Are Emergency Departments Really NO PLACE for Older People?

In November, the provincial adviser on health quality, Health Quality Ontario (HQO), published a report that found visits to Emergency Departments (EDs) across Ontario were going up. Their reason? Our ageing population. In 2014/2015, there were 5.9 million visits to EDs in Ontario, and 1.3 million of them were made by Ontarians aged 65 and over. That was up 29 per cent over the 1 million visits older adults made in 2008/2009 – the largest increase of any age group.

HQO’s report, Under Pressure, attracted significant media attention at the time. The fact that the largest increase in ED visits between 2008/2009 and 2014/2015 was among older Ontarians suggests that they are driving the overall increase. The rate at which older Ontarians use emergency services will keep growing over the next 25 years, the report said, as the proportion of Ontario’s population aged 65 and over increases to 25.3 per cent from the 16 per cent it is currently at.

As we started witnessing these upward trends, it was not uncommon to hear people come to unfounded conclusions about their causes, with some even surmising that older people often misused ED services for non-urgent issues largely as a way to deal with loneliness! With proper research, we now know that this couldn’t be further from the truth. Indeed, older adults are more likely than others to present to EDs with urgent or critical issues and are at least twice as likely to be admitted to the hospital from the ED, although most are still treated and discharged back into the community.

A Canadian Institute for Health Information report found that older Canadians are more likely to have longer lengths of stay in the ED and to be admitted to hospital than younger patients, largely because they are more complicated to care for due to a number of reasons. In older people, common diseases more often present atypically; they have multiple chronic conditions and are often on many medications, which can complicate approaches to diagnosis and treatment.  It is no wonder that such patients are more difficult and time-consuming to assess and manage in the ED compared with younger patients. Although older patients tend to receive the most resource-intensive care of any age group within EDs, their problems are less likely to be accurately diagnosed. Consequently, they are more likely to be discharged from EDs with unrecognized and untreated problems.  Finally, the relative lack of knowledge among ED physicians and nurses in geriatric principles of care and practice may be further compounding the strain of trying to adequately address the often complex and interrelated health and social care needs of older ED patients.

One of the reasons I was inspired to move back to Canada from the United States and specifically work at Mount Sinai Hospital was that I knew it had an incredible Emergency Department that was committed to improving the way it cared for its oldest patients.  With a belief that the entire ED had to become elder-friendly, my colleagues developed and implemented a series of care models and practices that recognize that older adults have unique needs that can be overlooked and left unmet in a fast-paced medical environment.