ORIGINAL CONTRIBUTION geriatrics
C a r e of the Elderly in EmergencyDepartments: Conclusions and Recommendations From the Section of Emergency Medicine, Department of
Arthur B Sanders, MD, FACEP, FACP
Surgery, University of Arizona College of Medicine, Tucson; and the Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force, lzansing, Michigan. Received for publication February 28, 1992. Accepted for publication March 12, 1992. This study was funded in part by a grant from the John A Hartford Foundation, New York.
JULY 1992 2 1 : 7 ANNALS OF EMER(3ENCY MEDICINE
Little attention is being paid to the special needs of elderly persons in emergency departments. Emergency health care professionals feel less comfortable caring for elderly than for nonelderly patients. The social and personal concerns of the elderly frequently are not addressed in ED encounters. There is a paucity of research and education in geriatric emergency medicine. Overall principles of care for elderly patients seeking emergency care have not been defined as they have for other special populations such as children. The disease-oriented model used for caring for nonelderly adult patients in EDs may not be appropriate for elderly patients. The emergency care of the elderly requires significantly more health care resources than does that of the nonelderly. Compared with nonelderly patients, elderly patients seeking emergency care are four times more likely to use ambulance services, five times more likely to be admitted to the hospital, five times more likely to be admitted to an intensive care bed, and six times more likely to receive comprehensive emergency services. Although 12% of the population is 65 years or older, this group accounted for 36% of all ambulance patient transports to EDs, 43% of all hospital ED admissions, and 48% of all critical care admissions from EDs. These problems are particularly important at this time because many hospitals and their EDs are faced with significant problems of overcrowding and inadequate resources to meet the health care needs of the communities they serve. Although the elderly are the fastest-growing segment of the population, little or no planning is ongoing to meet the emergency health care needs of the elderly in the future. The task force has provided specific recommendations for addressing these problems. [Sanders AB: Care of the elderly in emergency departments: Conclusions and recommendations. Ann EmergMed July 1992;21:830-834.]
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FINDINGS
The Geriatric Emergency Medicine Task Force found few studies in the literature addressing the care of the elderly in emergency departments. There is little evidence of planning to meet the emergency care needs of the elderly or to anticipate the future needs of an increasingly elderly population. No advocacy groups within emergency medicine, geriatrics, or the health care system appear to be concerned with the emergency health needs of the elderly. The elderly have unique physiologic, medical, and social needs that must be recognized by the emergency health care system. Elderly patients needing emergency care should be considered a special population analogous to pediatric patients needing emergency care. The task force has divided its conclusions and recommendations into the following four areas: resource issues, clinical issues, academic (education and research) issues, and social/personal issues. RESOURCE
ISSUES
C o n c J u s i 0 n Elderly patients require more emergency care resources than nonelderly patients.l,a • Elderly patients visit EDs in slightly greater numbers than their proportion in the total population. Fifteen percent of ED visits were by patients 65 years or older, a • Elderly patients seeking emergency care are more than five times more likely to be admitted to the hospital than nonelderly patients and are more than five times more likely to be admitted to intensive care beds. 4 • Elderly patients are more than four times more likely than nonelderly patients to use ambulance services for transp o r t a t i o n t o the ED. a About 30% of elderly patients seeking emergency care arrive by ambulance. 1,4 • Elderly patients are more than six times more likely than nonelderly patients to receive comprehensive ED services. 4 • Elderly patients require more medical and nursing time than nonelderly patients. 1,3 • Elderly patients are more likely to receive radiographs and laboratory and other ancillary tests than nonelderly patients. Seventy-seven percent of elderly patients seeking ED care receive radiographs, and 78% receive laboratory tests. 1 • The average total charges for ED visits of elderly patients are higher than those for the nonelderly population. Mean charges for the hospital, emergency physician, laboratory, radiographs, and ancillary services were all higher for elderly patients than for nonelderly patients. 1 • When patients without health insurance were excluded from the study's analysis, elderly patients still had higher health care charges, urgency levels, and use of radiography, laboratory, and ambulance services. 1 • Elderly patients account for 36% of an patients arriving by ambulance.4
