Geriatric Emergency Medicine

Christopher R. Carpenter, MD, MSc, FACEP; Lowell W. Gerson, PhD *
* Carpenter: Assistant Professor, Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO; Gerson: Professor Emeritus of Epidemiology, Northeastern Ohio Universities College of Medicine, Senior Scientist, Emergency Medicine Research Center, Summa Health System, Akron, OH.

The American Geriatric Society (AGS) project “Increasing Geriatric Expertise in Surgical and Related Medical Specialties” sponsored an effort to summarize the existing evidence and to identify priorities for future research in geriatrics aspects of several surgical and related medical fields. Ultimately, each specialty’s research agenda was dissemi-nated in a book (hereinafter referred to as New Frontiers1 and a Web site (, and many were also disseminated in professional journals, as was, for example, the agenda for emergency medicine. 2 In 2005, the AGS initiated a review of each specialty’s recommendations to analyze any progress made and evaluate whether any agenda items should be discarded or new ones added.

  This chapter summarizes the findings of our follow-up review for the field of emergency medicine. Overall, little progress has been made on most of the research questions in the time since publication of New Frontiers. Therefore, we did not change any of the agenda items. However, new developments have prompted us to add four new topics to the agenda—models of care, driving safety, stroke, and elder abuse and neglect—and to add new agenda items under some of the topics covered in the original agenda. (For discussions of the new topics and all the new agenda items, see the New Horizons in Geriatric Emergency Medicine section at the end of the chapter.)

  The Key Questions for geriatrics-oriented research in emergency medicine remain the same, as specified in New Frontiers:

EmergMed KQ1Can alterations in the process of emergency department care, such as those found to be beneficial elsewhere (ie, geriatric specialty inpatient units), improve the outcomes of older emergency department patients?
EmergMed KQ2What diagnostic and therapeutic interventions can improve outcomes in older emergency department patients with high-risk common complaints, such as abdominal pain and acute coronary syndromes?
EmergMed KQ3In older blunt multiple trauma patients, does early invasive monitoring and aggressive resuscitation result in improved outcomes?


The methods used to locate the evidence in the current review differ somewhat from those used for New Frontiers. RAND librarians conducted a PubMed search in July 2005 using the MeSH headings emergency medicine, emergency treatment, and emergency service,hospital. These headings were combined with the following MeSH terms: age, geriatric assessment, aged, aged 80 and over, frail elderly, longevity, and geriatrics. The following limits were placed on all searches: over age 65, English language, humans, years 2000–2005. This PubMed search was repeated in December 2005. Additionally, relevant journals (published between January 2004 and December 2005) were hand searched for topics specific to the overlap between geriatrics and emergency medicine. The hand-searched journals were the following: Journal of the American Geriatrics Society, Journal of Gerontological Sciences, Age Ageing, Journal of Emergency Medicine, Annals of Emergency Medicine, Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Internal Medicine, New England Journal of Medicine, and JAMA. Bibliographies of selected studies were also reviewed. Finally, a cited reference search using the Web of Science was conducted for each of those studies referenced in the chapter on geriatric emergency medicine in New Frontiers.

  The content expert (CRC) reviewed the titles and abstracts derived from the search to identify those that were germane to the goals of research in the emergency care of older patients. These goals were to improve patient care through optimum medical management, disease and injury prevention, and maintenance of well-functioning individuals. The content expert and the senior writing group member (LWG) drafted a paper that synthesized the current literature and suggested areas for further research. This paper was reviewed by a panel consisting of experienced investigators who were AGS members and emergency physicians with expertise in geriatrics. Each new research question was assigned a level, using the rating system developed for New Frontiers (see pp. 6–7 for definitions of levels A through D).

  The search of PubMed yielded 69 articles using emergency medicine, 1276 articles using emergency treatment, and 825 articles using emergency service, hospital. The search of PubMed and Web of Science, with the addition of the hand search of selected journals, resulted in a list of 2223 articles. Following review of titles and abstracts, 221 articles were obtained for inspection.

Progress in Geriatric Emergency Medicine

General Geriatric Emergency Care

Patterns of Emergency Department Use

See New Frontiers, p. 54.

EmergMed 1 (Level D)Observational and analytic studies on emergency department use should continue to come from large databases or national samples (such as the National Hospital Ambulatory Medical Care Survey database) so that the results can be generalized.

New Research Addressing This Question: The patterns of emergency department (ED) use among older adults have been well described by single-hospital and multicenter studies. Elder ED patients have distinct patterns of use and disease presentation. Recent studies demonstrated that older patients represent 12% to 21% of all ED encounters. Older adults are consistently over-represented in the ED in comparison with their proportions in the general population in their geographic vicinity, and the numbers of older patients are steadily increasing. 3 One third to one half of elder ED presentations result in a hospital admission. The atypical presentations and time-consuming evaluation of older patients often result in under-triage, delayed dispositions, and inaccurate diagnoses. 4,5 Several systematic reviews have evaluated predictors of ED use by older patients, intervention effectiveness, and outcomes. 6–8

Modification of This Question in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original question. (For new agenda items on this topic, see the subsection on patterns of ED use in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)

Physician Training and Comfort

See New Frontiers, p. 55.

