Patients awaiting psychiatric hospitalization are facing increased time “boarding”, resulting in more adverse events and overcrowding. At the same time, the number of geriatric patients presenting with psychiatric emergencies has also increased and these patients are at higher risk of prolonged boarding (Rhodes, 2016), further raising the risk of adverse events in a population with more medical comorbidities and frailty. Geriatric patients are at higher risk of falls, more prone to delirium, and more susceptible to medication side effects such as orthostatic hypotension, extrapyramidal symptoms, dysphagia, and over sedation. These side effects can impair functional ability, especially without systemic monitoring or preventive measures.
Methods
Retrospective EMR review of patients over age 65 who underwent behavioral health evaluation in the ER at two community hospitals in Massachusetts. Data points include diagnosis, disposition, length of stay, initiation of new medication, signs of functional decline, and physical therapy intervention.
Results
Data analysis is still pending and this is a preliminary report. In 2023-2024, there were 764 behavioral health evaluations, with 108 for patients over age 65. Average age was 76. 47 patients boarded more than 24 hours, with an average of 40 hours. 68 patients came from home, while 32 came from nursing facilities. 54 patients were discharged to inpatient psychiatry and 31 to home. 61 psychiatry consults (79%) were called, with 37 for patients with prolonged boarding. 18 patients (38%) had some level of functional decline, with 15 being dementia patients. 16 of these patients were started on psychiatric medication. 8 physical therapy consults were called.
Discussion:
The emergency room is not ideal for geriatric patients and poses many risks. Patients don’t have the same level of nursing care as they would on a medical floor, are typically not allowed to leave the room or ambulate freely, and typically have visitor restrictions. These are all factors that increase the risk for functional decline (Hirsch, 1990). Patients also don’t get ancillary services, such as physical therapy. In this study, we found that 38% of boarding patients had functional decline noted, with some eventually requiring medical admission. These patients were not routinely monitored for functional decline outside of psychiatry assessments, and most patients received limited assistance with maintaining mobility or other ADLs.
Conclusion:
This study reveals that boarding for geriatric patients awaiting psychiatric hospitalization is prolonged with the potential for producing functional decline that sometimes even necessitates medical admission. This risk can be compounded when they are managed with psychiatric medications. Consulting psychiatrists should take this into consideration when managing patients and may have to think more about when to recommend interventions to maintain functional status.
References:
Hirsch, C.H., Sommers, L., Olsen, A., Mullen, L. and Winograd, C.H.,The Natural History of Functional Morbidity in Hospitalized Older Patients. Journal of the American Geriatrics Society, 1990;38: 1296-1303.
Rhodes SM, Patanwala AE, Cremer JK, et al. Predictors of Prolonged Length of Stay and Adverse Events among Older Adults with Behavioral Health−Related Emergency Department Visits: A Systematic Medical Record Review. The Journal of Emergency Medicine. 2016;50(1):143-152.
Presentation Eligibility: Not previously published or presented
Diversity, Equity, and Inclusion: This presentation reflects the unique vulnerabilities of the elderly population with mental health emergencies and highlights how they may need to be better supported and advocated for in the emergency room setting.