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• Elderly patients account for 43% of all hospital admissions from EDs. 4 • Elderly patients account for 48% of all critical care unit admissions from EDs. 4 R e c o m m e n d a t i o n 1 The appropriateness of use of emergency services by elderly as well as nonelderly patients must be assessed with further studies. It is u n k n o w n whether the increased use of emergency care resources for the elderly population is necessary and appropriate. Available evidence indicates that elderly patients seeking emergency care are an ill population. 1,2 Strategies that make use of innovative alternatives to emergency health care resources need to be investigated. R e c 0 m m o n d a t i o n 2 Ongoing accurate information on the use of emergency services by the elderly should be compiled and made available so that planning for adequate resources can occur. R e c o m m e n d a t i o n 3 The structure of emergency health care delivery for elderly patients must be evaluated and innovations explored. For example, the role of geriatric emergency health care centers analogous to trauma centers or pediatric centers should be investigated. The center concept might provide a mechanism for delivering specialized care and attending to the special needs of geriatric patients but may be practical in only some communities. R e c o m m e n d a t i o n 4 Concern about adequacy of resources to meet the needs of an increasing population of elderly must be brought to the attention of hospitals, health policy analysts, health care workers, community organizations, foundations, and government organizations. P l a n n i n g must be performed to ensure adequate treatment of the elderly needing emergency care in the future. CLINICAL
ISSUES
C o n c I u s i o n Emergency health care workers feel less comfortable when dealing with elderly patients than when dealing with nonelderly patients. • When surveyed regarding seven common patient complaints, emergency physicians responded that they find it more difficult to treat elderly patients than nonelderly patients with the same complaints. 3 • Elderly patients require more time and ED resources than other adult patients. 1,3 • Better communication between emergency health care professionals and elderly patients, caretakers, and p r i m a r y care providers could facilitate the care of the elderly. Seventy-seven percent of emergency physicians reported moderate or frequent information transfer problems with nursing homes, and 44% reported moderate or frequent problems obtaining information from primary care physicians. 3 • Emergency physicians believe that there is a dearth of education and research in geriatric emergency care. z
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Fifty-three percent of residency-trained emergency physicians believed that they did not spend adequate time learning about geriatric emergency care in their training program. 3 Specific issues of concern to emergency physicians were: • Altered disease presentation in the elderly 3,5 • Multiple medications and drug interactions 3,5 • Altered physiology in the elderly 3,5 • Lack of knowledge and accepted standards for the emergency care of the elderly 3,s • Lack of ability to communicate with patients, p r i m a r y care physicians, and nursing home facilities 3,5 • Amount of medical and nursing time needed to deal with elderly patients1,3, 5 • Extent of social support services needed by the elderly 2,3,5,6 • Uncertainty regarding need for limitation of care 3,5 Elderly patients seeking emergency care have high acuity levels and receive comprehensive medical and nursing care. • Elderly patients are more likely to present to the ED with an urgent or emergent problem than nonelderly patients. Elderly patients are less likely than the nonelderly to present to EDs with nonurgent complaints. 1 • Elderly patients present to the EDs with more comorbid diseases than non-elderly patients. 1 • Most elderly patients have p r i m a r y care providers. They visit EDs because they feel too ill to go elsewhere and feel they will get better care in the ED. 2,6 • Forty-six percent of elderly patients seen in EDs receive comprehensive medical care compared with 13% of nonelderly patients.4 • Both elderly and nonelderly patients are generally satisfied with the care received in the ED. However, the elderly were less likely to r e p o r t that their complaint had been completely resolved. Waiting time was the most common problem reported regarding emergency care, although it was of less concern to the elderly than to nonelderly patients.2, 6 The task force has concluded that it is time to re-evaluate the disease-oriented model used to care for elderly patients in EDs. The medical model used for other adult patients may not be a p p r o p r i a t e for the elderly population. Similarly, the care model for elderly patients in a clinic or office setting may be i n a p p r o p r i a t e for an ED. Although emergency health care professionals seem to u n d e r s t a n d that the elderly represent a special population, general principles for the care of the elderly in EDs have not been defined. R e ¢ 0 nl m e n d a t i 0 n 1 Overall principles of care of the elderly in EDs need to be defined by experts in emergency and geriatric health care. A medical model a p p r o p r i a t e for ED treatment of geriatric patients that considers the special needs and altered physiology of the elderly population needs to be developed. These principles should provide guidelines for physicians, nurses, social workers, and prehospital care professionals.
