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The elderly in the emergency department: a critical review of problems and solutions

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Abstract

The elderly are an ever increasing population in overcrowded emergency departments (EDs) in many countries. They have multiple health problems and consume more time and resources than younger patients. They are more frequently admitted and experience adverse outcomes after they are discharged from the ED. These frail patients could require specific skills, instruments and organisational models of emergency care in order to look after their complex needs. As such, several approaches have been tried and tested to improve emergency care for them. This article analyses the epidemiological load and problems faced when confronted with elder ED patients. We critically review organisational models, clinical approaches and methodologies in order to reduce ED physicians’ difficulties and to improve quality of care and outcomes for elder patients. Triage, clinical assessment and discharge are identified as critical moments during an emergency care process, and interesting and useful instruments are proposed as possible solutions.

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References

  1. McCaig LF, Nawar EW (2006) National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Adv Data 372:1–32

    PubMed  Google Scholar 

  2. Strange GR, Chen EH, Sanders AB (1992) Use of emergency departments by elderly patients: projections from a multicenter data base. Ann Emerg Med 21:819–824

    Article  PubMed  CAS  Google Scholar 

  3. Baum SA, Rubenstein LZ (1987) Old people in the emergency room: age-related differences in emergency department use and care. J Am Geriatr Soc 35:398–404

    PubMed  CAS  Google Scholar 

  4. Schumacher JG, Deimling GT, Meldon S, Woolard B (2006) Older adults in the Emergency Department: predicting physicians’ burden levels. J Emerg Med 30:455–460

    Article  PubMed  Google Scholar 

  5. Schumacher JG (2005) Emergency medicine and older adults: continuing challenges and opportunities. Am J Emerg Med 23:556–560

    Article  PubMed  Google Scholar 

  6. George G, Jell C, Todd BS (2006) Effect of population ageing on emergency department speed and efficiency: a historical perspective from a district general hospital in the UK. Emerg Med J 23:379–383

    Article  PubMed  CAS  Google Scholar 

  7. — (2004) Sistema Informativo Emergenza Sanitaria (SIES) del Lazio. Capitolo 1 — Analisi generali Dati SIES andamenti temporali 2000–2004. Attività SIES anno 2004. http://www.asplazio.it/asp_online/att_ospedaliera/sies/sies_new/rapp_2004/volume/indice.php?menu=S22&emergenza=sies&sies=dati (accessed 23 May 2007)

  8. McCusker J, Karp I, Cardin S et al (2003) Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med 10:1362–1370

    Article  PubMed  Google Scholar 

  9. Downing A, Wilson R (2005) Older people’s use of Accident and Emergency services. Age Ageing 34:24–30

    Article  PubMed  Google Scholar 

  10. Gilboy N, Tanabe P, Travers DA et al (2005). Emergency Severity Index, Version 4: Implementation Handbook. Agency for Healthcare Research and Quality, Rockville, MD, AHRQ Publication No. 05-0046-2

    Google Scholar 

  11. Aminzadeh F, Dalziel WB (2002) Older adults in the Emergency Department: a systematic review of pattern of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 39:238–247

    Article  PubMed  Google Scholar 

  12. Sanders AB (2001) Older persons in the emergency medical care system. J Am Geriatr Soc 49:1390–1392

    Article  PubMed  CAS  Google Scholar 

  13. Khan SA, Miskelly FG, Platt JS, Bhattachryya BK (1996) Missed diagnoses among elderly patients discharged from an accident and emergency department. Emerg Med 13:256–257

    CAS  Google Scholar 

  14. Saliba D, Kington R, Buchanan J et al (2000) Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc 48:154–163

    PubMed  CAS  Google Scholar 

  15. Finn JC, Flicker L, Mackenzie E et al (2006) Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Med J Aust 184:432–435

    PubMed  Google Scholar 

  16. Ackermann RJ, Kemle KA, Vogel RL, Griffin RC (1998) Emergency Department use by nursing home residents. Ann Emerg Med 31:749–757

    Article  PubMed  CAS  Google Scholar 

  17. Turrel AR, Castleden CM (1999) Improving the emergency medical treatment of older nursing-home residents. Age Ageing 28:77–82

