Nuances of Helping Older Patients with Moderate Dementia in the Emergency Department

Michael L. Malone, MD

GED Newsletter, October 2019

Introduction

Older individuals who have middle stages of dementia may have difficulty with performing tasks, such as paying bills. They can, however, still recall significant details of their life. They may likely still reside in their own home but may forget what day it is or may confuse their words.

Implications

Taking a History in the ED

Taking a history in the Emergency Department can be difficult because these individuals may:

  • need extra time
  • forget key information which precipitated the ED visit
  • discount key information
  • require corroborating information

Explaining Test Results

Explaining test results may be difficult because these individuals may:

  • need extra time
  • need the information repeated

Some patients with dementia receive excessive diagnostic imaging when they present to the ED, when in fact the imaging could be better directed by a careful history and detailed physical examination.

Decision Making

Decision making can be complicated by:

  • the uncertainty of the patient’s capacity for making medical decisions
  • the need to engage more people in the process

Awaiting Results

Awaiting test results in the Emergency Department can be complicated by:

  • the risk of elopement during care
  • getting overwhelmed by new experiences and new care providers

Ten recommendations to improve the ED care experience for older patients with moderate dementia:

  1. Obtain information regarding the chief complaint from those who brought the individual to the ED. Determine if there were any important documents brought to the ED, e.g. transfer forms or a POLST form- in some states. Ask open-ended questions during your initial interactions.
  2. Obtain complete understanding of the patient’s cognitive function and ability to perform self- cares. What has been the time course of any changes? Any troubles now, as compared to their baseline? Any falls? Any new behavioral or psychological symptoms of dementia? Any change in level of consciousness or in alertness? There is likely no benefit from performing repeated memory screening in the Emergency Department for those who already have a diagnosis of cognitive impairment.
  3. Ask questions about their living situation and social contacts.
  4. Verify the patient’s comprehension during the conversation. Does the patient have decision making capacity? If not, who is named to such responsibility?
  5. Expedite care to avoid frustration for those who are more vulnerable to disruptions in their routine. Avoid hallway boarding for vulnerable older adults and (if needed) expedite waiting times to move the patient to a hospital bed.
  6. Carefully review medications prior to ED visit as well as who manages the medication set up and adherence.
  7. Provide comfort for the family caregiver during the entire process. Include the patient in your conversations, especially when engaging in dialogue with others in the room. These family caregivers are a part of the extended care team before, during, and after the ED visit. They can help in understanding the bio-psycho-social needs of the patient.
  8. See how the patient gets out of the bed and walks back and forth to the toilet. Simply evaluate the individual’s gait and balance by performing a Timed Up and Go test.
  9. Communicate with other providers to develop a thoughtful care plan- across the patient’s sites of care.
  10. Review and revise the formal care plan in the electronic health record.