Geriatric Emergency Medicine: Providing Older Missourians with the Care They Need and Deserve

Abstract

Emergency care of older adults evolved in an effort to meet the needs of our aging population. The pace of improving the quality and cost-effectiveness of emergency department (ED) care for older adults is accelerating with the development of Geriatric Emergency Department Accreditation (GEDA) and research initiatives forged by the Center for Leading Innovation and Collaboration (CLIC) and Geriatric Emergency care Applied Research (GEAR). The innovations of two Missouri EDs are highlighted, including how each approached fall risk and quality improvement efforts for aging populations with multimorbidity. Additional work is needed to accommodate this growing population and implement sustainable solutions.

“One of the paradoxes of the 2020 presidential campaign is that while many of the candidates are in their eighth decade of life, fundamental issues associated with the increasing age of American society are still receiving relatively little attention from the public, the press, and the politicians themselves. In 2031, the oldest baby boomers will turn 85, entering the land of the ‘old old,’ and facing exponentially higher risks for dementia, serious physical disabilities, and long-term dependency.”

-Susan Jacoby, NY Times December 23, 2019

Introduction

It is estimated that 10,000 baby boomers turn 65 every day, including a significant proportion in Missouri. According to the census bureau, in 2018 there were 52 million Americans 65 years of age or older, representing 16% of the U.S. population. By 2060 there will be 95 million > 65 years old, or 23% of the population. From 2002 to 2012 the number of geriatric ED visits increased by 42%.¹ In 2012 there were 43 million geriatric ED visits, with an estimated growth to 83 million visits by 2050.² In their last month of life, approximately half of American adults > 65 are seen in the ED, with 75% visiting an ED in their final six months.³ As previously detailed in this journal, the foresight and innovation of Missouri physicians are central to the story of geriatric emergency medicine.⁴

Because of increasing life expectancy and the growth of our older adult population, the American Geriatric Society (AGS) was founded in 1942.⁵ Geriatrics emerged as a subspecialty of Internal Medicine and Family Medicine, but it was not until 1988 that geriatric board certification was implemented. Geriatric practice included distinguishing between normal aging and disease, as well as recognizing that those over 65 are often more vulnerable to acute injury, at a greater risk of falling, at higher risk for polypharmacy and medication interactions, more likely to experience delirium, and often present with non-specific symptoms.⁶ It is important to keep in mind that the ED is often the first point of contact for older adults. For some, the ED might be their only resource for receiving healthcare. Benefits of developing a geriatric ED are multifactorial, and include screening for geriatric syndromes, concurrent management of the acute illness or injury, and prioritization of shared decision-making, assuring alignment with the patient’s goals.⁶

Adapting Graduate Medical Education for an Aging World

In order to improve care for those over 65, medical student competencies were developed by transdisciplinary stakeholders in 2009, identifying 26 requisite areas.⁷ Consequently, medical school curricula evolved to include “The Geriatric 5Ms” (Mind, Mobility, Medications, Multicomplexity, and Matters Most),⁸ which were reviewed and updated in 2021 (Association of Directors of Geriatric Academic Programs, accessed January 23, 2022). In 2010, geriatric competencies for emergency medicine residents were derived by the American Medical Association, AGS, American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), Council of Residency Directors, Emergency Medical Residents’ Association, and American Board of Emergency Medicine.⁹ These emergency medicine training requirements specified eight domains and 26 competencies for which the graduating emergency medicine (EM) resident is responsible (Table 1). The table is a guideline for competency-based training, requiring that EM residents go beyond didactics, and develop practices appropriate for each scenario. After a visit to the bedside with a trainee, the table can be used to reinforce relevant teaching points.

Table 1.

