a b s t r a c t

Older adults are a rapidly growing patient population with unique characteristics and health considerations. Over the past few years, emergency physicians have started to recognize the complexities and importance of Geriatric EMergency Medicine. Several noteworthy elements of their healthcare were brought to the fore- front of emergency medicine because this especially Vulnerable patient population was disproportionately affected by the pandemic. clinical topics such as delirium, telehealth, end-of-life care, and elder abuse came into focus; select relevant articles are reviewed. We also highlight equally notable literature which ad- dress clinically challenging topics, such as Hip fractures and syncope. Finally, articles about improving the experience of and decreasing recidivism in geriatric emergency department patients are reviewed. In short, this review article summarizes geriatric emergency medicine literature that can help you improve your practice while caring for older adults.

(C) 2021

1. Introduction

Caring for older adults in the emergency department (ED) is a privilege and a challenge. As the population ages and more older pa- tients visit the ED, clinicians must be up to date on the latest practice trends in the literature. Older patients are medically complex and often require more ED resources, interventions, and support than their younger counterparts. When faced with new disease processes, such as Coronavirus disease 2019 (COVID-19), and challenging patho- physiology, like delirium, emergency physicians must be prepared with the latest tools and data-driven procedures to limit morbidity and mortality. The 2020 articles listed below are changing the practice of geriatric emergency medicine (EM) and are laying the groundwork for the future of emergency medicine for older adults. The highlights are summarized in Table 1.

* Corresponding author at: 110 South Paca Street, Suite 200, 6th Floor, Baltimore, MD 21201, United States of America.

E-mail address: [email protected] (D. Khoujah).

1. COVID
   1. Aliberti MJR, Covinsky KE, Garcez FB, et al. A fuller picture of COVID-19 prognosis: the added value of vulnerability measures to predict mortality in hospitalised older adults. Age Ageing. 2021;50(1):32-39. doi: https://doi. org/10.1093/ageing/afaa240

Older adults suffer worse outcomes from COVID-19 than their youn- ger counterparts. This Sao Paulo-based study notes the trend in Brazil, as in other countries, that almost half of hospital admissions and nearly 80% of all deaths related to COVID-19 occur in older adults. The authors observed that while all older adults are at higher risk for the complica- tions and mortality of COVID-19, some older patients fared better than others and recovered well from the disease. This study sought to prog- nosticate the outcome of older adults admitted to the hospital with COVID-19 based on markers of vulnerability (modified PRO-AGE and Identification of Seniors at Risk (ISAR) scores) and illness acuity tools (National Early Warning Score and quick Sequential Sepsis- Related Organ Failure Assessment (qSOFA) scores) at time of admission [1-4]. The PRO-AGE tool is summarized in Table 2.

The study included 1428 Brazilian patients ages 50 years and above with confirmed COVID-19 and measured time-to-death within 1 and two months of hospital admission. Not surprisingly, patients with a

https://doi.org/10.1016/j.ajem.2021.04.034

0735-6757/(C) 2021

Table 1

Highlights of the 2020 geriatric emergency medicine literature

• COVID-19 causes worse outcomes in older adults. The modified PRO-AGE score can provide an estimated outcome prognosis.
• Delirium is a common presentation of COVID-19 in older adults and may be the Primary presentation.
• Family presence is an integral part of reducing delirium and should be encouraged.
• Radiologically occult hip fractures are common and may be missed on hip CT.
• Certain injury patterns are specific to elder abuse, such as maxillofacial, dental, or neck injuries, especially in the absence of lower extremity injuries.
• Goals-of-care conversations should be viewed as procedures which require an organized approach, knowledge, empathy, and deliberate practice.
• Home telehealth care is a feasible option in older adults when technological barriers are addressed and patient training is completed.
• Not all older adults that present to the ED for syncope have to be admitted to the hospital.
• Arranging primary care or specialist follow-up for older adults within 10-12 days of ED discharge decreases ED recidivism.
• Addressing the physical needs of older adults, decreasing wait times, and improving communication may improve the older patients’ ED experience; data is currently insufficient.

