Dec 7, 2014

Tales from the Emergency Room

I look over at her husband on the stretcher; he is staring quietly at the ceiling. My mind wanders for a moment―how much does he understand about what we are discussing, and maybe I shouldn't be having this discussion in front of him.

By Alex Mohseni
Alzheimer's Reading Room

I'll Take Care of You

“But he’s never been like this,” she tells me. I sit down, hold her wrinkly hands in mine, and look into her deep sad blue eyes and say, “I know.”

I look over at her husband on the stretcher; he is staring quietly at the ceiling. My mind wanders for a moment―how much does he understand about what we are discussing, and maybe I shouldn't be having this discussion in front of him.

My eyes and thoughts refocus on the patient’s wife in front of me. She’s looking for answers, options, treatments, and more than anything, hope.

His dementia has worsened, and rather suddenly, as it does sometimes. Sometimes we find a culprit―most often (in my experience) a urinary tract infection or just poor nutrition and dehydration.

We feel some degree of hope and even accomplishment in these circumstances, because our interventions in the emergency room can sometimes bring the patient back to their most recent baseline cognitive function.

Sometimes all it takes is some antibiotics and IV fluid.


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Often, though, the declines in mental function are irreversible. Either the dementia itself has progressed or other chronic conditions like cerebrovascular disease (stroke and other conditions that affect blood flow to the brain), and diabetes have worsened, causing damage to the already compromised brain.

“What can I do? Isn't there … some medicine?”

I shake my head, still holding her hand. She looks down at her lap, trying to understand her new reality. She is scared and sad, and I see her slowly realize how unprepared she is for this new life.

She will need more help, but her children live far away and it’s a Friday evening, so the hospital’s Case Management isn’t able to arrange for anything until Monday. The healthcare system isn’t able to manage this situation and neither is she.

What ensues is a combination of desperate attempts by us to make some argument to the hospital and insurance gatekeepers that this patient has an acute medical condition and needs to stay (this usually fails) as well as distressed phone calls from the wife to her family, friends and neighbors to see who can help her take care of her husband.

This scene replays itself each day in every emergency room in our nation.

Recent literature shows that seniors with dementia are 42% more likely to require hospitalization and 35% more likely to have an emergency room visit each year, compared with seniors without dementia (Source: “Hospital and ED use among medicare beneficiaries with dementia varies by setting and proximity to death.”  http://www.ncbi.nlm.nih.gov/pubmed/24711331).

Not only are seniors with dementia more likely to be admitted, they are also more likely to be readmitted within thirty days of discharge.

A recent study showed that seniors with dementia have a 20% chance of readmission within thirty days (Source: “Association of dementia with early rehospitalization among Medicare beneficiaries.”  http://www.ncbi.nlm.nih.gov/pubmed/24661400).

What I take away from these statistics is that as a community we are not succeeding enough in managing the health and safety of our loved ones with dementia. 

A 30-40% higher hospitalization and emergency room visit rate means that caregivers are finding it especially difficult to manage the physical, cognitive, and psychological challenges of seniors with dementia, and we need to work together to create better networks of support.

*Alex Mohseni is an Emergency Medicine physician in the Washington, DC region and the cofounder of Seniorbility .  Seniorbility helps keep seniors safe and independent at home by doing quick daily mental check-ups over the phone and providing those results to family daily by email. Dr. Mohseni received his B.S in Physiology and Neurobiology from the University of Maryland, his M.D. from the University of Maryland, and his EM training at Thomas Jefferson University Hospital.

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