Why Provide Specialized Care for Older Adults in the ED?

Older adults account for a disproportionate number of potentially avoidable patient hospital admissions from the ED.

Older adults account for 46% of all ED visits resulting in hospitalization³. Approximately one out of every 10 hospital admissions is potentially avoidable, and the majority (60%) of those admissions are for patients 65+⁴.

Geriatric EDs can reduce the likelihood of avoidable patient admissions to the hospital.

Comprehensive geriatric assessment (CGA) in the ED has been linked to reduced likelihood of admission at index ED visit in a growing number of studies^5-10, without increasing mortality risk^8,11-15. CGA and enhanced transitions of care planning in the ED may also reduce or delay nursing home admission12,15. Averting avoidable admission prevents the risk of iatrogenic complications and reduced functioning that can occur in hospitalized and institutionalized patients.

Geriatric ED programs have been shown to increase patient satisfaction.

Avoiding unnecessary hospitalizations is in keeping with the “4Ms Framework” of the growing “Age Friendly Health System” initiative¹⁶, specifically “What Matters” to the patient. Older adult patients that received comprehensive geriatric assessment and enhanced transitions of care services reported higher patient satisfaction^12,17,18.

Physical therapy services in the ED are associated with reduced ED revisits.

Falls are the leading cause of injury-related morbidity and mortality among Americans aged 65 and older¹⁹, resulting annually in over 2.8 million ED visits¹⁹ and $31.9 billion in direct medical costs to Medicare²⁰. Receiving physical therapy (PT) services (e.g., a referral) in the ED during ED visits for a ground-level fall has been associated with significantly lower likelihood of a fall-related ED revisit within 30 days and 60 days among adults 65+²¹. Expanding PT services in the ED may reduce future fall-related ED utilization and fall-related morbidity and mortality.

Older Adults with Dementia Revisit the ED at Significantly Higher Rates

Older adults with dementia are between 2.3²² – 3.7²³ times more likely to revisit the ED within 30 days of index ED visit compared to older adults without dementia. The ED has the potential to play a role in connecting patients and caregivers to appropriate medical and social resources for management of dementia and other comorbidities. Care transition protocols improve disease management and are associated with reduced ED utilization²⁴. Additionally, coordination of care and services for dementia patients is a goal of the National Plan to Address Alzheimer’s disease²⁵, and programs such as the Veterans Affairs’ “Partners in Dementia Care” have demonstrated value in improving dementia patients’²⁶ and caregivers’²⁷ outcomes as well as reducing ED and hospital utilization²⁸.

Delirium can be fatal for older adults, underscoring the need for proper identification and management in the ED.

Of the nearly 20 million older adults seen in the ED each year²⁹, approximately 8-17% present to the ED suffering from delirium³⁰. Patients with delirium have a 12-month mortality rate between 10-26%³¹, which is comparable to patients with sepsis or acute myocardial infarction³². Delirium is an independent predictor of mortality among ED patients diagnosed with delirium compared to patients without delirium, and the strongest association has been found at 30 days following an ED visit³³. EDs that screen for delirium and incorporate appropriate protocols may help reduce missed diagnosis of this potentially fatal condition.

Sources

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³WHI. Geriatric Emergency Department Factsheet (2013 HCUP-NEDS data). West Health Institute;2017.

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⁵Hwang U, Dresden SM, Rosenberg MS, et al. Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use. Journal of the American Geriatrics Society. 2018;66(3):459-466.

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⁷Keyes DC, Singal B, Kropf CW, et al. Impact of a New Senior Emergency Department on Emergency Department Recidivism, Rate of Hospital Admission, and Hospital Length of Stay. Annals of Emergency Medicine. 2014;63(5):517-524.

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²¹Lesser A, Israni J, Kent T, et al. Association Between Physical Therapy in the Emergency Department and Emergency Department Revisits for Older Adult Fallers: A Nationally Representative Analysis. Journal of the American Geriatrics Society. 2018;66(11):2205-2212.

²²LaMantia MA, Stump TE, Messina FC, et al. Emergency Department Use Among Older Adults With Dementia. Alzheimer disease and associated disorders. 2016;30(1):35-40.

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²⁷Bass DM, Judge KS, Lynn Snow A, et al. Caregiver Outcomes of Partners in Dementia Care: Effect of a Care Coordination Program for Veterans with Dementia and Their Family Members and Friends. Journal of the American Geriatrics Society. 2013;61(8):1377-1386.

²⁸Bass DM, Judge KS, Maslow K, et al. Impact of the care coordination program “Partners in Dementia Care” on veterans’ hospital admissions and emergency department visits. Alzheimer’s & Dementia: Translational Research & Clinical Interventions. 2015;1(1):13-22.

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³³Israni J, Lesser A, Kent T, et al. Delirium as a predictor of mortality in US Medicare beneficiaries discharged from the emergency department: a national claims-level analysis up to 12 months. BMJ Open. 2018;8(5):e021258.