Recurrent Emergency Department Visits Among Persons Living With Dementia: Bending the Curve

The rising number of persons living with dementia (PLWD) necessitates improved access to quality emergency care. As identified by Jones and colleagues in this issue of the Journal of the American Geriatric Society, one opportunity to improve care relates to reducing emergency department (ED) revisits among this vulnerable population.¹ The study used Ontario provincial administrative data to measure the incidence of ED revisits within one year (62% experienced at least one revisit) among older PLWD. Although important clinical and social data (e.g., severity of dementia, functional status, social supports) were unavailable for the analyses and only proxy measures were available for some characteristics (e.g., income and rurality for access to care), Jones and colleagues identified important factors associated with revisits (previous ED use, comorbidities, medications, and patient characteristics).¹

The study’s use of ED revisit within one year, instead of a shorter window such as 14 or 30 days, as the outcome measure does result in heterogeneity in the reason for revisiting the ED. Some of the reasons for ED revisits will be related to the initial ED visit while others will result from chronic medical and social issues, a pattern they identified and published previously.² Nonetheless, Jones and colleagues appropriately conclude that implementing geriatric- and dementia-friendly practices in EDs can improve the care of PLWD and their experience, potentially reducing ED revisits. Although this task is intimidating and the science is in its infancy, many resources exist to support geriatric emergency medicine and ED leaders desiring to support PLWD.

Work by Geriatric Emergency Care Applied Research Network 2.0 - Advancing Dementia Care (GEAR 2.0-ADC), a National Institutes of Health (NIH)-funded program to advance the science supporting emergency care for PLWD, can assist EDs hoping to implement these practices. GEAR 2.0-ADC developed a workgroup of transdisciplinary individuals, including PLWD and their care partners, geriatricians, social workers, nurses, emergency physicians, researchers, and others.³ (See Figure 1.) Through a rigorous process, they identified and prioritized research gaps in the emergency care of PLWD.⁴ The four priority areas identified included: 1) detection of ED patients with impaired cognition,⁵ 2) communication and decision making with PLWD and their care partners,⁶ 3) care transitions for ED patients with impaired cognition,⁷ and 4) clinical best practices in the ED setting for PLWD.⁸ The workgroup then performed a scoping review for each topic and developed specific questions within each area that would have the greatest impact on PLWD.^5–8 GEAR 2.0-ADC is now awarding $1.1 million in pilot research funding (using financial support from the NIH, the West Health Institute, and the Emergency Medicine Foundation) over three years to address these priority areas and questions. Findings from the workgroup and the pilot studies are publicly available (www.gearnetwork.org) and can benefit EDs working to improve the care of PLWD.

Figure 1. Transdisciplinary representatives from GEAR 2.0-Advancing Dementia Care.

* Identification categories not mutually exclusive

Geriatric EDs, as noted by Jones and colleagues, also present a valuable resource to improve care for PLWD.¹ To be a certified geriatric ED, the facility and attached hospital must meet numerous structural and process standards to deliver optimal care to older adults. One set of standards adds clinicians with geriatric emergency medicine expertise to provide education for all clinicians to enhance their knowledge and skills. By ensuring clinicians stay abreast of the latest research and best practices, they can better deliver high-quality care. A second set of standards related to the physical environment recommends ensuring a supportive and comfortable environment, such as sensory equipment to assist vision and hearing while reduce noise that can lead to confusion and agitation among PLWD. A third set of standards ensures that rigorous quality improvement practices regularly exist to assess and refine the care delivered. Finally, other standards focus on processes of care and connections to community and care transition resources.⁹

The availability of geriatric EDs and their associated resources is crucial in meeting the complex healthcare needs of PLWD, reducing the likelihood of ED revisits while improving patient outcomes and experiences. By expanding access to geriatric EDs and ensuring adequate staffing and resources, healthcare systems can better serve this vulnerable population and optimize their care. Over the past decade, many resources have been developed and are broadly available for those working to enhance the emergency care of PLWD, including the Geriatric ED Guidelines,⁹ the Geriatric ED Collaborative (https://gedcollaborative.com/), and the ACEP Geriatric ED Accreditation Program (https://www.acep.org/geda).

The study by Jones and colleagues provides valuable insights into the factors contributing to ED revisits among PLWD and begins to highlight the potential benefit of care transition interventions, including the importance of closer follow-up, geriatric referral, and post-ED care coordination with primary care and home care. This work is of great importance and interest to both academic and community partners. In fact, when prioritizing research in emergency care of PLWD, non-ED provider, PLWD, and care partner participants identified the issue of ED to community transitions as the highest research priority.⁷ Future research would benefit from more detailed datasets with a broader range of clinical, functional, organizational, and sociocultural predictors. By incorporating these additional variables, such as cognitive status, caregiver burden, access to care, and social determinants of health, we can gain a deeper understanding of the factors contributing to recurrent ED visits among PLWD. For instance, work that we have previously done has identified that primary care providers do not have the resources to fully diagnose and treat PLWD, leading to their referral to the ED. ^4,10

Future research must involve PLWD and their care partners as well. Qualitative research can provide insights into patient preferences, social and cultural factors influencing healthcare decisions, and the experiences of PLWD and their care partners as well as providing a deeper understanding of the barriers faced with ED transitions. Understanding these challenges can inform the development of effective interventions. Another important cross-cutting research focus is the impact and intersection of structural racism and ageism on emergency care for PLWD. Identifying and addressing any disparities in access to care, quality of care, and health outcomes is crucial for ensuring equitable healthcare for all PLWD.¹² Finally, it is important to note that solutions need to be developed to begin to address these issues, long before the perfect study identifies factors associated with ED revisits. Future interventions should incorporate transdisciplinary care models. Integrating multiple specialties, professions, disciplines, and services can facilitate emergency care and needed follow up, support the coordination of services, and ultimately promote better health outcomes. This is especially timely with the release of July 2023 Biden-Harris Medicare Guiding an Improved Dementia Experience (GUIDE) Model that will create new resources and services for PLWD assessments, care plans, and care coordination.¹³ Now more than ever, there will be the continuous need for transdisciplinary support, generating evidence and solutions to drive cost-effective and patient-centered care when facing the practical challenges of implementing geriatric emergency care.¹⁴

The findings of the study by Jones and colleagues emphasize the urgent need to enhance dementia care both surrounding and during the ED visit to reduce recurrent ED visits among older adults living with dementia. By recognizing the importance of a patient-centered approach, including dementia-friendly practices and geriatric-focused EDs, we can improve patient care, experiences, and outcomes. Identifying individuals at higher risk of recurrent ED visits through a history of previous ED utilization provides an opportunity for targeted interventions, follow-up, and engagement with community support. By implementing these strategies and promoting collaborative care, we can foster a more supportive and effective healthcare system for those living with dementia.