Abbreviations: COVID-19, Coronavirus disease 2019; CT, computed tomography; ED, emergency department.

Table 2

PRO-AGE score [1]

Clinical variables included in the PRO-AGE score

P hysical impairment (acute functional decline)

R ecent hospitalization (within 6 months)

O lder age (>90)?

A cute Mental status change (delirium)

G etting thinner (>=5% weight loss in the past year)

E xhaustion (fatigue)

* This item was removed in the modified PRO-AGE score.

higher modified PRO-AGE score at time of admission (i.e. those who are more vulnerable) had higher rates of death within the study time frame. In this population, the modified PRO-AGE outperformed the ISAR score in predicting morality. In addition, risk stratifying patients according to their modified PRO-AGE score within each category of the NEWS score improved the discrimination of its Mortality prediction. The authors concluded that 1) the modified PRO-AGE score is an accurate predictor of mortality in older patients with COVID-19, and 2) adding a baseline vulnerability score (specifically the modified PRO-AGE score) to an acu- ity assessment tool (specifically the NEWS score) improves the diagnos- tic prediction.

While the use of the modified PRO-AGE as a predictive model for COVID-19 patients would benefit from external validation, the study highlights the importance of taking baseline vulnerability into account when estimating the prognosis of COVID-19 rather than just the acute illness measurement. The study also provides clinicians in the ED with a framework to prepare patients and their families for the possible out- comes of hospitalization for COVID-19. Offering patients and their fam- ilies a reliable approach to prognostication at the onset of illness may help facilitate end-of-life conversations, plan for the likely need of skilled nursing facility placement after hospital discharge, and outline realistic expectations for the outcome of the hospitalization.

• 1. Kennedy M, Helfand BKI, Gou RY, et al. Delirium in older patients with COVID-19 presenting to the Emergency Department. JAMA Netw Open. 2020 Nov 2;3(11):e2029540. doi: https://doi.org/10.1001/jamanetworkopen.2020. 29540

Infections tend to present atypically in older adults, leading to missED presentations [5]. This is especially alarming with COVID-19, which often presents with non-respiratory symptoms [6]. This study

by Kennedy et al. aims to identify the frequency of delirium in older adults presenting to the ED with COVID-19 and the associated clinical outcomes.

In this multicenter, retrospective study of 817 older adults with con- firmed COVID-19, 28% had delirium at ED presentation and 37% of them lacked the Typical symptoms of fever or shortness of breath. In fact, de- lirium was the primary symptom in 16% of all study patients. Delirium was identified using a previously described medical record review ap- proach validated against the Confusion Assessment Method, and in- volved detailed review of all relevant Clinical Notes, including physician and nursing notes. It is worth noting that only 22% of those di- agnosed with delirium on chart review had the diagnosis of delirium documented in the charts using a delirium assessment tool. Delirium was more likely to occur in patients who were older, had an underlying neurological disease or sensory impairment, or lived in a long-term care facility, which is in line with prior studies [7]. As expected, the presence of delirium was associated with an increase in hospital admission, in- tensive care unit (ICU) stay, discharge to a rehabilitation facility, and death. The study is limited by its retrospective nature, which would be expected to underestimate the frequency of delirium given that the medical record review approach used has a sensitivity of only 74%. The generalizability of the data to all settings may be limited by the fact that 30% of this study’s patients had underlying cognitive impair- ment or dementia, increasing their risk of delirium.

Delirium is a frequent presentation of COVID-19 in older adults in the ED, either as a primary symptom or as part of an atypical COVID-19 presentation. This data highlights the importance of delirium screening now more than ever, reiterating the Geriatric Emergency De- partment Guidelines recommendations [8]. This increased frequency of delirium in older adults with COVID-19, which is higher than would be expected in the general geriatric ED population [9], is in line with the regularity of neuropsychiatric manifestations in the general COVID-19 adult population [10]. The increased mortality in COVID-19 patients with encephalopathy and the frequency of missed delirium diagnosis are in line with prior literature as well [9,10].

