Ten Commandments of Geriatric EM Care

With Christian Nickel

Christina Shenvi

Christian Nickel, an Emergency Physician in Basel, Switzerland, has developed 10 commandments (or suggestions) for providing high quality geriatric EM care. This is a dense, high-yield episode in which we cover a wealth of practical tips for improving the care of older patients.

The Ten “Commandments”

  1. Biological age does not equal chronological age
  2. Atypical is typical
  3. Be #uroskeptical – UTI overdiagnosis (see reference number 11)
  4. Vital signs: Normal can be abnormal; abnormal can be normal
  5. Gait is a vital sign
  6. There is no such thing as a mechanical fall
  7. Do not miss “the other kind of fall”
  8. Screen formally for cognitive impairment
  9. Look at patient medication
  10. Assess what matters most to your (older) patient. This is part of the 5 Ms: Mind, mobility, medications, multi-complexity, and what matters most.
Read about 4Ms


  1. Mitnitski AB, Graham JE, Mogilner AJ, Rockwood K. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr. 2002;2:1.
  2. Jorgensen R, Brabrand M. Screening of the frail patient in the emergency department: A systematic review. Eur J Intern Med. 2017;45:71-3.
  3. Arendts G, Burkett E, Hullick C, Carpenter CR, Nagaraj G, Visvanathan R. Frailty, thy name is. Emerg Med Australas. 2017;29(6):712-6.
  4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62.
  5. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, Lambrew CT, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283(24):3223-9.
  6. Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, et al. Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. Am Heart J. 2012;163(3):372-82.
  7. Metlay JP, Schulz R, Li YH, Singer DE, Marrie TJ, Coley CM, et al. Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med. 1997;157(13):1453-9.
  8. Caterino JM, Kline DM, Leininger R, Southerland LT, Carpenter CR, Baugh CW, et al. Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department. J Am Geriatr Soc. 2018.
  9. Caterino JM, Leininger R, Kline DM, Southerland LT, Khaliqdina S, Baugh CW, et al. Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department. J Am Geriatr Soc. 2017;65(8):1802-9.
  10. Karakoumis J, Nickel CH, Kirsch M, Rohacek M, Geigy N, Muller B, et al. Emergency Presentations With Nonspecific Complaints-the Burden of Morbidity and the Spectrum of Underlying Disease: Nonspecific Complaints and Underlying Disease. Medicine (Baltimore). 2015;94(26):e840.
  11. Burkett E, Carpenter CR, Arendts G, Hullick C, Paterson DL, Caterino JM. Diagnosis of urinary tract infection in older persons in the emergency department: To pee or not to pee, that is the question. Emerg Med Australas. 2019;31(5):856-62.
  12. Caterino JM, Kline DM, Leininger R, Southerland LT, Carpenter CR, Baugh CW, et al. Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department. J Am Geriatr Soc. 2019;67(3):484-92.
  13. Warmerdam M, Baris L, van Liebergen M, Ansems A, Esteve Cuevas L, Willeboer M, et al. The association between systolic blood pressure and in-hospital mortality in older emergency department patients who are hospitalised with a suspected infection. Emerg Med J. 2018;35(10):619-22.
  14. Grossmann FF, Zumbrunn T, Frauchiger A, Delport K, Bingisser R, Nickel CH. At risk of undertriage? Testing the performance and accuracy of the emergency severity index in older emergency department patients. Ann Emerg Med. 2012;60(3):317-25 e3.
  15. Lamantia MA, Stewart PW, Platts-Mills TF, Biese KJ, Forbach C, Zamora E, et al. Predictive value of initial triage vital signs for critically ill older adults. West J Emerg Med. 2013;14(5):453-60.
  16. Brabrand M, Kellett J, Opio M, Cooksley T, Nickel CH. Should impaired mobility on presentation be a vital sign? Acta Anaesthesiol Scand. 2018;62(7):945-52.
  17. Nickel CH, Kellett J, Nieves Ortega R, Lyngholm L, Wasingya-Kasereka L, Brabrand M. Mobility Identifies Acutely Ill Patients at Low Risk of In-Hospital Mortality: A Prospective Multicenter Study. Chest. 2019;156(2):316-22.
  18. Lewis ET, Dent E, Alkhouri H, Kellett J, Williamson M, Asha S, et al. Which frailty scale for patients admitted via Emergency Department? A cohort study. Arch Gerontol Geriatr. 2018;80:104-14.
  19. Sri-on J, Tirrell GP, Lipsitz LA, Liu SW. Is there such a thing as a mechanical fall? Am J Emerg Med. 2016;34(3):582-5.
  20. Schwartz AW. What Van Halen Can Teach Us About the Care of Older Patients. JAMA Intern Med. 2017;177(3):309-10.
  21. Carpenter CR, Scheatzle MD, D’Antonio JA, Ricci PT, Coben JH. Identification of fall risk factors in older adult emergency department patients. Acad Emerg Med. 2009;16(3):211-9.
  22. Carpenter CR, Avidan MS, Wildes T, Stark S, Fowler SA, Lo AX. Predicting geriatric falls following an episode of emergency department care: a systematic review. Acad Emerg Med. 2014;21(10):1069-82.
  23. Lundin-Olsson L, Nyberg L, Gustafson Y. “Stops walking when talking” as a predictor of falls in elderly people. Lancet. 1997;349(9052):617.
  24. Hullick C, Carpenter CR, Critchlow R, Burkett E, Arendts G, Nagaraj G, et al. Abuse of the older person: Is this the case you missed last shift? Emerg Med Australas. 2017;29(2):223-8.
  25. Clifford M, Ridley A, Gleeson M, Kellett J. The early mortality associated with agitation and sedation in acutely ill medical patients. Eur J Intern Med. 2013;24(8):e85.
  26. Han JH, Schnelle JF, Ely EW. The relationship between a chief complaint of “altered mental status” and delirium in older emergency department patients. Acad Emerg Med. 2014;21(8):937-40.
  27. Grossmann FF, Hasemann W, Graber A, Bingisser R, Kressig RW, Nickel CH. Screening, detection and management of delirium in the emergency department – a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Scand J Trauma Resusc Emerg Med. 2014;22:19.
  28. O’Sullivan D, Brady N, Manning E, O’Shea E, O’Grady S, N OR, et al. Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees. Age Ageing. 2018;47(1):61-8.
  29. Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013;62(5):457-65.
  30. Han JH, Vasilevskis EE, Chandrasekhar R, Liu X, Schnelle JF, Dittus RS, et al. Delirium in the Emergency Department and Its Extension into Hospitalization (DELINEATE) Study: Effect on 6-month Function and Cognition. J Am Geriatr Soc. 2017;65(6):1333-8.
  31. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-12.
  32. Tinetti M, Huang A, Molnar F. The Geriatrics 5M’s: A New Way of Communicating What We Do. J Am Geriatr Soc. 2017;65(9):2115.

This podcast uses sounds from freesound.org by HerbertBoland.

Image credit: Adobe purchased image.

This entry was posted in General Principles, Medications and Adverse Drug Events, Systems and Administration, Trauma. Bookmark the permalink.

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Christina Shenvi


Dr. Christina Shenvi is an associate professor of Emergency Medicine at the University of North Carolina. She is fellowship-trained in Geriatric Emergency Medicine and is the founder of GEMCast. She is the director of the UNC Office of Academic Excellence, president of the Association of Professional Women in Medical Sciences, co-directs the ACEP/CORD Teaching Fellowship, is on the Annals of EM editorial board, is on the Geriatric ED Accreditation board of governors, and she teaches and writes about time management at timeforyourlife.org.

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