This article explores the challenges and strategies for comprehensive care of elderly patients in emergency departments. It emphasizes the importance of considering geriatric syndromes, cognitive impairments, and mobility issues when making clinical decisions. The development and utilization of geriatric vulnerability scores, such as the Identification of Seniors at Risk (ISAR) score, offer better accuracy in assessing the needs of elderly patients. Comprehensive geriatric assessments and multidisciplinary teams are crucial in providing high-quality care. They consider socioeconomic factors, health literacy, and the unique needs of older individuals. The paper also highlights the importance of post-discharge care and considers subtle illness presentations in elderly patients.

Case study

 The concept of Geriatric Emergency Medicine is not new, but it has gained significance after the establishment of Emergency Medicine departments in medical colleges. Emergency Medicine and Geriatric Medicine are closely related specialities that have grown together. The quality of care in the emergency department can greatly benefit from a standardized approach and measurable outcomes.

However, the existing triaging methods in emergency departments primarily consider disease severity and do not adequately account for the specific challenges faced by elderly patients. To address this gap, there is a need for specialized geriatric vulnerability scores and tools, such as the Identification of Seniors at Risk (ISAR) score and fall risk assessment, to help identify which elderly patients are at higher risk for adverse outcomes. Understanding and accurately identifying high-risk elderly patients can enable hospitals to allocate resources more effectively and consider non-aggressive approaches when necessary. 

Challenges and Strategies for Comprehensive Care for Elderly Patients in Emergency Departments

Elderly patients aged 65 years and older frequently present to emergency departments worldwide with complex care needs that are not amenable to fast-tracking in the emergency department. A comprehensive approach is necessary, as these presentations often serve as sentinel events for older individuals.

Following their arrival at the emergency department, it is essential to promptly assess immediate medical issues, manage risk factors, and anticipate future adverse health outcomes. Emergency medicine physicians rely on accurate and sensitive information about a patient’s functional status to make crucial decisions, such as whether to admit or discharge the patient. The key considerations include determining whether the patient requires additional assistance or measures to ensure their safety in the community.

While acknowledging the valuable work of emergency physicians, it is crucial to emphasize the need to assess elderly patients as a whole rather than relying solely on specific parameters for clinical decisions. Geriatric syndromes, encompassing cognitive impairment, mobility issues, falls, incontinence, and depression, play a significant role in shaping patient care within the hospital. Decisions regarding admission or discharge from the emergency department are primarily based on an evaluation of the patient’s risk of experiencing short-term or long-term adverse outcomes, including functional decline, in-hospital mortality, institutionalization, and readmission within three to 12 months.

Triaging patients is typically done using a color-coded system to determine who requires immediate physician evaluation and which patients can be managed at a less urgent pace. The National Early Warning Score (NEWS) is often utilized for acute presentations, but it may have limitations, and there is a need for refined tools better suited to the elderly population. Similarly, the Emergency Severity Index (ESI) assists in categorizing patients based on clinical status, but this also requires refinement to cater to the unique needs of elderly individuals.

The Identification of Seniors at Risk (ISAR) score is a geographically inclusive tool that gauges the need for evaluation and intervention based on factors like assistance requirements. To address the complexity of elderly patients’ care, the Systematic Evaluation and Intervention for Seniors at Risk (SEISAR) tool has been developed. These tools provide better accuracy and sensitivity compared to traditional triage systems. Comprehensive geriatric assessments such as the Geriatric Giants or the ADRES (Activities of Daily Living, Dependency, Rehabilitation Potential, Evaluation, and Support) criteria can help identify high-risk patients who require specialized evaluation and ongoing care to prevent rehospitalization, morbidity, mortality, and institutionalization. 

Utilizing a geriatric multidisciplinary team to evaluate and manage these patients is essential for providing safe, high-quality care and should continue to evolve with the growing number of older adults seeking care in emergency departments. This team should take into account socioeconomic factors, health literacy, abilities, disabilities, and the unique needs of older individuals. Moreover, the use of specific screening tools helps identify patients who need additional support. These patients may be assessed for functionality and may require assistance with mobility, nutrition, and other activities of daily living. 

Collaboration with home care facilities can ensure a safe environment upon discharge, and patients and their families must be educated about post-discharge care. Lastly, it is essential to consider the subtle presentations of illness in elderly patients and not solely rely on acute symptoms to evaluate their condition. Their unique needs require a thoughtful and comprehensive approach to their care.

A Patient-Centered Approach for Revamping Healthcare Systems for Comprehensive Geriatric Assessment

To enhance the effectiveness of patient assessment, we should consider incorporating disease-specific prognostic instruments into the overall evaluation. This approach goes beyond merely addressing individual diseases or their interactions, as it takes into account the possible drug interactions and acute presentations specific to each patient’s unique circumstances. It is essential to consider the patient’s preferences and choices when making healthcare decisions, recognizing that judgment should come from the patient and their family. Collaboration among interprofessional team members is vital to ensuring alignment with the patient’s goals, emphasizing the importance of high-quality discharge education, whether it originates from the emergency department or elsewhere. The primary objective is to ascertain that the patient is safe, adequately nourished, properly medicated, and mobile. Additionally, we must ensure that the patient can return to their community with confidence, considering the potential adverse outcomes that elderly adults might face. By examining the environment and seeking assistance from NGOs and other relevant parties, we can provide better care for these patients. It is crucial to acknowledge that the most vulnerable patients stand to lose the most when healthcare systems are unsafe or inadequately designed to address their specific needs. Consequently, it is imperative to reevaluate our healthcare systems to accommodate the growing population of elderly individuals who require geriatric care. 

Just as we have specialized units like pediatric ICUs and trauma ICUs, establishing dedicated geriatric units, particularly in emergency departments, may be necessary. A radical redesign may be required to deliver safe, sustainable, and patient-centered care, recognizing the debt of gratitude we owe to this elderly population. To implement acute geriatric assessment effectively, it is essential to have a dedicated interface between geriatric care and the emergency department. This interface should include not only beds but also a specialized team with the capability to address the unique needs of geriatric patients, even amid chaotic emergencies. Access to social workers within the emergency department can help assess factors such as the patient’s financial situation and develop strategies for safe alternatives to hospital admission. Collaboration with the patient’s family is pivotal, as they can provide valuable insights into the patient’s history, preferences, and needs. Holistic evaluation of the patient should be the central focus, with tools serving as aids rather than replacements for comprehensive patient assessment. While acknowledging the commendable work of healthcare professionals in managing elderly patients within existing systems, it is essential to rethink whether we need a dedicated geriatric track or specialized facilities within healthcare settings. This consideration stems from the recognition of the unique challenges faced by elderly patients and the need to provide tailored care for this vulnerable segment of the population.

Conclusion

Comprehensive geriatric assessment is vital for elderly patients in emergency departments, highlighting the need for tailored care. Specialized tools, multidisciplinary teams, and proactive disease-specific approaches are crucial for their well-being. A patient-centered focus, incorporating prognostic instruments, preferences, and collaboration, is key. High-quality discharge education and post-discharge care support their return to the community with confidence. Failing to address the unique needs of the most vulnerable patients is detrimental. Healthcare systems must undergo a radical redesign to accommodate the growing elderly population, potentially by establishing dedicated geriatric units within emergency departments and enhancing their quality of care.