1. Delirium
   1. Deng LX, Cao L, Zhang LN, et al. Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: a sys- tematic review and Network meta-analysis. J Crit Care. 2020 Dec;60:241-248. doi: https://doi.org/10.1016/j.jcrc.2020.08.019. Epub 2020 Aug 31

Non-pharmacological interventions to treat agitation are an attrac- tive method to prevent and treat delirium in older adults, given the ex- tensive side effect profile of medications in this population. However, despite numerous studies, optimal interventions and their true efficacy remain unclear. This systematic review and network meta-analysis fo- cuses on all adult patients in the ICU; many of the included studies were older adults. The authors included 26 randomized controlled trials and cohort studies, with a total of 7035 patients, in which individual or multicomponent non-pharmacological interventions were compared with usual care. Some of these interventions are listed in Table 3. The

Table 3

Select non-pharmacological interventions for delirium prevention and treatment [14]

Intervention type

• • • Physical environment intervention (e.g. earplugs, eye masks, and light therapy to improve sleep)
    • Sedation reducing
    • Family participation
    • Exercise program
    • cerebral hemodynamics improving (avoiding Cerebral hypoxia)

most effective non-pharmacological intervention in decreasing the inci- dence of delirium when compared with usual care was family participa- tion (risk ratio RR 0.19, CI 95%: 0.08-0.44). All interventions had a significant effect on decreasing mortality at 28 days and a non- significant effect on delirium duration and ICU length of stay.

Although some of the studied interventions are not routinely used in the ED and the study population is specific to the ICU setting, the posi- tive results associated with family participation resonate with prior de- lirium literature in non-ICU settings [11,12]. This study provides additional support to the emphasis on family-centered care that is inte- gral to geriatric EDs. The need to advocate for family presence is now more important than ever; excluding caregivers of patients at high- risk for delirium from visitor restriction policies has been the focus of many geriatric experts and a priority for patient-centered care [13]. Family presence is an integral part of reducing delirium and should be encouraged.

1. Hip fractures
   1. Haj-Mirzaian A, Eng J, Khorasani R, et al. Use of advanced imaging for Radiographically occult hip fracture in elderly patients: a systematic review and meta-analysis. Radiology. 2020;296(3):521-531. doi: https://doi.org/ 10.1148/radiol.2020192167

Plain x-rays are insufficient to rule out hip fractures in older adults, as their sensitivity can be as low as 91% [15]. Missed fractures lead to

increased morbidity and mortality; mortality is doubled in patients with more than a 48-h operative delay [16].

This systematic review and meta-analysis by Haj-Mirzaian et al. reviewed 35 studies with a total of 2992 older adults suspected to have a hip fracture with no radiological evidence of a surgical hip frac- ture. They aim to identify the frequency of occult surgical hip fractures, high-risk subpopulations for these fractures, and the diagnostic perfor- mance of computed tomography (CT) and bone scans in identifying the Occult fractures. Of note, surgical hip fractures are those that require im- mediate surgery, namely femoral head, femoral neck, intertrochanteric, or subtrochanteric fractures. The frequency of radiologically occult hip fractures was 39% (95% CI: 35-43%) in patients with negative or equiv- ocal anteroposterior and lateral hip x-rays. Surgical hip fractures were present in 92% (95% CI: 83-98%) of patients with apparent isolated greater trochanter fracture, which would not require surgery on its own. Certain patient subgroups were more likely to have occult frac- tures than other older adults, namely patients >=80 years old, those with an equivocal radiographic report, or those with an identifiable his- tory of trauma. Several investigated factors were not correlated with an increase in the frequency of occult fractures, such as Patient sex or ra- diographic interpreter training. The sensitivity and specificity of CT when compared with magnetic resonance imaging (MRI), the desig- nated gold standard, was 79% and 91%, respectively. It was slightly outperformed by bone scans at 87% and 96%, respectively. The meta- analysis is limited by the retrospective nature of many included studies. It is noteworthy that not all identified surgical fractures will translate to

