Table 3.

Geriatric EM Resident Domains and Competencies

The graduating EM resident, in the context of a specific older patient scenario (real or simulated), must be able to:
Domain	Competency
I. Atypical presentation of disease	1Generate an age-specific differential diagnosis for elder patients presenting to the ED with general weakness, dizziness, falls, or altered mental status. 2Generate a differential diagnosis recognizing that signs and symptoms such as pain and fever may be absent or less prominent in elders with acute coronary syndromes, acute abdomens, or infectious processes. 3Document consideration of adverse reactions to medications, including drug–drug and drug–disease interactions, as part of the initial differential diagnosis.
II. Trauma including falls	4In patients who have fallen, evaluate for precipitating causes of falls such as medications, alcohol use/abuse, gait or balance instability, medical illness, and/or deterioration of medical condition. 5Assess for gait instability in all ambulatory fallers; if present, ensure appropriate disposition and follow-up including attempt to reach primary care provider. 6Demonstrate ability to recognize patterns of trauma (physical/sexual, psychological, neglect/abandonment) that are consistent with elder abuse. Manage the abused patient in accordance with the rules of the state and institution. 7Institute appropriate early monitoring and testing with the understanding that elders may present with muted signs and symptoms (e.g., absent pain and neurologic changes) and are at risk for occult shock.
III. Cognitive and behavioral disorders	8Assess whether an elder is able to give an accurate history, participate in determining the plan of care, and understand discharge instructions. 9Assess and document current mental status and any change from baseline in every elder, with special attention to determining if delirium exists or has been superimposed on dementia. 10Emergently evaluate and formulate an age-specific differential diagnosis for elders with new cognitive or behavioral impairment, including self-neglect; initiate a diagnostic workup to determine the etiology; and initiate treatment. 11Assess and correct (if appropriate) causative factors in agitated elders such as untreated pain, hypoxia, hypoglycemia, use of irritating tethers (defined as monitor leads, blood pressure cuff, pulse oximetry, intravenous access, and Foley catheter), environmental factors (light, temperature), and disorientation.
IV. Emergency intervention modifications	12Recommend therapy based on the actual benefit to risk ratio, including but not limited to acute myocardial infarction, stroke, and sepsis, so that age alone does not exclude elders from any therapy. 13Identify and implement measures that protect elders from developing iatrogenic complications common to the ED including invasive bladder catheterization, spinal immobilization, and central line placement.
V. Medication management	14Prescribe appropriate drugs and dosages considering the current medication, acute and chronic diagnoses, functional status, and knowledge of age-related physiologic changes (renal function, central nervous system sensitivity). 15Search for interactions and document reasons for use when prescribing drugs that present high risk either alone or in drug–drug or drug–disease interactions (e.g., benzodiazepines, digoxin, insulin, NSAIDs, opioids, and warfarin). 16Explain all newly prescribed drugs to elders and caregivers at discharge, assuring that they understand how and why the drug should be taken, the possible side effects, and how and when the drug should be stopped.
VI. Transitions of care	17Document history obtained from skilled nursing or extended care facilities of the acute events necessitating ED transfer including goals of visit, medical history, medications, allergies, cognitive and functional status, advance care plan, and responsible PCP. 18Provide skilled nursing or extended care facilities and/or PCP with ED visit summary and plan of care, including follow-up when appropriate. 19With recognition of unique vulnerabilities in elders, assess and document suitability for discharge considering the ED diagnosis, including cognitive function, the ability in ambulatory patients to ambulate safely, availability of appropriate nutrition/social support, and the availability of access to appropriate follow-up therapies. 20Select and document the rationale for the most appropriate available disposition (home, extended care facility, hospital) with the least risk of the many complications commonly occurring in elders during inpatient hospitalizations. 21Rapidly establish and document an elder’s goals of care for those with a serious or life-threatening condition and manage accordingly. 22Assess and provide ED management for pain and key nonpain symptoms based on the patient’s goals of care. 23Know how to access hospice care and how to manage elders in hospice care while in the ED.
VIII. Effect of comorbid conditions	24Assess and document the presence of comorbid conditions (e.g., pressure ulcers, cognitive status, falls in the past year, ability to walk and transfer, renal function, and social support) and include them in your medical decision-making and plan of care. 25Develop plans of care that anticipate and monitor for predictable complications in the patient’s condition (e.g., gastrointestinal bleed causing ischemia). 26Communicate with patients with hearing/sight impairments, speech difficulties, aphasia, and cognitive disorders (e.g., using family/friend, writing).

NSAID = nonsteroidal anti-inflammatory drug; PCP = primary care provider.