Key points

Introduction

The American Geriatrics Society was created in 1942 when visionary medical leaders understood that scientific advances would catalyze historically unprecedented growth in the proportion of aged adults in the next century. Although experts projected three-fold increases in the demand for geriatrics care between 2000 and 2030, most medical schools lacked divisions or departments of geriatrics in the late twentieth century. The John A. Hartford Foundation recognized that caring for an aging world would become the responsibility of all specialties rather than a handful of geriatricians. In response, they provided seed funding to emergency medicine in the 1990s that supported early research around the unique challenges of older adult care in the emergency department (ED) and ultimately catalyzed the subspecialty of geriatric emergency medicine ( Fig. 1 ).

Geriatric emergency medicine historical timeline. ACEP, American College of Emergency Physicians; AGS, American Geriatrics Society; EM, emergency medicine; ENA, Emergency Nurses Association; GSI, geriatrics for specialty initiative; SAEM, Society for Academic Emergency Medicine.

Over the next two decades, the Society for Academic Emergency Medicine (SAEM) and American College of Emergency Physicians (ACEP) created geriatric emergency medicine interest groups. Members of these ACEP and SAEM subgroups subsequently published the concept of a geriatric emergency department followed by quality indicators, resident core competencies, research priorities, and more textbooks. Self-described geriatric EDs (GEDs) began to appear in 2009 with increasing frequency. Unfortunately, the actual geriatric attributes of these EDs varied considerably. As the US population ages and the demand for high-value, low-cost care continues to rise, emergency medicine leaders will need to develop innovative, evidence-based practices for the care of older adults. However, the anticipated insolvency of Medicare by 2026 combined with a paucity of high-quality clinical research demonstrating inarguable benefit or cost-effectiveness will inevitably create tension between early innovators and health care system leaders seeking pragmatic solutions. As this history merges with present health care financing challenges, the subspecialty of geriatric emergency medicine will inevitably play a large part in the next articles of emergency medicine.

Epidemiology

According to the US Census Bureau, adults 65 years of age and older will outnumber children younger than 18 by 2034 for the first time in history. Furthermore, between 2016 and 2060, the US population will increase about 25%. However, the population growth of those greater than or equal to 65 years of age is expected to increase by 92%, those greater than or equal to 85 years of age by 198%, and those greater than or equal to 100 years of age by nearly 620%. The country’s EDs have already begun to appreciate these changing demographics.

Between 2007 and 2017, the total number of ED visits increased by nearly 19%, whereas those by patients greater than or equal to 65 years of age increased by 28%. ^, As the rate of growth of older adults outpaces the US population, the number of visits by this demographic is certain to rise. This rise in older adults seen in the ED will further strain many already overcrowded and underresourced departments, hospitals, and health care systems.

Older adults present to the ED with higher acuity and require more resources during their ED visits compared with younger adults. Moreover, compared with younger patients, the length of stay for older adults in the ED is significantly longer by 20%. When it comes to hospitalization, older adults are nearly seven times more likely to be admitted to the hospital and five times more likely to be admitted to the intensive care unit compared with patients younger than the age of 65.

Despite increased levels of acuity, resource use, and higher need for hospitalization in the older adult population, nearly 20% of these patients present to the ED with a specific self-care problem, such as those related to cognitive and functional impairments or difficulties with activities of daily living. ^, Many of these self-care issues are overlooked or otherwise not considered by ED clinicians who are focused on time-sensitive disease and injury because the traditional emergency model has been to focus on one problem per patient, whereas frail older adults sometimes require a more holistic approach.