Fig. 1. Risk stratification of hip fractures for imaging [18] (reprinted with permission). Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.

a change in clinical outcome; some older adults with identified surgical fractures will not undergo surgery as they are high-risk. The authors could not comment on some elements that play into the clinician’s sus- picion for pursuing the diagnosis, such as bone density, details of phys- ical examination findings, and type of trauma, due to the lack of sufficient data.

This meta-analysis emphasized the shortcomings of using CT imag- ing in patients with suspected hip fractures and negative initial x-rays, although it is currently recommended by the American College of Radi- ology Appropriateness Criteria as “usually appropriate”, on par with MRI [17]. It may be reasonable to perform an MRI instead of a CT in high-risk patients with negative radiographs, especially if they are >=80 years and/or have a clear history of trauma. Risk-stratifying patients with suspected hip fractures to pursue the most suitable advanced im- aging modality (whether CT or MRI) had been proposed by Cannon et al. in 2009 based on consensus and small studies [15] and should be revisited with this updated information. Their proposed algorithm is in Fig. 1. Moreover, advanced imaging should be strongly considered in patients with apparent isolated greater trochanter fracture, given the high rate of fracture extension into the intertrochanteric region and co-existence of a surgical fracture.

1. Elder abuse
   1. Rosen T, LoFaso VM, Bloemen EM, et al. Identifying injury patterns as- sociated with physical elder abuse: analysis of legally adjudicated cases. Ann Emerg Med. 2020 Sep;76(3):266-276. doi: https://doi.org/10.1016/j. annemergmed.2020.03.020. Epub 2020 Jun 10

Identifying cases of elder abuse is challenging in the ED and main- taining a high suspicion for maltreatment in this patient population is now more important than ever. As older adults become more isolated and have less access to community services during the pandemic, ex- perts suspect increased rates of elder abuse [18]. This groundbreaking study utilized data from successfully prosecuted elder abuse cases to create an elder abuse injury profile that physicians can use to differ- entiate injuries caused by unintentional fall from those caused by maltreatment. Using a comparative study with a case-control design, in- vestigators matched elder abuse cases that were successfully adjudi- cated in court 1:1 with demographically similar patients presenting to the ED with unintentional falls. One hundred successfully prosecuted elder abuse cases from an Elder Abuse law enforcement unit were uti- lized in the study and compared to matched control patients that were prospectively enrolled after presenting to the ED for an uninten- tional fall. All enrolled ED patients were screened for elder abuse using a validated screening tool to ensure that these were not maltreatment victims themselves. Photographs of the injuries of patients who experi- enced a fall were compared to the photographs of injuries from the vic- tims of abuse in the prosecuted cases.

The investigators determined that Physical abuse victims were more likely to have bruising and injuries on the maxillofacial, dental, or neck region, especially the left cheek, left face, and ears. Neck injuries specif- ically should trigger physicians to think of abuse as the mechanism for injury as the neck is typically protected during a fall. Victims of mal- treatment were less likely to have any fractures or lower extremity inju- ries. With this identification of injury patterns specific to maltreatment, physicians have another tool to help make the elusive diagnosis of elder maltreatment. Even with this new data that mirrors the child abuse lit- erature and likely increases the sensitivity of elder abuse detection in the ED, clinicians must keep in mind that in this study nearly one-fifth of the patients who had experienced physical abuse had no visible injuries.

The identification of injury patterns specific to elder abuse could ad- vance our use of artificial intelligence and machine learning through electronic medical record (EMR) systems to screen for and identify po- tential cases of maltreatment. Machine learning uses algorithms based

on copious amounts of data derived from electronic health records and insurance company databases to identify patients who are highly likely to be experiencing maltreatment.

