Volume 2 | Number 11 | original research
Alyssa Elman LMSW, Daniel Baek MPH, Elaine Gottesman LMSW, Michael E. Stern MD, Mary R. Mulcare MD, Amy Shaw MD, Morgan Pearman PA-C, Michelle Sullivan PA-C, Sunday Clark ScD MPH, Timothy F. Platts- Mills MD MSPH, Rahul Sharma MD MBA, Tony Rosen MD MPH
Many older adults in the United States are affected by unmet needs and social challenges that have a negative impact on their health and well-being. These include social isolation, inadequate care, inability to carry out daily activities, food insecurity, housing insecurity, poverty and abuse/neglect/exploitation. Such challenges make it difficult to obtain medical and dental care and manage vision/hearing problems. Affected patients have problems obtaining medications and adhering to medication regimens. These problems can compromise the nutrition of the elderly. They can contribute to anxiety, depression and loneliness, which in turn can also negatively affect a person's health and physical functioning.
Unmet needs and societal challenges intersect with the emergency department (ED) visit in two ways. First, they often contribute to a senior's decision to seek emergency department care. They are often a causative factor in an injury or the trigger for an illness.1Second, a visit to the emergency department may be one of the few times seniors leave the house or interact with a medical professional. This makes the visit to the SU a critical opportunity to identify and improve these issues. Sixty percent of cognitively intact seniors who present to the emergency department report ongoing nonmedical problems2; these problems may be even more common among older adults with cognitive impairment. Older adults report that they would like their non-medical issues addressed during an emergency room visit, yet these issues 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 for older adults. This document offers the opportunity to create a change in ED systems to better identify and improve linkages of services to deal with these issues. Emergency service providers should systematically screen older adults for unmet needs and social challenges as part of the emergency assessment. If available in the emergency department, a social worker, care manager, or care coordinator may be the ideal team member to detect these problems.4
The assessment typically involves asking a patient about his daily activities and functioning, his home environment, his medication regimen, and how he receives care. An alternative approach is to ask a more limited set of questions (eg, vital signs of hunger) and, if these initial questions are positive, to assess a broader range of issues.5Connecting an elderly patient with appropriate community services and resources can be very helpful.6Linking to adult day care or seniors services can also provide the elderly patient with necessary supports.7-10
Providing meals at home can sometimes delay the need for admission to a nursing home.11However, timely linkage to support services can be problematic depending on local resources. Sometimes family members or caregivers can help during the time until services can be provided.12While not ideal, hospitalization may be necessary for seniors for whom emergency care providers feel a safe discharge plan cannot be established.13,14Below, we discuss in more detail several unmet needs and societal challenges and recommend specific assessment and intervention strategies.
Even in the absence of a pandemic, an estimated 43% of seniors experience social isolation.15This disconnect can lead to loneliness, decreased quality of life and depression, and is associated with medical consequences including falls, cognitive decline and mortality.15,16The 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 already isolated. Gathering places such as senior centers and places of worship were closed. Social supports, including family and friends, may feel uncomfortable visiting or may be formally prohibited from visiting due to concerns of infecting an older adult or contracting COVID-19 itself. And while some studies suggest that older adults are more comfortable using technology as a platform for medical appointments than previously thought,17many seniors do not have internet access or cannot use the technology needed to conduct video chats. This last problem can be partially solved with the use of age-friendly technology that employs large icons and pre-programmed communication methods.18
The pandemic also presents significant transportation challenges, as seniors may rely on social supports or public transport to get to appointments and carry out essential errands. Without access to safe transportation, seniors cannot receive regular outpatient medical care or obtain prescription drugs. As a result, chronic health conditions can be exacerbated, which can lead to presentation and hospitalization in the emergency department.
Socially isolated seniors visit emergency services more often than those who feel connected,15This suggests that a visit to the emergency department can be an opportunity to identify this problem and initiate intervention with appropriate referrals. To assess social isolation in the ED, providers should explore the patient's social support network. Questions that focus on perceptions of loneliness, including how connected an older adult feels to friends and family or whether they have people they can talk to or depend on, can be particularly helpful.19
Many communities have recognized the importance of reducing seniors' social isolation amidst COVID-19 and have developed creative solutions to improve connectivity. In New York City, the Department of Aging has developed virtual centers for seniors and New York Connects has created a Friendship Line for seniors who may feel lonely. A large cable TV and Internet company in the New York area has created an affordable Internet option for seniors. Community-based counseling programs offer support via telephone or video conference. In Detroit, Michigan, an innovative telephone outreach program was established.19A senior travel program in Virginia offers private travel to and from medical appointments for seniors with chronic health conditions with frequent disinfection to reduce the transmission of infections.20It is essential to know and use local resources to provide assistance and referrals to the elderly in this difficult time.
