geriatric friendly systems in emergency departments to improve the experience and care for older adults, which will lead to better health outcomes and improved quality of life.

Become a Dementia Friend!

Dementia Friends Indiana, an outreach of CICOA, is challenging Hoosiers to create welcoming environments for people living with dementia and their caregivers. It’s easy to learn what you can do to make a difference – watch the video online or attend a session.

Become a Dementia Friend