EmergMed 2 (Level A)Randomized controlled trials are needed to assess the effectiveness of interventions (eg, educational models, standardized protocols) for improving quality of care of older emergency department patients.

New Research Addressing This Question: On the basis of narrowly focused research questions posed to emergency medicine residency directors over a decade ago, the majority of emergency physicians believe that insufficient time is spent on geriatrics issues in residency and that ongoing research is lacking. 9 More recent efforts to describe baseline knowledge and integrate geriatrics principles into medical student educational programs during elective rotations have met with moderate success, 10,11 but no research has evaluated residency or postresidency training in evolving concepts of emergency care for older adults. 12–14 Another survey over 10 years ago of 971 practicing emergency physicians with a 44% response rate reported that these clinicians said they had more difficulty in managing abdominal pain, altered mental status, dizziness, and trauma in older than in younger patients. 15 Although textbooks in general medical geriatrics have incorporated principles of evidence-based medicine in devising clinically relevant questions, assessing the quantity and quality of available evidence to answer these questions, incorporating patient differences and preferences to the available data, and moving from evidence to action, the available textbooks and other learning tools in emergency medicine have not yet incorporated this 21st-century extension of clinical epidemiology. 16,17

Modification of This Question in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original question. (For new agenda items on this topic, see the subsection on physician training and comfort in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)


See New Frontiers, p. 55.

EmergMed 3 (Level B)Large studies are needed to confirm the results of patient surveys and focus group interviews. Studies to identify characteristics of the micro-environment that affect outcomes in elderly patients (communication, emergency department environment) are needed to identify target areas for improvement.
EmergMed 4 (Level A)Following evidence-based identification of target areas for improvement, controlled studies of the effect of alterations in the micro-environment on outcomes for older emergency department patients should be performed. Such studies likely cannot be based on random assignments of individuals to interventions; rather, whole micro-environments will have to be compared.

New Research Addressing These Questions: One prospective study of urban older ED patients identified three variables which ED staff can influence: the patient’s perception of time spent in the ED, how well physicians and nurses shared information with the patient and included the patient in decision making, and pain management. 18 Recent reviews have summarized the available patient satisfaction literature 19 and the Institute of Medicine’s six quality domains: effective, timely, efficient, safe, patient-centered, and equitable care. 20 One randomized trial of replacing uncomfortable gurneys with reclining chairs found that doing so improved pain and satisfaction scores. 21

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions. (For new agenda items on this topic, see the subsection on ED environment in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)

Prehospital Care

See New Frontiers, p. 56.

EmergMed 5 (Level B)Cohort studies should be performed to describe the ability of prehospital care providers to assess older patients in their home environments. Areas where this may be particularly beneficial include the assessment of the home environment of patients with falls and functional decline, and the assessment of potential abuse. This research should focus on whether information about home environment provided by prehospital care providers affects patient outcomes.

New Research Addressing This Question: The AGS and the National Council of State Emergency Medical Services Training Coordinators developed a textbook and instructional program to train prehospital professionals to deliver state-of-the-art care to older adults (online at No reports of educational or outcomes-based results of these ongoing courses have yet been published. One survey noted that 70% of out-of-hospital providers believe that primary injury prevention should be a routine part of their professional mission, yet only 33% routinely educated their patients on injury prevention behaviors. 22

Modification of This Question in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original question. (For new agenda items relevant to aspects of this question, see the subsection on abuse and neglect under Trauma in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)

Cognitive Impairment

See New Frontiers, pp. 57–58.

EmergMed 6 (Level B)Screening tests for cognitive dysfunction for use in the emergency department should be validated against gold-standard assessment, and efforts should be made to determine if new, shorter screening approaches would be effective.
EmergMed 7 (Level B)Prospective cohort studies such as larger-scale longitudinal outcome studies of older patients with impaired cognition are necessary to confirm the finding that patients with undiagnosed delirium have worse outcomes than do those without delirium or with diagnosed and treated delirium.
EmergMed 8 (Level A)If research (EmergMed 7) confirms that older patients with delirium that is not diagnosed in the emergency department ultimately have worse outcomes than do those either without delirium or with recognized and treated delirium, interventional trials should be designed to determine the effect on outcomes of better screening and management of cognitive impairment in older emergency department patients.

New Research Addressing These Questions: Cognitive impairment, including delirium and dementia, is prevalent among older ED patients. 23,24 A recent prospective observational study demonstrated that although 26% of patients at one tertiary care ED had impairment, less than one third of them had documentation of the delirium or cognitive deficit by the emergency physician. 25 Furthermore, when the treating emergency physicians were notified of the impairment, the knowledge did not affect their management decisions on a single patient. 26 Multiple studies have since demonstrated an association between delirium with increased mortality 27–29 and diminished functional outcomes. 30 Other ED-based prospective studies have verified the poor recognition of cognitive impairments among senior patients. 24,31 Several rapid, ED-accessible screening tests for dementia and delirium have been developed. 32–37 Delirium intervention models have not been initiated from the ED in current study settings, 38,39 even though emergency medicine has been called upon to take a more active role in the evaluation and disposition of these patients. 40,41

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions.