Accreditation and care models

In response to many of these unique and unmet needs, a collaborative effort among ACEP, American Geriatric Society, Emergency Nurses Association, and SAEM led to the creation of GED guidelines designed to measurably improve care of older adults. These guidelines highlight six domains for quality improvement: (1) staffing and administration, (2) transitions of care, (3) education of ED staff, (4) quality improvement, (5) equipment and supplies, and (6) geriatric-specific policies and procedures. The subsequent endorsement of these guidelines by multiple emergency medicine organizations worldwide helped to accelerate the development of unique geriatric emergency care models and the more formal recognition of GEDs by health care systems. The development of these specific GEDs has increased considerably since the publication of the aforementioned guidelines with a 2018 paper having identified a total of 83 self-identified GEDs. ^, These guidelines and the subsequent acceleration in GEDs convinced ACEP to begin formal accreditation of hospitals’ efforts to implement geriatric quality improvement efforts into their EDs. GED accreditation is additional evidence of the emergence of unique needs of older adult care and further drives the dissemination of evidence-based geriatric emergency care and practice recommendations. It is hoped these recommendations will offer meaningful benefit to not only emergency medicine practitioners (EMPs), hospitals, health systems, and their community but also to older adult patients.

The development of the GED accreditation process, coupled with the GED guidelines published in 2014, have provided guidance, models, metrics, and motivation for hundreds of health care systems to improve care of older adults seen in the ED at the local level. This local innovation has helped to tailor care models specific to individual ED needs and the communities they serve. These care models may include a separate physical space for older adults, a geriatric champion on the ED staff, geriatric practitioners within the ED, or an ED-based observation unit focused on the care of older adults. As of January 2021, a total of 212 EDs received ACEP accreditation.

Screening tools

An important component of the GED guidelines and ACEP accreditation criteria is a process for identifying age-related vulnerabilities. ED research has consistently demonstrated that neither nurses nor EMPs proactively identify or document dementia, delirium, falls, malnutrition, depression, or other vulnerabilities. Identifying these issues is essential for GEDs because these problems are associated with increased (and perhaps preventable) risk of ED return visits, hospital admissions, and patient dissatisfaction. In response, numerous screening instruments exist to improve care of older adults. Some have been developed specifically for the ED, whereas others, not developed specifically for older adults seen in the ED, have been used in that setting. However, most of these screening instruments are imperfect to identify either high-risk (likelihood ratio+ >10) or low-risk (likelihood ratio- <0.10) subsets despite decades of research. Many theories exist as to why such instruments yield suboptimal accuracy. For example, in deriving vulnerability assessment instruments, such as the Identification of Seniors At Risk, investigators likely need to consider various issues, such as the process of care, ability to identify confounding geriatric syndromes in the ED, standardized definitions of outcomes, pragmatic capacity to predict complex outcomes after brief ED evaluation, and adherence to diagnostic accuracy reporting standards. ^, Pragmatically, neither patients nor clinicians tolerate paralysis by analysis while awaiting instruments that are more accurate. Today’s ED practitioners still need to make treatment and disposition decisions for patients, so they must rely on imperfect screening instruments while researchers strive to derive better instruments ( Fig. 2 ). Table 1 summarizes some of the most common screening tools currently used.

A growing appreciation for the importance of geriatric syndrome screening counterbalanced by the recognition of current instrument imperfections quantified in Table 1 leaves geriatric EDs confronting two paths forward for “vulnerability” screening. Option 1 would cease efforts to derive more accurate instruments than currently exist. Alternatively, Option 2a would adapt prior methods to derive “vulnerability” instruments that incorporate pre-ED data, dynamic re-evaluations throughout ED episode of care, social and system factors, and current disease severity, perhaps using disruptive innovation, such as machine learning. Option 2b could occur simultaneously with 2a, while responding to risk identified by currently available instruments with widely available and generally acceptable interventions.

( Modified from Carpenter CR, Mooijaart SP. Geriatric Screeners 2.0: Time for a Paradigm Shift in Emergency Department Vulnerability Research. J Am Geriatr Soc. 2020:1-4; with permission.)