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	1. Generate an age-specific differential diagnosis for elder patients presenting to the Ed with general weakness, dizziness, falls or altered mental status.
	2. Generate a differential diagnosis recognizing that signs and symptoms such as pain and fever may be absent of less prominent in elders with acute coronary syndromes, acute abdomens, o infectious processes.
	3. Document consideration of adverse reactions to medications, including drug-drug and drug-disease interactions, as part of the initial differential diagnosis.
II. Trauma inducing falls	4. In 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.
	5. Assess for gait instability in all ambulatory fallers; if present, ensure appropriate disposition and follow-up including attempt to reach primary care provider.
	6. Demonstrate 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.
	7. Institute appropriate early morning 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	8. Assess whether an elder is able to give an accurate history, participate in determining the plan of care, and understand discharge instructions.
	9. Assess 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.
	10. Emergently 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.
	11. Assess 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	12. Recommend 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.
	13. Identify 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	14. Prescribe appropriate drugs and dosages considering the current medication, acute and chronic diagnosis, functional status, and knowledge of age-related physiologic changes (renal function, central nervous system sensitivity).
	15. Search 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).
	16. Explain 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 effect, and how and when the drug should be stopped.
VI. Transitions of care	17. Document 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.
	18. Provide skilled nursing or extended care facilities and/or PCP with ED visit summary and plan of care, including follow-up written appropriate.
	19. With recognition of unique vulnerabilities in elders, assess and document sustainability for discharge considering the ED diagnosis, including cognitive function, the ability in ambulatory patents to ambulate safely, availability of appropriate nutrition/social support, and the availability of access to appropriate follow-up therapies.
	20. Select 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.
	21. Rapidly establish and document an elder's goals of care for those with a serious or life-threatening condition and manage accordingly.
	22. Assess and provide ED management for pain and key nonpain symptoms based on the patient's goals of care.
	23. Know how to access hospice care and how to manage elders in hospice care while in the ED.
VII. Effect of comorbid conditions	24. Assess 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.
	25. Develop plans of care that anticipate and monitor of predictable complications in the patient’s condition (e.g., gastrointestinal bleed causing ischemia).
	26. Communicate 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

Subsequent assessments of a geriatric education curricula for EM residents demonstrated improvement in knowledge and decision making after a series of six lectures and seven simulations that included all eight domains noted in Table 1. Most notable was an improvement in scores on a 35-question multiple choice test, with less dramatic changes in frequency of chemical sedation and placement of urinary catheters. The study included 29 residents at a single EM residency program.¹⁰

The Geriatric Emergency Department Collaborative (GEDC)

The GEDC [https://gedcollaborative.com] is a transdisciplinary, comprehensive, and free resource for geriatric emergency medicine and research, and peer-mentorship for EDs worldwide undergoing similar older adult process improvement efforts. In addition, GEDC provides “Implementation Toolkits” to catalyze and accelerate geriatric ED initiatives. GEDC’s website features a resource library and the open access Journal of Geriatric Emergency Medicine, as well as access to continuing medical education (CME), blogs, podcasts, and on-demand webinars [for CME see https://geriem.com and https://geriatric-ed.com]. A visit to the GEDC website featured articles on pain management in older adults, elder abuse and neglect, and clinical tips in the assessment of GU emergencies in older adults (Figure 1).

Figure 1.

The GEDC home page with mission statement and access to a Resource Library, Journal of Geriatric Emergency Medicine, on-Demand Webinars, and Implementation Toolkits. The research tab provides a link to the GEAR Network.

The Geriatric Emergency Department

Recognizing the need for a paradigm shift in the care of the older adult prompted more than 100 self-designated geriatric EDs to open in less than a decade.^11,12 Aware of the lack of rigor, evidence-basis, outcome assessment, or cost-effectiveness underlying these initial geriatric EDs, SAEM, ACEP, and AGS published consensus-based Geriatric ED guidelines in 2014.^13,14 Subsequently guidelines created by ACEP were used to officially designate EDs as GEDA (see Table 2).¹⁵ Similar to trauma-center designations, the accreditation consists of a three-tiered system of Gold, Silver, Bronze, or 1, 2, and 3. Level 1 GEDA sites must demonstrate 20 or more ongoing geriatric ED quality improvement (QI) efforts and have a local team of geriatric champions, including an ED nurse and physician, a pharmacist, physiotherapist, social worker, and a hospital administrator who meet regularly to review projects and outcomes. Level 2 GEDA sites must demonstrate 10 QI efforts. Level 3 GEDA sites require only one such geriatric quality improvement effort as well as a single nurse and physician champion with the vision and commitment to begin “geriatricizing” the care within likely smaller or geographically isolated hospitals.

Table 2.

Requirements for each GEDA Level illustrating stepwise, increasingly comprehensive requirements moving from Level 3 to Level 1.