Inadequate Attention/Assistance in ADL, ADL
Many elderly people experience functional decline and need assistance with 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 house, managing money, preparing meals, shopping for groceries and necessities, taking prescription medications, and using the phone to communicate. Receiving inadequate care or assistance with these ADLs and IADLs is a critical unmet need21 that can dramatically affect an elderly person's health and increase their mortality.22Prior to COVID-19, research showed that 75% of seniors presenting to the ER reported a decrease in ADLs and 65% reported a decrease in IADLs.23
The COVID-19 pandemic has likely increased the prevalence of unresolved functional challenges among older adults. Family members and friends who have already cared for an elderly person and, therefore, may have identified functional impairment, may not do so during a pandemic for fear of exposing themselves or the elderly person to the virus. Home-based 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 to get the necessary prescription medications or take them properly. They may have difficulty purchasing assistive devices, such as canes, walkers, hearing aids or eyeglasses, and may not be able to adjust current devices as needed.
Also, your own functional deficiencies can affect the ability of individuals to access the necessary medical care for the emergency department. As outpatient providers rely on telemedicine to care for patients during the pandemic, older adults with hearing loss or fine motor skill deficits may face increasing challenges getting the care they need without access to technology. Easy to use.sixteenWhile it is an important public health behavior, the use of masks by others makes it difficult for people with hearing or visual impairments to communicate.24
Emergency service providers must recognize these challenges and proactively assess an older adult's functional status and the care/assistance they are receiving. Emergency personnel can educate family members or other informal caregivers on how to provide appropriate care. When appropriate, social workers and care managers should be involved to help establish or modify home care during the pandemic. Assistive devices must be delivered to the patient or delivery must be scheduled.25
Many elderly people experience food insecurity, defined as the lack of access to nutritionally adequate food due to limited resources, such as financial resources, availability of healthy foods and transportation.5Food-insecure seniors are at greater risk not only for malnutrition, but also for heart disease, diabetes, depression, and ADL dependence.5,26,27Before COVID-19, 8.7% of seniors living alone and 7.2% of seniors living with others were food insecure.28Up to 15% of seniors presenting to the emergency room were malnourished and, of these patients, food insecurity was a contributing factor in over 25%.5
The COVID-19 pandemic has dramatically increased the risk of food insecurity among seniors. Meal delivery services such as Meals on Wheels have had to suspend operations. Senior centers, where many seniors received meals, were closed. Many seniors cannot go to the grocery store due to functional limitations, transportation issues, or fear of exposure to COVID-19. Online grocery services have replaced in-person shopping for many, but they can 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, which will be discussed below, may affect food purchases for seniors, their families and caregivers.
Existing screening tools such as the malnutrition screening tool29and the Hunger Vital Sign (HVS)30ED providers can use the food insecurity screen to assess this critical issue. For patients who test positive, referrals can be made to local service providers as well as the Federal Supplemental Nutrition Assistance Program.31The use of HVS to identify older emergency room patients with unmet non-medical needs and refer them to community-based services was recently piloted in a US emergency department;5Unpublished results support the feasibility of this approach.
Housing insecurity, which includes low-quality housing, homelessness, overcrowding and lack of affordability, is an increasingly common problem for older people.32Housing-insecure seniors, particularly the homeless, have increased health care needs related to geriatric conditions, along with functional and cognitive decline.33Homeless people often visit the emergency room for care34but they show improvement in depressive symptoms and use less acute care after obtaining housing.33
Older adults with unsafe housing are likely to be at greater risk of exposure and illness from COVID-19. Homeless shelters have been a nesting place for the spread of COVID-19.35People living in homelessness and substandard housing may not be able to properly quarantine if exposed or socially isolated if they develop symptoms and therefore may become vectors for further spread. Also, they may not be able to take care of themselves if they get 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 abandoned hotel rooms into housing for the homeless. Emergency service providers should ask older adults about their home environment to assess their safety and security. They should explore the possibility of an older adult living with a relative or friend if their current living situation is unsafe. Emergency service providers should consider admitting patients if they have questions about their ability to safely care for themselves or receive care from others in their home environment. Patients facing this societal challenge are likely to be at much greater risk of re-presenting to the ER and having poor outcomes if released back into the same living environment during the pandemic.
