The Geriatric Emergency Department by Kevin Klauer, DO
KEY POINTS AND RECOMMENDATIONS
1. Be conscious of the term “geriatric,” realizing that many individuals over age 65 do not view themselves as elderly or frail and indeed are neither.
2. Vital signs and Injury Severity Score are inaccurate predictors of geriatric trauma mortality and should not be relied upon as sole markers of trauma team activation.
3. Aging populations continue to alter trauma epidemiology with falls becoming a leading etiology of trauma, necessitating all hospitals to reconsider criteria for trauma activation or patient transfer.
4. Understanding that a proportion of older ED patients will experience functional decline and return visits in the following weeks is important, but the unmet challenge is to identify which patients are vulnerable for preventable adverse outcomes.
5. Older adults frequently present with multiple chronic co-morbidities and vague symptoms or with symptoms that are challenging to trace to the underlying acute etiology of the complaint. Emergency medicine providers face the daunting task of maintaining ED throughput while limiting erroneous diagnoses or management decisions and reducing hospital admissions in an era of a frayed primary care safety net. Challenge accepted via the ongoing Geriatric ED Accreditation process, bearing in mind the potential harms of over-testing and the measurable harms of hospital admission for frail elderly patients.
6. Numerous “geriatric syndromes” are routinely under-recognized using the traditional longitudinal focus on one patient-one problem, including dementia and delirium. Disruptive innovation is underway to evaluate alternative approaches to geriatric syndrome recognition, including use of smartphone screening platforms and volunteer-based ED screening programs.
7. An increasingly holistic approach to geriatric emergency care may represent a Pandora’s box of previously unrecognized risks like occult dementia or fall risk. Failing to evaluate pragmatic pathways to screen for prevalent geriatric syndromes will inevitably backfire on busy EDs by missing the opportunity to prevent functional decline, patient dissatisfaction, and return visits that clog the system on a different day.
8. Effective adaptations to emergency care for vulnerable older adults have used geriatric trained nurse screening and post-discharge follow-up to reduce admission rates. Alternatively, simpler programs using scripted nurse call-back of all geriatric patients within days of ED discharge did not reduce return visits.