The rapid transformation that no one noticed or acknowledged (even though it was as obvious daylight)

When I started my emergency medicine practice in 2000 (which was not too long ago), on the acute side, maybe 1 out of 10 charts was a patient over the age of 65. In that, maybe 1 chart out of 20 was someone over the age of 90. Well, that is what my impression was. Whether I am right or accurate is something else.But it did not seem like older people was the major explanation of emergency department (ED) volumes. But over the years, things slowly changed. The change was slow or was it? Or was it just that we did not pay attention? Or the fact that we did not want to acknowledge it? Whatever the reason, reality has caught up to us and we are awkward at the very least. Now, in 2021, it feels like over 2 charts out of 10 is someone over the age of 85. It is also not unusual to see patients over the age of 95 or 98. And I see this occurrence at least 3-4 times in an 8-hour shift.

Age is not the issue; it is more that I realize I am not medically prepared to care for these patients. When I think more deeply, it is not so much that I am not prepared; I am mostly not supported by my system that is not prepared.

Despite the alarming change in our patient demographic over this long period, our operating system and habits have not changed for the last 25-30 years. Our hospitals and emergency departments were designed to care for the young with one medical complaint. To be honest, we (the collective us) have done nothing to meet the new demands.Our current emergency departments have not kept up with the times. It is easy to understand how our departments have not kept up with the increase in volumes. But what lies underneath this ill preparedness is the more important fact our departments and systems have not kept up with the needs of our communities. It is a long time coming. It is not a surprise to anyone in healthcare and non-healthcare. The most junior of all policy designers can see it coming miles away. So, why did we do nothing? Companies that fail to innovate, adapt and plan for the future have all left the marketplace. We know of major companies like Block Buster, Sears, Kodak, Polaroid, Compaq, Palm, and Border Bookstore to only name a few.The Canadian healthcare system is a monopoly, so it does not disappear like those major brands. No other players are here to compete. Therefore, it has survived, but severely underperforming (I did not want to use more harsh words here). If it were to compete like all companies we are familiar with, it would not be surprising to see its demise. What it does is cripple along and delivers mediocre service, especially to our most vulnerable population. COVID has just brought to light the mediocre service offering. I am not even referring to the decrepit state of our long-term care system. That deserves a blog all on its own at another time. I am referring to the fact that our emergency departments are providing very transactional episodic care to our elderly that really does not address the acute issues, let alone all the underlying chronic problems of our elderly patients. The emergency department system and set-up is awkward at best to look after those often long neglected needs. I see it daily. I am also a daily contributor to the problem. I am asked to evaluate these frail elderly patients, either from the community or from LTC. I do what I can it the ED. Once the “acute” problem is ruled out, I let them go back to wherever they were from with little support or care afterwards. It is no longer my problem. It is now ‘their problem”. I feel bad every time I do this. I feel horrible. But what else can I do? Before working in LTC myself, I felt “comfortable” sending these patients back. I was really hoping these patients get the follow-up and care they needed. Whether that was going to happen or not was something different. And to be honest, I relied on “others” without truly knowing whether that was going to occur or not. For some reason, I felt that was good enough. I did not know better. Ignorance is bliss. As a family doctor, I would always pick up the gaps of the emergency department. Very often, there was no clinic follow-up, no specialist follow-up. Often, there would be prescriptions without limited use codes. My patients would not get their prescriptions for days to weeks. Often, as a family doctor, I would have no idea what investigations were performed in the ED. With frail elderly patients with cognitive impairment added on to their language barrier, it is most of the time impossible to get it on history from them or their family members who also had the same language barrier. Family members who themselves are overwhelmed with the entire process are no better at providing a coherent story. I cannot blame them. But I will blame the system.

Now, as a LTC physician myself, I see all the gaps originating from the ED visit. I am constantly chasing after information and advocating for my patients to get them the required follow-up they need.Given the fact that, more often than not, with our patients suffering from cognitive impairment, the flow of information is disastrous at best. In addition, once outside the walls of the ED and the hospital, the wait times for the specialist visit or follow-up are deadly (sometimes, my patients die before they got their consultation) long. Often, my patients are returned back to the home despite their needs not addressed acutely. It is not unfamiliar that I have to send my patients back to the hospital 2 or 3 times before an emergency doctor or Internist admits them. But by that time, the condition has deteriorated. Many times, the condition has deteriorated to the point of no return. I have seen this too often. I do not blame the physicians. The emergency physician and the internist are doing their best in a system that is broken and unsupportive. I blame the system. I blame Ageism.

While in the emergency department, our elderly patients are also not treated well. Remember that our EDs are not adapted to the obvious population change over the last 25-30 years. Our EDs are built to deliver care to the young with 1 acute complaint. It is not designed to meet the needs of our elderly with multiple acute and chronic complaints. Our EDs and our training (medical, nursing, pharmacy) are designed to provide the best care for the young. We have not caught up. It is not only a question of physical design and training. It is also a question of mindset. We are most likely the first generation of healthcare providers that have to face the reality of a massive number of elderly people in our population. We are the first generation to have to meet this drastic challengedue to unprecedented change in patient demographic. I can tell you, we are not ready. It is not surprising we do not recognize Ageism. Ageism is the new racism. As a society, we have not dealt with racism to its full extent. As healthcare providers, we have not even begun to recognize Ageism. This is where we need to start.

Notwithstanding the need to build better and bigger EDs that can handle the volume of the future, there is an immediate need to build EDs that can meet the needs of this growing segment of our population. Our EDs and systems are not elder friendly. Our training is not elder focused. Our mindset is elder prejudiced.

There is a willingness now to change all of this. There is a movement in the emergency medicine community. There is an international and national desire to change how things are done for our elderly patients in the ED. In Canada, we have 1 fellowship program led by Dr. Don Melady at Mount-Sinai in Toronto. We have 1 elder-friendly emergency department in Sherbrook, Quebec. There will be more over the next few years I hope.

But we cannot stop at bettering the physical space only. It has to be a “package deal”. What we need is a consolidation and design of a true value chain to enhance the journey of our elderly patients through our healthcare system. Since I am an emergency physician, I can start with the emergency department. The product needs to include integration and collaboration beyond the walls of the emergency department. The care of our elderly patients should be collaborative with our in-hospital and out-of-hospital partners. There should be an outreach component to assure the handing of the baton of care is appropriate and secure. Our training should be enhanced to include geriatric emergency medicine. Our training should touch upon dealing with more chronic issues, medication management (inappropriate drug selection according to BEERS, overdosage, polypharmacy, prescribing cascade), Gentle Persuasive Approach (GPA) technique, and U-first training. First and foremost, our entire system and training curriculum need to eliminate Ageism. Let’s start here to help address the inadequacies of our EDs