Functional Assessment

See New Frontiers, pp. 58–59.

EmergMed 9 (Level B)Development and testing of measures for functional assessment that are feasible and valid in elderly emergency department patients are needed.
EmergMed 10 (Level B)Case-control or cohort studies are needed to determine whether older emergency department patients with functional impairments have worse outcomes than do those without impairment.
EmergMed 11 (Level A)Controlled intervention trials are needed to determine whether the detection and management of functional impairment in older emergency department patients have an effect on these outcomes.

New Research Addressing These Questions: No new research addressing these questions was found.

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions.

Medication Use

See New Frontiers, pp. 59–60.

EmergMed 12 (Level B)Large, long-term studies of the outcomes when older patients are prescribed potentially inappropriate medications are needed.
EmergMed 13 (Level A)Interventional trials (randomized or by comparison of micro-environments) are needed of methods to reduce prescription of potentially inappropriate medications for older patients, such as educational sessions or computer-assisted decision support systems integrated into emergency department discharge instructions.

New Research Addressing These Questions: The Beers criteria for potentially inappropriate medication use in older adults was updated in 2003. 42 Although these criteria have not been validated for use in ED settings, they have been used to characterize medication use problems. Using the older 1997 Beers criteria, a review of the 2000 National Hospital Ambulatory Medical Care Survey demonstrated “inappropriate” medication administration in 12.6% of ED visits by elderly persons from 1992 to 2000. The number of ED medications was found to be the strongest predictor of inappropriate prescribing. 43 Additionally, 25% of patients aged 60 or over at one institution were noted to have pre-existing drug interactions before any medications were prescribed by the emergency physician. 44 Another retrospective study noted that recognized adverse drug-related events were the reason for over 10% of all ED visits. 45 Older ED patients are able to correctly identify only 43% of their prescription medications, 46 and only 39% of community-dwelling older adults bring a medication list with them to the ED, and 34% of those lists are inaccurate. 47

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions. (For new agenda items relevant to this topic, see the subsection on medication use in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)

Screening and Comprehensive Geriatric Assessment in the ED

General Geriatric Assessment Tools

See New Frontiers, pp. 60–62.

EmergMed 14 (Level B)Comprehensive emergency department screening of older patients is feasible and inexpensive; however, outcomes have not been affected, possibly because of low compliance with recommendations and follow-up. Potential interventions to improve compliance with recommendations and follow-up, including direct referral to geriatrics teams, should be prospectively evaluated.
EmergMed 15 (Level B)The Identification of Seniors at Risk tool should be employed at independent sites to determine its value in selecting high-risk elderly patients for interventional trials of geriatric assessment.

New Research Addressing These Questions: The deficiencies in the care of older ED patients include a failure to identify high-risk conditions or refer to available community resources. Multiple brief ED screening tools and multidisciplinary interventional teams have been evaluated: Triage Risk Screening Tool, 48 Identification of Seniors at Risk, 49 and the Domain Management Model. 50 Questions of time and resource availability may limit the widespread implementation of these systems in the majority of EDs. The Discharge of Elderly from the Emergency Department (DEED II) study was a prospective randomized controlled trial of a comprehensive geriatric assessment, which was found to lower in-hospital resource consumption without affecting nursing home admission or mortality. 51 Like the DEED II trial, all successful ED interventional trials have included a home assessment component. Most interventional studies used a specialized nurse practitioner to identify and follow elderly patients. 38,51–55

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions. (For new agenda items relevant to this topic, see the subsection on general geriatric assessment tools in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)

Screening for Specific Conditions

See New Frontiers, pp. 63–64.

EmergMed 16 (Level B)Studies are needed to develop brief screening instruments for specific conditions for use with older patients in the emergency department.
EmergMed 17 (Level A)Screening for asymptomatic conditions in older patients in the emergency department should be done only if detection of the abnormality results in treatment of the disorder and this treatment results in improvement in outcomes. Randomized interventional trials are needed to assess short- and long-term outcomes of patients who have screening and treatment for these conditions.

New Research Addressing These Questions: Conditions such as correctable undetected visual acuity deficit, hearing deficit, malnutrition, depression, dementia, delirium, substance abuse, and elder mistreatment have high ED prevalence, validated screening tools, and effective interventions. Nevertheless, case-finding for these conditions is not commonly done in the ED. Depression, for example, affects up to one third of elderly ED patients and one half of hospitalized and homebound elderly patients. Depressed patients use the ED more often than those who are not depressed and have longer lengths of stay when admitted. Brief screening tools, such as a three-question instrument, have been developed to replace the cumbersome Geriatric Depression Scale and the modified Koenig Scale, but they have yet to undergo multicenter validation. 56,57

  No study has addressed the optimal screening test for alcohol abuse in ED older persons, although several relatively brief screens exist: CAGE, Alcohol Use Disorders Identification Test (AUDIT), Michigan Alcoholism Screening Test (MAST-Geriatric Version), and the Alcohol-Related Problems Survey (ARPS). A systematic review of self-reported alcohol screening instruments assessed the CAGE, MAST, and AUDIT screening tools, but did not assess the ARPS. 58 Another study of 574 patients aged 65 or over found the ARPS to be more sensitive than the CAGE, AUDIT, or MAST. 59 The ARPS was specifically designed to assess older adults who are at risk of experiencing problems because of their alcohol consumption alone or in conjunction with their underlying comorbidities, functional status, and medication use. The ARPS is much longer than the AUDIT or CAGE screening tools, though. 60–62

  Brief screening tools for malnutrition (DETERMINE 63 and Subjective Global Assessment 64), visual acuity, 65 and hearing loss exist, but they are probably underused and have not been evaluated in ED settings. 66 Screening tools for elder mistreatment and cognitive deficiencies are discussed elsewhere in this article.

