Category: Mental Health
Increased ED Visits May Herald Geriatric Mental Health Crisis
May 24, 2011 (Honolulu, Hawaii) — An
increase in emergency department (ED) visits by elderly patients in
Hawaii is a strong indicator that a national geriatric mental health
crisis is brewing, new research suggests.
A study presented here at the American Psychiatric Association (APA)
2011 Annual Meeting shows a 30% increase over 1 year in geriatric
psychiatric visits that included longer length of stays.
"Our findings are consistent with the notion that elderly patients
with psychiatric symptoms are being underserved … due to various
shortages including cuts in community services, provider shortages of
those specializing in geriatric mental health as well as limited
research funding earmarked for the geriatric population and limited
reimbursement for [mental health] providers," principal investigator
Brett Y. Lu, MD, PhD, medical director of psychiatric emergency services
and director of community geriatric psychiatry, Queen's Medical Center,
Honolulu, Hawaii, told reporters attending a press briefing.
Driving this trend, said Dr. Lu, is the aging baby boomer population.
It is expected that by 2030 the number of Americans aged 65 or older
will double to 70 million. Of these, 30% will develop dementia, which is
frequently accompanied by severe behavioral and psychiatric symptoms,
including hallucinations, wandering, paranoia, and combative and
Given the demographics, "there is bound to be a disproportionate
increase in the number of elderly requiring psychiatric services. With
resources lagging, it is expected there is going to be a crisis in
geriatric mental health as early as 2011 specifically, because that is
the year when the oldest baby boomers will hit age 65," said Dr. Lu.
Typical scenarios that are becoming more common in the psychiatric ED
include elderly patients being dropped off by exhausted or "desperate"
caregivers or family members who need respite and nursing home patients
who have been discharged because of dangerous or combative behavior,
said Dr. Lu. In addition, in Hawaii there is a growing problem of
homeless elderly, who often end up in the psychiatric ED because they
exhibit socially inappropriate behavior.
Furthermore, police often bring delusional or violent elderly
patients to the ED after a 911 call. Dr. Lu noted that between 2009 and
2010, there was a 2-fold increase in such calls made to the Honolulu
police due to elderly patients attacking their caregivers.
Many health care organizations, most notably the Alzheimer's
Association, have begun to warn that this wave of aging baby boomers,
often described as the "Silver Tsunami," along with the concomitant
surge in dementia cases, is threatening to overwhelm healthcare
On the basis of their clinical experience, which suggested increased
utilization of psychiatric ED services by seniors, Dr. Lu and his fellow
investigators suspected this disturbing trend may have already begun
and set out to determine whether their suspicions would be borne out by
For the study, the researchers sampled all visits to the Queen's
Medical Center ED from 2007 to 2011. This ED is the largest and has the
highest volume in Hawaii. It is also the only ED in Honolulu staffed by
psychiatrists 24 hours per day, 7 days a week, and has the acute
capacity of geriatric psychiatric admissions.
Over the 4-year study period, the researchers tracked the number of
visits triaged to the psychiatry section of the ED. They also tracked
length of stay according to age. In total there were 14,402 visits; of
these, 787 were for individuals aged 65 or older.
Year-by-year analysis showed an increasing percentage of psychiatric ED visits by older patients (P
= .01). The largest increases (30%) occurred from 2008 to 2009. In
addition, length of stay for older patients was significantly longer (P < .01), with a median of 403 minutes vs a median of 357 minutes for younger patients.
Mental health resources, Dr. Lu said, have not kept pace with the
growing psychiatric needs of this population, and, as a result, the ED
has become the de facto point of care.
"There need to be policy changes including increased awareness of the
plight of the geriatric population with psychiatric needs. This will
include changes in the implementation of community resources, increasing
incentives for residents considering a career in geriatric psychiatry,
and pharmacological as well as nonpharmacological ways of decreasing
behavioral symptoms," said Dr. Lu.
"Given that there is no FDA [Food and Drug Administration]-approved
medication for any dementia-related [behavioral] symptoms, a lot of
primary care physicians are reluctant to prescribe any medications and
the outcome for that is that patients can get even worse," he said.
Asked by Medscape Medical News to comment on the study,
Iqbal "Ike" Ahmed, MD, a geriatric psychiatrist and board member of the
American Association of Geriatric Psychiatry (AAGP) said the study's
findings are cause for major concern.
Although Dr. Ahmed was not involved in the research, he said he has
worked in the ED at Queen's Medical Center and has experienced this
"The fact is there is not an adequate number of mental health
providers for the elderly — psychiatric or otherwise — so what
happens is family members and caregivers and even institutions like
nursing homes don't know who to turn to get help and out of desperation
they bring people to the emergency department. We can't do anything
about the demographics but we can do something about the availability of
services, not only in Hawaii, but nationally," said Dr. Ahmed.
Dr. Ahmed said the AAGP is working to address the issue at multiple
levels. At the federal level, he said, the AAGP is lobbying to increase
reimbursement for geriatric psychiatry. It is also initiating several
programs to make the subspecialty more attractive by establishing
scholarships for medical students and residents.
"We are also working to make medical students and psychiatric
trainees more aware of geriatric psychiatry as an interesting and
worthwhile field. There is a lot of gratification in taking care of our
seniors. It is also an intellectually stimulating field because it is an
interface of psychiatry, medicine, and neurology so it can be very
intellectually challenging," he said.
The association is also working to improve the educational curriculum
for geriatric psychiatry by increasing the amount of time residents
spend in training, he added.
Importantly, said Dr. Ahmed, the issue is now officially on the national radar. He noted that the Institute of Medicine is conducting a consensus study to determine the mental and behavioral health care needs of Americans over age 65.
Dr. Lu and Dr. Ahmed have disclosed no relevant financial relationships.
American Psychiatric Association (APA) 2011 Annual Meeting. NR08-42. Presented May 17, 2011.