New Age: Why the World Needs Geriatric Emergency Medicine

Published on November 1, 2013
The world’s elderly population continues to explode, creating both strain and opportunity in the field of emergency medicine. Emergency physicians need to respond by solidifying the ED as the hub of care for the aging patient.

Edina Petrovic, an 82-year-old retired elementary school teacher, is upset. She does not want to be admitted to the hospital. “I have to take care of my husband and who is going to feed my cat?” Edina’s husband, who has moderate dementia, is sitting next to her, holding her hand and reassuring her he can care for himself for a few days.

Mrs. Petrovic fell in her kitchen this morning stating she caught her foot on the rug. She could not get up and her husband called 911. Several neighbors were present and were anxiously talking over one another when EMS arrived. She was getting more agitated about the situation and stated, “I am okay, just get me up and you can all go home.” Her best friend and neighbor convinced her to go to the ED. A cervical collar was placed and she was strapped down to a backboard for transfer. Her only complaint was right hip pain, although EMS crew also noticed a “goose egg” on the back of her head. She denied hitting her head or any other injuries.

In the trauma bay, the team quickly moved Edina from the gurney to the exam bed. The EKG leads and pulse ox were attached. An additional 16 gauge IV was placed (after third attempt to find vein). Her blood pressure was checked every 5 minutes. She was focused on the cuff commenting it was “hurting my arm” while the physician quickly ran through the trauma evaluation including a FAST exam. Her clothes were removed, much to her angst. She was then turned onto her side for the spine and rectal exam – which she was not expecting and became visibly upset. When asked to rank her pain, she stated “a lot, now leave me alone”.

Off to the radiology suite she went for additional imaging. CXR, pelvis and hip x-rays were negative. The CT head demonstrated a scalp hematoma and CT C/T/L spines were negative. The ED physician recommended admission for observation as she had difficulty bearing weight on her right leg and concern for the head injury.

The percentage of the world’s population over 60 years of age will double from about 11% to 22% between 2000 and 2050. Although more developed countries have the oldest population profiles, the vast majority of older people and rapidly aging populations are in less developed countries. The repercussions of the rapidly aging world population are noticed throughout society, but nowhere are they more evident than in the healthcare system. Policy makers have to make decisions about hospital admissions, costs, social services, and manpower. The benefits of these changes may not be seen for several years. However, sometimes small and seemingly simple changes focused on the elderly emergency department patient (e.g. follow-up phone call after visit) have been shown to have immediate positive outcomes. (Jones et al, Poncia et al).

This was the subject of two symposia presented by the Society of Academic Emergency Medicine (SAEM) at this year’s International Association of Gerontology and Geriatrics (IAGG) World Congress in Seoul, South Korea. The group from SAEM’s Academy of Geriatric Emergency Medicine spoke on “Building a Geriatric Friendly Emergency Department” and “How to Engage Organized Medicine in Geriatric Education, Research, and Knowledge Translation.”

The IAGG was founded in 1950 with the mission of promoting worldwide gerontological research and training through collaboration between international, inter-governmental, and non-governmental organizations. The world congress is held every four years in different countries throughout the world. The main theme for the 2013 conference in Seoul was “Digital Ageing: A New Horizon for Health Care and Active Aging” (e.g. robotics, personal health tracking, data sharing, on-line education). There were over 5,000 conference attendees from more than 90 countries. Symposia topics in biological science, clinical medicine, social and behavioral science and research policy and practice were presented.

Emergency departments throughout the world are starting to see the influx of the elderly patients and their complex medical needs. This increase is not only due to the aging population, but also to the shrinking primary care pool of physicians (both family medicine and internal medicine) and subsequent lack of access to basic health care assessment and prevention. The team from SAEM presented several new and emerging concepts of care for the geriatric patient in the emergency department.