Algorithms that incorporate data from inpatient, outpatient, ED, and psychiatric service documentation could be derived for older adults to specifically look for signs of maltreatment. Certain triggers like “(1) have two or more visits to different EDs with a hospitalization within a 3-month period, (2) receive forearm x-rays, (3) are diagnosed with an ulnar fracture, (4) do not follow up after discharge with a pri- mary care provider or refill chronic medications” could be incorporated to differentiate potential victims of abuse [19]. These tools of artificial intelligence could then signal the healthcare clinician to provide a more formal screening for abuse. Experts have long speculated that targeted screening would be more effective at identifying and reporting elder abuse than the unmet expectation of universal screening [19] or the current overreliance on healthcare clinician gestalt alone for identi- fication for elder abuse.

1. Goals of care at the end of life
   1. Ouchi K, Lawton AJ, Bowman J, et al. Managing code status conversa- tions for seriously ill older adults in respiratory failure. Ann Emerg Med. 2020 Dec;76(6):751-756. doi: https://doi.org/10.1016/j.annemergmed. 2020.05.039. Epub 2020 Aug 1

Half of older adults visit the ED in the last month of life [20] and up to 80% of them do not possess Advance directives [21], necessitating that code status conversations be managed by emergency physicians. Aligning the care that the patient receives and its expected prognosis with the patient’s values and priorities are of utmost importance. This concept paper by Ouchi et al. starts by reviewing relevant prognostic

Fig. 2. Outcomes in older adults intubated in the hospital [22].

Fig. 3. Outcomes in older adults admitted to the intensive care unit [23].

Table 4

Steps to establish goals of care in the Emergency Department [23]

1. Establish urgency and elicit understanding
2. Break bad news
   1. Ask for permission to discuss the situation
   2. Disclose the headline
3. Develop therapeutic alignment with the patient/surrogate
4. Ascertain Baseline function
5. Explore the patient’s values and goals
6. Summarize understanding about baseline function, values, and desired health status
7. Recommendation of intensive treatment focused on recovery form illness or on comfort.

data in critically ill older adults, some of which are summarized in Figs. 2 and 3. Data regarding care priorities of older adults is mentioned as well, focusing on how the majority of older adults prioritize quality over ex- tension of life. The authors propose 7 essential steps to manage a code status conversation for older adults in respiratory failure- each step ac- companied by examples and supplemental videos. The steps are sum- marized in Table 4. These steps and examples can be easily adapted to other invasive procedures and goals of care in general. The authors use the words “procedural skill” to describe a code status conversation which highlights its importance and distances it from the traditional viewpoint of a “communication soft skill”. These conversations are mas- tered through deliberate practice, just like any procedure. The proposed steps may be conducted in a non-linear fashion and are conducted with the patient and/or surrogate, depending on the clinical situation. Avoid- ance of medical jargon is emphasized and expressing empathy is en- couraged. Care recommendations focus on whether the likely outcome would be considered worse than death for the patient. This proposed framework is a must-read for all emergency physicians as it simplifies an important topic that has long been marginalized in the training of non-palliative care specialists.

1. Telehealth
   1. Hawley CE, Genovese N, Owsiany MT, et al. Rapid integration of home telehealth visits amidst COVID-19: what do older adults need to succeed? J Am Geriatr Soc. 2020;68(11):2431-2439. doi: https://doi.org/10.1111/ jgs.16845, https://doi.org/10.1111/jgs.16845

