By Sara Corvinelli

Graphic design by Athena Li

“Unless you’re a paediatrician or an obstetrician, you’re a geriatrician,” says Dr. Jacques Lee, an emergency physician at Mount Sinai Hospital and Research Chair in Geriatric Emergency Medicine (GEM) at Schwartz/Reisman Emergency Medicine Institute (SREMI). The field of GEM aims to address the unique and unmet needs of older people who seek emergency care.¹ With a growing aging population, patients 65 years and older account for over 25% of all Emergency Department (ED) visits in Canada as of 2014.² The future of emergency medicine demands attention to how well we care for this older population. 

Older people are especially vulnerable to complex care challenges, including falls, delirium, and loneliness, but they are often overlooked in a fast-paced ED. While our population continues to age, the significant demographic shift termed the “Silver Tsunami” is imminent in emergency care. To address this, leaders in GEM are working towards novel solutions and advocacy for age-friendly practices in the ED. Dr. Lee’s research program encourages slowing down and recognizing the person behind the patient. 

Dr. Lee’s path to improving emergency care for older people was shaped by clinical insight and research training. He pursued his medical education at the University of Alberta and completed a residency in emergency medicine at McGill University. Following this, Dr. Lee began his scientific career at Sunnybrook Hospital, where he conducted research in management and measurement of acute pain. In his clinical practice, he noticed the shifting demographics in the ED—a rising number of seniors—and recognized a growing need to further optimize the merging of emergency and geriatric care. In 2018, he joined Sinai Health and was named the Inaugural Research Chair in GEM at SREMI.

Dr. Lee’s research stands on two key pillars, both of which are rooted in the context of caring for aging adults in the ED. The first explores delirium, a serious and common condition characterized by a sudden change in mental state. Delirium is underrecognized by ED staff despite its association with a three-fold increased risk of death.³ The second examines social isolation and loneliness, a crisis that impacts both mental and physical health of older adults, as loneliness is “just as bad for you as smoking a pack of cigarettes a day,” Dr. Lee says.⁴ Delirium and loneliness can be lethal, but are often overlooked as they present with less obvious, more insidious symptoms than other afflictions in the ED.

Delirium affects around 12% of older people who seek care at Canadian EDs.³ It is associated with prolonged hospitalization, loss of independence, and increased risk of cognitive decline and mortality.³ However, delirium remains poorly understood by researchers and clinicians. “After 400 years, no one knows what’s actually going on in the brain when you have delirium,” Dr. Lee says. The real breakthrough lies in understanding what causes delirium, and finding a test that provides an objective diagnosis, thereby increasing recognition rates. 

In pursuit of this breakthrough, Dr. Lee is investigating biomarkers and measurable changes in the body that provide insights into a person’s health. To do so, Dr. Lee and his team are analyzing urine samples of older adults with hip fractures who are at risk of delirium. Urine samples were collected in the ED at baseline, then twice daily to track delirium development. Dr. Lee aims to identify changes in metabolites associated with the onset of delirium in hopes of enhancing our current understanding of the underlying pathophysiology. Discovery of biomarkers associated with delirium onset may enable the development of diagnostic tools for earlier recognition of delirium in the ED. 

In parallel to understanding what causes delirium, there is a dire need to improve its prompt recognition. “The best delirium recognition rate in the emergency department is 50%. If your child brings that report card home, you don’t put it up on the fridge,” says Dr. Lee. To address this, his research team is conducting a multi-centre prospective cohort study, called Better ED Delirium Recognition (BEDDeR), which will compare innovative strategies to recognize delirium in the ED, including the use of tablet games and hospital volunteers administering a simple screening tool. The findings will support the creation of solutions to improve delirium recognition rates. “We must move past, ‘delirium recognition is terrible,’ to, ‘let’s start improving it’,” Dr. Lee emphasizes.

In addition to Dr. Lee’s research on delirium, while at the frontlines of the COVID-19 pandemic, he witnessed the emerging crisis of loneliness in elderly patients. Dr. Lee recounts the story of an older patient who was brought to the ED by ambulance from an assisted living home. He vividly recalls the patient’s stark words: “He looked at me and said, ‘Don’t send me back, doctor. I’m dying of loneliness.’” Dr. Lee realized that social isolation and loneliness are profoundly underappreciated social determinants of health. This inspired the formation of his “How-RU” program of research. Patients recently discharged from the ED that experience social isolation in their current living situation are connected with hospital volunteers for weekly conversations on the phone or via video call. The program addresses loneliness among older patients, and through sub-studies Dr. Lee hopes to advance the development of evidence-based, practical tools to identify social isolation and loneliness.

Whether screening for delirium or loneliness, it is crucial to recognize that older patients are people with stories, not just medical conditions. The ED is prone to the “blue gown effect”, where “[…] an older person shows up, they’re wearing a blue gown, and they all look the same. You don’t know this person is a retired CEO and still active on their board of directors. You lose all that context. That’s what leads to mistakes,” Dr. Lee says. He looks forward to ushering in a new era of person-centred care for older people in the ED. 

Dr. Lee is working toward a future where loneliness screening is routine and delirium recognition rates improve with the use of new tools and cultural change. He hopes, “In the future, asking about loneliness in the ED will be as normal as asking [older patients] if they smoke.” The possibilities are in reach, and Dr. Lee believes that someday, we will “reach a point where we can just dip a urine test strip and know a patient has delirium or is about to get it. That would be a huge step forward.”

To ensure lasting progress, Dr. Lee is passing the torch to the next generation and encouraging more physicians to participate in GEM research. His mission is to make compassionate, evidence-based care for older adults the norm, not the exception. He envisions people saying, “Of course we needed to improve care for older people. It was horrible what we did before.” There may be resistance to change, but the evidence is clear. Dr. Lee hopes for a turning point when screening for delirium, asking about loneliness, and recognizing the person behind the patient become “so obvious that nobody even thinks twice—like washing your hands.”

References: 

1. Melady D, Schumacher JG. Developing a Geriatric Emergency Department: People, Processes, and Place. Clin Geriatr Med. 2023;39(4):647-58.
2. Latham LP, Ackroyd-Stolarz S. Emergency department utilization by older adults: a descriptive study. Can Geriatr J. 2014;17(4):118-25.
3. Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4):443-50.
4. Holt-Lunstad J, Smith TB, Baker M, et al. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015;10(2):227-37.