Financial insecurity was a reality for many seniors before the COVID-19 outbreak, and 9.2% of American seniors had incomes below the poverty line.36The poverty rate among older adults is highest among the elderly (≥65 years) and among blacks and Hispanics.37
COVID-19 has been financially devastating, causing massive job losses as well as temporary but dramatic drops in the stock market and retirement investment accounts. COVID-19 related deaths among older adults are likely to lead to an increase in financially vulnerable elderly families, with the surviving spouse struggling with money.38Financial insecurity can cause and exacerbate other unmet needs and social challenges described above, as older people may not have the necessary resources to pay for care, medication, transportation, food and housing. Furthermore, unpaid utility bills can lead to service interruptions that create an unsafe living environment. COVID-19 also presents other financial challenges. Seniors receiving a fixed income through checks in the mail may be reluctant or have difficulty depositing or cashing these checks during the pandemic. Online banking and bill paying has become more common during the pandemic. While many seniors are comfortable using them, others may need training and assistance.
While emergency service providers may not be able to address COVID-19-related financial insecurity in elderly patients, they should be aware of its potential importance and relevance to acute issues that precipitate presentation to the ER. Community services, including the local or regional Agency on Aging, can provide resources to pay for necessary expenses and help with financial management and paying bills. Additionally, older patients can be directed to resources at financial institutions that offer online financial management training.
Elder abuse, which includes physical abuse, neglect, sexual abuse, verbal abuse, emotional abuse, psychological abuse and financial exploitation, is a serious problem that is critical to identify in the ED. Elder abuse occurs frequently, affecting 5 to 10% of seniors living in the community and over 20% of those living in long-term care facilities.39Elder abuse has medical consequences, with victims having much higher mortality than other older adults and higher rates of depression and exacerbation of chronic illnesses.39Victims of elder abuse are less likely to see a primary care provider than other older adults and are more likely to go to the emergency department.39Research has shown that 7% of elderly patients with cognitively intact erectile dysfunction report abuse if asked,2but emergency professionals rarely identify or address this issue during an emergency consultation.39,40
The COVID-19 pandemic and the public health response have likely increased the frequency and severity of elder abuse.41Stay-at-home orders or a period of quarantine can be disastrous for a victim who is now trapped at home with an abuser. Unemployment, decreased income and increased stress for family caregivers, all known risk factors for elder abuse, are more common during the pandemic. Rising rates of substance abuse and mental illness among caregivers may also contribute to the rise in elder abuse during the pandemic. Access to community support services and senior centers, as well as interactions with family and friends who can prevent abuse or intervene, can be severely limited.41Nursing homes and assisted living residents may also be in greater danger. Restricting family visits, while necessary to reduce the transmission of infections, reduces facility liability and eliminates opportunities to identify problems with the care provided to residents.
Because an emergency room visit for an acute illness or injury may be the only time an elderly victim leaves home during the pandemic, emergency care providers must make identifying elder abuse a priority. The incorporation of protocols for the detection of elder abuse should be considered,42how many cases are subtle and involve various types of abuse. Social workers can take the lead in ED assessment when available. Several ED-specific tools have recently been developed and tested: the ED Senior Abuse Identification Tool (ED Senior AID);43a multi-step screening approach that incorporates the ED Senior AID tool,42, and the Emergency Department Elder Abuse Assessment Tool for Social Workers (ED-EMATS).44The last of these is designed specifically for social workers.
