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Hospitals Re-Think Neurological Services to Meet Geriatric Needs

Joe Cantlupe, for HealthLeaders Media, April 5, 2013

Patients receive clinical assessment within 30 minutes and have 24-hour access to physicians and nurses trained in senior care. One of the most important elements in the care for geriatric patients is having a pharmacist working with the ED staff, which enables staff to coordinate with patients and their families to "provide education as needed and get them into physical therapy if need be," says Howard Dickey-White, MD, the president of University Emergency Specialists and a UH Regional Hospitals ED physician. He says it was important that the hospital not only deal with the presenting emergency issue, but also with the chronic medical conditions and social needs.

The patients are screened for depression, dementia, delirium, or functional decline, and the hospital refers social services, if needed, for psychological concerns. The evaluation includes medication reviews, especially for those who have experienced falls or a sudden acute mental status change. There are also evaluations for potential abuse or neglect. The hospital works with a caregiver to ensure safe transition to home or other healthcare facilities.

"We really felt we had an opportunity and responsibility for due diligence to see what we could do to elevate care. It was not that much of a stretch to see that the Senior ER can be a life-changing event. Often, it was confusing the patients to navigate the system," Delgado says.

"When we have the assessment, the additional risks can be identified, such as dementia and depression and those sorts of things," she adds.

As part of the evaluation and screening for geriatric syndromes such as depression, dementia, or functional decline, the hospitals hire nurses who have designation as Nurses Improving Care for Healthsystem Elders. These professionals are trained to address the challenges of elderly patients in acute care hospitals. The NICHE program is based at the NYU College of Nursing and involves almost 450 hospitals and healthcare facilities.

Success key No. 3: Maturing Minds Clinic

A growing elderly population is virtually a constant in Florida, and at Florida Hospital, leaders are working to unravel some of the mysteries of dementia to reduce readmissions and emergency department use.

Through its Maturing Minds Clinic, the hospital evaluates elderly patients who may have had a misdiagnosis of dementia. The hospital has enrolled at least 100 elderly patients in the program, which uses a multidisciplinary team to assess patient needs. Specifically, patients are evaluated for normal pressure hydrocephalus, which has symptoms similar to dementia but can be reversed with appropriate treatment.

An estimated 375,000 Americans are misdiagnosed with dementia or Parkinson's disease, yet have symptoms caused by NPH. Florida Hospital officials estimate as many as 10% of patients who are diagnosed with dementia may have NPH.

"Some of those symptoms actually mimic dementia symptoms," says Spielman. "If you don't evaluate for it, which can include an MRI or other testing, you may not know what it is. It was important to have a fully integrated team, including neurology specialists in rehab, surgery, neuroradiology, neuropsychology, and nursing." Each member "does a full assessment from his or her specialty standpoint on these patients."

The NPH condition occurs when cerebrospinal fluid accumulates in the brain without a significant increase in pressure. The accumulation may lead to the slow onset and progression of symptoms. Because of the difficulty in diagnosis, it is often untreated for extended periods.

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