    Article  Google Scholar 

  18. Terrell KM, Miller DK (2006) Challenger in transitional care between nursing homes and emergency departments. J Am Med Dir Assoc 7:499–505

    Article  PubMed  Google Scholar 

  19. Jones JS, Dwyer PR, White LJ, Firman R (1997) Patient transfer from nursing home to emergency department: outcomes and policy implications. Acad Emerg Med 4:908–915

    PubMed  CAS  Google Scholar 

  20. Davis MN, Toombs Smith S, Tyler S (2005) Improving transition and communication between acute care and long-term care: a system for better continuity of care. Ann Long-Term Care 13:25–32

    Google Scholar 

  21. Sanders AB (1997) Emergency care for patients in long-term care facilities: a need for a better communication. Acad Emerg Med 4:908–915

    Article  Google Scholar 

  22. Terrell KM, Brizendine EJ, Bean WF et al (2005) An extended care facility-to-emergency department transfer form improves communication. Acad Emerg Med 12:114–118

    Article  PubMed  Google Scholar 

  23. Bianco A, Pileggi C, Angelillo AF (2003) Non-urgent visits to a hospital emergency department in Italy. Public Health 117:250–255

    Article  PubMed  CAS  Google Scholar 

  24. Sklar DP, Crandall CS, Loeliger E et al (2007) Unanticipated death after discharge home from the emergency department. Ann Emerg Med 49:735–745

    Article  PubMed  Google Scholar 

  25. Then KL, Rankin JA, Fofonoff DA (2001) Atypical presentation of acute myocardial infarction in 3 age groups. Heart Lung 30:285–293

    Article  PubMed  CAS  Google Scholar 

  26. Grossman SA, Brown DF, Chang Y et al (2003) Predictors of delay in presentation to the ED in patients with suspected acute coronary syndromes. Am J Emerg Med 21:425–428

    Article  PubMed  Google Scholar 

  27. Coronado BE, Pope JH, Griffith JL et al (2004) Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: a multicenter study. Am J Emerg Med 22:568–574

    Article  PubMed  Google Scholar 

  28. Olsson T, Terent A, Lind L (2005) Charlson Comorbidity Index can add prognostic information to Rapid Emergency Medicine Score as a predictor of long-term mortality. Eur J Emerg Med 12:220–224

    Article  PubMed  Google Scholar 

  29. Elie M, Rousseau F, Cole M et al (2000) Prevalence and detection of delirium in elderly emergency department patients. CMAJ 163:977–981

    PubMed  CAS  Google Scholar 

  30. Hustey FM, Meldon SW (2002) The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 39:248–253

    Article  PubMed  Google Scholar 

  31. Inoyue SK (2006) Delirium in older persons. N Engl J Med 354:1157–1165

    Article  Google Scholar 

  32. Hustey FM, Meldon SW, Smith MD, Lex CK (2003) The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 41:678–684

    Article  PubMed  Google Scholar 

  33. Kakuma R, du Fort GG, Arsenault L et al (2003) Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 51:443–450

    Article  PubMed  Google Scholar 

  34. Chiovenda P, Vincetelli GM, Alegiani F (2002) Cognitive impairment in elderly ED patients: need for multidimensional assessment for better management after discharge. Am J Emerg Med 20:332–335

    Article  PubMed  Google Scholar 

  35. Sanders AB (1996) Emergency care of the elder person. Beverly Cracom Publications, St Louis

    Google Scholar 

  36. Chung MK, Bartfield JM (2002) Knowledge of prescription medications among elderly emergency department patients. Ann Emerg Med 39:605–608

    Article  PubMed  Google Scholar 

  37. Budnitz DS, Pollock DA, Weidenbach KN et al (2006) National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296:1858–1866

    Article  PubMed  CAS  Google Scholar 

  38. Hohl CM, Lord V, Colacone A, Pépin J (2005) Emergency physician recognition of adverse drug-related events in elder patients presenting to an emergency department. Acad Emerg Med 12:197–205

    Article  PubMed  Google Scholar 

  39. Beers MH, Storrie M, Lee G (1990) Potential adverse drug interactions in the emergency room. An issue in the quality of care. Ann Intern Med 112:61–64

