Introduction
Many older adults in the United States are affected by unmet needs and social challenges that negatively impact their health and well-being. These include social isolation, inadequate care, inability to perform daily activities, food insecurity, housing insecurity, poverty, and abuse/neglect/exploitation. Such challenges make it more difficult to obtain medical and dental care and manage vision / hearing impairments. Affected patients have trouble obtaining medications and remaining adherent to medication regimens. These issues may compromise an older adults’ nutrition. They may contribute to anxiety, depression, and loneliness, which in turn can also negatively affect a person’s physical health and function.
Unmet needs and social challenges intersect with the emergency department (ED) visit in two ways. First, they often contribute to an older adult’s decision to seek ED care. They are often a causal factor in an injury or the precipitant of an illness.1 Second, an ED visit may be one of the few times that older adults leave their homes or interact with a medical professional. This makes the ED visit a critical opportunity for identification and amelioration of these issues. Sixty percent of cognitively intact older adults presenting to the ED report ongoing nonmedical problems2; these issues may be even more common among cognitively impaired older adults. Older adults report that they would like to have their nonmedical problems addressed during an ED visit, but such problems are rarely identified, much less addressed.3
The COVID-19 pandemic and its public health response have highlighted the burden of unmet needs and social challenges in older adults. This paper offers an opportunity to create ED systems change for improved identification and enhanced service linkages to address these issues. ED providers should systematically assess older adults for unmet needs and social challenges as part of the ED evaluation. If available in the ED, a social worker, care manager, or care coordinator may be the optimal team member to screen for these issues.4
Assessment typically involves asking a patient about their daily activities and functioning, their home environment, their medication regimen, and how they receive care. An alternative approach is to ask a more limited set of questions (e.g., hunger vital signs), and if those initial questions are positive, then assess a broader range of problems.5 Connecting an older adult patient to appropriate community-based services and resources may be very helpful.6 Linkage to adult day care or to senior services can also supply the older patient with needed supports.7-10
Provision of in-home meals can sometimes delay need for nursing home admission.11 However, timely linkage to support services may be problematic depending on local resources. Family members or caregivers can sometimes assist during the gap until services can be delivered.12 While not optimal, admission to the hospital may be necessary for older adults for whom ED providers estimate that a safe discharge plan cannot be established.13,14 Below, we discuss in more detail several unmet needs and social challenges and recommend specific assessment and intervention strategies.
Social Isolation
Even in the absence of a pandemic, an estimated 43% of older adults experience social isolation.15 This disconnection can lead to loneliness, decreased quality of life, and depression, and is associated with medical consequences including falls, cognitive decline, and mortality.15,16 The public health response to COVID-19, including stay-at-home orders and social distancing measures, has dramatically increased the prevalence of social isolation in older adults and exacerbated the problem for those who were already isolated. Places of gathering, such as senior centers and places of worship, have closed. Social supports, including family and friends, may not feel comfortable visiting or are formally prohibited from visiting due to concerns about infecting an older adult or contracting COVID-19 themselves. And although some studies suggest that older adults are more comfortable using technology as a platform for medical encounters than previously thought,17 many older adults do not have internet access or cannot use the technology necessary to conduct video conversations. The latter problem may be solved in part with the use of elder-friendly technology employing large icons and pre-programmed methods of communication.18
The pandemic also presents important transportation issues, as older adults may rely on social supports or public transportation to go to appointments and run essential errands. Without access to safe transportation, seniors are unable to receive regular outpatient health care and obtain prescription medications. As a result, chronic health conditions may be exacerbated, which can lead to ED presentation and hospitalization.
Socially isolated older adults present to EDs more frequently than those who feel connected,15 suggesting that an ED visit may be an opportunity to identify this issue and initiate intervention with appropriate referrals. To assess for social isolation in the ED, providers should explore the patient’s social support network. Questions targeting perceived loneliness, including how connected an older adult feels to friends and family or if they have people they can talk to/depend on may be particularly helpful.19
Many communities have recognized the importance of reducing social isolation in older adults amid COVID-19 and have developed creative solutions to improve connectedness. In New York City, the Department for the Aging developed virtual senior centers, and New York Connects created a Friendship Line for older adults who may be feeling lonely. A major cable/internet company in the New York area created an affordable internet option for seniors. Community-based counseling programs have offered support by phone or video conference. In Detroit, Michigan, an innovative telephone outreach program was established.19 A senior ride program in Virginia provides private rides to and from medical appointments for older adults with chronic health conditions with frequent sanitization to reduce infection transmission.20 Being aware of and utilizing local resources is imperative to provide assistance and referrals to older adults during this challenging time.
