At emergency departments, more patience for elderly patients

SINGAPORE — In the last three years, Mr Fong Kam Saw, 82, has made 13 to 14 trips to the emergency department (ED) for falls, breathlessness and fever.

Due to multiple chronic conditions including chronic obstructive pulmonary disease, a seemingly minor infection could prove fatal.

His most recent visit last December for diarrhoea turned out to be salmonella poisoning.

“Who likes going to the emergency department but what can we do (about it)? When we take my dad to see a general practitioner, he always ends up being referred there because of his age and long history of medical conditions,” said his daughter Agnes Fong, 60.

Ms Fong and her siblings joke that he would probably have accrued sufficient miles for an around-the-world trip, had he flown on an airline as frequently. But Mr Fong’s regular trips to the ED are no laughing matter.

The proportion of elderly patients at hospitals’ EDs has risen in the last decade, experts told TODAY.

Like Mr Fong, many of them are caught in the revolving door of emergency room visits and re-admissions – a trend not expected to ease anytime soon given Singapore’s ageing population, although the authorities are actively tackling the issue.

Older adults aged 65 and above now form up to 21 to 40 per cent of ED users, using proportionally more ED services than any other age group, said Adjunct Associate Professor Amila Punyadasa, organising chairperson of The Society for Emergency Medicine in Singapore’s 2018 Annual Scientific Meeting that took place last month. Geriatric emergency medicine was among the topics discussed.

The proportion of elderly patients seen at the Singapore General Hospital’s (SGH) ED has grown from one in four in 2007, to one in three last year, said Dr Juliana Poh, a consultant at SGH’s department of emergency medicine. This translates to an increase of about 25 per cent of elderly patients seen per day, from 94 to 118 patients, over the last decade.

At Tan Tock Seng Hospital (TTSH), elderly attendances at its ED have grown by about 20 per cent in the last 10 years. The department handles about 450 attendances per day and seniors now form about 30 per cent of the cases, up from about 25 per cent a decade ago.

At the National University Hospital (NUH), the average ED attendances of seniors has grown from 1,850 per month in 2016 to about 2,060 last year.

Elderly ED patients tend to have more diagnostic tests, longer stays and higher admission rates than younger patients, said Adj Assoc Prof Punyadasa, a senior consultant at Ng Teng Fong General Hospital’s emergency medicine department.

“Ten years ago, if we admitted 100 patients per day, 40 of them were elderly. Now, the elderly make up almost 55 per cent of ED admissions. And for every two patients we discharge, one will come back within 12 months, which is similar to international statistics,” said Dr Foo Chik Loon, senior consultant at TTSH’s department of emergency medicine.

SLOWING DOWN FOR THE ELDERLY

Elderly patients are generally more challenging to treat than younger ones, due in part to their multiple chronic conditions and lower body reserves, which mean that even minor ailments like diarrhoea or a fall can be potentially life-threatening.

“Elderly patients tend to be of higher acuity, meaning they are assigned Priority 1 or Priority 2 in the ED. More time and patience are required to elicit history from patients and their caregivers, and a detailed systematic examination is a must,” said SGH’s Dr Poh.

Their symptoms tend to be non-specific or atypical – giddiness, breathlessness, weakness and fever, for instance – making it hard for doctors to pin down a cause.

For example, in a heart attack, an elderly person may experience breathlessness, falls or confusion instead of the classic symptom of crushing chest pain, the doctors said.

“Sometimes it may take a few days before you can pinpoint the cause. We spend more time and resources on them to get the complete picture. It’s very different from younger patients who tend to present with very straightforward conditions,” said Dr Foo.

There are also other considerations. “Generally, if an elderly person is sick for two days for instance, he will need double the time to recover. We need to make sure there’s someone there to help them recover or it may be unsafe for the elderly to be discharged,” he said.

“In younger patients, we don’t usually ask questions like who they live with and if there is someone to care for them at home.”

Hospitals have begun adapting to the surge in elderly ED users.

In the last decade, TTSH has revamped its ED facilities, staff training and basic care.