Improving older adults’ access to care may be successfully accom- plished through telehealth [24], especially with a decrease in available transportation, with an additional bonus of avoiding high-risk expo- sures to infectious diseases. This three-phased, mixed-methods study aims to identify and address barriers to integrating video home telehealth visits into a geriatrics renal clinic. A needs assessment was performed to identify patient-perceived barriers to completing a home telehealth visit, followed by the pilot intervention, and finally a post- visit evaluation. In an in-person paper-based survey, patients identified “interest” as the most commonly perceived barrier to telehealth, followed by “access to technology” (whether the internet, a compatible device, or both) and “confidence”. The pilot addressed these barriers by conducting individualized patient training on using the app, scheduling a demo with the telecommunication technician team, and using a tele- phone visit as a back-up plan in case of technical difficulties. In addition, patients were offered compatible devices, although none utilized this service. A semi-structured telephone interview evaluated the perceived barriers 1 week after the visit was completed. Interest and confidence were no longer an issue, and access to technology was overcome by bor- rowing a device from a family member or loved one and receiving help from them either before or during the visit. Technical difficulties oc- curred in 42% of visits but all these visits were successfully completed via telephone.

The study was small, including only 32 patients who completed the visit with a 37.5% response rate on the post-visit evaluation. The most important limitation of this study is selection bias; participants were all relatively independent with a good baseline literacy (able to read and write comfortably). In addition, it was small (from a single center). The rationale behind the lack of interest was not explored, despite it being the most significant barrier mentioned.

The manuscript offers a detailed description of the piloting process

of telehealth visits and overcoming the perceived barriers, utilizing evidence-based implementation strategies based on Expert Recommen- dations for Implementing Change, which can be applicable in varioUS settings. Opportunities for utilization of telehealth exist where in- person physical examination is not necessary, such as certain urgent care conditions, medication refills, chronic disease monitoring, and fol- low up with allied health care professionals such as case managers and dietitians [25,26], and, if implemented correctly, is the future of accessi- ble healthcare.

1. Cardiac
   1. Probst MA, Gibson T, Weiss RE, et al. Risk stratification of older adults who present to the emergency department with syncope: the FAINT score. Ann Emerg Med. 2020 Feb;75(2):147-158. doi: https://doi.org/10.1016/j. annemergmed.2019.08.429. Epub 2019 Oct 23

Many older adults will visit the ED every year with a chief complaint of syncope or near syncope and more than 50% of them will be hospital- ized [27]. Determining the appropriate disposition for older adults pre- senting with syncope continues to challenge emergency clinicians, given that previously developed clinical decision rules have not been shown to outperform clinician judgement [28]. The investigators in this study completed a prospective, observational study of 3177 pa- tients ages 60 and above in 11 different EDs who presented for syncope or near syncope in an attempt to develop a Disposition decision aid. Pa- tients were excluded if they had evidence of intoxication, seizure, stroke, transient ischemic attack, trauma or hypoglycemia. The pro- posed tool, the FAINT score (Table 5), had a sensitivity of 96.7% for predicting death or serious cardiac outcome at 30 days. In addition, the tool outperformed unaided physician gestalt, which was assessed by asking physicians to predict the probability that a patient would die or suffer a serious cardiac event in 30 days on a scale of 0%-100%. This study suggests that patients that have no history of heart failure or cardiac arrhythmia, and have a normal electrocardiogram (ECG), pro-B-type natriuretic peptide, and High-sensitivity troponin levels have <1% risk of a serious adverse outcome within 1 month of presentation.

The FAINT tool is not designed to evaluate for all causes of syn-

cope. The tool only evaluates for the risk of death or adverse cardiac outcome at 30 days and does not include other Life-threatening causes of syncope such as gastrointestinal bleeds, strokes, intracra- nial hemorrhage, or Pulmonary embolisms. Despite the multicenter

Table 5

FAINT score [29] (Reprinted with modification and permission)

F	History of heart Failure	1
A	History of Arrhythmia	1
I	Abnormal Initial ECG	1
N	Elevated N-terminal-prohormone BNP	2
T	Elevated high-sensitivity troponin T	1

Clinical variable Points

Risk of death or serious cardiac outcome at 30 days: Score 0: 0.9%

Score 1-2: 3%

Score 3-5: 6-10%

Score 6: 24.1%

Abbreviations: BNP, beta-natriuretic peptide; ECG, electrocardiogram.

nature of the study, the FAINT score has not been externally validated and is therefore not ready to be universally adopted. It remains to be seen if this tool will perform as well outside of the population in which it was studied.

