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GENERAL PRINCIPLES

Adults age 65 years and older compose 15% of the population and are projected to grow to approximately 20% by 2030. Although older adults represent 15% of all emergency department (ED) visits, they account for almost half of all hospital admissions from the ED. Medicare data reveal that 16% to 26% of hospital admissions are considered potentially avoidable hospitalizations and account for over $5.4 billion annually. Older adults are more likely to present with urgent and emergent medical conditions confounded by multiple medical and psychosocial comorbidities. Older adults are five times more likely to be admitted as compared to younger adults. The demographic shift, increased utilization, and complex clinical presentations present a challenge for managing ED visits by older adults. Models of emergency care are evolving in response to these challenges to meet the particular needs of this growing population.

Older adults present to the ED for urgent and emergent conditions, often with atypical features or vague symptoms, multimorbidities, and polypharmacy, which require extensive rapid workups and coordinated care to determine optimal dispositions. Complex clinical presentations put older adults at risk for delays in diagnosis, adverse events, medication side effects, insufficient treatment plans, cognitive and functional decline, delirium, falls during and subsequent to their ED visit and/or hospitalization, ED revisits, and readmissions. Structural aspects of the ED and hospital environment may also increase these risks. The often complex psychosocial needs require early and intensive multidisciplinary case management to improve patient outcomes. Older adults are at risk of discharge from the ED with unrecognized illness or unmet psychosocial needs, and 20% experience a change in the ability to care for themselves after an acute illness or injury. Complications commonly ensue, with an often rapid decrease in function and quality of life; not surprisingly, 27% will experience ED revisit, hospitalization, or death within 3 months. This chapter addresses the complex needs of the older adults presenting to the ED and suggests models of care, structural enhancements, and clinical care protocols to improve quality care for older adults.

The current model of emergency care is designed to rapidly treat the acutely ill and injured. To identify and address older persons’ complex medical and psychosocial needs, emergency providers must account for baseline cognitive and functional limitations, obtain the past history from and collaborate with multiple sources, and develop a broad differential. Such an intensive patient-centered approach will allow emergency providers to create appropriate care plans that place older adults’ needs in context.

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Ortman  JM, Velkoff  VA, Hogan  H. An aging nation: the older population in the United States. Washington, DC: US Census Bureau; 2014:25–1140. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed March 22, 2020.
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Shenvi  CL, Platts-Mills  TF. Managing the elderly emergency department patient. Ann Emerg Med. 2019;73(3):302–307.  [PubMed: 30287120]
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Weeks  WB, Weinstein  JN. Medicare’s per-beneficiary potentially avoidable admission measures mask true performance. J Gen Intern Med. 2019; doi:10.1007/s11606-019-05354-3.

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