Inadequate Care/Assistance In ADLs, IADLs
Many older adults experience decline in function and need assistance in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs include bathing, grooming, toileting, transferring, and self-feeding; IADLs include cleaning the home, managing money, preparing meals, shopping for groceries and necessities, taking prescribed medications, and using the telephone to communicate. Receiving inadequate care or assistance with these ADLs and IADLs is a critical unmet need21 that can dramatically impact an older adult’s health and can increase their mortality.22 Before COVID-19, research showed that 75% of older adults that present to the ED reported ADL decline, and 65% reported IADL decline.23
The COVID-19 pandemic has likely increased the prevalence of unaddressed functional challenges among older adults. Family and friends who had previously checked in on an older adult and thus may have been able to identify a functional decline may not do so during a pandemic due to concerns of exposing themselves or the older adult to the virus. Home care workers may no longer provide services due to personal concerns or agency policy, leading to inadequate care and worsening of existing health problems. An older adult may not be able obtain necessary prescription medications or to take them properly. They may have difficulty acquiring assistive devices such as canes, walkers, hearing aids, or glasses, and may not be able to have current devices adjusted as needed.
Additionally, functional impairments themselves may impact the ability of older adults to access necessary medical care outside of the ED. With outpatient providers relying on telemedicine to care for patients during the pandemic, older adults with hearing loss or impairments in fine motor skills may face increasing challenges in obtaining the care they need if they do not have access to user-friendly technology.16 While an important public health behavior, the use of masks by others makes communication more difficult for those with hearing or vision impairment.24
ED providers should recognize the existence of these challenges and proactively assess an older adult’s functional status and the care/assistance they are receiving. The ED team can educate family members or other informal caregivers about how to properly provide care. When appropriate, social workers and care managers should be involved to assist with setting up or modifying home care during the pandemic. Assistive devices should be given to the patient or delivery should be arranged.25
Food Insecurity
Many older adults experience food insecurity, defined as a lack of access to nutritionally adequate foods due to limited resources, such as financial resources, availability of healthy foods, and transportation.5 Older adults with food insecurity are at increased risk of not only malnutrition but also heart disease, diabetes, depression, and ADL dependence.5,26,27 Before COVID-19, 8.7% of older adults living alone and 7.2% of older adults living with others had food insecurity.28 As many as 15% of older adults presenting to the ED were malnourished, and of those ED patients, food insecurity was a contributing factor in more than 25%.5
The COVID-19 pandemic has dramatically increased the risk of food insecurity among older adults. Meal delivery services, such as Meals on Wheels, have had to suspend operations. Senior centers, where many older adults received meals, have been closed. Many older adults are not able to go to grocery stores due to functional limitations, transportation issues, or fear of COVID-19 exposure. Online grocery services have replaced in-person grocery shopping for many but may be difficult to navigate for some older adults who have established routines and are inexperienced in using technology. Financial issues due to the economic impact of COVID-19, to be discussed below, may affect food purchasing for older adults, their families, and their caregivers.
Existing screening tools such as the Malnutrition Screening Tool29 and the Hunger Vital Sign (HVS)30 food insecurity screener may be used by ED providers to assess for this critical issue. For patients who screen positive, referrals to local service providers may be made as well as to the federal Supplemental Nutrition Assistance Program.31 The use of the HVS to identify older ED patients with unmet nonmedical needs and refer them to community-based services was recently piloted in a U.S. ED;5 unpublished results support the feasibility of this approach.
Housing Insecurity
Housing insecurity, which includes poor housing quality, homelessness, overcrowding, and lack of affordability, is an increasingly common problem for older adults.32 Older adults with housing insecurity, particularly homelessness, have greater health care needs relating to geriatric conditions along with functional and cognitive impairment.33 Homeless individuals frequently visit the ED for care34 but have improvements in depressive symptoms and utilize less acute care after obtaining housing.33
Older adults with insecure housing are likely at increased risk of COVID-19 exposure and disease. Homeless shelters have been a nidus for COVID-19 spread.35 Homeless and marginally housed individuals may not be able to adequately quarantine if they are exposed or socially isolate if they develop symptoms and may, therefore, become vectors for further spread. Also, they may not be able to care for themselves if they become sick.
Many communities have recognized the importance of addressing housing insecurity as a way to contain the COVID-19 pandemic. One approach has been to convert unused hotel rooms into housing for the homeless. ED providers should ask older adults about their home environment to assess its safety and security. They should explore the potential for an older adult to relocate to the home of a family member or friend if their current living situation is unsafe. ED providers should consider admission for patients if there is concern about ability to care for themselves or receive care from others safely in their home environment. Patients facing this social challenge are likely at much higher risk for ED re-presentations and bad outcomes if discharged back to the same living environment during the pandemic.