Source: http://www.acepnow.com/article/acep-accredits-geriatric-emergency-care-emergency-departments/

LEVEL	STAFFING	EDUCATION	SAMPLE POLICY	SAMPLE OUTCOME MEASURES	STANDARDED EQUIPMENT
3	One nurse end one physician to provide generic-focused education	No requirements	Evidence of adherence to urinary catheter avoidance policy	No requirements	Mobility aids
2	Level 3 staffing + transitional care nurse + interdisciplinary care team (physical therapy, occupational therapy, social work, pharmacy) + dedicated hospital administrator who supervises and supports GED	Document geriatric EM-appropriate educational CME for providers working in the GED	Standardized assessments for delirium, dementia, eider abuse, and falls Access to postdischarge follow-up resources Such as community paramedicine	Proportion of patients assessed (for delirium, dementia, falls, etc.) and proportion identified as high-risk Rates for hospital admissions and ED returns Proportions of patients with extended ED lengths of stay (>8 hours)	Mobility aids, nonslip socks pressure-reducing mattresses, hearing aids, bedside commodes, condom catheters, bedside transition stools large-face analog docks
1	Level 2 requirements + patient adviser or patient council providing monthly input on GED care quality	Same as level 2	Same as level 2+ guidelines defining criteria for accessing the GED	Same as level 2	Ideally a separate space within or adjacent to non-geriatric ED

The ultimate goal is to provide the best care possible for the older adult. ACEP’s keen and forward-thinking interest in this sphere promotes a “triple aim” of healthcare: Improving patient experience, reducing per capita costs, and improving the health of populations overall. Hospitals and health systems can be significantly impacted when providing poorly coordinated, inefficient care. “Unnecessary” readmissions of Medicare patients can result in up to a 3% reduction of federal Medicare payments for standard fee-for-service Medicare. Managed Medicare may deny Inpatient Levels of reimbursement for repeat hospital admissions deemed unnecessary, denying payment completely, or recommending Observation Level of Care with substantially reduced reimbursement. In addition, many hospitals and health systems participate in or manage Accountable Care Organizations. Such arrangements, as well as bundled payment contracts and value-based payment arrangements, often share financial risks for avoidable care with the hospital and health system. Hospital Presidents and Chief Financial Officers will be familiar with such single-line items in their budgets, but often lack detailed understanding of causes at a clinical granular level as to how to improve such financial impacts. ED physicians caring for dizzy patients on 20 or more medications, or needing assistance walking to the bathroom or with activities of daily living, yet live independently, can provide insight. Partnership between such ED physicians and C-Suite executives is essential to provide resources to such older adults, both in the ED, the hospital, and at their home. To this end, specific imperatives include decreasing admissions and readmissions, decreasing falls, attention to medication management, delirium prevention, and advanced care planning. Depending on the level achieved, anywhere from 1 to 20 initiatives, not including hospital wide policies, are undertaken. As of January 2022, GEDA were issued to 288 U.S. EDs, of which 19 were Level 1, 34 were Level 2, 235 were level 3. The most common initiatives were fall prevention, and minimizing urinary catheter use.¹⁶

Team of Geriatric Champions

Developing a geriatric-centric ED is clearly a team effort, certainly not a one-person job. Nevertheless, endeavors of this magnitude must start at the beginning, and they may simply be one nurse and one healthcare provider, bringing additional staff members into the activity “inch by inch.”¹⁷ Physicians, Advanced Practice Nurses, RNs, Independent Care Techs, Social Workers, Physical and Occupational Therapists, Pharmacists, Dietitians, Home Care, Engineering, Prosthetics, and Medical Administration all play important roles. Overcoming inertia to build and then sustain a program requires resources and time, as well as published protocols and policies. Ideally, initiatives to improve the process, experience, cost-effectiveness, and outcomes of care for older adults will include partnering with facility Quality, Geriatrics, and Graduate Medical Education where applicable. Programs generally start small, with one ED physician and one nurse or nurse educator.^16,18 Adding the ED pharmacist is key to monitoring for polypharmacy and drug interactions, which are very common among the geriatric population.^19,20 In addition, care partner burden can be evaluated by social work²¹ and strength and gait evaluations can be performed by physical therapy.²²

The Geriatric Emergency Department Infrastructure

While the architectural changes to a space are far less important to improving older adult emergency care than are trained and motivated champions empowered with evidence-based protocols, structural changes nonetheless are one component of the aforementioned guidelines. A geriatric ED can be a separate space designated for those over 65 (Figure 2). More commonly, the main ED is adapted towards holistic care of older individuals. These include dimmable lighting, contrasting colors, large print placards, and more appropriate signage, as well as improved acoustics. The geriatric ED guidelines provide a range of protocols to prevent post-visit falls, identify delirium, avoid polypharmacy, identify vulnerability, and enhance transition of care through communication with family and care partners, inpatient and outpatient teams, and home health. The importance of coordinated multidisciplinary inpatient and outpatient care cannot be overstated. In fact, the American College of Surgeons launched a similar “Geriatric Surgery Verification” accreditation program in 2019 [https://www.facs.org/quality-programs/geriatric-surgery]. Critical Care and Hospitalist services are contemplating related efforts. In best practices, geriatric ED teams actively screen older patients for geriatric syndromes such as delirium,²³ dementia,²⁴ frailty,²⁵ elder abuse,²⁶ and polypharmacy,²⁰ typically utilizing appropriately trained nurses, advanced practice providers, or physicians. However, volunteers,²⁷ pad-based technology,²⁸ and machine learning²⁹ are emerging as alternatives to burdening busy healthcare teams with additional responsibilities. Ultimately, clear and readable discharge instructions that synthesize the geriatric screening results and actionable response, are essential for meaningful shared decision making.³⁰

