International Journal of Gerontology 8 (2014) 56e59

Contents lists available at ScienceDirect

International Journal of Gerontology

journal homepage: www.ijge-online.com

Review Article

The Geriatric ED: Structure, Patient Care, and Considerations

for the Emergency Department Geriatric Unitq
John H. Burton*, Janet Young, Carol A. Bernier
Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA

a r t i c l e i n f o s u m m a r y

Article history: The emergency department (ED) is a unique medical care environment with many challenges. Aging
Received 18 November 2013 populations increasingly use the ED as an acute and chronic treatment site given the accessibility and
Received in revised form resources inherent to emergency provider staff. Given the challenges of emergency medical practice,
6 January 2014
particularly with limited interaction time and awareness for each patient, older patients are at a rela-
Accepted 7 January 2014
Available online 3 June 2014
tively high risk for inadequate or insufficient comprehensive care at these sites. This article discusses a
number of considerations for the development of a unique elderly patient treatment space and care
approach in the modern ED. A geriatric-specific approach should incorporate opportunities to enhance
Keywords:
emergency department,
patient encounters by alterations in the traditional physical treatment space, the approach to medical
emergency medicine, and traumatic evaluations, neurocognitive functional assessment, and decision support for medical care
geriatrics and disposition following the ED visit.
Copyright ! 2014, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. All rights reserved.

1. Introduction patient. Multidisciplinary staff should work in collaboration to

The aging population of developed countries continues to create
a large and disproportionate effect on emergency department (ED)
operations. This trend is expected to continue1,2. Older patients,
generally defined as patients age 70 years and older, have unique
risks, considerations, and needs that must be addressed by the ED
healthcare team in order to realize the greatest potential impact of
a single emergency care visit. Visits to the ED by older patients must
be considered high-risk events because of relatively high rates for
medical errors, adverse drug interactions, patient injury, propensity
to return to the ED, readmission to the hospital, and death as
compared to the ED population at large2e7.
In this review article, we address the growing and persistent
challenges to meaningful evaluation of the older ED patient. We
describe a number of opportunities to improve patient care in this
population when an age-specific treatment area is staffed with
personnel trained and experienced in caring for the geriatric ED
q Conflicts of interest: The authors have no relevant financial interests related to
the material in the manuscript.
* Correspondence to: Dr John H. Burton, Department of Emergency Medicine,
1906 Belleview Avenue, Roanoke, VA 24014, USA.
E-mail address: jhburton@carilionclinic.org (J.H. Burton).
recognize and direct the unique encounters for older patients.
Healthcare institutions have tremendous potential gains for pa-
tients, families, and healthcare services when an integrated geri-
atric ED unit is functional as an integrated component of a larger
healthcare network.
2. A unique ED evaluation and treatment space
Older patients are at increased risk for a number of specific
events during their ED visit in comparison with younger, less
vulnerable populations. Impaired hearing and vision will often
limit site awareness and adaptation of the older patient to an un-
familiar environment. Similarly, baseline confusion, delirium, poor
balance, and spatial awareness increase risk to the older patient of
injuries in the typically designed healthcare facility8,9. When these
common factors for older patient limitations are not considered,
the consequences may be falls, new or worsening delirium, and
increased situational confusion9.
Falls during healthcare visits by older patients visiting the
hospital and ED is a major cause of avoidable harm in the healthcare
setting7,10e12. Significant reductions in injury risk can be attained
by designing treatment facilities and programs to identify high-risk
populations and reduce high-risk areas12,13. Treatment space

