Care of the Older Adult in the Emergency Department

 

OVERVIEW

A. One in five patients 65 to 74 years of age and one in four patients 75 years of age and older visit the ED each year.

B. The ED is:

  1. The portal to other settings, including the hospital, long-term care, and mental health facilities
  2. Used for the performance of complex diagnostic workups, overflow, and off-hour medical care
  3. For some older adults, the only source of healthcare evaluation and treatment

 

BACKGROUND AND STATEMENT OF THE PROBLEM

A. As compared with younger people, older adults:

  1. Have more diagnostic tests, longer stays in the ED, and are more likely to be admitted to the hospital
  2. Are more likely to be readmitted on discharge from the ED, and also at risk for functional loss and higher rates of mortality
  3. Are more likely to experience missed or incorrect diagnoses, inadequate pain management, and less information

ASSESSMENT OF THE OLDER ADULT IN THE ED

A. Triage/primary assessment

  1. Delays in triage for older adults are associated with increased waiting time, anxiety, and discomfort, and increased risk of mortality.
  2. Use assessment tools.
    • The CTAS demonstrates high validity for older adults; it is especially useful in categorizing severity and identifying older adults who require immediate lifesaving intervention.
    • The ESI includes a comprehensive algorithm that describes symptoms and physiological indicators, as well as the resources anticipated to be used. There are reports of undertriage using this tool when guidelines are not precisely followed.
  3. A–B–C: Identify and treat life-threatening conditions.
    • Airway: Challenges to establishing an airway include the presence of dentures, kyphosis, and cervical rigidity.
    • Breathing and ventilation: Consider age-related changes, including decreased pulmonary compliance, respiratory reserve, and arterial oxygenation.
    • Circulation: Use of antihypertensive medication may inhibit physiological response and/or mask signs of hypovolemic shock.
  4. Consider atypical presentation and “red flags” (acute change in mental status and/or physical function, dyspnea, fatigue, self-neglect, apathy, and falls).

B. Screening for risk of adverse outcomes; useful in guiding a plan to prevent avoidable complications during the ED stay, if admitted during hospitalization, and after an ED visit when transitioning to home or another setting

  1. TRST: predictive of subsequent ED use, hospitalization, and NH admission
  2. ISAR: predictive of increased risk of death, institutionalization, functional decline, and both repeat ED visit and hospital admission in the following 6 months after an ED visit