1. Geriatric Emergency Departments
   1. Magidson PD, Huang J, Levitan EB, et al. Prompt outpatient care for older adults discharged from the Emergency Department reduces recidi- vism. West J Emerg Med. 2020 Oct 20;21(6):198-204. doi: https://doi.org/ 10.5811/westjem.2020.8.47276

When emergency clinicians discharge an elderly patient from the ED, the chance that the patient will return within the next 30 to 90 days is higher than for their younger counterpart [30]. Numerous strat- egies to reduce ED recidivism exist, including the organization of close outpatient follow-up with a primary care provider after a visit to the ED. In this study, investigators utilized a pre-existing database, the na- tional REasons for Geographic and Racial Differences in Stroke (REGARDS) study database, to review almost 15,000 repeat ED visits within a 90-day period of the initial visit. The database represents a trove of demographic and medical information for thousands of patients 65 and older and is also linked to Medicare claims, allowing study au- thors to extrapolate data to numerous medical conditions and proce- dures aside from stroke. This study demonstrated that more than 20% of the older adults discharged from the ED will have a repeat visit to the ED within 30 days. Older patients, those with more comorbidities, and those with a Lower socioeconomic status (qualifying for both Med- icaid and Medicare) were the most likely to return to the ED for a repeat visit within 90 days. If patients were able to see a primary care practi- tioner or specialist within 30 days following their ED visit, they had a de- creased ED recidivism rate, more so if within 10-12 days of discharge. Delayed follow-up visits (i.e. more than 30 days after the ED visit) did not affect the recidivism rate. The authors speculate that further im- provement in the transitional care after ED discharge may be accom- plished by standardizing the communication between ED and outpatient practitioners.

• 1. Berning MJ, Oliveira J E Silva L, Suarez NE, et al. Interventions to im- prove older adults’ Emergency Department patient experience: a systematic review. Am J Emerg Med. 2020 Jun;38(6):1257-1269. doi: https://doi.org/ 10.1016/j.ajem.2020.03.012. Epub 2020 Mar 12

Prior studies suggest that improving patient experience in the ED improves patient compliance with clinician treatment plans after the ED visit and can lead to better clinical outcomes [31]. Recognizing that the needs of older adults in the ED probably differ from the needs of the general ED population, this systematic review sought to identify in- terventions that improved the ED experience for patients 65 and older. The authors included 21 studies, which included a total of 3163 patients, that reviewed interventions to improve the ED experience of older adults in a variety of categories (Table 6). Some of the interventions

Table 6

Studied interventions to improve the quality of emergency care for older adults [32] Studied interventions to improve the quality of emergency care for older adults

were expansive, such as the conversion of a physical space into a Geriatric ED, while others were more modest in scope, like screening for hearing loss and providing assistive listening devices to those who needed it. In general, the EDs that addressed the physical needs of older adults, tacklED wait times, and improved communication had the most favorable trends in their patient experience scores. Because of the wide array of included studies and variability in methods and data collection, the authors deemed the certainty of evidence to be “very low.” The patient feedback for most of these studies was also mostly based on non-validated questionnaires, making it difficult to ex- clude bias. However, the review does offer a buffet of choices for EDs looking for ideas on how to improve the ED experience for older adults. Further study is needed to determine which of these interventions of- fers the most cost-effective techniques to improve the experience of our older patients when visiting the ED.

Declaration of Competing Interest

None.

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Role of health care

practitioners

Content of communication and patient education

Geriatric- trained healthcare professionals

Patient liaison

2009;37(2):144-52. https://doi.org/10.1016/j.jemermed.2007.12.039.

1. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative com- plications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77(10):1551-6. https://doi.

Barriers to communication Hearing screen and provision of an assistive

listening device to those in need

Wait times “No wait” policy for Geriatric patients

Physical needs Non- slip floors

care transitions Pharmacist review of discharge medication list

org/10.2106/00004623-199510000-00010.