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R e c o m m e n d a I i o n 2 There is a need for an assessment of the knowledge, attitudes, and behaviors of emergency health care workers toward elderly patients. R e c o rn m e n d a t i o n 3 Communication among emergency health care workers, geriatricians, p r i m a r y care providers, and chronic care facilities must be improved. Both health care professionals who treat acute problems and health care professionals who treat chronic problems of the elderly should develop an increased understanding of the principles, attitudes, priorities, and limitations of the systems in which they function. This may be encouraged through rotations during training programs, continuing education, and open dialogue among health care professionals. Professional organizations can facilitate communication and provide joint programs. Information technology has enormous potential for implementing innovative approaches to information transfer in the patient care setting. Emergency health care professionals need to work closely with p r i m a r y care providers and caregivers to ensure adequate information transfer, especially with regard to decisions on withholding or limiting medical care. R e c o m m e n d a t i o n 4 A cadre of future leaders in geriatric emergency medicine must be developed. Such leaders can bridge the gap between geriatrics and emergency medicine and serve as advocates for the care of the elderly in EDs. At present, there is a lack of leadership and advocacy in the field of geriatric emergency medicine. In the specialty of emergency medicine, for example, there are society sections, fellowship training programs, journals, and scientific meetings of health care workers who deal with pediatric emergency medicine. Physicians can obtain special certification in pediatric emergency medicine from the American B o a r d of Emergency Medicine. Similarly, within the geriatric health care community, few leaders have focused their efforts on the emergency care of elderly patients. F u t u r e leadership can be developed through fellowship programs, sectional status, networking groups at national meetings, position statements, and joint programs in the geriatric and emergency medicine community. ACADEMIC ISSUES C o n c I [] s i o n- E d u c a t i o n There is a dearth of educational programs on the emergency care of the elderly. Most (69%) of the practicing physicians surveyed reported that insufficient continuing medical education was available in topics on geriatric emergency medicine. Fifty-three percent of residency-trained emergency physicians said they considered their education on the emergency care of the elderly during residency training to have been insufficient. Less than 5% of practicing physicians' continuing education time is devoted to topics in geriatric emergency care. 3 There is also a scarcity of training and educational programs for paramedics and
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emergency nurses on the special needs of the elderly seeking emergency care. C 0 n c I u s i 0 n - R e s e a r c h There is a paucity of research in geriatric emergency medicine. Seventy-one percent of practicing emergency physicians and 65% of residency directors believe that research efforts regarding geriatric emergency care are insufficient.3,5 More research needs to be completed on the special needs of the elderly in EDs. The task force has concluded that both the difficulty in the care of the elderly in EDs and the lack of educational programs for health care professionals arise from insufficient knowledge in fundamental areas of geriatric emergency medicine. R e c 0 m m e n d a t i [] n 1 A curriculum and syllabus on meeting the special needs of the geriatric population should be developed and incorporated into training programs for all emergency health care professionals. Such a syllabus could also be used for continuing medical education programs for practicing emergency health care professionals. In addition to academic institutions, professional organizations in botkemergency medicine and geriatrics should be encouraged to increase the amount of educational material on the special needs of elderly patients seeking treatment in EDs that is available to health care practitioners. Educational programs should be developed for all emergency health care professionals including physicians, nurses, social workers, and paramedics. R e c 0 m m e n d a t i 0 n 2 Research in geriatric emergency medicine must be stimulated, especially through interdisciplinary efforts of geriatricians and emergency health care workers. Funding organizations and health policy makers should be made aware of the critical need for additional research in this area. R e c o m m e [] d a t i o n 3 Outcome criteria for geriatric emergency medicine should be defined. This requires a multidisciplinary effort involving patients, physicians, social workers, nurses, and home/institutional caregivers. Optimal outcome criteria may not be simply survival or prolongation of life but may involve other issues such as pain control or symptom management. R e c o m m e n d a t i o n 4 There is a need for more research and education regarding the problems of multiple medications, altered physiology, and altered disease presentation in the elderly. R e c o m m e n d a t i o n 5 There is a need for research and innovative approaches to meet the social and personal needs of the elderly who need emergency care. R e c o m m e n d a t i 0 n 6 There is a need for research evaluating the use of ED services to care for elderly patients. Research investigating alternative strategies that decrease the need for ambulance services, hospital admission, and comprehensive ED evaluation should be encouraged. R e c o m m e n d a t i o n 7 Greater attention needs to be paid to the problems of uncertainty and doubt for emergency
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health care workers in dealing with elderly patients' complaints. SOCIAL/PERSONAL ISSUES C o n c I u s i o [] The social/personal circumstances of elderly
