geriatrics
Hospital Care and Older Adults
Emergency Department Care
In 2015, almost 57,000 adults over age 65 visited the emergency department (ED), and 33.6% of those patients were admitted to the hospital, a 20% decrease from the 42% admitted in 2006 ( Emergency department care references ). Older patients tend to be sicker. Some hospitals now have special geriatric EDs staffed with geriatric-trained nurses and physicians, which may be contributing to the reduction in hospital admissions ( A visit to an ED may create more stress for older adults because there are typically no special accommodations for them (eg, quiet rooms, lower beds, extra pillows, indirect lighting). However, some hospital systems are creating special geriatric EDs, which are spaces in the regular ED dedicated to the care of older adults. These geriatric EDs have geriatric-trained physician and nursing staff as well as specialized equipment, such as gurneys with pressure-reducing mattresses that reduce risk of pressure injuries and improved lighting and acoustics to promote vision and hearing. Evaluation of an older adult usually takes longer and requires more diagnostic tests because many older patients do not present with clear-cut or typical symptoms and signs of a disorder. For example, myocardial infarction manifests as chest pain in<50% of patients>80 years of age. Instead, older patients may complain of feeling generally weak or just not feeling themselves. Factors that are not apparent (eg, polypharmacy, adverse drug effects) may affect an older patient’s presentation. For example, a fall may result from abuse, an adverse drug effect (eg, oversedation), hazards in the home, physical problems (eg, poor vision), depression, or a chronic alcohol use disorder. Adverse drug effects account for at least 5% of hospital admissions for older adults. About 30 to 40% of older patients who visit the ED are cognitively impaired but do not have a diagnosis of dementia; in 10%, cognitive impairment consistent with delirium is unrecognized. When indicated (eg, if an older patient is having difficulty with orientation to person, place, or time), a How to Assess Mental Status should be done in the ED. However, a standardized cognitive assessment is appropriate for any older patient visiting the ED. Cognitive impairment affects the reliability of the patient history as well as the diagnosis, increases the risk of delirium during a hospital stay, and must be considered when planning the patient’s disposition. Knowing whether onset of cognitive impairment is recent helps determine whether the impairment should be fully assessed in the ED. Cognitive impairment of recent onset may indicate sepsis, occult subdural hemorrhage, or an adverse drug effect. Suicide risk, fall risk, incontinence, and nutritional and immunization status should be assessed in the ED so that follow-up care can be arranged. Good communication among ED physicians and patients, caregivers, family members, primary care physicians, and staff members of long-term care facilities greatly enhances the outcome of older patients with complicated problems. Advance directives should be promptly and clearly communicated to emergency medicine practitioners. Baseline information from the patient’s personal physician facilitates assessment and management planning in the ED. Reports to the patient’s primary care physician should describe even simple injuries (eg, ankle sprain, Colles wrist fracture) because such injuries can dramatically affect functional ability and independence. Discharge planning may be complex because acute illness or injury may impair functional ability more in older patients (eg, a simple ankle sprain that would be only an inconvenience for a 20-year-old person may be incapacitating for an older person who does not have good support at home). Discharge planning may be improved when nurses, social workers, and primary care physicians are involved. It should include the following: Functional status assessment Strategies to manage problems (eg, depression, alcohol use disorder, impaired functional status) identified during the ED assessment Determination of whether patients can obtain and take drugs as directed and can obtain the necessary follow-up care Assessment of caregiver capabilities (eg, whether Respite Care are needed) Many older patients are hospitalized after they are evaluated in the ED. Occasionally, older patients are brought to the ED by caregivers who refuse to take them home or who leave, abandoning them in the hospital. 1.Sun R, Karaca Z, Wong HS: Trends in Hospital Emergency Department Visits by Age and Payer, 2006-2015. HCUP Statistical Brief #238, 2018. Agency for Healthcare Research and Quality. 2.Hwang U, Dresden SM, Rosenberg MS, et al: Geriatric emergency department innovations: Transitional care nurses and hospital use.J Am Geriatr Soc66(3):459-466, 2018. doi: 10.1111/jgs.15235 