1. Ross AB, Lee KS, Chang EY, et al. ACR appropriateness criteria((R)) acute hip pain- suspected fracture. J Am Coll Radiol. 2019;16(5S):S18-25. https://doi.org/10.1016/ j.jacr.2019.02.028.
2. Han SD, Mosqueda L. Elder abuse in the COVID-19 era. J Am Geriatr Soc. 2020;68(7):

1386-7. https://doi.org/10.1111/jgs.16496.

1. Rosen T, Zhang Y, Bao Y, et al. Can artificial intelligence help identify elder abuse and neglect? J Elder Abuse Negl. 2020;32(1):97-103. https://doi.org/10.1080/ 08946566.2019.1682099.
2. Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency de- partment in last month of life; Most admitted to hospital, and many die there. Health Aff. 2012;31(6):1277-85. https://doi.org/10.1377/hlthaff.2011.0922.
3. Oulton J, Rhodes SM, Howe C, Fain MJ, Mohler MJ. Advance directives for older adults in the Emergency Department: a systematic review. J Palliat Med. 2015;18

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1. Ouchi K, Jambaulikar GD, Hohmann S, et al. Prognosis after emergency department intubation to inform shared decision-making. J Am Geriatr Soc. 2018;66(7): 1377-81. https://doi.org/10.1111/jgs.15361.
2. Ouchi K, Lawton AJ, Bowman J, Bernacki R, George N, Ouchi K, et al. Managing code status conversations for seriously ill older adults in respiratory failure. Ann Emerg Med. 2020;76(6):751-6. https://doi.org/10.1016/j.annemergmed.2020.05.039.
3. Batsis JA, DiMilia PR, Seo LM, et al. Effectiveness of ambulatory telemedicine care in older adults: a systematic review. J Am Geriatr Soc. 2019;67(8):1737-49. https:// doi.org/10.1111/jgs.15959.
4. DiGiovanni G, Mousaw K, Lloyd T, et al. Development of a telehealth geriatric assess- ment model in response to the COVID-19 pandemic. J Geriatr Oncol. 2020;11(5): 761-3. https://doi.org/10.1016/j.jgo.2020.04.007.
5. Tan LF, Ho Wen Teng V, Seetharaman SK, Yip AW. Facilitating telehealth for older adults during the COVID-19 pandemic and beyond: strategies from a Singapore

geriatric center. Geriatr Gerontol Int. 2020;20(10):993-5. https://doi.org/10.1111/ ggi.14017.

1. Probst MA, Kanzaria HK, Gbedemah M, Richardson LD, Sun BC. National trends in re- source utilization associated with ED visits for syncope. Am J Emerg Med. 2015;33 (8):998-1001. https://doi.org/10.1016/j.ajem.2015.04.030.
2. Costantino G, Casazza G, Reed M, et al. Syncope risk stratification tools vs clinical judgment: an Individual patient data meta-analysis. Am J Med. 2014;127(11): 1126.e13-25. https://doi.org/10.1016/j.amjmed.2014.05.022.
3. Probst MA, Gibson T, Weiss RE, et al. Risk stratification of older adults who present to the emergency department with Syncope: the FAINT score. Ann Emerg Med. 2020; 75(2):147-58. https://doi.org/10.1016/j.annemergmed.2019.08.429.
4. Martin-Gill C, Reiser RC. Risk factors for 72-hour admission to the ED. Am J Emerg Med. 2004;22(6):448-53. https://doi.org/10.1016/j.ajem.2004.07.023.
5. Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on Healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(4):e94207. https://doi.org/10.1371/journal.pone.0094207.
6. Berning MJ, Oliveira JE, Silva L, Suarez NE, et al. Interventions to improve older adults’ Emergency Department patient experience: a systematic review. Am J Emerg Med. 2020;38(6):1257-69. https://doi.org/10.1016/j.ajem.2020.03.012.