patients receiving emergency care are frequently not addressed in ED visits. • The functional status of elderly persons is not routinely evaluated in EDs. Elderly patients discharged from the EDs had greater problems in their ability to care for themselves as a result of their illness or i n j u r y than did nonelderly patients. Less than 30% of elderly patients reported that inquiries were made during their ED visits regarding their ability to care for themselves. 2 • Although being seen in an ED presents an opportunity to evaluate a patient's health care needs, questions about preventive health measures such as immunizations and nutrition are not usually addressed in an ED encounter. • Elderly patients are frequently uncomfortable in the ED environment. They are unfamiliar with the emergency care system, frightened by their i n j u r y or illness, and uncomfortable with the physical surroundings. 6 • Psychosocial issues such as elder abuse/neglect, depression, suicide prevention, and substance abuse are not commonly addressed in an ED encounter. • Most EDs do not have protocols for detecting and dealing with elder abuse as they do for child abuse. Only 27% of physicians reported that protocols for elder abuse were available at their hospitals. 2 Although there is much speculation about the incidence of elder abuse/neglect, there is little reliable information in the medical literature concerning the extent of this problem. R e c o m m e n d a t i o [ ] 1 Attention to the social, psychological, and functional status of the elderly should be part of the defined principles of emergency care of the elderly. Implementing this principle on a routine basis will require added resources to address the problems defined. R e c o m m e n d a t i o n 2 The mental and functional status of the elderly should be addressed as part of the emergency encounter. Because most existing scales for evaluating mental status and activities of daily living have been formulated for clinic or primary care settings, they may not be appropriate in EDs. New evaluation tools or modifications of existing tools need to be standardized for application in the ED setting. R e c o m m e n d a t i o n 3 Psychosocial problems in the elderly, including possibilities of elder abuse/neglect, depression, suicide prevention, and substance abuse, should be routinely addressed. Research should be u n d e r t a k e n to determine the most effective methods of screening and dealing with psychosocial problems in the emergency health care setting. R e c o m m e n d a t i o [] 4 Preventive health measures such as immunizations, nutritional status, and prophylaxis for
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falls and pedestrian injuries should be addressed in elderly patients who are at risk for these problems. R e c 0 m m e n d a t i o n 5 The potential role of a geriatric health care worker in emergency medicine should be investigated. Geriatric health care workers can help provide functional assessments and attend to the personal and social needs of elderly patients, as well as act as advocate for the elderly in the emergency health care system. Re c 0 m m e n d a t i o [] 6 The physical plant of EDs should be made more user-friendly for elderly patients. Strategies can be developed so that elderly patients feel more comfortable in an ED, especially with regard to privacy, physical comfort, explanation of tests and procedures, and attention to anxieties and questions about care. This will require more time and attention from emergency health care professionals. R e c 0 m m e n d a t i o n 7 The concept of discharge planning for elderly patients leaving the ED needs re-evaluation. Innovative approaches to discharge planning that incorporates social and personal as well as medical and nursing needs can be developed. Improved ED discharge procedures might decrease the necessity for hospital admission.
REFERENCES 1. Singal BM, Hedges JR, Rousseau EW, et al: Geriatric patient emergency visits Part I: Comparison of geriatric and younger patients. Ann EmergMed 1992;21:802-807. 2. Hedges JR, Singal BM, Rousseau EW, et al: Geriatricpatient emergency visits Part I1: Perceptions of visits by geriatric and younger patients. Ann EmergMed1992;21:808-813. 3. McNamara RM, Rousseau EW, Sanders AB: Geriatric emergency medicine: A survey of practicing emergency physicians. Ann EmergMed 1992;21:796-801. 4. Strange GR, Chen EH, Sanders AB: Use of emergency departments by elderly patients: Projections from a multicenter data base. Ann EmergMet 1992;21:819-824. 5. Jones JS, Rousseau EW, Schropp MA, et al: Geriatric training in emergency medicine residency programs. Ann EmergMed 1992;21:825-829. 6. Baraff LJ, Bernstein E, Bradley K, et al: Perceptions of emergency care by the elderly: Results of multicenter focus group interviews. Ann EmergMed 1992;21:814-818.
Address for reprints: Arthur B Sanders, MD, FACEP, FACP, Section of Emergency Medicine, University of Arizona College of Medicine, I501 North Campbell, Tucson, Arizona 85724.
SUMMARY
The SAEM Geriatric Emergency Medicine Task Force has studied the care of the elderly in EDs and concluded that the special needs of the elderly are not being addressed adequately. Emergency health care professionals receive little education in geriatric emergency medicine and feel less comfortable when caring for elderly than for nonelderly patients. The elderly require significantly more emergency care resources than do the nonelderly. With the population of elderly patients rapidly increasing and many hospitals and their EDs facing significant p r o b lems of overcrowding and inadequate resources, the problem of providing a p p r o p r i a t e emergency care for the elderly may become a crisis unless planning is undertaken. The task force has provided specific recommendations in the areas of clinical service, research, education, resources, and social/personal issues. With a p p r o p r i a t e planning and resources, the emergency health care needs of the elderly can be met.
