ED Boarding Times for Older Adults with Dementia Surged Between 2015 and 2022

The Growing Crisis of Geriatric Boarding in Emergency Medicine

Emergency department crowding represents a significant clinical challenge for older adults, who are predisposed to higher rates of mortality and functional decline during acute care encounters [1]. In patients with cognitive impairment, the high-sensory environment of a crowded department frequently precipitates agitation and hyperactive delirium (an acute neuropsychiatric syndrome marked by restlessness and increased psychomotor activity), which complicates diagnostic workups and management [2, 3]. Although the integration of specialized geriatric services may help mitigate prolonged length of stay, these resources are not universally available across hospital systems [4]. Clinical outcomes are further influenced by the intersection of cognitive status and social determinants of health (the environmental and socioeconomic conditions that impact health risks and outcomes), which can impede equitable care delivery [5, 6]. National trends demonstrate that boarding times (the duration an admitted patient remains in the emergency department awaiting an inpatient bed) are rising, with the most pronounced delays occurring among patients with dementia [7]. A recent cross-sectional analysis now offers fresh insights into the specific geographic and demographic factors influencing these clinical bottlenecks, highlighting an urgent need for operational interventions to protect vulnerable patients.

National Trends in Boarding Duration and Frequency

To quantify the scope of this bottleneck, researchers conducted a cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (a nationally representative database of hospital-based outpatient and emergency care) spanning the years 2015 to 2022. The study focused on adults aged 65 years or older who were admitted to the hospital directly from the emergency department. Out of an estimated 7.05 million eligible patient encounters, the analysis utilized 4.45 million encounters with complete data sets. The authors used linear probability models (statistical tools that estimate the likelihood of a binary outcome, such as whether a patient was boarded or not) to assess associations between the study year, geographic region, rurality, and dementia status. The findings revealed that across the entire study period, 85.2% of eligible geriatric encounters involved boarding for at least 2 hours. While boarding rates remained relatively stable in the mid-80% range from 2015 to 2018, with temporary dips in 2017 and 2020, the frequency of boarding increased significantly toward the end of the study period. Rates rose to 92% during the 2021 to 2022 interval, suggesting a worsening systemic failure to transition admitted geriatric patients to inpatient beds. Specifically, each additional calendar year was associated with a 3.2% increase in the probability of 4-hour boarding (95% confidence interval [CI] 2.4% to 4.0%). Furthermore, the duration of these delays grew annually, as each calendar year was linked to an increase of 15.3 minutes in total boarding time (95% CI 10.0 to 20.0). For practicing physicians, these data points underscore a progressive lengthening of the time older adults spend in a high-stimulus environment, which directly increases the risk for hospital-acquired complications like delirium and falls.

Vulnerability in Dementia and Metropolitan Settings

The data show a stark escalation in wait times over a four-year period, with the burden falling disproportionately on patients with cognitive impairment. In 2018, the mean boarding time was 138 minutes (95% CI 112 to 164). By 2022, this figure more than doubled, as the mean boarding time increased to 343 minutes (95% CI 238 to 448). This shift indicates that even the average older patient now spends nearly six hours in the emergency department after the decision to admit has been made, delaying the initiation of definitive inpatient care protocols. The burden of these delays is exceptionally high for the most vulnerable patients. Among those with Alzheimer's disease-related dementia, the mean boarding time reached 501 minutes (95% CI -20 to 1,022), representing over eight hours of waiting. Within this dementia subgroup, the researchers found that boarding increases were most pronounced among patients aged 75 years or older and those located in metropolitan areas. For clinicians, these findings highlight a critical intersection of cognitive vulnerability and urban hospital crowding. Prolonged boarding in the emergency department is particularly taxing for patients with dementia, as the lack of a quiet, stable environment can exacerbate agitation, precipitate acute delirium, and necessitate the use of chemical or physical restraints. These complications often extend the overall hospital length of stay and worsen long-term functional prognoses, emphasizing the need for targeted triage pathways that expedite inpatient bed placement for cognitively impaired older adults.

References

1. Savioli G, Ceresa IF, Bressan MA, et al. Geriatric Population Triage: The Risk of Real-Life Over- and Under-Triage in an Overcrowded ED: 4- and 5-Level Triage Systems Compared: The CREONTE (Crowding and R E Organization National TriagE) Study. Journal of Personalized Medicine. 2024. doi:10.3390/jpm14020195

2. Fogg C, Griffiths P, Meredith P, Bridges J. Hospital outcomes of older people with cognitive impairment: An integrative review. International Journal of Geriatric Psychiatry. 2018. doi:10.1002/gps.4919

3. Kennedy M, Koehl JL, Shenvi C, et al. The agitated older adult in the emergency department: a narrative review of common causes and management strategies. Journal of the American College of Emergency Physicians Open. 2020. doi:10.1002/emp2.12110

4. Nothelle S, Slade EP, Magidson PD, et al. Association of hospital and health system factors with emergency department length of stay in older adults with dementia. BMC Emergency Medicine. 2025. doi:10.1186/s12873-025-01353-2

5. Chary A, Suh M, Ordoñez E, et al. A scoping review of geriatric emergency medicine research transparency in diversity, equity, and inclusion reporting. Journal of the American Geriatrics Society. 2024. doi:10.1111/jgs.19052

6. Crouch MC, Salazar MBRC, Harris SJ, Rosich R. Dementia, Substance Misuse, and Social Determinants of Health: American Indian and Alaska Native Peoples’ Prevention, Service, and Care. Chronic Stress. 2023. doi:10.1177/24705470221149479

7. Lee S, Gunaga S, Liu SW, et al. Emergency Department Boarding for Older Adults: The Impact of Geography, Temporal Trends, and Dementia Status.. Annals of emergency medicine. 2026. doi:10.1016/j.annemergmed.2026.03.011