http://dx.doi.org/10.1016/j.ijge.2014.01.002
1873-9598/Copyright ! 2014, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
The Geriatric ED
improvements can affect a number of interventions, including the
removal of elevated thresholds for ingress and egress to treatment
rooms. Other contributors to uneven walking surfaces in treatment
areas that can be removed or altered include rugs, carpets, and
textured tiles.
Transport methods and necessity should be reviewed for
consideration for fall reduction. Staff-assisted, low-risk transport
methods within the treatment setting such as wheelchairs, carts,
and gurneys should be readily available. A reduction in patient
transport can also affect risk in this environment. Transport can be
reduced considerably by the use of bedside radiographic and
portable laboratory assessment, which not only prevents this risk of
transport and transfer injuries, but also prevents the patient from
being introduced to an additional new treatment space.
Patient-contact materials and the routine physical handling of
older patients should be carefully considered. Standardized treat-
ment and transfer methods, such as the common prehospital
practice of placing patients into a restrained board-and-collar
setup, should be reviewed for a riskebenefit assessment in this
population2,14. Restraining older patients may exacerbate dementia
and confusion while offering very little potential benefit for
immobilization. Typical nonpadded or minimally padded restraint
materials used for excessive periods can place patients at relatively
higher risks for skin breakdown and ulceration. Commonly used
materials and movement equipment may unintentionally result in
a high propensity for skin tears in frail patients. Items such as
medical tape and adhesive devices are frequently applied to thin,
friable skin and exhibit greater adhesive bond than the intradermal
tensile strength of the older patient’s skin, resulting in skin injury,
improperly positioned drainage catheters, and loss of intravenous
access.
When properly trained for age-specific awareness, medical staff
can have an enormous effect on the ED experience of the older
patient. Hospital and ED administrative commitment to hospital
implementation of geriatric-specific healthcare plays a pivotal role
in improved outcomes for older persons across the healthcare fa-
cility15. Healthcare administrators tasked with elder-specific
training and patient staffing ratios should take into consideration
the increased need for ambulatory support, personal hygiene
assistance, and injury prevention strategies essential to providing
an optimum environment for the geriatric ED patient and his or her
family12. Child life specialists are routinely used in pediatric EDs,
resulting in the nonpharmacologic reduction of pain, amelioration
of anxiety, and the increased healthcare satisfaction for families16.
Whereas geriatric or elder life specialists are recognized for
improved inpatient outcomes, including limiting functional decline
and reducing delirium, their routine use in EDs currently is very
limited17,18. Because older persons are at increased risk for func-
tional decline, even after relatively minor traumatic injuries, every
effort should be made to staff elderly-specific acute care areas with
geriatric life specialists, a decision that may result in decreased
inpatient admissions and unscheduled revisits19,20.
3. A standardized, population-specific medical evaluation
approach
Increasing patient age imparts a higher risk for significant car-
diovascular disease in both chronic and acute conditions during ED
visits for older persons. Stroke and myocardial infarction occur with
increasing frequency as patients age, with the added burden of
increased morbidity and mortality. Acute infectious disease pre-
sentations are common in older ED patients, often presenting in
advanced stage including sepsis. Acute traumatic injuries, often
secondary to falls and other forms of minor blunt trauma, are also
common in geriatric populations. These acute and chronic
57
conditions can be exacerbated by the increased likelihood for
baseline comorbid illnesses in this population8,9.
Chronic medications used for the treatment of common diseases
such as hypertension, diabetes, or hypercoagulability may yield an
impaired or deleterious response in the older patient with an acute
illness or injury. Patient delirium, infections, pain, prescribed
medications, and chronic disease exacerbation may result in acute
modifications of the patient’s functional status9.
Given the increased relative prevalence of chronic serious
illness, in addition to the enhanced risk of life-threatening medical
conditions, it should not be surprising that geriatric ED patients
undergo increased diagnostic testing and prolonged ED throughput
and evaluation times5,21. Similarly, increased patient mortality risk
translates to higher resource utilization and hospital admission in
this population, relative to their younger counterparts.
High risk of serious acute illness or exacerbation of chronic
illness renders a unique opportunity to invoke the routine use of
high-intensity protocols to screen geriatric ED patients4. The high
risk to older patients of impaired perfusion, terminal vascular
events, medication reaction(s), toxicological events, and ischemia
should prompt the utilization of electrocardiogram, and laboratory
screening for cardiovascular injury and metabolic disturbance(s) to
be routine. Fig. 1 displays a modification of standard Advanced
Trauma Life Support (ATLS) evaluation for patients with blunt
traumatic injury in the geriatric patient.
The enhanced risk of illness or drug-related electrolyte and fluid
imbalances should render intravenous access and laboratory
assessment, including toxicological assessment, as commonplace.
Advanced imaging modalities, such as computed tomography (CT),
ultrasonography (US), and magnetic resonance imaging (MRI) have
substantial roles to play in the routine assessment of acutely ill
geriatric ED patients with the common complaints of altered
mental status, abdominal pain, chest pain, and fall-related trauma5.
Limited, goal-specific ultrasound has demonstrated the ability to
rapidly and accurately diagnose the critically ill when extensive
medical history is unavailable22.
A protocolized, chief complaint and history-targeted approach
should incorporate a greater awareness of the atypical presentation
of disease, the complex interrelated acute medical and psychosocial
issues of such patients, and the appropriate use of available
screening and assessment tools. Approaches directed in this
fashion can assist emergency physicians in providing high-quality
care to the aging population.