Figure 2.

Courtesy of UC San Diego. Dedicated Geriatric ED featuring non-slip floors, natural lighting, noise free rooms, and scenic photos.

Missouri Geriatric Emergency Departments

The St. Louis John Cochran Veterans Administration ED, under the direction of Edward Fieg, DO, developed a protocol to identify older adults (> 65 years of age) at risk due to medical, social, and administrative issues, independent of their presenting chief complaint. Staff are trained to utilize one or more screening tools, complete a Computerized Patient Record System (the Veterans Administration electronic medical record) template, and notify the veteran’s PCP of the results. A geriatric clinic is also available for referrals. In particular, high risk complaints, including falls, care partner concerns, multiple ED visits, polypharmacy, age > 85, and others, will lead to a screening via a variety of tools that may help to predict near future ED visits, hospitalization, and mortality.

Two of the screening tools employed are the identification of seniors at risk (ISAR) (Table 3a) and triage risk screening tool (TRST) (Table 3b). ISAR is a six-point system,^31,32 and a score of two or more predicts a greater likelihood of ED return, emergency hospitalization, and six-month mortality. Those with 2+ points tend to be older and take more medications, are more likely to have 30- and 90-day ED revisits, and are more likely to have 30- and 180-day hospitalizations for serious medical or trauma related problems. TRST has a similar approach, with a score of two or more associated with increased risk of ED visit and hospitalization.³³ Despite their frequent utilization, more recent analysis has shown that “no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients.” However, ISAR/TRST are still useful in clinical practice, since they attune healthcare staff to geriatric concerns, and currently a superior tool has not been identified.

Why Falls Are So Important: Gravity is a Killer

One in three adults age 65 or older fall each year. Those older adults who sustain a fall are two to three times more likely to fall again. Falls are the leading cause of both fatal and non-fatal injuries to older Americans (National Council on Aging, Falls Prevention Facts, 2020). Falls increase the risk for hospitalization, decrease the ability to perform activities of daily living, and decrease the ability to perform instrumental activities of daily living, e.g. banking, shopping, preparing meals, paying bills, etc.³⁴ High risk falls often result in nursing home placement and death. Ten percent of falls in this population will result in serious injury (fracture, joint dislocation, or closed head injury). The total economic burden of falls is approximately $50 billion, 75% of which is paid by Medicare and Medicaid (cdc.gov fact sheet). In 2018 an estimated 2.4 million ED visits for adults > 65 were attributed to falls, motor vehicle crashes, unintentional prescription opioid overdoses, and self-harm. A striking 91.8% of these visits were due to falls.³⁵ Unfortunately, there is little research evidence to support fall prevention screening or fall prevention protocols, though Emergency Medicine is working diligently to close this knowledge gap.^36–38

Falling Forward to Prevent Post-ED Injuries

Missouri Baptist Medical Center (MBMC) in St. Louis County achieved GEDA Level 3 status in January 2019. The motivation to obtain this accreditation derived from the fact that 37% of the ED volume are individuals > 65 years old, many of whom presented after a fall. A retrospective review of 989 geriatric patients seen for falls revealed that 628 were discharged home [MoBap achieves ACEP Geriatric Accreditation; first in region at www.missouribaptist.org, March 6, 2019. Accessed January 5, 2022]. A multidisciplinary team of ED physicians and nurses, Primary Care Providers (PCP), Pharmacists, Therapy Staff, Case Management, Barnes Jewish Christian Home Health Care, and Washington University Emergency Care Research Core Fall Experts developed a program to arrange a follow up home visit immediately after discharge, to be coordinated with the patient’s PCP.