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C a r e of the Elderly in EmergencyDepartments: Conclusions and Recommendations From the Section of Emergency Medicine, Department of
Arthur B Sanders, MD, FACEP, FACP
Surgery, University of Arizona College of Medicine, Tucson; and the Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force, lzansing, Michigan. Received for publication February 28, 1992. Accepted for publication March 12, 1992. This study was funded in part by a grant from the John A Hartford Foundation, New York.
JULY 1992 2 1 : 7 ANNALS OF EMER(3ENCY MEDICINE
Little attention is being paid to the special needs of elderly persons in emergency departments. Emergency health care professionals feel less comfortable caring for elderly than for nonelderly patients. The social and personal concerns of the elderly frequently are not addressed in ED encounters. There is a paucity of research and education in geriatric emergency medicine. Overall principles of care for elderly patients seeking emergency care have not been defined as they have for other special populations such as children. The disease-oriented model used for caring for nonelderly adult patients in EDs may not be appropriate for elderly patients. The emergency care of the elderly requires significantly more health care resources than does that of the nonelderly. Compared with nonelderly patients, elderly patients seeking emergency care are four times more likely to use ambulance services, five times more likely to be admitted to the hospital, five times more likely to be admitted to an intensive care bed, and six times more likely to receive comprehensive emergency services. Although 12% of the population is 65 years or older, this group accounted for 36% of all ambulance patient transports to EDs, 43% of all hospital ED admissions, and 48% of all critical care admissions from EDs. These problems are particularly important at this time because many hospitals and their EDs are faced with significant problems of overcrowding and inadequate resources to meet the health care needs of the communities they serve. Although the elderly are the fastest-growing segment of the population, little or no planning is ongoing to meet the emergency health care needs of the elderly in the future. The task force has provided specific recommendations for addressing these problems. [Sanders AB: Care of the elderly in emergency departments: Conclusions and recommendations. Ann EmergMed July 1992;21:830-834.]
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ELDERLY Sanders
FINDINGS
The Geriatric Emergency Medicine Task Force found few studies in the literature addressing the care of the elderly in emergency departments. There is little evidence of planning to meet the emergency care needs of the elderly or to anticipate the future needs of an increasingly elderly population. No advocacy groups within emergency medicine, geriatrics, or the health care system appear to be concerned with the emergency health needs of the elderly. The elderly have unique physiologic, medical, and social needs that must be recognized by the emergency health care system. Elderly patients needing emergency care should be considered a special population analogous to pediatric patients needing emergency care. The task force has divided its conclusions and recommendations into the following four areas: resource issues, clinical issues, academic (education and research) issues, and social/personal issues. RESOURCE
ISSUES
C o n c J u s i 0 n Elderly patients require more emergency care resources than nonelderly patients.l,a • Elderly patients visit EDs in slightly greater numbers than their proportion in the total population. Fifteen percent of ED visits were by patients 65 years or older, a • Elderly patients seeking emergency care are more than five times more likely to be admitted to the hospital than nonelderly patients and are more than five times more likely to be admitted to intensive care beds. 4 • Elderly patients are more than four times more likely than nonelderly patients to use ambulance services for transp o r t a t i o n t o the ED. a About 30% of elderly patients seeking emergency care arrive by ambulance. 1,4 • Elderly patients are more than six times more likely than nonelderly patients to receive comprehensive ED services. 4 • Elderly patients require more medical and nursing time than nonelderly patients. 1,3 • Elderly patients are more likely to receive radiographs and laboratory and other ancillary tests than nonelderly patients. Seventy-seven percent of elderly patients seeking ED care receive radiographs, and 78% receive laboratory tests. 1 • The average total charges for ED visits of elderly patients are higher than those for the nonelderly population. Mean charges for the hospital, emergency physician, laboratory, radiographs, and ancillary services were all higher for elderly patients than for nonelderly patients. 1 • When patients without health insurance were excluded from the study's analysis, elderly patients still had higher health care charges, urgency levels, and use of radiography, laboratory, and ambulance services. 1 • Elderly patients account for 36% of an patients arriving by ambulance.4