C. General assessment

  1. History
    • Social history: living situation, marital status, work status, advance directives, support within family and community, and stressors
    • Past medical/surgical history: medication use, allergies, weight loss/changes in oral intake, and recent changes in diagnosis or medication regimens
    • Baseline cognition, mood, and physical function: early and sensitive indicators of physiological dysfunction
  2. Cognition and mood
    • Cognitive impairment: Geriatric Emergency Medicine Task Force recommends a mental status examination for older adults presenting to ED.
      • Six-Item Screener
    • Delirium: Abrupt onset of cognitive impairment suggests delirium.
      • Two-step process included in the Geriatric Emergency Department Guidelines Task Force: DTS followed by bCAM
    • Depression: Depression may interfere with clinical presentation and may be associated with greater number of ED visits.
      • ED-DSI: a three-question screener
  3. Physical function; recent loss often preceding the visit to the ED and can signify underlying illness
    • Basic ADL: Katz Activities of Daily Living Index or Barthel Index
    • IADL: Lawton Instrumental Activities of Daily Living Scale
  4. Medications
    • ADEs: One third are related to one of the following: warfarin, insulin, and digoxin.
    • PIMs: Greater number is associated with frequent ED use.
    • Geriatric Emergency Department Guidelines Task Force recommends the following:
      • Medication reconciliation
      • Screening for polypharmacy, PIMs, and ADEs; collaborating with the pharmacist, interdisciplinary team as indicated, and attending physician to correct
  5. Falls; number one cause of nonfatal injuries treated in hospital emergencies in people older than 65 years
    • ED evaluation
      • Assess for injury (consider occult presentation), including complete physical examination; EKG; complete blood count; electrolytes; medication evaluation, including measurable levels; and appropriate imaging.
    • Assess for the cause of the fall.
      • Targeted interview with the patient and family regarding previous falls, location, activity, potential environmental factors, and symptoms preceding the fall
      • Comprehensive history and physical examination
    • Estimate future fall risk, guided largely by determining the reasons for past falls.
  6. Substance misuse
    • Misuse: use of a drug for purposes other than that for which it was intended
    • Alcohol abuse: present in 14% of older adults presenting to the ED
      • Screening tool: Alcohol Use Screening and Assessment for Older Adults, which has
    • Evaluation
      • In patient’s social network, identify which members are supportive of treatment and which are potentially hazardous to the patient. Harmful network members include active substance abusers; those who “enable” the patient’s misuse; and those who abuse the patient physically, sexually, or emotionally.
      • Patient’s mood, cognition, sleep patterns, and mental health history, including past treatment, should also be ascertained.
      • It should also be verified that the patient has adequate housing and access to food, adequate transportation, and medical care.
      • When there is evidence of substance misuse, nursing interventions focus on (a) monitoring for withdrawal; (b) providing an environment that is safe from potential harms to patient; and (c) collaborating with the patient, family, physician, and social worker to secure a mental health evaluation and program directed to the substance abuse needs and support.
      • Careful handoff should include the communication of the patient’s history and clinical findings, as well as safety issues, including fall risk and the presence of delirium.
  7. EM
    • EM is defined as physical, verbal, sexual, and psychological abuse, as well as abandonment, exploitation, and neglect.
    • Nurse is expected to know the organization’s policies for reporting suspected EM, as required by The Joint Commission on Accreditation and state mandatory reporting requirements.
    • Red flags that warrant suspicion of EM include delays in seeking treatment; signs of withholding or giving too much medication; missed appointments; use of several hospitals; driving to a hospital farther away from home; description of an event that does not fit the injury sustained; repetitive injuries; and signs of caregiver indifference, berating or threatening comments, hypervigilant/possessive behavior, or excessive concerns over finances.
    • When EM is suspected:
      • Separate the older adult from the caregiver and obtain a detailed history and physical assessment; interviewing the patient about their feelings of safety is an important aspect of screening.
      • Conduct a careful medical history, including baseline conditions, and a comprehensive physical examination.
        1. Physical examination cues may include poor hydration; poor hygiene; suspicious injuries in unusual locations and bruises in various stages of healing; and unexplained abrasions and/or markings on skin, including human bite marks, skin tears, pressure ulcers, or genital complaints, including infections or injury.
        2. Follow mandatory reporting procedures.

NURSING CARE STRATEGIES

A. Delirium and dementia

  1. Preventing delirium
    • Control the environment.
      • Support the family/familiar person (or volunteer) present with the patient.
      • Provide sensory aids (glasses and hearing aids and offering hearing amplifiers and magnifiers as indicated).
      • Control noise.
      • Avoid excessively bright lights when possible.
      • Provide comfort measures, including fluids and a warm blanket.
    • Additional nursing interventions include promoting mobility and addressing need for pain management, toileting, rest/sleep, and fluid/hydration.
  2. Managing delirium, in addition to interventions aimed at reversing the cause
    • Continue to provide aforementioned supportive measures.
    • Avoid physical and chemical restraints.
    • Educate patient/family about the etiology of delirium and interventions.
    • Involve family in promoting safety and comfort for the patient.

B. Prevention of falls and related injuries

  1. Collaborate with the interdisciplinary team to modify fall risk (e.g., correct orthostasis, remove offending medications).
  2. Provide close oversight.
  3. Encourage physical activity (e.g., range of motion).
  4. Pay attention to toileting.
  5. For the person who is at risk for injury caused by cognitive impairment, weakness, and low mobility, provide low beds with bedside mats.

C. Prevention of pressure ulcers

  1. The use of pressure-redistributing foam mattresses has shown to be a cost-effective approach to prevent ED-acquired pressure ulcers.
  2. The use of reclining chairs in the ED instead of ED gurney beds has been shown to reduce pain and improve patient satisfaction.
  3. Evidence-based guidelines to prevent and manage pressure ulcers should be followed, including skin assessment, pressure relief/off-loading, prevention/treatment of infection, pain control, and nutritional evaluation and management.

D. Prevention of CAUTI

  1. CAUTI is a UTI that occurs while a patient has an IUC or within 48 hours of its removal.
  2. Preventive practices include the following:
    • Avoid unnecessary urinary catheter use.
    • Consider removal prompts and nurse-initiated urinary catheter discontinuation protocols.
    • Use an aseptic technique and sterile products during catheter insertion; maintain cleanliness.
    • Communicate plan/need for surveillance and for the earliest removal during handoffs.