In the MBMC ED, providers caring for patients > 65 receive a prompt (“Best Practice Advisory”) in the electronic health record as a reminder to consider ordering a Geriatric Fall Risk Referral. A two to three minute order entry process results in a Home Health Referral. A therapist is ultimately deployed to the patient’s home, where their fall risk is assessed, and recommendations are made to decrease the likelihood of a future fall. The therapist interacts with the PCP to obtain orders for needed durable medical equipment for the patient, and coordinates additional therapy and home health care if needed. In late 2019 the team at MBMC began to review data to assess the impact of this program, but due to the pandemic, additional data was not reviewed.

Key to the future: Geriatric Emergency Care Research

The growth of our older adult population has been well documented, as has their increasing ED utilization. Medical science has elucidated the unique pathophysiology and psychosocial aspects of aging. As the role of the ED has become more critical, so has the stress on ED infrastructure. How can we more efficiently use our resources to improve the care of older adults? The current evidence base for geriatric emergency care has been described as “nascent.”³⁹ More than ever, we need quality randomized controlled trials (RCT) to build on the many published observational studies. Funding is essential for innovations and outcomes-based research, even if it means “putting the cart before the Clydesdale.” As the practice of medicine increasingly incorporates Clinical Practice Guidelines (CPGs) to help foster the development of best practices, it is clear that adaptations are necessary with respect to older adults with multiple chronic conditions (MCC).^40,41 Historically, CPGs excluded individuals due to an upper age limit in 1/3 of studies, and additional exclusion criteria that could lead to under-representation of older adults included polypharmacy/concomitant medication use (37%), cardiac issues (30%), cancer history (24%), and cognitive impairment (20%).⁴² The importance of including older adults in clinical trials that lead to publication of CPGs has been emphasized.⁴³ The Center for Leading Innovation and Collaboration (CLIC) has initiated a curriculum for inclusion of older adults in clinical and translational research (https://clic-ctsa.org). Additionally, the AGS and associated entities have received a grant from the National Institute on Aging to research MCCs.

GEAR: Geriatric Emergency care Applied Network

The GEAR network (https://gearnetwork.org) drives innovation in ED research. As a multidisciplinary task force, the GEAR network prioritizes and helps to provide funding from the NIH and other resources to researchers committed to improving emergency care of older adults. Our aging population with increased ED utilization, and consequently, an increased need for studies to improve care, led to this network’s formation. GEAR 1.0 focuses on falls, elder abuse, medication safety, care transitions, and cognitive impairment. GEAR 2.0’s focus is dementia and other cognitive abnormalities.

Moving Forward

In addition to increased research funding, efforts to provide an impetus to hospitals to invest in geriatric emergency care and pursue GEDA status must continue.⁴⁴ As an increasing number of EDs achieve GEDA status, and as more high quality research emerges, it is conceivable that The Joint Commission and CMS will employ quality metrics (e.g. return visits/readmissions, ED-related falls) germane to the care of older adults. Hospitals may benefit from such an investment by being proactive in this regard. The potential for ED overcrowding to benefit from geriatric protocols may one day ring true. In 2021 Hwang et al. published a paper on cost outcomes among Medicare beneficiaries,⁴⁵ and demonstrated a reduction in cost to the Medicare program, but not to the hospitals and providers that have made accredited geriatric EDs possible. Further insight into the costs to hospitals and health systems to provide efficient care to the older adult is warranted, possibly focusing on older patients in ACOs or other scenarios. If financial benefits are manifested by geriatric emergency care programs, reimbursement by Medicare or other health care payers is certainly warranted. As more information becomes available in support of the extraordinary benefit of improved older adult care, perhaps more funding will lead to additional advances. One key question is who will pay for the advances.

Tables 3a and 3b.

Each of the 6-question screening tools can be utilized to gather information of potential value to assist in management and decision making of older adults presenting to the ED.

Table 3a.

ISAR Questions

1. Before the illness that brought you to the ED, did you need someone to help you on a regular basis?

2. Since the illness or injury that brought you to the ED, have you needed more help than usual to take care of yourself?

3. Have you been hospitalized for one or more nights during the past 6 months?

4. In general, do you see well?

5. In general, do you have serious problems with your memory?

6. Do you take more than 3 different medications every day?

Table 3b.

TRST Questions

1. Is there a history of cognitive impairment

2. Difficulty walking/transferring or recent falls?

3. Has there been an ED visit in the last 30 days or hospitalization in the last 90 days?

4. Five or more medications?

5. Lives alone and/or no longer available caregiver?

6. ED staff is concerned about one of the following: nutrition/weight loss, sensory deficits, incontinence, medication issues, depression?