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions.

Specific Clinical Syndromes

Abdominal Pain

See New Frontiers, p. 65.

EmergMed 18 (Level B)Prospective longitudinal cohort or case-control studies of elderly emergency department patients with abdominal pain are necessary to adequately define which patients with abdominal pain have serious disease and which have benign disease.
EmergMed 19 (Level B)The value of history and physical examination findings, laboratory examination, and imaging studies in older emergency department patients should be prospectively evaluated.

New Research Addressing These Questions: One prospective multicenter study demonstrated a 58% admission rate for adults aged 60 or over who were evaluated for acute, nontraumatic abdominal pain; 18% subsequently required surgery or an invasive procedure and 11% returned to the ED within 2 weeks. 67 In another study EM physicians were found to have used computerized tomography (CT) imaging in 37% of patients, with a diagnostic accuracy of 57% for all patients and 75% for surgical patients. 68 A third study found that EM physicians relied heavily on CT to alter admission decisions in 26% of cases and improve diagnostic certainty. 69

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions. (For a new agenda item for this topic, see the subsection on abdominal pain in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)


See New Frontiers, p. 66.

EmergMed 20 (Level A)Randomized controlled trials are necessary to assess the value of a falls prevention program in reducing subsequent falls by elderly patients presenting to the emergency department with a fall.

New Research Addressing This Question: Older adults who present to the ED with a fall often do not receive current guideline care, 70 although ED-initiated home modifications, 71 vestibular assessment, 72 and multidisciplinary falls prevention programs 73 have identified some high-risk fall populations, and subsequent preventive measures have been found to reduce the incidence of subsequent falls. 74,75 A meta–analysis of 40 randomized controlled trials to prevent falls in older adults, mostly outpatient, demonstrated effectiveness in reducing the rate of falling; the most efficacious intervention consisted of multifactorial falls risk assessment and management. 76 The cost-effectiveness of multidisciplinary interventional programs is being assessed in a randomized controlled trial. 77

Modification of This Question in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original question. (For new agenda items on this topic, see the subsection on falls in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)

Infectious Disease

See New Frontiers, pp. 66–67.

EmergMed 21 (Level B)Up to now, studies of fever and infectious disease in older emergency department patients have been observational and analytic retrospective studies. Prospective observational cohort studies, including longitudinal studies of outcomes and predictors of outcomes, are needed.
EmergMed 22 (Level A)Descriptive studies of emergency-department based immunization programs have found them to be feasible. Intervention trials for older persons are necessary to determine if such programs are beneficial (because they access an underservedpopulation) and whether they provide more cost-effective care and reduce adverse outcomes in comparison with usual care.

New Research Addressing These Questions: Fever remains a common and ominous presenting complaint among older ED patients. Identification of afebrile septic patients or febrile patients at increased risk of adverse outcome remains challenging. ED and non-ED studies have been limited to retrospective analyses with often contradictory findings. 78–80 In the United States, 58% of sepsis occurs among patients aged 65 or over. 81 The Surviving Sepsis Campaign guidelines include source control and rapid reduction of broad-spectrum antimicrobial coverage to monotherapy active against the causative organism, particularly among elderly patients with increased likelihood of repeat antibiotic exposures resulting in the accumulation of multi-drug–resistant microbes. 82,83 In an initial trial, early goal-directed therapy was randomized to patients with a mean age of 67,with a 16% absolute reduction in mortality without significantly increased adverse events associated with increasing age. 84

  A review of the National Hospital Ambulatory Medical Care Survey (NHAMCS) for all ED vaccinations between 1992 and 2000 described over 27 million ED vaccinations, although 93% were against tetanus. 85 ED patients are rarely vaccinated against influenza or pneumococcus, despite the increased frequency with which EM physicians manage the complications associated with these infections. 85,86 One single-center ED study noted that only 9% of adults aged 65 or over received an appropriate pneumococcal vaccination, despite the 90% goal set by Healthy People 2010. 87,88 When ED patients are referred to their primary care physician for pneumococcal vaccination, only 10% compliance is observed. 89 Tetanus immunity wanes to 59% in persons aged 70 or over, and 8.3% lack an appropriate rise in antitoxin titers in response to a tetanus booster. 90

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions. (For new agenda items on this topic, see the subsection on infectious disease in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)

Acute Coronary Syndromes

See New Frontiers, pp. 67–69.

EmergMed 23 (Level B)Studies of techniques to improve recognition and appropriate treatment of acute coronary syndromes in older emergency department patients should be performed.
EmergMed 24 (Level A)Older patients should be included in randomized controlled trials of acute coronary syndromes treatment.

