15: Providing Quality Care to Older Adults in the Emergency Department

Adults age 65 years and older comprise 13% of the population, and are projected to grow to approximately 20% by 2030. Although older adults represent 25% of all emergency department (ED) visits, they account for almost half of all ED admissions and 60% of those that are considered preventable. They are more likely to present with urgent and emergent medical conditions, and are 5 times more likely to be admitted. This demographic shift and utilization pattern imply the number of ED visits by older adults will only increase. Models of emergency care must adapt to meet the special needs of this growing population.

Due to the medical and psychosocial complexity of many older adults, the ED is often an appropriate setting for care. However, presentations to the ED are often confounded by atypical features or vague symptoms, multiple comorbidities, and polypharmacy. For this reason, older adults are at high risk for adverse medication events or side effects, cognitive and functional decline, delirium, and falls during and subsequent to their ED visit and/or hospitalization. These clinical factors put older adults at risk for delays in diagnosis, inappropriate and insufficient treatment plans, ED revisit and rehospitalization. Structural aspects of the ED and hospital environment may also increase these risks. In addition, the often complex psychosocial needs require early intensive multidisciplinary case management to improve patient outcomes (Table 15–1). Older adults are often discharged from the ED with unrecognized illness or unmet social 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 functioning 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 adult presenting to the ED and suggests key models of care, structural enhancements, financing, 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, as opposed to managing older adults with complex and atypical presentations, multiple comorbidities, and acute exacerbations of chronic disease. To identify and address older persons’ complex medical and psychosocial needs, emergency providers must account for baseline cognitive and functional limitations, obtain history from and collaborate with multiple sources, and develop a broad differential. Such an intensive case management approach will allow emergency providers to develop appropriate care plans that place older adults’ needs in context.

Models of geriatric emergency care are already being implemented. While their shared goal is to adapt the ED environment and care plans to the needs of older adults, the way the models are implemented will clearly differ. Elements currently include geriatric-friendly structural modifications such as diurnal lighting and noise reduction, universal screening and risk assessment, such as with the Identification of Seniors at Risk and the Timed Up & Go fall risk assessment, enhanced care coordination between ED and community health care providers, and linkages to community resources. No outcome data yet exists for such models of care, and no one approach has been standardized or described as superior. Most ED models of geriatric emergency care adapt these elements from other care settings, and almost all utilize a case-management approach, a collaborative assessment, planning, and care coordination process to improve outcomes for older adults.

In a 2011 systematic review of ED-based case management for older adults, Sinha et al identified 8 operational components that can inform the development of a comprehensive geriatric emergency care model. Key operational components include: ‘implementation of an evidence based practice model; universal screening with validated risk assessment tools; nursing or midlevel clinician-directed geriatric case management; focused geriatric assessments to identify clinical and nonclinical factors that may impact care planning and future health care utilization; ED initiation of care and disposition planning; interprofessional and multidisciplinary work practices between the ED providers, hospital, primary care, and community health care providers; follow-up after discharge to maintain and facilitate care plans; and evaluation and monitoring of outcome measures for continuous quality improvement.’ Furthermore, capacity building through the training of existing providers in geriatric competencies can also enhance care of older adults. This evidence base provides a framework to redesign emergency care for the older adult.

The environment of the ED itself places older adults at risk for iatrogenic complications. The ED is a high-risk setting that can precipitate delirium, disorientation, anxiety, agitation, falls, disrupt the sleep–wake cycle, and impair communication in the visual and hearing-impaired. ED structural modifications can improve patient outcomes and safety. The ideal ED for older adults would feature diurnal lighting and noise reduction to preserve the sleep–wake cycle, as well as appropriate environmental stimuli and cognitive activities to prevent delirium. EDs can also modify flooring, add handrails, and develop appropriate signage to improve safety.

Comprehensive geriatric emergency care offers potential cost-savings for EDs, hospitals, and health systems. Accurate assessment of the value of reducing falls, delirium, and adverse medication events on the cost of prolonged hospitalization, ED revisit, and rehospitalization is essential to make an evidence-based case to support financing a comprehensive geriatric ED. Collaboration with existing hospital and community health care partners to maximize available resources can improve cost savings and make financing geriatric ED interventions feasible.