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• Elderly patients account for 43% of all hospital admissions from EDs. 4 • Elderly patients account for 48% of all critical care unit admissions from EDs. 4 R e c o m m e n d a t i o n 1 The appropriateness of use of emergency services by elderly as well as nonelderly patients must be assessed with further studies. It is u n k n o w n whether the increased use of emergency care resources for the elderly population is necessary and appropriate. Available evidence indicates that elderly patients seeking emergency care are an ill population. 1,2 Strategies that make use of innovative alternatives to emergency health care resources need to be investigated. R e c 0 m m o n d a t i o n 2 Ongoing accurate information on the use of emergency services by the elderly should be compiled and made available so that planning for adequate resources can occur. R e c o m m e n d a t i o n 3 The structure of emergency health care delivery for elderly patients must be evaluated and innovations explored. For example, the role of geriatric emergency health care centers analogous to trauma centers or pediatric centers should be investigated. The center concept might provide a mechanism for delivering specialized care and attending to the special needs of geriatric patients but may be practical in only some communities. R e c o m m e n d a t i o n 4 Concern about adequacy of resources to meet the needs of an increasing population of elderly must be brought to the attention of hospitals, health policy analysts, health care workers, community organizations, foundations, and government organizations. P l a n n i n g must be performed to ensure adequate treatment of the elderly needing emergency care in the future. CLINICAL
ISSUES
C o n c I u s i o n Emergency health care workers feel less comfortable when dealing with elderly patients than when dealing with nonelderly patients. • When surveyed regarding seven common patient complaints, emergency physicians responded that they find it more difficult to treat elderly patients than nonelderly patients with the same complaints. 3 • Elderly patients require more time and ED resources than other adult patients. 1,3 • Better communication between emergency health care professionals and elderly patients, caretakers, and p r i m a r y care providers could facilitate the care of the elderly. Seventy-seven percent of emergency physicians reported moderate or frequent information transfer problems with nursing homes, and 44% reported moderate or frequent problems obtaining information from primary care physicians. 3 • Emergency physicians believe that there is a dearth of education and research in geriatric emergency care. z
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Sanders
Fifty-three percent of residency-trained emergency physicians believed that they did not spend adequate time learning about geriatric emergency care in their training program. 3 Specific issues of concern to emergency physicians were: • Altered disease presentation in the elderly 3,5 • Multiple medications and drug interactions 3,5 • Altered physiology in the elderly 3,5 • Lack of knowledge and accepted standards for the emergency care of the elderly 3,s • Lack of ability to communicate with patients, p r i m a r y care physicians, and nursing home facilities 3,5 • Amount of medical and nursing time needed to deal with elderly patients1,3, 5 • Extent of social support services needed by the elderly 2,3,5,6 • Uncertainty regarding need for limitation of care 3,5 Elderly patients seeking emergency care have high acuity levels and receive comprehensive medical and nursing care. • Elderly patients are more likely to present to the ED with an urgent or emergent problem than nonelderly patients. Elderly patients are less likely than the nonelderly to present to EDs with nonurgent complaints. 1 • Elderly patients present to the EDs with more comorbid diseases than non-elderly patients. 1 • Most elderly patients have p r i m a r y care providers. They visit EDs because they feel too ill to go elsewhere and feel they will get better care in the ED. 2,6 • Forty-six percent of elderly patients seen in EDs receive comprehensive medical care compared with 13% of nonelderly patients.4 • Both elderly and nonelderly patients are generally satisfied with the care received in the ED. However, the elderly were less likely to r e p o r t that their complaint had been completely resolved. Waiting time was the most common problem reported regarding emergency care, although it was of less concern to the elderly than to nonelderly patients.2, 6 The task force has concluded that it is time to re-evaluate the disease-oriented model used to care for elderly patients in EDs. The medical model used for other adult patients may not be a p p r o p r i a t e for the elderly population. Similarly, the care model for elderly patients in a clinic or office setting may be i n a p p r o p r i a t e for an ED. Although emergency health care professionals seem to u n d e r s t a n d that the elderly represent a special population, general principles for the care of the elderly in EDs have not been defined. R e ¢ 0 nl m e n d a t i 0 n 1 Overall principles of care of the elderly in EDs need to be defined by experts in emergency and geriatric health care. A medical model a p p r o p r i a t e for ED treatment of geriatric patients that considers the special needs and altered physiology of the elderly population needs to be developed. These principles should provide guidelines for physicians, nurses, social workers, and prehospital care professionals.
