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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #10, #29, #30, #31, #42, #53, #54

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LEARNING OBJECTIVES

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Learning Objectives

  • Gain a perspective on the unique and essential role of the emergency department (ED) plays in the care of older people.

  • Describe key aspects of guidelines for geriatric EDs.

  • List differences in the evaluation of older versus younger patients in the ED.

  • Recognize risk factors for functional decline in older people discharged from the ED.

  • Summarize options to hospitalization for older patients evaluated in the ED.

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Key Clinical Points

  1. Multiple organizations have endorsed guidelines for geriatric EDs that recognize that symptoms may be nonspecific and response to therapy difficult to predict in older ED patients, and the importance of the biopsychosocial model of care in evaluating and managing older ED patients.

  2. The Geriatric Emergency Care Model encourages routine assessment of cognitive and functional status.

  3. Adverse drug events account for more than 10% of ED visits among older patients.

  4. Geriatric EDs are emerging as a new model of care that include environmental modifications and different approaches to evaluating the older patient.

  5. Geriatric Emergency Medical Service trauma triage protocols can improve care for older adults who are injured.

  6. EDs play an important role in managing older patients after natural disasters.

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INTRODUCTION

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The Emergency Department (ED) plays a unique and essential role in the care of the older adult. The ED is open 24 hours a day, 7 days a week, 365 days a year. It provides access to the millions of people who have no other entry point for health care. It gives care to people who have no established community provider and acts as the gatekeeper between the community and the hospital. Older people use the ED at higher rates than other populations, present more often with urgent and emergent conditions, and are more frequently transported by ambulance. In addition, the ED is a major care provider for nursing home residents; one of four nursing home residents is transported to an ED yearly.

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The prevailing model of care in EDs has been established for over 50 years but does not conform well to the needs of the older adult. Based on principles proposed in 1962 by the Committee on Trauma of the American College of Surgeons, EDs are designed for rapid evaluation and treatment of the emergent and urgent needs of acutely ill and injured patients. ED care differs from care delivered in other settings. Typically, there is no preexisting relationship between the patient and the physician. The process rewards speed, the time frame is immediate, and the focus is on the patient’s complaint. It is not friendly to the older patient with complex needs who require thorough assessment and evaluation and whose care process is slow moving.

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In 2013, the American College of Emergency Physicians, the American Geriatrics ...

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