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A visit to the emergency room is no fun for anybody. But older people face challenges that can make a tough situation worse.

The lights, noise and endless activity can be confusing and even trigger delirium. Slick floors pose fall risks, as do hospital beds that can be hard to get in and out of.

Some emergency departments, however, are taking steps to improve the experience for older adults. These geriatric or age-friendly approaches can make a difference, experts say.

"In the past, we've always treated everybody in the ED the same, regardless of age," said Dr. Liz Goldberg, an associate professor of emergency medicine and geriatrics at the University of Colorado School of Medicine in Aurora. Now, there's more focus on doing things differently for older adults "because they have different needs and different diagnoses, and they require that special attention."

Dr. Ula Hwang, medical director of geriatric emergency medicine at NYU Langone Health in New York City, said that back in 2007, she had trouble finding an academic journal to publish a paper she co-wrote that spelled out the concept of a geriatric emergency department.

The need for age-friendly care is clear, Hwang said. Older adults visit emergency departments nearly 33 million times a year, or 21% of all such visits, according to Centers for Disease Control and Prevention .

The American College of Emergency Physicians started certifying geriatric emergency departments in 2018. Today, more than 500 hospitals in the United States have earned some level of certification. Even more may have made age-friendly changes without seeking full certification, said Goldberg, the immediate past president of the Academy for Geriatric Emergency Medicine.

"It's been expanding really quickly," she said.

Who needs age-friendly emergency care?

In an urgent situation, Hwang said, the need for fast, specialized care will be the same for any age. A heart attack with blocked or narrowed areas of a coronary artery, for example, can be treated in a catheterization lab or with anticoagulant therapy that can quickly restore blood flow to the heart, while patients with stroke will be evaluated for the type of stroke and the appropriate treatment.

It's the more ambiguous emergency cases where age-related differences come in, said Hwang, who also is a professor of emergency medicine and population health at the NYU Grossman School of Medicine. "Those patients are the ones that often get a pretty long and extensive workup while they're in the emergency department," and that's where age-friendly care can make a difference from the start.

Goldberg said most emergency departments are busy and chronically overcrowded.

"The emergency department is a very fast-paced, loud environment," she said, where a lack of beds means patients can spend hours or days boarded in a hallway that was never intended to be used as a space for treatment. Lights are kept bright at all hours, and the constant activity can be stressful and disorienting, or worse.

"You really don't want an 85-year-old or older patient lingering and sort of stranded in the emergency department for hours and days on end," Hwang said. "It's been shown that if you're an older adult and you board in the emergency department overnight, you are at greater risk for developing delirium, even potentially having an inpatient mortality."

An age-friendly emergency department helps prevent such problems both through protocols and changes to the physical space.

Physically, the adaptations can include non-slip floors and an abundance of handrails and assistive devices such as walkers to prevent falls, Goldberg said.

Clear signs can keep people from getting lost, and large-print forms can make sure vision problems don't get in the way of understanding instructions.

Age-friendly protocols cover other issues, Hwang said. Many are built around four themes – finding what matters most to patients; evaluating medication; "mentation," or cognitive issues; and mobility. These "4Ms" are the foundation of models for age-friendly care.

An emphasis on evaluation

Care might start with screening the patient for dementia or other cognitive issues, Hwang said. "If they have cognitive impairment, they might not even follow what's going on" and struggle to follow directions.

An evaluation would look for root causes of a problem. If a younger person comes in after a fall, standard care might call for treating the injury and moving on. But with older patients, Hwang said, "we have to also think about, 'Well, what caused these things?'"

A symptom that's ambiguous, such as dizziness or trouble walking, might have been caused by something serious, such as a stroke, Hwang said. Or a medication issue might be behind a dip in blood pressure that led someone to lose their balance and fall. So a review of a patient's prescriptions is also a foundation of age-friendly care.

Older adults are more likely than younger people to be on multiple medications with confusing regimens, Goldberg said. At the same time, kidney and liver function decline with age. Given those organs' role in processing drugs, standard doses might need to be different for older people.

"We see that a lot," she said, "where well-meaning clinicians put patients on medications that are great if you're 40 years old and very spry – and not so great if you're 80."

Age-friendly care also calls for health care staff to work with patients to understand what they really want from a visit to the emergency department.

A younger person, Hwang said, may be likely to show up in the emergency department with a fresh problem. They may want a full evaluation and may expect to be checked into the hospital with the long-term expectation of being cured.

Older adults, she said, may tend to need help with existing issues and not be interested in spending days getting analyzed for a problem they know isn't going away.

Someone who knows they have congestive heart failure, for example, might experience a flare-up of symptoms. But "it's not like we're going to cure this condition," Hwang said. The patient might simply want relief from pain or shortness of breath so they can get back home.

In other cases, Goldberg said, a patient might prefer hospice care to extensive medical treatment. "It actually takes quite a bit of training to not do what physicians do best, and just power through all the possible interventions we could deliver in a patient that's very, very sick." A geriatric emergency department can provide social workers and other experts to help caregivers.

Delirium in the emergency department has been linked to accelerated cognitive decline and prolonged hospital stays for older adults. People with dementia are at higher risk for delirium. Age-friendly protocols emphasize preventing it through steps such as keeping the person hydrated and limiting equipment, such as monitors and catheters, attached to them, Goldberg said.

Age-friendly changes in an emergency department can also allow caregivers to sit with patients or move them to quieter areas where the lighting is dimmed at night, Goldberg said, and provide display clocks to help them stay oriented.

How does an age-friendly ER help?

Studies have shown several benefits from age-friendly emergency care.

"From the patient's perspective, there's a lot of increased patient satisfaction," Hwang said, because the health care staff is taking time to listen to their needs.

Geriatric-oriented care can cut down on avoidable hospitalizations, Hwang said. And it can save money. One study, led by Hwang and published in in 2021, showed that an age-friendly emergency department reduced the total cost of care for Medicare beneficiaries by more than $3,200 over the subsequent 60 days after their initial emergency visit.

It also can keep older patients healthier. One study Goldberg led, published in the in 2020, found that a group of patients who received consultation from a pharmacist and a physical therapist in the emergency room to prevent falls were half as likely to require a return visit and a third as likely to have a visit because of a fall within six months, as compared with a group that received no such help.

Efforts that prevent delirium can also prevent falls during the hospital stay, Goldberg said.

The number of age-friendly emergency departments has been growing, and they can be found nationwide. But only about 1 in 10 emergency departments have geriatric certification from the . Many are urban teaching hospitals. But rural areas are disproportionately older, and "there is definitely a push to try to get more rural emergency departments geriatric accreditation," Hwang said.

In many cases, someone needing emergency care won't have a choice of where they go, Goldberg said. And an age-friendly department might not even be the first choice, depending on the emergency. If you're caring for someone having stroke symptoms, for example, you will be better off calling 911 so they can be taken to a stroke center – and the one nearest you might not have geriatric accreditation.

But for someone in a large city who has choices, Goldberg said, it could be worthwhile to find out ahead of time which ones are either fully ACEP certified or recognized by the nonprofit .

Hwang is hopeful the idea will continue to spread. "Maybe 10 years ago, we were the innovative concept," which has grown into a popular model. But there's definitely room for more widespread implementation, she said. "It's a much-needed thing."