TRANSITIONS FROM THE ED

A. Problem: misinformation

  1. Primary source of older adults’ dissatisfaction with ED care
  2. Contributes to readmission

B. Factors associated with misinformation: underrecognition of cognitive dysfunction, lower health literacy, and financial impediments to prescriptions and recommended outpatient follow-up

  1. Four systematic processes to ensure appropriate transfer of information to patient/family and providers (Geriatric Emergency Department Guidelines Task Force, 2014):
    • Discharge planning
      • Components include (a) evaluation of the clinical status related to the admitting problem, (b) assessment of physical and psychosocial functional status (including fall/safety risk), (c) risk assessment for subsequent functional decline (e.g., ISAR, TRST), (d) assessment of caregiver availability and ability, (e) an appraisal of the patient/family readiness and ability to learn, (f) medication review, (g) review of advance directives, and (h) referrals with follow-up arrangements.
      • Patients and families prefer active engagement, and a range of options will support the patient’s preferences and goals.
      • CMS recommends that EDs maintain a file of appropriate community-based services, supports, and facilities to which the patient can be referred.
    • Patient/family education
      • A challenge to patient/caregiver understanding is limited literacy and numeracy.
      • Print discharge instructions are often not written at appropriate reading levels.
      • To address challenges:
        1. Written instructions should be at the appropriate grade level (established using a literacy calculator).
        2. Use plain language, focusing on “need to know” information, limiting the documents to essential content in order to avoid information overload.
        3. Provide information and educational material in large font suitable for older adults.
        4. Use the teach-back method.
        5. Use a standardized tool that assesses older adults’ ability to self-administer medication such as the DRUGS. This tool requires subjects to perform the following four tasks with each of their medications: (a) identify the appropriate medication, (b) open the container, (c) select the correct dose, and (d) report the appropriate timing of doses
    • Handoff
      • Recommended standardized information to provide cross-settings include:
        • Presenting complaints
          1. Test results and interpretation
          2. ED therapy and clinical response
          3. Consultation notes (in person or via telephone) in ED
          4. Working discharge diagnosis
          5. ED physician note, or copy of dictation
          6. Patient condition (including fall risk, functional and cognitive status)
          7. New prescriptions and alterations with long-term medications
          8. Discharge recommendations, including physical activity, diet, and resources/services
          9. Support systems
          10. Advance directives
          11. Follow-up plan
      • Additional approaches include:
        1. a verbal report from ED nurses provided to the NH, as well as written documentation;
        2. an emergency form in NH residents’ charts that contains predocumented information with an area to write in the reason for transfer;
        3. brief NH-to-ED and ED-to-NH transfer forms that are accepted and used by local NHs and EDs;
        4. structured data sharing; and
        5. INTERACT tools, a checklist of key transfer documents, lists of critical data for interfacility communication at the time of transfers, a medication reconciliation form, and transfer forms.
    • Follow-up
      • Telephone follow-up for patients discharged from the ED
      • Home visits provided to high-risk individuals
      • Telemedicine alternatives when indicated, especially in rural areas

EVALUATION AND EXPECTED OUTCOME(S) FOR CARE OF OLDER ADULTS IN THE ED

A. Improved patient/family satisfaction and experience

B. Processes

  1. Adherence to evidence-based practice and guidelines
  2. Throughput and waiting times

C. Better clinical outcomes, including fewer falls, pressure ulcers, and hospital-acquired infections, and improved diagnostic accuracy

D. Improved organizational outcomes, including readmission rates (ED and hospital) and cost

E. Enhanced staff competencies and satisfaction

ABBREVIATIONS

A–B–C          airway–breathing–circulation

ADE              adverse drug events

ADL              activities of daily living

bCAM           Brief Confusion Assessment Method

CAUTI           catheter-associated urinary tract infection

CMS              Centers for Medicare & Medicaid Services

CTAS             Canadian Triage and Acuity Scale

DTS               Delirium Triage Screen

DRUGS          Drug Regimen Unassisted Grading Scale

ED-DSI          Emergency Department Depression Screening Instrument

EM                elder mistreatment

ESI                 Emergency Severity Index

IADL              instrumental activities of daily living

INTERACT     Interventions to Reduce Acute Care Transfers

ISAR             Identification of Seniors at Risk

IUC               indwelling urinary catheter

NH                nursing home

PIMs             potentially inappropriate medications

TRST             Triage Risk Screening Tool

UTI                urinary tract infection

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 42, Arendacs, R. & Boltz, M. (2025) Care of the Older Adult in the Emergency Department

 

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Park, S., Kim, A. J., Ah, Y-.M., Lee, M. Y., Lee, Y. J., Chae, J., Rho, J. H., Kim, D.-S., & Lee, J.-Y. (2022). Prevalence and predictors of medication-related emergency department visit in older adults: A multicenter study linking national claim database and hospital medical records. Frontiers in Pharmacology, 13, 1009485. https://doi.org/10.3389/fphar.2022.1009485. Evidence Level IV.