For instance, its ED boasts larger elder-friendly signages, colour contrasts between the walls and floors, as well as less glaring lights.

A care nurse is on hand to regularly remind elderly patients to visit the washroom or accompany them there to prevent falls, which is a major issue in every ED, said Dr Foo.

TTSH was the first hospital here to establish geriatric emergency medicine (GEM), and over 100 nurses and doctors have undergone the training in the last decade.

Prior to discharge, elderly patients undergo a geriatric screening conducted by a GEM-trained nurse to ascertain if they are well enough to go home. About 10 per cent of patients originally planned for discharge end up being admitted, said Dr Foo. NUH has a similar system in place.

“When elderly patients come into the ED for falls or fractures for instance, we treat them but in reality, they have many other underlying issues such as change of medication, lack of support at home, vision issues. If we treat just the fractures but don’t address other hidden or unmet needs and discharge them, the patients will come back again,” said Dr Foo.

In 2015, the SGH introduced a new care model with the Acute Medical Ward (AMW), which provides patients with more rapid multi-disciplinary care for certain conditions.

The short-stay 67-bed ward receives about 20 to 25 patients per day from the hospital’s ED, half of whom are over 70 years old.

Pneumonia and lower respiratory tract infection, cellulitis (a bacterial skin infection) and skin soft-tissue infection and urinary tract infections were among the top diagnoses at the AMW in 2016, said Dr Tharmmambal Balakrishnan, consultant at SGH’s department of internal medicine.

Patients at the ward are generally discharged 2.4 days earlier and this has freed up an average of five beds a day.

“On average, the AMW has resulted in 20 per cent savings from the average patient bill. Overall, early discharge with AMW benefits elderly patients and may help to prevent deconditioning (physical decline) as they are more likely to go home following acute illness if they are admitted to AMW,” she said.

Most of the EDs here have follow-up care programmes in place.

For instance, the NUH emergency medicine department works closely with its Transitional Care Team to coordinate medical care for the elderly patients after discharge.

Elderly patients who are well enough to be discharged but who still require rehabilitation are identified by the clinicians for transfer to the community hospital, said Dr Sim Tiong Beng, a senior consultant at NUH’s emergency medicine department.

GREATER ROLE FOR GENERAL PRACTITIONERS

More can be done to meet the needs of ED users and stem the tide of re-admissions, the experts said.

“One of the unfortunate gaps is that many seniors here don’t usually have that one family physician who knows their medical condition and history well enough,” said Dr Foo.

“Compare this to countries like Australia where primary care physicians, who make house calls, are usually elderly persons’ first point of contact when they are unwell, and going to the hospital becomes their last resort,” he said.

There are also limitations with the existing National Electronic Health Record (NEHR) system, the national database of patients’ medical history established to make doctor visits more efficient. As of last November, only 3 per cent of doctors in private practice were submitting data, causing a huge gap in records.

But legislation will be tabled this year to make it compulsory for all doctors to do so.

“This is a system that needs to be improved if we want to move primary care away from the ED to the general practitioner, who can actually handle many of the Priority 3 cases. For the elderly especially, it will be more convenient to consult their nearby general practitioner rather than make a trip to the hospital,” said Dr Poh.

Patients with acute symptoms who are in a stable condition and are able to walk are usually considered Priority 3 cases.

“If the management plan for less complicated conditions is clearly spelt out in the patient’s records, and the platform is able to support communication among the various health practitioners, we will be able to get a better picture of the patient’s healthcare journey and improve healthcare. This means patients may be able to avoid that trip to the hospital specialist outpatient clinic or emergency department,” added Dr Poh.

Mr Fong’s children are keeping their fingers crossed for now.

During the festive season in 2016, he was rushed to the ED after feeling breathless and nauseous, and subsequently developed a severe blood infection that almost killed him.

“We’re taking measures, such as ensuring his food is thoroughly cooked and he gets ample rest, to ensure an ‘uneventful’ Lunar New Year,” said Ms Fong.