New Research Addressing These Questions: Older patients, especially the oldest old (aged 85 and over) and women, present atypically with acute coronary syndromes. Although older patients represent 37% of acute myocardial infarctions (AMIs), they consisted of only 2% of study populations from 1960 to 1992 and only 9% from 1992 to 2000. 91 Regardless of the under-representation of seniors in these studies, several large randomized controlled trials have consistently demonstrated the efficacy of thrombolytic therapy in older AMI patients, with diminished relative risk countered by substantial absolute mortality reductions, although several recent observational studies have questioned these results. 92–96 Additionally, several studies have indicated that the older patients most likely to receive the greatest benefit from guideline-based therapy (aspirin, β-blockers, angiotensin-converting enzyme inhibitors) are the least likely to receive them. 97–101 Older age is consistently associated with symptom-to-treatment time delays exceeding 12 hours, with reperfusion therapy efficacy diminished beyond this therapeutic window. 102,103 Although discrepant data exist, randomized trials of percutaneous intervention versus thrombolytics in the elderly patient generally favor percutaneous intervention. 104–112

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions.

Cardiopulmonary Arrest

See New Frontiers, pp. 69–70.

EmergMed 25 (Level B)Cohort or case-control studies are necessary to determine in which patients resuscitation for out-of-hospital arrest is futile. However, it appears that age alone should not be used to make this decision.
EmergMed 26 (Level B)Prospective multicenter longitudinal studies on the clinical course of older emergency department patients with important conditions (abdominal pain, fever, acute coronary syndromes) are needed. (See also the Key Questions, at the beginning of the chapter.)

New Research Addressing These Questions: Multiple prospective and retrospective studies on the outcome of cardiopulmonary arrest in older patients have recently been the subject of a systematic review. 113 Although the results vary, the majority of studies indicate that age is not an independent predictor of cardiac arrest mortality. 114–116 Instead, premorbid health, performance status, duration of cardiopulmonary arrest, delayed defibrillation, and initial rhythm are predictors of outcome. Patients with unwitnessed arrests and those with asystole have poorer outcomes at any age. Increased availability of cardiopulmonary resuscitation 117,118 and rapid access to automated external defibrillators 114 may improve survival of elderly cardiac arrest victims.

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions. (For a new agenda item on this topic, see the subsection on cardiopulmonary arrest in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)


See New Frontiers, pp. 70–74.

Triage and Mortality

EmergMed 27 (Level B)Research on older trauma patients would benefit from standardization of outcomes, including short- and long-term survival and also functional outcome.
EmergMed 28 (Level B)Valid and accurate ways to predict outcomes in older trauma patients must be developed on the basis of cohort or case-control studies that can identify risk factors for bad outcomes.

New Research Addressing These Questions: Increasing age is associated with increased morbidity and mortality in geriatric trauma patients, 119–123 but good outcomes can be achieved when appropriate trauma care is provided to those individuals with survivable injuries. 124–128 Guidelines have sought to summarize the available data and provide a basis for standardization of care while outlining future research initiatives, though existing evidence is of varying quality and heterogeneous design. 129 Therefore, most of the recommendations are based upon Level III evidence. Among the guideline assertions are that all other factors being equal, age alone is not predictive of poor outcomes after trauma and patients aged 55 or over are under-triaged to trauma centers. Some have agreed and called for early trauma team activation using age as a criterion, 130 although others have noted increasing volumes at Level I trauma centers and suggested consideration of the mechanism of injury and comorbidities before deciding to transfer to a tertiary medical center. 131 The EAST guidelines also note extremely high mortality rates for patients aged 55 or over, with base deficits < −6 and for those aged 65 or over with a presenting Glasgow Coma Scale < 8, trauma score < 7, or a respiratory rate < 10. Pre-existing comorbidities independently affect outcomes for older trauma patients adversely. 132,133 Mild traumatic brain injury, either in isolation or in combination with multisystem trauma, is associated with increased mortality and worse functional outcomes. 134–137

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions. (For new agenda items on this topic, see the subsection on triage and mortality in New Horizons in Geriatric Emergency Medicine, at the end of the chapter.)


See New Frontiers, pp. 74–75.

EmergMed 29 (Level B)Cohort or case-control studies are needed to determine which older patients are at risk for multiple-organ failure and death after blunt trauma and to construct a predictive model.
EmergMed 30 (Level B)Exploratory studies are needed to identify new noninvasive ways of determining which older trauma patients might benefit from invasive monitoring and aggressive resuscitation.
EmergMed 31 (Level A)To determine whether early invasive monitoring and aggressive resuscitation of high-risk older trauma patients result in improved outcomes, large-scale randomized controlled trials should be performed, and outcomes that include not only short-term mortality but also long-term mortality and function should be used. (See also the Key Questions, at the beginning of the chapter.)