Patterson, B. W., Repplinger, M. D., Pulia, M. S., Batt, R. J., Svenson, J. E., Trinh, A., Mendonça, E. A., Smith, M. A., Hamedani, A. G., & Shah, M. N. (2018). Using the Hendrich II inpatient fall risk screen to predict outpatient falls after emergency department visits. Journal of the American Geriatrics Society, 66(4), 760–765. https://doi.org/10.1111/jgs.15299. Evidence Level IV.

Pham, B., Teague, L., Mahoney, J., Goodman, L., Paulden, M., Poss, J., Li, J., Ieraci, L., Carcone, S., & Krahn, M. (2011). Early prevention of pressure ulcers among elderly patients admitted through emergency departments: A cost-effectiveness analysis. Annals of Emergency Medicine, 58(5), 468–478.e3. https://doi.org/10.1016/j.annemergmed.2011.04.033. Evidence Level IV.

Platts-Mills, T. F., Travers, D., Biese, K., McCall, B., Kizer, S., LaMantia, M., Busby-Whitehead, J., Cairns, C. B. (2010). Accuracy of the Emergency Severity Index triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention. Academic Emergency Medicine, 17(3), 238–243. https://doi.org/10.1111/j.1553-2712.2010.00670.x. Evidence Level IV.

Salvi, F., Morichi, V., Grilli, A., Lancioni, L., Spazzafumo, L., Polonara, S., Abbatecola, A. M., De Tommaso, G., Dessi-Fulgheri, P., & Lattanzio, F. (2012). Screening for frailty in elderly emergency department patients by using the Identification of Seniors At Risk (ISAR). Journal of Nutrition, Health & Aging, 16(4), 313–318. https://doi.org/10.1007/s12603-011-0155-9. Evidence Level III.

Slater, B., Dalawari, P., & Huang, Y. (2013). Does the teach-back method increase patient recall of discharge instructions in the emergency department? Annals of Emergency Medicine, 62(4 Suppl. 2). https://doi.org/10.1016/j.annemergmed.2013.07.335. Evidence Level III.

Stefanacci, R. G., & Riddle, A. (2018). Assisting keeping older adults out of the emergency room. Geriatric Nursing, 39(5), 599–603. https://doi.org/10.1016/j.gerinurse.2018.09.002 Evidence Level VI.

Stoeckle, A., Iseler, J. I., Havey, R., & Aebersold, C. (2019). Catching quality before it falls: Preventing falls and injuries in the adult emergency department. Journal of Emergency Nursing, (3), 257–264. https://doi.org/10.1016/j.jen.2018.08.001. Evidence Level V.

Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7(8), 499–505. https://doi.org/10.1016/j.jamda.2006.03.004. Evidence Level IV.

Vaughan, C. P., Burningham, Z., & Kelleher, J. L., McGwin, G., Jasien, C. L., Hastings, S. N., Stevens, M. B., Morris, I., Jackson, G. L., & The EQUIPPED VA Implementation QI Group. (2023). A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. Academic Emergency Medicine, 30(4), 340–348. https://doi.org/10.1111/acem.14697. Evidence Level II.

Vollbrecht, M., Biese, K., Hastings, S. N., Ko, K. J., & Previll, L. A. (2018). Systems-based practice to improve care within and beyond the emergency department. Clinics in Geriatric Medicine, 34(3), 399–413. https://doi.org/10.1016/j.cger.2018.04.005.Evidence Level V.

Wong, J., Marr, P., Kwan, D., Meiyappan, S., & Adcock, L. (2014). Identification of inappropriate medication use in elderly patients with frequent emergency department visits. Canadian Pharmacists Journal,147(4), 248–256. https://doi.org/10.1177/1715163514536522. Evidence Level IV.

Yang, W., & Huang, J. (2017). Chronic subdural hematoma: Epidemiology and natural history. Neurosurgery Clinics of North America, 28(2), 205–210. https://doi.org/10.1016/j.nec.2016.11.002. Evidence Level V.

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