New Multidisciplinary Project Advances Emergency Care for Older Patients

In 2020, the U.S. Census Bureau estimated that the country’s 65-and-older population had reached nearly 56 million, surging by 39 percent in only a decade. As the U.S. population continues to age, a unique multidisciplinary project at NYU Langone Health, GeriED, is gearing up to advance age-appropriate care in the emergency department (ED) for those older adults. The partnership between specialists in geriatrics and emergency medicine—in combination with nurses, case managers, pharmacists, social workers, and others—seeks to streamline ED care and smooth care transitions to reduce multiple risks.

“For older adults, the emergency room can be a dangerous place because there’s so much going on,” says geriatrician and project lead Sara Zalcgendler, MD. “This partnership is about addressing and minimizing some of the big dangers and obstacles, and doing what we can to protect these vulnerable patients.”

The team effort allows specialists like Dr. Zalcgendler to screen for, recognize, and assess conditions that might otherwise be missed, says Ula Hwang, MD, MPH, medical director of Geriatric Emergency Medicine. The GeriED project, she adds, is one of few in the country that has an embedded geriatrician to screen for at-risk ED patients in need of additional consultations.

“That’s really a unique approach, and we’re now trying to come up with flags, track boards, and other ways that will make it easier to quickly identify those high-risk patients,” Dr. Hwang says.

A Focus on Risk Reduction

One common issue in busy EDs is a long boarding time for patients admitted to the hospital. “Studies have shown when older patients stay for prolonged periods in the emergency department, they’re at greater risk of developing delirium and they’re at greater risk of dying,” says Dr. Hwang.

Bright lights and noise, lack of sleep, dementia, language barriers, and a lack of social support can all contribute to the risk, as can constipation, urinary retention, and uncontrolled or unrecognized pain. “A lot of our adults can’t verbalize these symptoms or aren’t expressing them in the typical way,” Dr. Zalcgendler says. A careful geriatric assessment and physical exam can uncover risk factors that might otherwise be missed.

Beyond addressing the patients’ acute medical presentations, Dr. Hwang says, reducing the risk means paying attention to additional factors like social and functional support systems and cognitive function.

“As emergency physicians, it’s not just making sure that patients don’t have a broken bone and then letting them go home. It’s now understanding, well, why did they fall?” she says. “Even if they don’t have anything broken, they may still have a painful injury. Is it safe and can they still go home and take care of themselves?”

Dementia or cognitive impairment in an older adult can further increase the risk for developing delirium. In addition, those patients may struggle to understand why they’re in the ED or how to follow medical instructions, such as new prescriptions and subsequent appointments. “We really want to make sure that we’re aware of an individual who has cognitive impairments or limitations,” Dr. Hwang says.

Minimizing Boarding Times, Avoiding Admissions

To help minimize boarding times, Dr. Zalcgendler talks with older patients, accompanying caregivers, the ED care team, social workers, and outpatient providers if they’re available. She assesses the patients for active delirium or the risk thereof and tries to further reduce the danger through medication reconciliation.

Another big goal is preventing unnecessary hospital admissions for the geriatric population. Hospital stays increase the risk of delirium and can exacerbate patients’ weakness, especially those with impaired mobility. The partnership has already helped multiple patients avoid admission, however, through consultations involving Dr. Hwang, Dr. Zalcgendler, and other specialists.

In one case, an older man taking a blood thinner for a serious heart condition presented to the ED after a serious fall. Although imaging didn’t reveal any broken bones or internal bleeding, one of his eyes was swollen shut.

After the hospital’s ophthalmology team confirmed that he hadn’t injured his eye, Dr. Zalcgendler talked to the patient, his family, and his outpatient cardiologist to discuss the case and how many days he could safely withhold the blood thinner to allow his eye to heal. “The family and the patient felt comfortable about going home,” she recalls. “The emergency room team felt comfortable, I felt comfortable, and the cardiologist agreed with the plan and scheduled a close follow-up with the patient, so I viewed that as a very big win.”