A new model for emergency care of geriatric patients.

The special challenges of geriatric patients in the emergency department (ED) have been discussed for several decades. The unique nature of older patients and the notable challenges of caring for them have been described. Teaching curricula have even been developed for emergency medicine residents and practicing physicians to address these challenges and to optimize quality of care. The importance of optimizing care for elder patients in the ED does not need to be debated. What can be questioned, however, is whether there is evidence that the nation’s emergency caregivers are meeting these challenges. Are patients being better served? Are emergency physicians more at ease, and less frustrated? It is likely that EDs still have a long way to go. The specialty’s leaders must continue to clarify the challenges and devise ways to implement the lessons learned. In this issue of Academic Emergency Medicine, four articles provide further insight into geriatric issues in emergency medicine. Although each provides important new information, none disputes what we have known for a long time. The older patient in the ED, with impaired functional status, need for assistance at home, comorbid conditions, and physiologic differences, offers challenges to the caregiving system and the caregivers themselves. It is important to recognize the insights offered in these articles, but it is equally important to recognize that emergency physicians are not easily able to deal with the information. Whether it is a call for implementation of screening tools or a need to deal with geriatric patients who are not equally referred to trauma centers, we are mostly left wondering what to do. As we analyze these articles, maybe we should also analyze our systems of care. We might have to conceive of innovative delivery systems to decrease our frustration and optimize geriatric ED care. Perhaps then we can make more progress in the coming decade than we have in the past. We must first recognize important information, and challenges, presented in this issue of the journal. Lane and colleagues report that seriously injured older patients are less likely to be taken to a trauma center than are younger patients with the same severity of injury. McCusker et al in Montreal demonstrate the benefit of a brief screen in planning care after discharge. Meldon and colleagues in Cleveland show the value of a brief screen in identifying patients likely to use expensive health services within four months of their ED visit. The aims of the Montreal and Cleveland studies are similar. Both authors report results of secondary analyses from randomized trials to evaluate the effect of an ED case-finding program. They both use a brief screen followed by a more detailed evaluation and referral to clinical services. The two studies use sixitem screens that might look different, but are really quite similar. Both screens question independence, health care use, functional impairment, cognitive impairment, and polypharmacy. These papers have another commonality that they share with data presented from the Pennsylvania trauma registry. All three papers raise important questions about improving processes of emergency care for older patients. This is the cardinal research question raised by the Research Agenda Setting Process (RASP), summarized in the forth geriatric emergency medicine paper in this issue of AEM. RASP is a project convened by the American Geriatrics Society with support from the John A. Hartford Foundation. The goal was to set a geriatric research agenda for ten surgical and related medical specialties. The highestpriority research question is ‘‘Can alterations in the process of ED care. . .improve the outcomes of older ED patients? These processes of care, as demonstrated by the three studies, include out-of-hospital care, care in the ED, and linkages with providers after discharge. The studies reported in this issue are early in a research path leading to improved outcomes for older patients. We must answer the questions RASP raised and incorporate the results as best practices to improve care of and outcomes for older patients.