Financial Insecurity
Financial insecurity was a reality for many older adults before the COVID-19 outbreak, with 9.2% of U.S. older adults having income below poverty thresholds.36 The poverty rate among older adults is highest in the oldest old (aged ≥65) and among Black and Hispanic individuals.37
COVID-19 has been financially devastating, causing massive job losses as well as temporary but dramatic reductions in the stock market and retirement investment accounts. COVID-19-related deaths among older adults will likely lead to an increase in financially vulnerable older single-person households, with the surviving partner struggling with money.38 Financial insecurity can cause and worsen the other unmet needs and social challenges described above, as older adults may not have the funds they need to pay for care, medication, transportation, food, and housing. Also, unpaid utility bills can lead to service shut-offs causing an unsafe living environment. COVID-19 poses other financial challenges as well. Older adults who receive a fixed income via checks in the mail may be reluctant to or have difficulty depositing or cashing these checks during the pandemic. Online banking and bill payment have become more common during the pandemic. Though many older adults are comfortable using these, others may need training and assistance.
Although ED providers likely cannot solve COVID-19-related financial insecurity in older adult patients, they should be mindful of its potential importance and relevance to the acute issues precipitating the ED presentation. Community services including the local or regional Area Agency on Aging may be able to provide resources to pay for necessary expenses and to assist with financial management and bill payment. Also, older adult patients may be directed to resources at financial institutions that provide training on online financial management.
Elder Abuse/Neglect/Exploitation
Elder mistreatment, which includes physical abuse, neglect, sexual abuse, verbal abuse, emotional abuse, psychological abuse, and financial exploitation, is a serious issue that is critical to identify in the ED. Elder mistreatment occurs commonly, impacting 5-10% of community-dwelling older adults and more than 20% of those living in long-term care.39 Elder mistreatment has medical consequences, as victims have much higher mortality than other older adults and increased rates of depression and exacerbations of chronic illness.39 Elder mistreatment victims are less likely to see a primary care provider than other older adults and more likely to present to the ED.39 Research has shown that 7% of cognitively intact older adult ED patients report mistreatment if asked,2 but ED providers seldom identify or address this issue during an ED visit.39,40
The COVID-19 pandemic and the public health response have likely increased both the frequency and severity of elder mistreatment.41 Stay-at-home orders or a quarantine period may be disastrous for a victim now trapped at home with an abuser. Unemployment, decreased income, and increased stress for family caregivers, all of which are known risk factors for elder mistreatment, are more common during the pandemic. Increased rates of substance abuse and mental illness among caregivers may also contribute to increased elder mistreatment during the pandemic. Access to community support services and senior centers as well as interactions with family and friends who are able to prevent mistreatment or intervene may be severely limited.41 Nursing home and assisted living residents may also be in increased danger. Restricting family visits, while necessary to reduce infection transmission, reduces facility accountability and eliminates opportunities to identify issues with the care provided to residents.
Because an ED visit for an acute injury or illness may be the only time that a victimized older adult leaves their home during the pandemic, ED providers should prioritize identifying elder mistreatment. Incorporating protocols for elder mistreatment screening should be considered,42 since many cases are subtle and involve multiple types of mistreatment. Social workers may take the lead in assessment in EDs where they are available. Several ED-specific tools have recently developed and tested: the ED Senior Abuse Identification tool (ED Senior AID);43 a multi-step screening approach incorporating the ED Senior AID tool,42, and the Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS).44 The last of these is specifically designed for social workers.
ED providers should report all potential cases of elder mistreatment to the appropriate authorities. Health care providers are mandatory reporters for elder mistreatment in most but not all U.S. states, and, in many, elder abuse must be reported even if the victim does not want a report made. Requirements vary by state, and information can be obtained from a state’s Department of Health website.
Online Tools To Find Local Resources
ED providers may not be familiar with local community-based organizations and resources to which older adult patients can be connected. Free online tools, such as the website www.findhelp.org, developed by AuntBertha.com, can be used to find available social services by zip code. This is particularly relevant in EDs where social workers and care coordinators may not be available to help and during nights and weekends. Notably, some hospital systems have begun integrating these tools into their electronic health records and ED workflows, recognizing their potential to help patients during and after the pandemic.