Table 1

Geriatric ED screening instruments

Domain	Studied Specifically in the ED	Pearls and/or Pitfalls
Falls
Timed Get Up and Go Graded tool for fall risk assessment	Yes	Quick to complete (less than a minute); however, LR+ only 0.99 and LR- 1.04 for patients in the ED.
Chair test Graded tool to assess strength and endurance	Yes	Quick to complete (less than a minute); however, recent evidence suggests poor accuracy (LR+ 1.02 and LR- 0.92) for patients in the ED.
Hendrich II Fall Risk Model Graded risk factor model used to assess risk for falls	Yes	Get Up and Go test is a component of this tool; originally designed as an inpatient fall risk tool with questionable utility in the ED. ED-based sensitivity/specificity unavailable.
Carpenter Tool , Scale that identifies risk for fall within 6 mo	Yes	Identifies low-risk, not high-risk with LR+ of 2.38 and LR- of 0.11 at score >1. Awaits external validation.
Delirium
bCAM , Binary screen for delirium	Yes	Found to have LR+ of 20 and LR- of 0.17. When performed with the DTS, LR+ 19.52 and LR- 0.19.
DTS Binary screen for delirium	Yes	Found to have LR+ of 2.18 and LR- of 0.04. When performed with the bCAM LR+ of 19.52 and LR- of 0.19 in the ED.
4 ATs Graded score for identification of delirium or cognitive impairment	Yes	Rapidly performed in the ED LR+ of 3.23 and LR- of 0.22.
Elder Abuse
Elder abuse suspicion index Binary screen that may raise the concern for abuse	No	Short, 6-question screening tool (completed in <2 min) with LR+ 1.88 and LR- 0.71.
Hwalek-Sengstock Elder Abuse Screening Test Adjunctive survey to supplement clinical concern for abuse	No	External validated tool that may identify elders who would benefit from protective services. , ED-based sensitivity/specificity unavailable.
Elder Assessment Instrument Unscored survey	Yes	Lengthy, 41-question, survey that has been used in the ED settings. , ED-based sensitivity/specificity unavailable.
Functional capacity
Katz Index of Independence in Activities of Daily Living Graded score for patient independence	No	Well established tool that can identify those patients at risk of not being able to complete ADL in the community. There are no formal reliability or validity studies in ED settings.
Vulnerability
Triage Risk Assessment Tool Binary tool used to predict future increased risk of negative outcomes	Yes	5-questions derived to predict multiple outcomes, including 30-d any adverse outcome (LR+ 1.3, LR- 0.67).
ISAR Binary tool used to predict negative outcomes	Yes	A 6-question tool originally designed for deployment in the ED. Prognostic accuracy suggests ISAR is not consistently able to predict risk of ED returns, functional decline, readmissions, or adverse outcomes. For example, LR+ 1.3, LR- 0.56 for any adverse outcome at 30-d.
Frailty
CFS , Overall health summary of patient, single score	Yes	Applicability to ED, given it comments more on the likelihood of death or institutionalization, is less obvious. Area under the curve for 30-d mortality and hospitalizations was 0.81 and 0.72, respectively. In ED, CFS reliability >0.86 for all age groups.
Edmonton Frail Scale Graded scale to identify frail older adults	No	Validated tool for use by nongeriatricians in various settings; however, not studied in the ED.
FRAIL Scale Graded scale to identify frail older adults	No	Validated study that can help clinicians identify patients at risk for decline in health functioning long-term and outside of the ED setting. ED-based sensitivity/specificity unavailable.
Dementia
AMT-4 Binary evaluation for abnormal cognition	Yes	Only validated in European EDs. LR+ 7.7, LR- 0.31.
Caregiver AD8 Binary assessment for cognitive impairment	Yes	Less accurate but the only instrument not requiring patient participation and most sensitive for highly educated. LR+ 2.5, LR- 0.39.
Ottawa 3DY Binary evaluation for cognitive dysfunction	Yes	Less accurate than AMT-4, LR+ 2.3, LR- 0.17.

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