As dementia rates increase, experts warn hospital emergency rooms are
underprepared
[April 16, 2025]
By DEVNA BOSE/Associated Press and BENJAMIN THORP/Side Effects
Public Media
AURORA, Ill. (AP) — At her mother’s home in Illinois, Tracy Balhan flips
through photos of her dad, Bill Speer. In one picture, he’s smiling in
front of a bucket of sweating beers and wearing a blue T-shirt that
reads, “Pops. The man. The myth. The legend.”
Balhan’s father died last year after struggling with dementia. During
one episode late in his life, he became so agitated that he tried to
exit a moving car. Balhan recalls her dad — larger than life, steady and
loving — yelling at the top of his lungs.
His geriatric psychiatrist recommended she take him to the emergency
room at Endeavor Health’s Edward Hospital in the Chicago suburb of
Naperville because of its connection to an inpatient behavioral care
unit. She hoped it would help get him a quick referral.
But Speer spent 12 hours in the emergency room — at one point restrained
by staff — waiting for a psych evaluation. Balhan didn’t know it then,
but her dad’s experience at the hospital is so common it has a name: ER
boarding.
One in six visits to the emergency department in 2022 that resulted in
hospital admission had a wait of four or more hours, according to an
Associated Press and Side Effects Public Media data analysis. Fifty
percent of the patients who were boarded for any length of time were 65
and older, the analysis showed.
Some people who aren’t in the middle of a life-threatening emergency
might even wait weeks, health care experts said.
ER boarding is a symptom of the U.S. health care system’s struggles,
including shrinking points of entry for patients seeking care outside of
ERs and hospitals prioritizing beds for procedures insurance companies
often pay more for.
Experts also warn the boarding issue will worsen as the number of people
65 and older in the U.S. with dementia grows in the coming decades.
Hospital bed capacity in the U.S. may not keep up. Between 2003 and
2023, the number of staffed hospital beds was static, even as emergency
department visits shot up 30% to 40% over that same period.
Number of hospital beds at issue
For older people with dementia, boarding can be especially dangerous,
Chicago-based geriatric psychiatrist Dr. Shafi Siddiqui said. One
research letter published in June 2024 in the Journal of the American
Medical Association looked at more than 200,000 patients and found long
ER stays could be linked to a higher risk of dementia patients
developing delirium — a temporary state of mental confusion and
sometimes hallucinations.
“People need to be enraged about (boarding),” said Dr. Vicki Norton,
president-elect of the American Academy of Emergency Medicine.
National emergency physician groups have lobbied for years to keep
boarding under control. While they’ve made some progress, nothing
substantial has changed, despite concerns that it leads to worse patient
outcomes.
Dr. Alison Haddock, president of the American College of Emergency
Physicians, said that’s because boarding is a failing of the entire
health care system that manifests in the ER, so solving it demands a
systemic approach.
Federal and state policy decisions made nearly 40 years ago limited the
number of hospital beds, said Arjun Venkatesh, who studies emergency
medicine at Yale. People are now living longer, he said, resulting in
more complicated illnesses.
In 2003, there were 965,000 staffed hospital beds compared to 913,000 in
2023, according to the American Hospital Association. And another JAMA
research letter published in February shows there are 16% fewer staffed
beds in the U.S. post-pandemic.
The ones available may be prioritized for “scheduled care” patients who
need non-urgent procedures, like cancer care or orthopedic surgeries.
Insurance companies pay hospitals more for those surgeries, Haddock
said, so hospitals aren’t likely to move patients into those beds — even
as emergency rooms fill up.
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The Riverside Medical Center Emergency Department in Kankakee, Ill.,
is seen on Jan. 29, 2025, where Nancy Fregeau said she took her
husband, Michael Reeman, three times in 2024. (Benjamin Thorp/WFYI
Public Media via AP)
 Where can people go?
Though long stays in the emergency department are common, there
isn’t good data that tracks the extremes, emergency medicine experts
said.
The Centers for Medicare and Medicaid Services recently ended a
requirement that hospitals track the “median” wait times in their
emergency departments. An advisory group that develops quality
measures for CMS recommended that the agency try to more accurately
capture long emergency department stays. That measure has recently
been submitted to CMS, which can choose to adopt it.
Patients’ families worry that long emergency room stays may make
things worse for their loved ones, forcing some to search for
limited alternatives to turn for support and care.
Nancy Fregeau lives in Kankakee, Illinois, with her husband Michael
Reeman, who has dementia.
Last year, she said he visited the Riverside Medical Center
emergency department several times, often staying more than four
hours and in one case more than 10, before finally getting access to
a behavioral care bed. Riverside declined to comment on Reeman’s
case.
During long waits, Fregeau doesn’t know what reassurance she can
offer her husband.
“It’s hard enough for anyone to be in the ER but I cannot imagine
someone with dementia being in there,” she said. “He just kept
saying ‘When am I going? What’s happening?’”
Since November, Reeman has been going to the MCA Senior Adult Day
Center in Kankakee. Fregeau said Reeman treats the day center like
it’s his job, offering to vacuum and clean, but comes home happier
after having time around other people and away from the house.
In Illinois, there are fewer adult day centers than there are
counties, and other resources for people with dementia are
shrinking, too. A report from the American Health Care Association
and the National Center for Assisted Living found that 1,000 nursing
homes in the U.S. closed between 2015 and 2022. At least 15
behavioral health centers, which are facilities that specialize in
treating mental health issues, closed in 2023.
With fewer places for patients to go after being discharged,
hospital beds are being used for longer, exacerbating the boarding
problem. It’s becoming more difficult to get a specialty hospital
bed, especially when patients’ dementia causes aggression.
That was the case for Balhan’s father, who became increasingly
agitated during his ER stay. Hospital staff told Balhan the
behavioral care unit wasn’t taking dementia patients, so Speer was
stuck in the ER for 24 hours until they found a behavioral health
facility, separate from the health system, that would take him.
While the hospital couldn’t comment on Speer’s specific situation,
Endeavor Health spokesperson Spencer Walrath said its behavioral
care unit typically admits geriatric psychiatry patients, including
those with dementia, but it depends on factors like bed availability
and the patient’s specific medical needs.
Balhan feels that the U.S. health care system failed to treat her
dad as a human being.
"It didn’t feel to me like he was being treated with any dignity as
a person,” she said. “If anything could change, that would be the
change that I would want to see."
___
AP data journalist Kasturi Pananjady contributed to this report.
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