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R e c o m m e n d a I i o n 2 There is a need for an assessment of the knowledge, attitudes, and behaviors of emergency health care workers toward elderly patients. R e c o rn m e n d a t i o n 3 Communication among emergency health care workers, geriatricians, p r i m a r y care providers, and chronic care facilities must be improved. Both health care professionals who treat acute problems and health care professionals who treat chronic problems of the elderly should develop an increased understanding of the principles, attitudes, priorities, and limitations of the systems in which they function. This may be encouraged through rotations during training programs, continuing education, and open dialogue among health care professionals. Professional organizations can facilitate communication and provide joint programs. Information technology has enormous potential for implementing innovative approaches to information transfer in the patient care setting. Emergency health care professionals need to work closely with p r i m a r y care providers and caregivers to ensure adequate information transfer, especially with regard to decisions on withholding or limiting medical care. R e c o m m e n d a t i o n 4 A cadre of future leaders in geriatric emergency medicine must be developed. Such leaders can bridge the gap between geriatrics and emergency medicine and serve as advocates for the care of the elderly in EDs. At present, there is a lack of leadership and advocacy in the field of geriatric emergency medicine. In the specialty of emergency medicine, for example, there are society sections, fellowship training programs, journals, and scientific meetings of health care workers who deal with pediatric emergency medicine. Physicians can obtain special certification in pediatric emergency medicine from the American B o a r d of Emergency Medicine. Similarly, within the geriatric health care community, few leaders have focused their efforts on the emergency care of elderly patients. F u t u r e leadership can be developed through fellowship programs, sectional status, networking groups at national meetings, position statements, and joint programs in the geriatric and emergency medicine community. ACADEMIC ISSUES C o n c I [] s i o n- E d u c a t i o n There is a dearth of educational programs on the emergency care of the elderly. Most (69%) of the practicing physicians surveyed reported that insufficient continuing medical education was available in topics on geriatric emergency medicine. Fifty-three percent of residency-trained emergency physicians said they considered their education on the emergency care of the elderly during residency training to have been insufficient. Less than 5% of practicing physicians' continuing education time is devoted to topics in geriatric emergency care. 3 There is also a scarcity of training and educational programs for paramedics and
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emergency nurses on the special needs of the elderly seeking emergency care. C 0 n c I u s i 0 n - R e s e a r c h There is a paucity of research in geriatric emergency medicine. Seventy-one percent of practicing emergency physicians and 65% of residency directors believe that research efforts regarding geriatric emergency care are insufficient.3,5 More research needs to be completed on the special needs of the elderly in EDs. The task force has concluded that both the difficulty in the care of the elderly in EDs and the lack of educational programs for health care professionals arise from insufficient knowledge in fundamental areas of geriatric emergency medicine. R e c 0 m m e n d a t i [] n 1 A curriculum and syllabus on meeting the special needs of the geriatric population should be developed and incorporated into training programs for all emergency health care professionals. Such a syllabus could also be used for continuing medical education programs for practicing emergency health care professionals. In addition to academic institutions, professional organizations in botkemergency medicine and geriatrics should be encouraged to increase the amount of educational material on the special needs of elderly patients seeking treatment in EDs that is available to health care practitioners. Educational programs should be developed for all emergency health care professionals including physicians, nurses, social workers, and paramedics. R e c 0 m m e n d a t i 0 n 2 Research in geriatric emergency medicine must be stimulated, especially through interdisciplinary efforts of geriatricians and emergency health care workers. Funding organizations and health policy makers should be made aware of the critical need for additional research in this area. R e c o m m e [] d a t i o n 3 Outcome criteria for geriatric emergency medicine should be defined. This requires a multidisciplinary effort involving patients, physicians, social workers, nurses, and home/institutional caregivers. Optimal outcome criteria may not be simply survival or prolongation of life but may involve other issues such as pain control or symptom management. R e c o m m e n d a t i o n 4 There is a need for more research and education regarding the problems of multiple medications, altered physiology, and altered disease presentation in the elderly. R e c o m m e n d a t i o n 5 There is a need for research and innovative approaches to meet the social and personal needs of the elderly who need emergency care. R e c o m m e n d a t i 0 n 6 There is a need for research evaluating the use of ED services to care for elderly patients. Research investigating alternative strategies that decrease the need for ambulance services, hospital admission, and comprehensive ED evaluation should be encouraged. R e c o m m e n d a t i o n 7 Greater attention needs to be paid to the problems of uncertainty and doubt for emergency
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health care workers in dealing with elderly patients' complaints. SOCIAL/PERSONAL ISSUES C o n c I u s i o [] The social/personal circumstances of elderly