New Research Addressing These Questions: The EAST guidelines generated recommendations based only upon Level II or Level III evidence for management of older trauma patients. Pulmonary artery catheter hemodynamic monitoring on any geriatric patient with a high-risk mechanism, chronic cardiovascular disease, or physiologic compromise was one of their recommendations. Additionally, they recommended maintaining cardiac index above 4 L/min/m2 and oxygen consumption above 170 mL/min/m2129

Modification of These Questions in Light of New Research: Since the publication of New Frontiers no evidence has emerged to prompt a modification of the original questions.

New Horizons in Geriatric Emergency Medicine

Advancements in other specialties with potential impact upon ED care of older adults have prompted the addition of four new topics for the research agenda in emergency care for older patients: models of care, driving safety, stroke, and abuse or neglect. In addition, several questions have been added to the original topics in New Frontiers to address the need for alternative study designs or additional information.

General Geriatric Emergency Care

Patterns of ED Use

ED professionals have identified problems associated with the transfer of patients from long-term-care facilities. These include transfers that are deemed inappropriate and failure to provide information in a timely and useful manner. This is an area in which quality of patient care can be improved. The following questions should be answered.

EmergMed 32 (Level D)Prospective studies are needed that identify patterns of emergency department use, risk factors, and interventions among older people living in residential and long-term-care facilities, given their exclusion from most emergency department studies of older adults.
EmergMed 33 (Level C)Prospective studies are needed to evaluate communication between the emergency department and primary physician and assess the relation of outcomes to the exchange of information, follow-up interval, and patient satisfaction toward services rendered.
EmergMed 34 (Level A)Randomized controlled trials with blinded outcome assessors and controlled interventions are needed to study whether measures to improve clinical outcomes in the emergency department can simultaneously reduce service utilization rates of older adults.

Physician Training and Comfort

Existing initiatives to improve residency training in the care of elderly patients provide models that could be used in the field of emergency medicine. For example, the AGS, as part of its program to increase expertise in surgical and related medical specialties, established the Geriatrics for Specialty Residents (GSR) program. GSR, through a competitive process, identified and supported training projects.

EmergMed 35 (Level C)Systematic evaluation of training effectiveness on clinically important outcomes is needed. This evaluation should begin with an assessment of the attitudes, knowledge, and skills of residents who participate in any program to improve emergency care for older adults.
EmergMed 36 (Level B)Prospective studies are needed to assess the effectiveness of interventions (eg, educational models, standardized protocols) for improving the quality of care of older emergency department patients.
EmergMed 37 (Level B)Systematic reviews and, when possible, meta-analyses are needed to summarize the best available diagnostic, prognostic, and therapeutic evidence with regard to care for older adults presenting to the emergency department. These reviews should follow established protocols, such as the Cochrane review methodology, including planned periodic updates.


There is discussion, but no evidence, about the effect of the environment on the older patient’s care and well-being. The ED environment includes the physical and social environment. Elements such as architecture, physical configuration, equipment, furnishings, décor, and communication are topics that have been discussed. Studies are needed to quantify the environmental effect on the outcomes of care, to identify areas for improvement, and to evaluate the changes. Evidence from individual studies could be synthesized into guidelines for improving processes of care of older ED patients.

EmergMed 38 (Level C)Large prospective studies, including surveys of patients, caregivers, and staff, and observational studies of emergency department facilities and procedures should be performed to identify areas for improvement of the emergency department micro-environment. These could assess elements such as physical plant and communication during evaluation and pre-discharge, follow-up phone interviews by ancillary personnel, and assistance with social priorities (transportation, follow-up appointment scheduling, and medication procurement).
EmergMed 39 (Level B)Prospective studies, including surveys of patients, caregivers, and staff, should be conducted to describe the effect of changes in the micro-environment on processes of care for older emergency department patients.
EmergMed 40 (Level A)Randomized trials of the effects of specific modifications of the micro-environment on outcomes for older emergency department patients should be conducted.

Models of Care

We examined alternative models to hospital care with regard to the decision in the ED to admit the older patient or discharge him or her for care at home. A Cochrane review of “hospital at home” care as an alternative to inpatient management of common admitting diagnoses reviewed 22 trials, with early hospital discharge demonstrating a nonsignificant trend toward decreased mortality for stroke and chronic obstructive pulmonary disease subsets. 138 In the United States, a quasi-randomized trial of community-dwelling elderly patients who required hospital-at-home care for pneumonia, heart failure, cellulitis, or chronic obstructive pulmonary disease demonstrated improved satisfaction scores from patients and family members without a difference in functional status or mortality at 2 weeks. 139 Other researchers have assessed home hospitalization or early hospital discharge after an uncomplicated first ischemic stroke, demonstrating a similar improvement in patient satisfaction in addition to lower rates of depression and nursing home admissions. 140,141

EmergMed 41 (Level B)Randomized trials are needed to assess alternatives to inpatient management of selected conditions in appropriate subsets of acutely ill older adults and to assess optimal candidate selection, patient and caregiver satisfaction scores, cost-effectiveness, mortality, and functional outcomes in varying health care settings.
EmergMed 42 (Level A)Randomized trials based on results of studies in EmergMed 41 should be conducted to evaluate the effectiveness of home care in selected older patients.