Geriatric Blunt Trauma
Normal primary survey
(ABCD)
Secondary survey
abnormal
Yes No
Infection/ischemia screening
Continue ATLS guidelines
EKG
Resuscitation, imaging
Lactate
Continue ATLS guidelines
Fig. 1. Modification of ATLS guidelines for the assessment of geriatric blunt trauma.
58
4. A neurocognitive approach to functional assessment
In addition to medical evaluation, geriatric ED patients should
undergo a standardized neurocognitive assessment during their ED
visit. Delirium, dementia, and depression are common illnesses in
this population9. Current emergency medicine clinical practice
does not routinely incorporate cognitive assessment as a compo-
nent of a typical patient evaluation. The pace and challenge of most
ED environments requires clinicians to reduce as much time and
effort as possible from items that extend beyond the basic chief
complaint-driven medical assessment. Elderly patients require an
extended evaluation that often reaches beyond the acute single
complaint to incorporate a more global view of patient health, risk,
and needs.
A number of neurocognitive assessment tools have been eval-
uated in the ED and acute care setting23. These assessments are
often referred to as a comprehensive geriatric assessment (CGA), an
interdisciplinary patient evaluation that determines the medical,
psychological, and functional capabilities of an older individual. The
goal of CGA is to develop a coordinated and integrated plan for
treatment and long-term patient follow-up24,25.
A recent systematic review noted four different functional
assessment tools to be appropriate for use in geriatric patients in
the ED23. The authors emphasize that the function level in geriatric
patients has been identified as a predictor of adverse patient
events, including returns to the ED or hospital following the index
visit. Investigations have also demonstrated that ED patients who
are subjected to CGA are more likely to be alive and in their own
homes at the completion of defined periods8.
Assessment tools for older patients focus on a number of
consistent areas with an emphasis on functional assessment,
cognitive function, resource availability, and resource dependency.
Cognitive and functional impairment are common in geriatric pa-
tients in the ED8. Acute functional impairment caused by illness
would be expected to result in short-term resource dependency,
including needs for assisted daily living. However, many older pa-
tients are resource dependent as a baseline, and therefore an acute
event or exacerbation of chronic condition can significantly in-
crease the need for extrinsic resources to support health and
function in the short and long-term timeframe.
5. A multidisciplinary approach to ED treatment and
disposition
The typical ED treatment team will consist of emergency
physician and nurses, respiratory therapists, radiology technicians,
and support staff. It is unusual for ED staff members to have
geriatric-specific training or approach expectations as a routine
skill in the daily approach to their patients. Although pediatric ED
teams and staff are widely recognized as possessing unique and
essential age-specific preparation, the same concepts are unusually
applied to the geriatric ED population, which surprisingly is larger
and at significantly increased risk of mortality from disease epi-
sodes. To counter the elevated potential for high morbidity and
mortality in older patients, the optimized geriatric ED should
incorporate fellowship-trained geriatric emergency physicians,
geriatric life specialists, ED pharmacists, social workers, and elder-
specific approaches to patient treatment and disposition
decisions26,27.
A geriatric ED should be staffed by personnel specially trained in
the care of older persons. Ideally, an emergency physician uniquely
trained in the evaluation and assessment of older persons in the
acute settings should be evaluating medical needs. Fellowship
training in geriatric emergency medicine specifically focuses on
interdisciplinary teamwork approaches to patient safety for older
J.H. Burton et al.
adults, with particular emphasis on improving the care, outcomes,
and safe discharge practices in the ED. Complementary geriatric life
specialists can provide cognitive screenings, promote cross-
discipline teamwork, and engage family and social supports to
promote evidence-based geriatric outcomes. Designated ED phar-
macy staff can reduce the inappropriate use of medications during
the transition from skilled nursing facilities to hospital-based care,
when medication errors are most likely to occur28.
Routine ED disposition planning tends to focus on immediate,
short-term recovery considerations. Given the elevated risk for
mortality in older patients, a multi-disciplinary, long-term vision
should incorporate planning and integration of end-of-life prepa-
ration including hospice services when appropriate. Placement
considerations should also include rehabilitation, observation, and
assisted living as options in disposition considerations. To fully
explore each of these options, an integrated team should include
personnel from social work, physical and occupational therapy, and
admission/discharge planning disciplines. Optimally, these re-
sources should be integrated into a treatment team approach for a
comprehensive disposition planning process for each geriatric
encounter. These assets should be coupled with post-ED discharge
follow-up assets, such as medical homes, to monitor and adjust the
planning process3,29.
6. Summary
The chief complaint-centered, single-encounter emergency visit
typical of modern EDs is not an optimal setting for delivery of care
to many complex geriatric patients. Although the modern ED im-
aging, laboratory testing, and treatment resources necessitate that
this location is the epicenter for immediate acute illness care,
modifications to the typical patient environment and resource
utilization should be considered in order to optimize opportunities
for outcomes in older patients.
A geriatric-specific approach should include considerations for
changes in the ED physical treatment space, including materials
and space design. Patient evaluation and treatment should incor-
porate many geriatric-specific protocols including comprehensive
screens for ischemia and sepsis. The ED evaluation should incor-
porate a neurocognitive functional assessment. Enhanced resources
available for these patient encounters should include decision
support for medical care, complex pharmacy medication manage-
ment, and social resources for a comprehensive consideration for
disposition and patient placement following the ED visit.
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