The first key concept is embracing that emergency departments around the world are the “hub of care” for elderly patients (figure 1). Emergency providers need to move beyond the concept of “admit versus discharge” for our elderly patients and think in terms of a continuum of care. Hospital admission rates for the elderly vary significantly throughout the world (figure 2). Research has shown that admission of the elderly patient is not always beneficial as it can lead to deconditioning, DVT/PE’s, nosocomial infections, medication errors, longer LOS and bed blocks. These in turn cause diversions and ED overcrowding. Examples of this “continuum of care” model include the geriatric emergency review clinic, observational and stepdown units, faint and fall clinic, virtual hospitals, palliative care units, and admit-to-home programs, just to name a few. (Conroy)

In order to establish the emergency department as the hub of care for the elderly, three things must be agreed upon:

1) Education

The entire workforce – from EMS to IV/phlebotomist/radiology technicians to medical students – needs to be educated on geriatric physiology, medication management, atypical presentation of disease and cognitive/behavioral disorders. These educational innitiatives can take a variety of forms. When educating EMS, consider providing lectures at local or regional meetings on atypical presentations in the geriatric patient, geriatric trauma, pain management, etc. Take time to engage EMS personnel in “real time” when they arrive with a patient. Expand on the patient’s chief complaint, physical findings, vital signs, EKG, etc... There are also resources available online developed by the American Geriatrics Society and the National Council of State EMS Training Coordinators (

When teaching IV/phlebotomists/radiology techs and nurses aids, give short presentations at meetings and bedside teaching to recognize abnormal vital signs and cognitive impairment (delirium and dementia). Take opportunities to observe and report abnormal physical findings such as bruising, petechiae, bleeding, bony deformity, difficulty with gait and balance. When educating the nursing staff, identify nurses who have an interest in geriatric medicine to be leaders and educators for the staff. Encourage these leaders to consider joining the Emergency Nursing Association (, which offers a Geriatric Emergency Nursing Education (GENE) online learning module. This newly updated program includes video, images, animation, voice-over narration, and knowledge checks.

Since there are simply not enough geriatricians to serve the burgeoning older population, it is essential that emergency medicine physicians have competency in the core geriatric topics and principles. Resources for medical students and residents are available through the Portal of Geriatric Online Education ( as well as all the major professional socities.

2) Targeting and Screening

There has been a change in the paradigm of the ED patient we are seeing all over the world. We are moving from the younger patient with a single complaint – acute issue, easier to diagnose and treat with rapid dispositions – to the geriatric patient with multiple problems, acute or subacute or chronic condition. Our new goals are controlling symptoms, maximizing function and maintaining continuity of care. “Targeting” involves identification of those patients by location (e.g. skilled nursing facility, lives alone), condition (e.g. falls, dementia) or risk (e.g. multiple medications, elder abuse), and intervening with structured evaluation and follow-up. Screening elderly patients for conditions known to be detrimental – such as falls, dementia, delerium and elder abuse – helps providers identify and address hidden needs. Any healthcare provider (CNA, technician, nurse, physician) can be trained to implement the appropriate screening tool with the goal of quick and appropriate intervention to reduce repeat ED visits and possible hospitalizations.

3) Networking

Geriatric emergency care relies heavily on establishing direct and supportive relationships with all of the essential players, from hospital administration to the medical home (transition/urgent care systems), to assisted living and home care organizations. This is the best way to attain the triad of (1) better health care, (2) better health and (3) lower costs for beneficiaries. We aim to improve individual patient experiences of care along the Institute of Medicine’s six domains of quality (Safety, Effectiveness, Patient Centeredness, Timeliness, Efficiency and Equality). We encourage better health for entire populations by addressing causes of poor health, such as physical inactivity, behavioral risk factors, lack of preventative care and poor nutrition. And finally we lower the total cost of care resulting in reduced private and government expenditures by improving care, ultimately enhancing the health care system. (Carpenter)

The key to accomplishing these three goals is to have “geriatric friendly” emergency departments, or, better yet, Geriatric Emergency Departments. During the symposia, Dr. Mark Rosenburg discussed the steps that his ED went through to establish what is one of the first Geriatric Emergency Departments in the United States. In the USA, there are now over fifty Geriatric Emergency Departments and work is in progress for developing a certification process for these departments. Dr. Foo discussed the success of the emergency department observational unit at Tan Took Seng Hospital in Singapore in reducing readmittance to the ED and hospitalizations (Foo et al).