Driving Safety

Motor vehicle crashes are the leading cause of injury-related mortality in the 65-to-74-year age group and are the second leading cause of death for all adults aged 65 or over. Older drivers are more likely to experience medication- and disease-related functional decline. Because current projections indicate increasing numbers of elderly drivers who are driving more miles per year at older ages than ever before, some have predicted a doubling of the number of automobile-related fatalities in the elderly age group by 2030. 142 Though a number of state motor vehicle policies have proven effective with regard to teenaged drivers, with the exception of mandatory seatbelt laws, these results have not been replicated with older drivers. 143 Because assessments of individual patients, family members, and clinicians are poor predictors of potentially hazardous drivers, 144,145 the American Medical Association and the National Highway Safety Administration have published the Physician’s Guide to Assessing and Counseling Older Drivers to facilitate physicians’ assessment of the older person’s driving skills and guidance to change dangerous behaviors to avoid future accidents. 146 No single finding or combination of deficits has been demonstrated to identify individuals at high risk for future motor vehicle accidents, and no validated tool exists with which to screen elderly patients who use the ED. 147,148

EmergMed 43 (Level B)Prospective validation studies of brief, low-cost screening tools for use in the emergency department to identify impaired older drivers are needed; such tools must be acceptable to patients and staff.
EmergMed 44 (Level A)Randomized trials are needed to demonstrate that the emergency department identification of chronically impaired elderly drivers can reduce motor vehicle accident mortality and morbidity rates.

Medication Use

The cross-cutting issues chapter of New Frontiers (see pp. 369–419) identified medication misuse, overuse, and underuse as an area of concern. These remain issues for emergency physicians and researchers.

EmergMed 45 (Level B)Prospective studies are needed to validate the use of Beers’ criteria to assess medication use by older emergency department patients.
EmergMed 46 (Level A)Prospective studies are needed to determine the prevalence of clinically meaningful adverse drug events among older emergency department patients.
EmergMed 47 (Level A)Randomized trials are needed to demonstrate that improved recognition in the emergency department of potential adverse drug events in older patients can reduce the incidence rates of adverse events.

Screening and Comprehensive Geriatric Assessment in the ED

General Geriatric Assessment Tools

Screening and assessment studies conducted in the ED (see discussion of the Identification of Seniors at Risk 49 and Triage Risk Screening Tool 48 projects in the subsection on general geriatric assessment tools in Progress in Geriatric Emergency Medicine) have primarily been conducted by research personnel and have not been part of normal ED procedures. There has been discussion, but no research, about alternate ways of implementing screening programs.

EmergMed 48 (Level C)Prospective studies are needed to evaluate the cost-effectiveness of interventions by non-nursing, non-physician specialists such as trained “geriatrics technicians.”
EmergMed 49 (Level B)All studies of emergency department interventions should include quality-of-life measures and indicators of health care service delivery quality among the outcomes assessed.
EmergMed 50 (Level A)Randomized controlled trials of emergency department case-finding interventions should be conducted withblinded outcome assessors to measure the effect of these interventions on outcomes of care.

Specific Clinical Syndromes

Abdominal Pain

Research published since New Frontiers (see descriptions in the subsection on abdominal pain in Progress in Geriatric Emergency Medicine) has cast light on the value of diagnostic testing and imaging in the evaluation of older patients presenting with abdominal pain. However, they do not address the question of whether there is a benefit to the patient with earlier detection.

EmergMed 51 (Level A)Prospective cohort studies are needed to determine whether the rapid identification of older emergency department abdominal pain patients at high risk for adverse outcomes or need for timely surgical intervention can improve outcomes while lowering overall costs.


ED-based and outpatient research published since New Frontiers (see descriptions in the subsection on falls in Progress in Geriatric Emergency Medicine) identified successful falls reduction programs. These studies have not created a cost-effective falls prevention strategy for use in the ED.

EmergMed 52 (Level B)Prospective cohort studies to develop a brief, effective screen are needed to identify patients that are most likely to benefit from falls prevention programs.
EmergMed 53 (Level A)Randomized controlled trials are needed to assess the efficacy and cost-effectiveness of emergency department–initiated falls prevention interventions for elderly patients at high risk for falls to reduce repeat falls, injurious falls, and subsequent use of health care resources.

Infectious Disease

Research published since New Frontiers identified lack of tetanus immunity and less-than-optimal rates of pneumococcal and influenza vaccination as continuing issues in prevention of infectious disease in older patients. It is not known whether the less-than-optimal rate of tetanus immunity is due to a delayed amnestic response or lack of prior immunization. Pneumococcal and influenza vaccinations are recommended for older adults. The ED is one venue for administering these vaccinations, but it is not clear whether the ED is a cost-effective location for an immunization program.

EmergMed 54 (Level B)Prospective cohort studies are needed to determine whether older adults’ less-than-optimal tetanus immunity is the consequence of a delayed amnestic response to tetanus immunization or a lack of previous immunizations or immunosenescence.
EmergMed 55 (Level B)Randomized controlled trials of emergency department–based immunization programs for pneumococcus and influenza are needed to determine whether such programs are cost-effective and whether they reduce pneumonia and influenza incidence and death rates.