Emergency service providers must report all potential cases of elder abuse to the appropriate authorities. Health professionals are mandatory whistleblowers for elder abuse in most, but not all US states, and in many, elder abuse must be reported even if the victim does not want a report to be made. Requirements vary by state and information can be obtained from the state Department of Health website.Mandatory State Report
Online tools to find local resources
Emergency service providers may not be familiar with local community organizations and resources that elderly patients can connect to. Free online tools such as the websitewww.findhelp.org, powered by AuntBertha.com, can be used to find available social services by zip code. This is particularly relevant in emergency departments, where social workers and care coordinators may not be available to help and during evenings and weekends. In particular, some hospital systems have begun to integrate these tools into their electronic health records and emergency 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 seniors. Due to the migration of young and healthy people to urban centers, rural areas have a high proportion of elderly people and people with underlying health conditions that make them particularly vulnerable to poor outcomes from COVID-19 infection.45Loneliness and isolation are more common in rural than urban areas among seniors, a feeling that is amplified during COVID-19. Additionally, these areas often struggle with hospital closures and a shortage of healthcare workers, making it difficult to treat COVID-19 and other chronic illnesses.45The pandemic has intermittently disrupted routine and elective medical care that is often critical to the financial health of hospitals, making it even harder for rural hospitals to stay open.45Furthermore, patients with severe COVID-19 often need to be transferred to urban hospitals for treatment, which can create social challenges for the patient and their family who have to travel long distances.45Emergency practitioners working in rural hospitals must recognize these significant challenges when evaluating seniors during this pandemic.
Incorporating telehealth strategies into emergency care, which has shown great promise during COVID-19,46,47and expanded dramatically with the passage of the CARES Act, can be a particularly valuable tool in assessing the unmet needs of older adults. Research has shown that seniors are comfortable receiving care through a telehealth interface.17Telehealth is a powerful tool to assess seniors who cannot access the emergency room for any reason, including those living in rural areas, and it can help reduce emergency room visits.48It is also helpful for those who do not wish to report to the emergency room due to concerns about exposure to infection. Telehealth can be integrated into post-discharge follow-up programs, allowing providers to reassess a high-risk senior in their home environment to confirm they can care for themselves and/or receive the care they need, as well as help them. them stay more connected socially. It is critical that efforts are made to make technology more age-friendly and keep pace with the needs of older patients as telehealth becomes more integrated into models of care.
Emergency medical services (EMS) providers, who often assess an elderly patient at home shortly after activating 911, can play a critical role in identifying unmet needs. Emergency service providers should take any concerns expressed by the EMS seriously and should proactively ask the EMS about any non-medical/social issues upon receipt of a report about an older adult patient. Additionally, EMS providers can identify and potentially even initiate an intervention for unmet needs and social challenges in seniors who refuse to be transported to the emergency department. community paramedicine49provides an opportunity for post-discharge follow-up and other regular home check-ups with seniors, particularly when other community services cannot safely access homes. Innovative programs that integrate an in-person EMS assessment with a telehealth assessment by an emergency services provider also show promise.50
New tools and strategies are being developed to identify and address unmet needs and social challenges among older adults in the ED. Future triage approaches may be enhanced by algorithms that use data from electronic health records to find patients at risk. Effective management of these non-medical but critical issues is also increasingly recognized as a priority for payers, including the Centers for Medicare and Medicaid Services, as well as responsible care organizations, because correcting them will reduce health care costs. avoidable. The COVID-19 pandemic has exacerbated many of these issues for older adults, but the pandemic also provides an important opportunity to raise awareness among emergency physicians, nurses and social workers about the potential of using the emergency visit to identify and initiate interventions. .
Unmet needs and societal challenges can have a profound negative impact on the health of older adults, particularly during and after the COVID pandemic. A visit to the emergency room provides a unique and critical opportunity to identify these issues and initiate intervention for these vulnerable seniors who cannot be seen in any other medical setting. By assessing unmet needs and societal challenges, considering a team-based approach to how they can be improved, using online tools, and integrating telehealth and EMS, EMS providers have the potential to dramatically improve health and quality of life. of elderly patients. .
unmet needs, social challenges, geriatric emergency medicine, elder abuse
Alyssa Elman LMSW1, Daniel Baek MPH1, Elaine Gottesman LMSW1, Michael E. Stern MD1, María R. Mulcare MD1, Amy Shaw MD2, Morgan Pearman PA-C1, Michelle Sullivan PA-C1, Domingo 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, Carolina do Norte
The authors have no conflicts of interest to report.
Autor para correspondência: 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,firstname.lastname@example.org, 212-746-0780 (phone), 212-746-4883 (fax)
Funding: Tony Rosen's participation was supported by a Paul B. Beeson Emerging Leaders in Aging Career Development Award (K76 AG054866) from the National Institute on Aging. The content is the sole responsibility of the authors and does not necessarily represent the official opinion of the National Institutes of Health.
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