Geriatrics-Friendly Emergency Care

One of the places where older adults may receive health care is the emergency department (ED) at a hospital. ED visits can be confusing and intimidating for anyone. This is especially true for older adults and caregivers. The ED is often loud and can seem chaotic. Busy health professionals may conduct very quick initial evaluations. This is understandable in an emergency. However, the evaluation may likely be too brief to effectively cover an older person’s chronic medical problems and medications. Long waits and a confusing environment can also make it more likely for older adults in the ED to develop delirium.

Delirium is a serious state of mental confusion that can lead to difficulty thinking and remembering.

Fortunately, some EDs are changing and getting more “geriatrics-friendly.” Many hospitals are recognizing the importance of geriatrics principles (principles from the branch of health care dedicated to our care as we age). These hospitals are changing their EDs to make them safer and more effective for older individuals.

If you are an older adult or someone who cares for an older person, it can help to learn about “geriatrics-friendly” ED care and whether it’s available in your area. This can help put you at ease if you ever need emergency medical attention.

Characteristics of a geriatrics-friendly ED

Training in the care of older adults

EDs treat patients of all ages for any urgent condition. However, our bodies change with age and our health care needs to change as well. Geriatrics-friendly EDs have staff members who are trained in and dedicated to emergency care specifically for older adults. These staff members may be specialized nurses, case managers, or social workers. They often help doctors and other staff evaluate and communicate with patients, caregivers, and other providers.

Part of providing geriatrics-friendly care in the ED is knowing how to screen for problems that are common for older adults. The healthcare professionals trained in providing care to older people will ask screening questions during a check-up of the older person. Common screening questions ask about:

  • the ability to care for ourselves at home
  • the ability to think clearly and shift or maintain attention
  • the ability to walk a short distance
  • any additional social needs which could play a role in recovery from illness or injury (such as how often we’re visited by family or friends)

These questions also screen for “red flag” conditions. For example, these include a decline in function, sudden confusion, or trouble with walking or balance. Older adults who have these conditions will be offered additional evaluation and care to address these concerns. These concerns often play a critical role in how quickly and safely we recover.

A geriatrics-friendly environment

An ED evaluation often takes many hours. It may require staying in the ED while waiting for a bed in the hospital. Geriatrics-friendly EDs often have a system in place to frequently check on older people. This can help reduce the potential for confusion or complications. It is important that the ED keeps an older person warm, fed, comfortable, mobile (if possible), and not left alone for long periods of time. Overlooking these important needs can lead to an increased risk for delirium.

ED staff also can help get necessary medications and food during an older adult’s ED stay. They can move older adults to a quieter, calmer room if wait times are long. The goal is to make the ED experience less stressful for older people and their caregivers.

Additionally, many geriatrics-friendly EDs provide unique types of equipment and supplies. These make visits as comfortable as possible for older adults. These resources include bedside portable commodes (toilets), reclining examination chairs, warming blankets, and voice amplification devices. The ED should also give older adults who need help access to mobility aids and walkers. These promote safe standing and walking for people who are vulnerable because of illness or injury. All these tools can help an older person during evaluation and while waiting to return home or to a hospital room. Likewise, a chair for a family caregiver should be easily accessible.

Attention to medications

Changes in our bodies as we age can increase the chances of side effects when taking medications. This is important to consider during emergency care. Because older people often have more health problems, they often take more medications than younger people. This means that older adults are more likely to experience harmful interactions between different medications.

In order to address these issues, geriatrics-friendly EDs make sure to pay attention to the medications older people are taking. They may use the following tools:

  • “Medication reconciliation” is the process of creating the most accurate list possible of all medications someone is taking (including prescriptions and over-the-counter treatments). Then that list is compared with medications in the person’s medical records.
  • A “full pharmacy review” will create a complete and correct list of the current medications a person should be taking every time there is a move from one healthcare setting to another. (These moves may include going from the ED to a hospital room to a rehabilitation facility, for example.)

These practices lower the chance that older adults in the ED will receive incorrect medications or medication doses.

Attention to your personal goals of care

Geriatrics-friendly EDs may also help older individuals determine their personal “goals of care” and how to achieve them. A discussion about goals of care means that healthcare staff will talk to you about your wishes and values in your life. This discussion can help you decide which treatments you choose for your illness.

One tool for expressing healthcare goals is a legal document called an “advance directive.” Advance directives explain what kind of end-of-life care someone wants or doesn’t want, depending on their personal preferences.

A geriatrics-friendly ED may have a system to consider and document goals of care. This system can include creating or incorporating an advance directive into a person’s medical records. Older adults can help in this process by making sure they tell ED staff their goals of care early. To be prepared in advance for an emergency, older people or caregivers should have a copy of the advance directives handy. If possible, this important paperwork should be brought to an ED visit. Another way to make sure your wishes can be communicated as quickly as possible is to give your advance directive to your day-to-day healthcare team to keep on file.

If you or someone you care for doesn’t have an advance directive, talk with family and others to discuss your goals of care. This way they are as clear as possible before an emergency. A geriatrics-friendly ED will work hard to incorporate these goals into all treatment decisions.

Another thing geriatrics-friendly EDs are good at is balancing treatments that attempt to cure an illness versus managing symptoms. This is particularly true for older adults with advanced illnesses. For example, “palliative care” is specialized care for relieving pain and other symptoms of an illness. Treatment plans may best meet a person’s needs by incorporating palliative care. If you or someone you care for needs emergency care, ask if any ED staff are trained in palliative care. If not, ask if palliative care professionals are available in the ED, hospital, or by outpatient referral.

Attention to care as you move into and out of the ED

Older adults may move between different locations several times between the time they reach the ED and the time they return home. For example, older adults may arrive from a residential or nursing facility, and then be transferred from the ED to an Intensive Care Unit (ICU). After the ICU, they may then move to a hospital room. Then they may transition to a rehabilitation facility before being discharged.

With each move (also known as a “care transition”), we receive care from different healthcare providers. During these moves, there is a risk of experiencing communication breakdowns between teams. A geriatrics-friendly ED should have a plan for reducing transitions. They should also make sure transitions occur as smoothly as possible when it comes to sharing information about care needs and expectations.

Research shows that older people who go through fewer transitions are given fewer inappropriate medications and have better health outcomes.

Once an older person is ready to leave the ED, the ED staff will coordinate to make sure there are safe care transitions to other care sites (including home). Geriatrics-friendly EDs should also have a system for communicating with staff “back home” for older people who live in residential or nursing facilities.

After discharge, the ED staff may arrange to follow up with the older adult’s primary care provider or home nursing/therapy services. Other older people may need further evaluation from home care nurses and therapists. Still others may be eligible for safe alternatives to hospitalization directly from the ED, such as a Hospital at Home program or a transfer to a rehabilitation or respite facility. Getting information about transitions early in the ED visit can help give older adults and caregivers peace of mind.

Support for caregivers

Caregivers play an essential role in supporting older adults before, during, and after an ED visit. During an ED visit, staff can work with caregivers to see how caregivers can help older adults with their care and care preferences. The ED should also have a system to contact caregivers and/or keep them comfortable and included in the decision-making process during the older person’s ED visit.

 

Source: Geriatric Emergency Department Guidelines, developed and endorsed by the American College of Emergency Physicians, the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine, and supported through the AGS Geriatrics-for-Specialists Initiative which is funded by the John A. Hartford Foundation. See GeriatricsCareOnline.org for the full guidelines. 

Last Updated August 2019