patients receiving emergency care are frequently not addressed in ED visits. • The functional status of elderly persons is not routinely evaluated in EDs. Elderly patients discharged from the EDs had greater problems in their ability to care for themselves as a result of their illness or i n j u r y than did nonelderly patients. Less than 30% of elderly patients reported that inquiries were made during their ED visits regarding their ability to care for themselves. 2 • Although being seen in an ED presents an opportunity to evaluate a patient's health care needs, questions about preventive health measures such as immunizations and nutrition are not usually addressed in an ED encounter. • Elderly patients are frequently uncomfortable in the ED environment. They are unfamiliar with the emergency care system, frightened by their i n j u r y or illness, and uncomfortable with the physical surroundings. 6 • Psychosocial issues such as elder abuse/neglect, depression, suicide prevention, and substance abuse are not commonly addressed in an ED encounter. • Most EDs do not have protocols for detecting and dealing with elder abuse as they do for child abuse. Only 27% of physicians reported that protocols for elder abuse were available at their hospitals. 2 Although there is much speculation about the incidence of elder abuse/neglect, there is little reliable information in the medical literature concerning the extent of this problem. R e c o m m e n d a t i o [ ] 1 Attention to the social, psychological, and functional status of the elderly should be part of the defined principles of emergency care of the elderly. Implementing this principle on a routine basis will require added resources to address the problems defined. R e c o m m e n d a t i o n 2 The mental and functional status of the elderly should be addressed as part of the emergency encounter. Because most existing scales for evaluating mental status and activities of daily living have been formulated for clinic or primary care settings, they may not be appropriate in EDs. New evaluation tools or modifications of existing tools need to be standardized for application in the ED setting. R e c o m m e n d a t i o n 3 Psychosocial problems in the elderly, including possibilities of elder abuse/neglect, depression, suicide prevention, and substance abuse, should be routinely addressed. Research should be u n d e r t a k e n to determine the most effective methods of screening and dealing with psychosocial problems in the emergency health care setting. R e c o m m e n d a t i o [] 4 Preventive health measures such as immunizations, nutritional status, and prophylaxis for
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falls and pedestrian injuries should be addressed in elderly patients who are at risk for these problems. R e c 0 m m e n d a t i o n 5 The potential role of a geriatric health care worker in emergency medicine should be investigated. Geriatric health care workers can help provide functional assessments and attend to the personal and social needs of elderly patients, as well as act as advocate for the elderly in the emergency health care system. Re c 0 m m e n d a t i o [] 6 The physical plant of EDs should be made more user-friendly for elderly patients. Strategies can be developed so that elderly patients feel more comfortable in an ED, especially with regard to privacy, physical comfort, explanation of tests and procedures, and attention to anxieties and questions about care. This will require more time and attention from emergency health care professionals. R e c 0 m m e n d a t i o n 7 The concept of discharge planning for elderly patients leaving the ED needs re-evaluation. Innovative approaches to discharge planning that incorporates social and personal as well as medical and nursing needs can be developed. Improved ED discharge procedures might decrease the necessity for hospital admission.
REFERENCES 1. Singal BM, Hedges JR, Rousseau EW, et al: Geriatric patient emergency visits Part I: Comparison of geriatric and younger patients. Ann EmergMed 1992;21:802-807. 2. Hedges JR, Singal BM, Rousseau EW, et al: Geriatricpatient emergency visits Part I1: Perceptions of visits by geriatric and younger patients. Ann EmergMed1992;21:808-813. 3. McNamara RM, Rousseau EW, Sanders AB: Geriatric emergency medicine: A survey of practicing emergency physicians. Ann EmergMed 1992;21:796-801. 4. Strange GR, Chen EH, Sanders AB: Use of emergency departments by elderly patients: Projections from a multicenter data base. Ann EmergMet 1992;21:819-824. 5. Jones JS, Rousseau EW, Schropp MA, et al: Geriatric training in emergency medicine residency programs. Ann EmergMed 1992;21:825-829. 6. Baraff LJ, Bernstein E, Bradley K, et al: Perceptions of emergency care by the elderly: Results of multicenter focus group interviews. Ann EmergMed 1992;21:814-818.
Address for reprints: Arthur B Sanders, MD, FACEP, FACP, Section of Emergency Medicine, University of Arizona College of Medicine, I501 North Campbell, Tucson, Arizona 85724.
SUMMARY
The SAEM Geriatric Emergency Medicine Task Force has studied the care of the elderly in EDs and concluded that the special needs of the elderly are not being addressed adequately. Emergency health care professionals receive little education in geriatric emergency medicine and feel less comfortable when caring for elderly than for nonelderly patients. The elderly require significantly more emergency care resources than do the nonelderly. With the population of elderly patients rapidly increasing and many hospitals and their EDs facing significant p r o b lems of overcrowding and inadequate resources, the problem of providing a p p r o p r i a t e emergency care for the elderly may become a crisis unless planning is undertaken. The task force has provided specific recommendations in the areas of clinical service, research, education, resources, and social/personal issues. With a p p r o p r i a t e planning and resources, the emergency health care needs of the elderly can be met.
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