As with most global conferences, the rich discussions with international colleagues that followed the lectures were the true highlights. In order for geriatric emergency medicine to thrive, these liasions will need to be maintained and strengthened. There are several professional international geriatric organizations including the IAGG, Japan Geriatrics Society, Australian and New Zealand Society for Geriatric Medicine, European Union Geriatric Medicine Society and the American Geriatric Society. We need to work across specialties, and between organizations to generate high-yield peer reviewed research priorities.

For emergency physicians throught the world, there has never been a better time to get started. We are facing the “perfect storm” of an increasing geriatric global population, rising health-care costs and too few geriatric-trained health care professionals. Emergency departments sit at a unique crossroad in the continuum of patient care, overlapping with outpatient, inpatient, prehospital, home, and extended care settings. We need to start addressing how care for the elderly is delivered not only within the ED itself, but also at transitions of care to and from the ED.

There are however, concerns raised regarding the geriatric ED. Cost is one of the main issues being addressed. New facilities, additional equipment, and increased staffing are all things that cost money. Many emergency departments operate on very limited budgets and may be unwilling to invest in the geriatric ED at the expense of other aspects of emergency care. Hospitals may also struggle with which patient could benefit from the geriatric services. Healthy, more independent seniors directed to the specialized geriatric areas may find it somewhat offensive. While most physicians would agree that the new design features being implemented in geriatric emergency departments are positive changes, some argue that these changes would be more effective if implemented throughout the ED.

One of the main hurdles to overcome is demonstrating that the geriatric ED can provide better health, improved patient experiences and reduced cost to the healthcare system. To accomplish this, we need to continue to build on well designed health services research focused on the clinical and economic outcomes of the geriatric ED. Emergency medicine has recognized the special needs of children and psychiatric patients. Now is the time to also address the focused needs of older adults within the emergency department setting.

To return to the opening patient scenario, if Ms. Petrovic had presented to a Geriatric Emergency Department, her care and disposition would have been managed differently.

EMS would have faxed in the EKG (normal) and given a pre-arrival report stating they were concerned about head trauma and possible hip fracture. With her permission, they would have placed her medication bottles into a bag and brought them into in the ED.

You could hear the ambulance sirens approaching, but when they arrived the atmosphere in the trauma bay would be jarringly calm. There would be no beeping machines, glaring lights or loud voices talking over one another. Edina would be transferred to a thick mattress and additional padding would be arranged for neck and upper back with her noticeable thoracic kyphosis. A senior life specialist volunteer would be present, providing comforting conversation. In this case, the volunteer recognizes one of the patient’s hearing aids is missing and reaches for the amplified headphones. An IV technician obtains US-guided venous access with a single attempt. Clothes are removed after explanation and with a respectful gentleness. The physician talks to her directly during her exam and pauses when needed to answer questions. Her pain is addressed and treated with repositioning, Tylenol and a cool compress.

The ED social worker was present when she arrived and located her husband and best friend to bring them back to the trauma bay. The ED pharmacist completed the medication reconciliation.

After x-rays were cleared, a physical therapist is consulted who prescribes a front-wheeled walker and arranges for home physical therapy. Edina demonstrates the ability to ambulate with the walker in the ED. The social worker arranges a daily home visit by a visiting nurse to assess fall risk and a follow-up of the head injury. A follow-up visit to her primary care office is also arranged. The emergency department is changing as the world’s population ages; the time is now for emergency medicine to adapt to meet the challenge.

Kathleen Walsh DO, MS is a Assistant Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. She is fellowship trained and board certified in Geriatric Medicine.

Melissa Stiles MD is a Professor of Family Medicine with the University of Wisconsin School of Medicine and Public Health. She is also fellowship trained and board certified in Geriatric Medicine and board certified in Palliative Medicine.

Chik Loon Foo MBBS is a senior consultant at Tan Tock Seng Hospital (TTSH), whose emergency department is the busiest in Singapore. His special interests are in geriatrics and medical informatics.

This article originally appeared in issue 11 of Emergency Physicians International

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