Emergency care for the older adult involves treating both acute illnesses and injuries, as well as exacerbations of chronic disease. The most common reasons older adults present to the ED include falls, chest pain, adverse medication effects, neuropsychiatric disorders, alcohol and substance abuse, elder abuse and neglect, abdominal pain, and infections. The older adult will often present with vague symptoms, atypical presentations of common diseases, multiple acute conditions, and confounding medical comorbidities. Additionally, up to 40% of older adults will have cognitive impairment that is not readily apparent to emergency providers, further complicating their medical and psychosocial evaluation and disposition. For this reason, innovative approaches are necessary to deliver optimal care to this population.

Universal Screening

Validated screening tools are used in other care settings and can rapidly identify those at high risk for poor outcomes. The Identification of Seniors at Risk (ISAR) (Table 15–2) is one such screening tool useful in the ED. It is comprised of 6 questions that identify older adults who are at high risk for poor health outcomes and intense health care resource utilization. Patients self-report functional capacity, need for assistance, visual acuity, memory, and recent hospitalization, and number of medications. If positive, the ISAR would then be followed by targeted interventions to address patients’ needs.

Falls

Approximately 33% of all older adults will fall annually, and 10% of such falls will result in major injuries. Falls are the leading cause of injury and injury-related death resulting in significant morbidity, disability, and decreased independence and quality of life. ED screening with the Timed Up & Go Test (see Table 15–2) is a simple means to rapidly identify patients at risk for falls with minimal equipment, training, or professional expertise. Identifying risk factors that contribute to falls, such as gait instability and environmental hazards, is important to create safe discharge plans for older adults.

Delirium

Delirium is an emergency medical condition that affects 10% of older adults in the ED and independently carries a high morbidity and mortality. Delirium can prolong hospital length of stay, increase dependence, and is independently associated with poor health outcomes. It is underrecognized and undertreated in the ED. The Confusion Assessment Method (CAM) (see Table 15–2) is a validated tool that has been adapted for use in the ED. CAM-rated delirium is associated with falls resulting in injuries, inadequate pain control, and increased sedative or restraint use, all of which can result in prolonged hospitalization, poor functional outcomes, institutionalization, and increased mortality. This 5-minute test can differentiate delirium from dementia by the presence of mental status changes that are acute in onset and fluctuating in course, characterized by inattention, disorganized thinking, and an altered level of alertness. Older adults identified as having delirium often require admission. If discharged, they are often non-compliant with medications and unable to recall discharge instructions, placing them at risk for ED revisit and rehospitalization.

Cognitive Impairment

Between 16% and 40% of older adults presenting to the ED will have some form of cognitive impairment. In one study, 70% of those discharged home with cognitive impairment had no prior history of dementia and were less likely to have assistance with home care. Thus, the cognitively impaired will require focused ED assessment and multidisciplinary case management to ensure their cognitive limitations do not result in poor health outcomes.

Emergency care will continue to evolve to meet the demographic changes of the 21st century, and is necessary to improve the quality and decrease the costs of health care for older adults. Goals of geriatric emergency care remain the same as for all emergency patients: to provide appropriate, timely, and comprehensive emergency care for acute illnesses and injuries and exacerbations of chronic disease. Universal screening in the ED will evolve and help identify older adults who are at high-risk for falls, delirium, and subsequent functional or cognitive impairment. This, in turn, may improve outcomes and decrease the harms associated with health care utilization. Future goals include improving pain management, access to ED-based palliative care services, and linkages to geriatric primary care, home care, and community resources. Finding alternatives to the use of chemical sedation and restraints will further improve emergency care for older adults. Structural modifications will allow EDs to adapt to the special needs of older adults. An intensive and multidisciplinary case management approach will help emergency providers develop care plans that meet not only older adults’ goals of care but also their psychosocial needs.