    PubMed  CAS  Google Scholar 

  40. Terrel KM, Heard K, Miller D (2006) Prescribing to older ED patients. Am J Emerg Med 24:468–478

    Article  Google Scholar 

  41. Hohl CM, Dankoff J, Colacone A, Afilalo M (2001) Polypharmacy, adverse drug-related events, potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med 38:666–671

    Article  PubMed  CAS  Google Scholar 

  42. Beers MH (1997) Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 157:1531–1536

    Article  PubMed  CAS  Google Scholar 

  43. Fick DM, Cooper JW, Wade WE et al (2003) Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med 163:2716–2724

    Article  PubMed  Google Scholar 

  44. Caterino JM, Emond JA, Camargo CA (2004) Inappropriate medication administration to the acutely ill elderly: a nationwide emergency department study, 1992–2000. J Am Geriatr Soc 52:1847–1855

    Article  PubMed  Google Scholar 

  45. Wilber ST, Blanda M, Gerson LW (2006) Does functional decline prompt emergency department visits and admission in older patients? Acad Emerg Med 13:680–682

    Article  PubMed  Google Scholar 

  46. Gerson LW, Blanda M, Dhingra P et al (2001) Do elder emergency department patients and their informants agree about the elder’s functioning? Acad Emerg Med 8:721–724

    PubMed  CAS  Google Scholar 

  47. Rodriguez-Molinero A, Lopez-Dieguez M, Tabuenca AI et al (2006) Functional assessment of older patients in the emergency department: comparison between standard instruments, medical records and physicians perceptions. BMC Geriatr 6:13

    Article  PubMed  Google Scholar 

  48. Caplan GA, Brown A, Croker WD, Dooland J (1998) Risk of admission within 4 weeks of discharged from the emergency department — the DEED study. Discharge of elderly from the emergency department. Age Ageing 27:697–702

    Article  PubMed  CAS  Google Scholar 

  49. Fried LP, Tangen CM, Walston J et al; Cardiovascular Health Study Collaborative Research Group (2001) Frailty on older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 56:M146–M156

    PubMed  CAS  Google Scholar 

  50. Giugliano RP, Camargo CA Jr, Lloyd-Jones DM et al (1998) Elderly patients receive less aggressive medical and invasive management of unstable angina. Arch Intern Med 158:1113–1120

    Article  PubMed  CAS  Google Scholar 

  51. Magid DJ, Masoudi FA, Vinson DR et al (2005) Older Emergency Department patients with acute myocardial infarction receive lower quality of care than younger patients. Ann Emerg Med 46:14–21

    Article  PubMed  Google Scholar 

  52. Wilber ST, Gerson LW, Terrell KM et al (2006) Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of Emergency Care in the U.S. health system. Acad Emerg Med 13:1345–1351

    Article  PubMed  Google Scholar 

  53. Adams JG, Gerson LW (2003) A new model for emergency care of geriatric patients. Acad Emerg Med 10:271–274

    Article  PubMed  Google Scholar 

  54. Wilber ST, Burger B, Gerson LW, Blanda M (2005) Reclining chairs reduce pain from gurneys in older emergency department patients: a randomized controlled trial. Acad Emerg Med 12:119–123

    Article  PubMed  Google Scholar 

  55. Hastings SN, Heflin MT (2005) A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med 12:978–986

    Article  PubMed  Google Scholar 

  56. McCusker J, Verdon J (2006) Do geriatric interventions reduce emergency department visits? A systematic review. J Gerontol A Biol Sci Med Sci 61:53–62

    PubMed  Google Scholar 

  57. Baumann MR, Strout TD (2007) Triage of geriatric patients in the Emergency Department: validity and survival with the Emergency Severity Index. Ann Emerg Med 49:234–240

    Article  PubMed  Google Scholar 

  58. Ross MA, Compton S, Richardson D et al (2003) The use and effectiveness of an Emergency Department Observation Unit for elderly patients. Ann Emerg Med 41:668–677