Rural Emergency Medicine
COVID-19 presents unique challenges for those residing in rural communities, including older adults. Due to the migration of young, healthy people to urban centers, rural areas have a high proportion of older adults and those with underlying health conditions that make them particularly vulnerable to poor outcomes from COVID-19 infection.45 Loneliness and isolation is more common in rural than urban areas among older adults, a feeling that is magnified during COVID-19. In addition, these areas often struggle with hospital closures and healthcare worker shortages, resulting in difficulties treating COVID-19, as well as other chronic illness.45 The pandemic has intermittently halted elective and routine medical care, which are typically critical to the financial health of hospitals, making it even more challenging for rural hospitals to remain open.45 Further, patients with severe COVID-19 often need to be transferred to urban hospitals for treatment, which can result in social challenges for the patient and family needing to travel long distances.45 Emergency providers working in rural hospitals should recognize these important challenges when assessing older adults during this pandemic.
Telehealth
Incorporating telehealth strategies into emergency care, which has proven so promising during COVID-19,46,47 and has expanded dramatically with the passage of the CARES Act, may be a particularly valuable tool to assess older adults for unmet needs. Research has shown that older adults are comfortable receiving care via a telehealth interface.17 Telehealth is a powerful tool to assess older adults who are unable to access the ED for any reason, including those who live in in rural settings, and may help to reduce ED visits.48 It is also useful for those who are unwilling to present to the ED because of concern for infection exposure. Telehealth may be integrated into post-discharge follow-up programs, allowing providers to reassess a high-risk older adult in their home environment to confirm that they are able to provide for themselves and/or receiving the care they need – and also to help them stay more socially connected. It is critical that efforts are made to make technology more senior-friendly and keep up with the needs for elderly patients as telehealth becomes more integrated into care models.
EMS
Emergency medical services (EMS) providers, who often evaluate an older adult patient in their home environment soon after a 911 activation, can play a critical role in identification of unmet needs. ED providers should take seriously any concerns that EMS expresses and should proactively ask EMS about any social / non-medical issues when receiving report about an older adult patient. Additionally, EMS providers may identify and even potentially initiate intervention for unmet needs and social challenges in older adults who refuse transport to the ED. Community paramedicine49 offers an opportunity for post-discharge follow-up and other regular in-home check-ins with older adults, particularly when other community-based services are unable to safely access homes. Innovative programs integrating an in-person EMS evaluation with a telehealth evaluation by an ED provider are also promising.50
The Future
New tools and strategies to identify and address unmet needs and social challenges among older adults in the ED are being developed. Future screening approaches may be enhanced by algorithms using data from electronic health records to find patients at risk. Effectively managing these non-medical but critically important issues is also increasingly recognized as a priority for payors, including the Centers for Medicare and Medicaid Services, as well as accountable care organizations, because fixing them will reduce avoidable health care costs. The COVID-19 pandemic has made many of these issues worse for older adults, but the pandemic also provides an important opportunity to raise awareness among emergency physicians, nurses, and social workers about the potential to use the ED visit to identify and initiate interventions.
Summary
Unmet needs and social challenges can have a profound negative impact on the health of older adults, particularly during and after the COVID pandemic. An ED visit provides a unique and critical opportunity to identify these issues and initiate intervention for these vulnerable older adults who may not be seen in any other medical setting. By assessing for unmet needs and social challenges, considering a team-based approach as to how they may be ameliorated, using online tools, and integrating telehealth and EMS, ED providers have the potential to dramatically improve the health and quality of life of older patients.
Key Words
unmet needs, social challenges, geriatric emergency medicine, elder abuse
Affiliations
Alyssa Elman LMSW1, Daniel Baek MPH1, Elaine Gottesman LMSW1, Michael E. Stern MD1, Mary R. Mulcare MD1, Amy Shaw MD2, Morgan Pearman PA-C1, Michelle Sullivan PA-C1, Sunday Clark ScD MPH3, Timothy F. Platts-Mills MD MSPH4, Rahul Sharma MD MBA1, Tony Rosen MD MPH1
- Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New York
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New York
- Boston Trauma Institute, Department of Surgery, Boston University School of Medicine
- Quantworks, Inc. Carrboro, North Carolina
Conflicts Of Interest
The authors have no conflicts of interest to report.
Acknowledgements
Corresponding Author: Tony Rosen MD MPH, Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New York, 525 East 68th Street, Room M130, New York, NY 10065, aer2006@med.cornell.edu, 212-746-0780 (phone), 212-746-4883 (fax)
Funding: Tony Rosen’s participation was supported by a Paul B. Beeson Emerging Leaders Career Development Award in Aging (K76 AG054866) from the National Institute on Aging. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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