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General Principles

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.

Table 15-1.Geriatric emergency medicine high-yield facts.

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, ...

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