    Article  PubMed  Google Scholar 

  59. Miller DK, Lewis LM, Nork MJ, Morley JE (1996) Controlled trial of a geriatric case-finding and liaison service in an emergency department. J Am Geriatr Soc 44:513–520

    PubMed  CAS  Google Scholar 

  60. Rubenstein LZ (1996) The emergency department: a useful site for CGA? J Am Geriatr Soc 44:601–602

    PubMed  CAS  Google Scholar 

  61. Rubenstein LZ, Stuck AE, Siu AL, Wieland D (1991) Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Soc 39:8S–16S

    PubMed  CAS  Google Scholar 

  62. Stuck AE, Siu AL, Wieland DG et al (1993) Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 342:1032–1036

    Article  PubMed  CAS  Google Scholar 

  63. Landefeld CS, Palmer RM, Kresevic DM et al (1995) A randomized trial of care in hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 332:1338–1344

    Article  PubMed  CAS  Google Scholar 

  64. Bernabei R, Landi F, Gambassi G et al (1998) Randomised trial of impact of model of integrated care and case management for older people living in the community. BMJ 316:1348–1351

    PubMed  CAS  Google Scholar 

  65. Reuben DB (2003) Comprehensive Geriatric Assessment and systems approaches to geriatric care. In: Cassel CK, Leipzig R, Cohen HJ et al (eds) Geriatric medicine, 4th Edn. Springer-Verlag, New York, pp 195–204

    Google Scholar 

  66. Rozzini R, Frisoni GB, Ferrucci L et al (2002) Geriatric Index of Comorbidity: validation and comparison with other measures of comorbidity. Age Ageing 31:277–285

    Article  PubMed  Google Scholar 

  67. Charlson ME, Pompei P, Ales KL, MacKenzie RC (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    Article  PubMed  CAS  Google Scholar 

  68. Inouye SK, van Dyck CH, Alessi CA et al (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113:941–948

    PubMed  CAS  Google Scholar 

  69. Pfeiffer E (1975) Short Portable Mental Status Questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 23:433–441

    PubMed  CAS  Google Scholar 

  70. Sheikh JI, Yesavage JA (1986) Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. In: Brink TL (ed.) Clinical gerontology: a guide to assessment and intervention. The Haworth Press, New York, pp 165–173

    Google Scholar 

  71. Hoyl MT, Alessi CA, Harker JO et al (1999) Development and testing of a five-item version of the Geriatric Depression Scale. J Am Geriatr Soc 47:873–878

    PubMed  CAS  Google Scholar 

  72. Fillenbaum G (1978) Multidimensional Functional Assessment: The OARS Methodology — A Manual. Center for the Study of Aging and Human Development, Duke University, Durham, NC

    Google Scholar 

  73. Murray SB, Bates DW, Ngo L et al (2006) Charlson Index is associated with one-year mortality in emergency department patients with suspected infection. Acad Emerg Med 13:530–536

    Article  PubMed  Google Scholar 

  74. McCusker J, Bellavance F, Cardin S et al (1999) Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 47:1229–1237

    PubMed  CAS  Google Scholar 

  75. Wilber ST, Lofgren SD, Mager TG et al (2005) An evaluation of two screening tools for cognitive impairment in older emergency department patients. Acad Emerg Med 12:612–616

    Article  PubMed  Google Scholar 

  76. Fabacher DA, Raccio-Robak N, McErlean MA et al (2002) Validation of a brief screening tool to detect depression in elderly ED patients. Am J Emerg Med 20:99–102

    Article  PubMed  Google Scholar 

  77. Hustey FM (2005) The use of a brief depression screen in older emergency department patients. Acad Emerg Med 12:905–908

    Article  PubMed  Google Scholar 

  78. Siebens H (2005) The Domain Management Model — A tool of teaching and management of alder adults in emergency departments. Acad Emerg Med 12:162–168

    Article  PubMed  Google Scholar 

  79. Mion LC, Palmer RM, Anetzberger GJ, Meldon SW (2001) Establishing a case-finding and referral system for at-risk older individuals in the Emergency Department setting: the SIGNET model. J Am Geriatr Soc 49:1379–1386

