About 14% of people ages 71 and older in the United States have dementia. Alzheimer's disease, the most common type, affects about 5.3 million people ages 65 and older-10% of the older adult population. Symptoms of dementia include difficulties with memory, language, communication, visual perception, and problem-solving-as well as with cognitive skills such as reasoning, judgment, and the ability to focus. As the population of Americans 65 years and older continues to grow-it's anticipated to nearly double from 48 to 88 million between now and 2050-so too will the prevalence of dementia.
Older Americans are frequent users of hospitals. In 2012, about 35% of hospitalized patients were ages 65 and older, and in 2012-2013 older adults were responsible for nearly 16% of visits to EDs. But hospitals-fast-paced, noisy, and often labyrinthine spaces with alternating clinicians on any given shift-can be challenging for older patients, whose illnesses tend to be more complex than those of younger people, and who often present with comorbidities and functional and cognitive impairments. Those with dementia are particularly vulnerable, facing an increased risk of delirium, falls, and functional decline that may lead to a prolonged hospital stay or rehabilitation.
Clinicians, too, find caring for older patients challenging. In one 2013 survey, 527 ED nurses from 49 U.S. hospitals were asked to identify the issues they believe EDs need to address to improve their care of older adults. The most common were showing respect for patients and caregivers, using correct and best procedures and treatment, having sufficient time and staff to do things right, ensuring successful transitions, and providing a safe and enabling environment. One nurse said, "I believe that many elderly are just ignored because they can't communicate or are confused." Another added, "When it is extremely busy it is impossible[horizontal ellipsis] we are concentrating on immediate needs and they have ongoing needs that are very important."
TACKLING THE ISSUE IN HOSPITALS
Scores of resources and toolkits are available to assist hospitals to better accommodate older patients, particularly those with dementia. One set of guidelines-Dementia Friendly Hospitals, developed by the Minnesota collaborative ACT on Alzheimer's-offers suggestions for how best to interact with patients, provide continuity of care, focus on patient-centered care, and adapt physical spaces. They include the following:
* Provide a quiet space with minimal distractions.
* Be patient and avoid arguing.
* Learn about the patient's baseline behavior from caregivers and have a plan in place to recognize, assess, and intervene should agitation occur.
* Continually assess medications and educate caregivers on medication use.
* Allow patients to have familiar items in the room.
* Arrange furniture in the room to prevent falls and wandering.
* Use recognizable symbols to label rooms, such as a toilet to identify the bathroom.
Education models for clinicians have also proven effective. In one 2014 study, a full-day educational program called the Dementia Friendly Hospital Initiative was offered to 355 participants-primarily nurses, but also to therapists, social workers, and chaplains. It consisted of five didactic modules, slides, videos, learning activities, and handouts. Participants filled out questionnaires both before and after the program regarding their attitudes, practices, confidence, and knowledge; their scores revealed significant improvement at the program's end.
Another initiative, Nurses Improving Care for Healthsystem Elders (NICHE)-an international nursing education and consultation program developed in 1992 by the New York University Rory Meyers College of Nursing-offers resources for nursing and interdisciplinary teams caring for older adults. Its eight-week online course, the Leadership Training Program (designed for nurse clinician leaders, clinical educators, administrators, and direct care staff), offers webinars, practice-based assignments, discussion forums, and interactive calls, and assists users in implementing elder-friendly programs within their organizations (see https://nicheprogram.org).
GERIATRIC EDs
In recent years, some hospitals-including Northwestern Memorial Hospital in Chicago, Mount Sinai Hospital in New York City, and St. Joseph's University Medical Center in Paterson, New Jersey-have opened geriatric EDs to better accommodate older patients. But efforts nationwide are still piecemeal. The first attempt at standardization arrived in 2013 with the publication of Geriatric Emergency Department Guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. The guidelines provide a template for staffing, equipment and supplies, staff education, policies and procedures, follow-up care, and performance improvement measures. Recommendations include having a geriatric ED medical director and nurse manager either exclusively in the ED or as part of a hospital-based Acute Care of Elders team; encouraging nursing staff to participate in geriatric-specific education; screening for dementia or delirium; and adopting new equipment-including beds that allow safe transferring, extra thick or soft gurney mattresses that decrease the risk of skin breakdown, warm blankets, bedside commodes, and acoustically enhanced drapes.
"The guidelines are beautiful on paper," says Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP, professor and Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. "But getting hospitals to implement them is another story." Acute care settings, she says, are designed for the ease and efficiency of providers, not the comfort of patients. "Maybe we should have a realistic understanding of what a hospital is and what it's there for. If you have someone bleeding after a car crash, the staff isn't going to be attentive to the discomfort of other patients. Maybe we just can't have it all." Still, she says, at the very least hospitals can prioritize measures they feel are most needed or feasible. "Environmental changes such as reducing noise levels, keeping older adults visible from the nurses' station, having appropriate chairs and beds, and making bathrooms accessible can be easily implemented." She adds that clinician education could also be helpful, provided it's accompanied by oversight.
But hospitals may be only one piece of the puzzle; a more comprehensive solution to improving care for older adults and keeping them out of hospitals in the first place may lie at the societal level. To that end, Dementia Friendly America, a collaborative of more than 35 leading organizations, is working to foster change in communities by offering toolkits and resources for all sectors, including transportation, banking, retail, and faith. AARP has also created a network of "age-friendly communities" that have committed to become hospitable to people of all ages-231 communities have thus far signed on (see http://www.aarp.org).
Congress, too, has joined in the effort. In November 2017 a bipartisan bill-the Building Our Largest Dementia Infrastructure for Alzheimer's Act-was introduced to "authorize the expansion of activities related to Alzheimer's disease, cognitive decline, and brain health."
While these measures sound promising, time will tell if they will amount to something more than a wish list for an increasing number of aging Americans.-Dalia Sofer