The Geriatric Emergency Department

Abstract

With the aging of the population and the demographic shift of older adults in the healthcare system, the emergency department (ED) will be increasingly challenged with complexities of providing care to geriatric patients. The special care needs of older adults unfortunately may not be aligned with the priorities for how ED physical design and care is rendered. Rapid triage and diagnosis may be impossible in the older patient with multiple comorbidities, polypharmacy, and functional and cognitive impairments who often presents with subtle clinical signs and symptoms of acute illness. The use of Geriatric Emergency Department Interventions, structural and process of care modifications addressing the special care needs of older patients, may help to address these challenges. J Am Geriatr Soc 55:1873-1876, 2007. Key words: emergency medicine; geriatric health services F or most of the 20th century, the growth of the population aged 65 and older has far outpaced other age groups, and this trend will continue well into the 21st century. As a result of this demographic shift and an increase in longevity resulting from changes in lifestyles, health, and medical advances, one in five Americans will be aged 65 and older in 2030. By 2050, nearly 25% of Medicare beneficiaries will be aged 85 and older. 1 As the U.S. population continues to age, the healthcare system will need to face and embrace the challenges of caring for older adults. Care for elderly people is increasingly being sought in emergency departments (EDs), where older patients typically present with complex medical conditions, stay longer for more-extensive diagnostic testing and treatment regimens, and require special needs during their visit. The use of Geriatric Emergency Department Interventions may help to address these challenges and thereby improve the quality of care of elderly people in the ED. OLDER ADULTS AND THE EDAlthough the aging population will affect all areas of health care, the ED is likely to be disproportionately affected. In 2002, approximately 58% of 75-year-olds had at least one visit to an ED, as compared to 39% of those of all ages, and ED use increased with increasing age.3 Once in the ED, older patients are more likely to have an emergent or urgent condition, be hospitalized, and be admitted to a critical care unit. 4 In addition, older patients are also more likely to receive a greater number of diagnostic tests, spend longer times in the ED, and have higher charges for their ED services than younger patients. 5The Disconnect Between Emergency and Elder Care The ED is a unique environment where highly specialized care is delivered to the acutely ill and injured and safety net care is provided to disenfranchised and vulnerable populations. Although studies have begun to demonstrate disparities in care for older adults, most have focused on specific diseases or conditions 6 and have not looked specifically at how ED care and environmental factors may be associated with patient outcomes. Nonetheless, there are indications that the cu...

Particular Emergency Department for Seniors

“…So, seniors require not only longer admissions [8,10], but more care time than the other age groups. Because of the unusual and atypical presentation of diseases in the elderly, they may need complicated, time-consuming clinical and para-clinical investigations.…”

“…The other possible problem is the amount of day light. As EDs are usually in basement or first floor, and also due to some safety issues, there are not enough windows [8]; therefore, the light of the EDs are supplied by fluorescence lamps which can lead to delirium or exacerbation of dementia in the elderly [22]. Then, the environment of the current ED may cause some new health problems, such as dementia or delirium, for seniors who have referred to EDs in order to receive care and cure for other disorders.…”

“…In addition, longer admission time may complicate their problems because of the environmental factors and mismatched devices. In fact, lying on a usual beds and mattresses for a long time in EDs may result in bed sores in seniors [8]. Another architectural design of the EDs relates to the floors that are often soft and smooth in order to be easily and frequently cleaned, yet these kinds of floor may cause slipping or falling in the elderly.…”

“…Another architectural design of the EDs relates to the floors that are often soft and smooth in order to be easily and frequently cleaned, yet these kinds of floor may cause slipping or falling in the elderly. Since they usually suffer from inaccurate balance, they easily slip over these floors [8], and bone fractures superimpose their health problems. Bone fracture is a complicated health problem in the elderly, so such preventable accidents can result in serious morbidities or mortality [8,24].…”

Structural Quality Indicators to Support Quality of Care for Older People With Cognitive Impairment in Emergency Departments

“…For example, the increased risk of developing delirium 4,5,7,19 may call for modification of the complex ED environment to a quiet setting with implemented cognitive screening tools and orientation cues, such as visible daylight, clocks, calendars, or familiar objects, to prevent this acute confusional state. 14,20,21 Donabedian 22 defined structure, along with process and outcome, as a fundamental aspect of quality of health care. Care structure is concerned with constant organizational factors of care.…”