    Article  PubMed  CAS  Google Scholar 

  80. McCusker J, Jacobs P, Dendukuri N et al (2003) Cost-effectiveness of a brief 2-stage emergency department intervention for high risk elders: results of a quasi-randomized controlled trial. Ann Emerg Med 41:45–56

    Article  PubMed  Google Scholar 

  81. Meldon SW, Mion LC, Palmer RM et al (2003) A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med 10:224–232

    Article  PubMed  Google Scholar 

  82. McCusker J, Verdon J, Tousignant P et al (2001) Rapid emergency department intervention for elders reduces risk of functional decline: results of a multi-center randomized trial. J Am Geriatr Soc 49:1272–1281

    Article  PubMed  CAS  Google Scholar 

  83. Mion LC, Palmer RM, Meldon SW et al (2003) Case finding and referral model for Emergency Department elders: a randomized clinical trial. Ann Emerg Med 41:57–68

    Article  PubMed  Google Scholar 

  84. McCusker J, Dendukuri N, Tousignant P et al (2003) Rapid two-stage emergency department intervention for seniors: impact on continuity of care. Acad Emerg Med 10:233–243

    Article  PubMed  Google Scholar 

  85. Fan J, Worster A, Fernandes CMB (2006) Predictive validity of the Triage Risk Screening Tool for elderly patients in a Canadian emergency department. Am J Emerg Med 24:540–544

    Article  PubMed  Google Scholar 

  86. McCusker J, Cardin S, Bellavance F, Belzile E (2000) Return to the emergency department among elders: patterns and predictors. Acad Emerg Med 7:249–259

    PubMed  CAS  Google Scholar 

  87. McCusker J, Bellavance F, Cardin S et al (2000) Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit. Ann Emerg Med 36:438–445

    PubMed  CAS  Google Scholar 

  88. Dendukuri N, McCusker J, Belzile E (2004) The Identification of Seniors At Risk screening tool: further evidence of concurrent and predictive validity. J Am Geriatr Soc 52:290–296

    Article  PubMed  Google Scholar 

  89. Caplan GA, Williams AJ, Daly B, Abraham K (2004) A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the Emergency Department — The DEED II Study. J Am Geriatr Soc 52:1417–1423

    Article  PubMed  Google Scholar 

  90. Guttman A, Afilalo M, Guttman R et al (2004) An emergency department-based discharge coordinator for elder patients: does it make a difference? Acad Emerg Med 11:1318–1327

    Article  PubMed  Google Scholar 

  91. Basic D, Conforti DA (2005) A prospective, randomised, controlled trial of an aged care nurse intervention within the Emergency Department. Aust Health Rev 29:51–59

    Article  PubMed  Google Scholar 

  92. Bridges J, Meyer J, McMahon K et al (2000) A health visitor for older people in an accident and emergency department. Br J Community Nurs 5:75–80

    PubMed  CAS  Google Scholar 

  93. Poncia HD, Ryan J, Carter M (2000) Next day telephone follow up of the elderly: a needs assessment and critical incident monitoring tool for the accident and emergency department. J Accid Emerg Med 17:337–340

    PubMed  CAS  Google Scholar 

  94. Sanders AB (1992) Care of the elderly in emergency departments: conclusions and recommendations. Ann Emerg Med 21:830–834

    Article  PubMed  CAS  Google Scholar 

  95. Wilber ST, Gerson LW (2003) A research agenda for geriatric emergency medicine. Acad Emerg Med 10:251–260

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Internal Medicine, University “Politecnica delle Marche”, Ancona, Italy

    F. Salvi, V. Morichi, A. Grilli & P. Dessì-Fulgheri

  2. Geriatric Emergency Service, Italian National Institute for Research and Care on Aging (INRCA), Ancona, Italy

    R. Giorgi & G. De Tommaso

  3. Clinica di Medicina Interna, Azienda Ospedali Riuniti, Via Conca 71, I-60126, Ancona, Italy

    F. Salvi

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  1. F. Salvi
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  2. V. Morichi
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Salvi, F., Morichi, V., Grilli, A. et al. The elderly in the emergency department: a critical review of problems and solutions. Int Emergency Med 2, 292–301 (2007). https://doi.org/10.1007/s11739-007-0081-3

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