A Cochrane review of thrombolytics in acute ischemic stroke treated within 3 hours of symptom onset noted a significant decrease in the odds of dependency or death, 149 but with the exception of the National Institute of Neurological Disorders and Stroke trial, all studies specifically excluded those over 80 years of age. 150–152 Therefore, little information is available to confidently assess the safety or efficacy of thrombolysis in this stroke population. A retrospective review of acute ischemic stroke patients aged 80 or over demonstrated an intracranial hemorrhage rate of 10%, with no improvement in overall mortality when compared with historical cohorts. 153 A multicenter retrospective review of those aged 80 or over demonstrated no differences in favorable or poor outcomes, though a nonsignificant tendency for higher in-hospital mortality was noted. 154 Some have proposed stroke-specific Acute Care for Elders (ACE) units, 155 and others have established home care models for managing uncomplicated acute stroke patients. 140,141 Model systems for stroke care begin in the ED and require integration between the ED and other hospital departments.

EmergMed 56 (Level B)Randomized controlled trials evaluating models of care for uncomplicated elderly ischemic stroke patients presenting to the emergency department, including Acute Care for Elders (ACE) units and early discharge to home with supportive care, should be conducted. These trials should assess cost-effectiveness, patient satisfaction, and long-term outcomes, including death and disability.
EmergMed 57 (Level A)Randomized controlled trials of older acute ischemic stroke patients presenting within 3 hours of symptom onset should be conducted with intravenous tissue plasminogen activator to assess bleeding risk and functional outcomes.

Cardiopulmonary Arrest

Research published since New Frontiers demonstrated the value of automated external defibrillators (see descriptions in the section on cardiopulmonary arrest in Progress in Geriatric Emergency Medicine). The value for aged populations specifically has not been demonstrated.

EmergMed 58 (Level A)Prospective community trials of cardio-ulmonary resuscitation training for seniors and rapid access to automated external defibrillators are needed to evaluate the effect of early resuscitation and defibrillation on age-, gender-, anddisease-matched controls for important outcomes such as death and return to baseline function.


Triage and Mortality

Research published since New Frontiers (see descriptions in the section on triage and mortality in Progress in Geriatric Emergency Medicine) indicates the need for the following additions to the research agenda.

EmergMed 59 (Level B)All research concerning the older trauma patient should use similar functional outcomes and standardized definitions of what constitutes “elderly” and “pre-existing medical condition.”
EmergMed 60 (Level A)Prospective trials are needed to evaluate the diagnostic and prognostic value of injury mechanism, age, traumatic brain injury, and injury severity scores in improving outcomes in older emergency department patients with blunt and penetrating trauma.

Abuse and Neglect

Elder mistreatment includes abuse, neglect, exploitation, and abandonment of an older person. Recognized as a significant problem since the 1970s, elder mistreatment affects an estimated 1.3% to 10% of the elderly age group, with differing results likely related to widely varying definitions of abuse. Although several causative theories have provided the basis upon which screening tools have been developed, little research has tested these competing theories, even though they form the foundation of assessment instruments being used. A variety of screening and intervention tools exist, though some are too time-consuming for routine use in the ED , and many require input from the caregiver, who may or may not be present during the ED evaluation. Few have been validated in ED settings, and the prevalence of elder mistreatment among different demographic subsets of those utilizing the ED has not been studied. 156–161

EmergMed 61 (Level B)Screening tests for elder mistreatment suitable for use in the emergency department should be developed and validated against the tests developed for other settings.
EmergMed 62 (Level B)Cross-sectional studies are needed to estimate the prevalence of elder mistreatment among older emergency department patients.
EmergMed 63 (Level A)If a high prevalence of elder mistreatment is found (see EmergMed 62) and a rapid identification tool is validated (see EmergMed 61), interventional trials of elder mistreatment detection and management in the emergency department should be performed.


  1. Solomon DH, LoCicero J, 3rd, Rosenthal RA (eds): New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties. New York: American Geriatrics Society, 2004 (online at
  2. Wilber ST, Gerson LW. A research agenda for geriatric emergency medicine. Acad Emerg Med 2003;10:251-260.
  3. Downing A, Wilson R. Older people’s use of accident and emergency services. Age Ageing 2005;34:24-30.
  4. Rutschmann OT, Chevalley T, Zumwald C, et al. Pitfalls in the emergency department triage of frail elderly patients without specific complaints. Swiss Med Wkly 2005;135:145-150.
  5. Schumacher JG. Emergency medicine and older adults: continuing challenges and opportunities. Am J Emerg Med 2005;23:556-560.
  6. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002;39:238-247.
  7. Hastings SN, Heflin MT. A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med 2005;12:978-986.
  8. McCusker J, Karp I, Cardin S, et al. Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med 2003;10:1362-1370.
  9. Jones JS, Rousseau EW, Schropp MA, Sanders AB. Geriatric training in emergency medicine residency programs. Ann Emerg Med 1992;21:825-829.
  10. Lee M, Wilkerson L, Reuben DB, Ferrell BA. Development and validation of a geriatric knowledge test for medical students. J Am Geriatr Soc 2004;52:983-988.
  11. Shah MN, Heppard B, Medina-Walpole A, et al. Emergency medicine management of the geriatric patient: an educational program for medical students. J Am Geriatr Soc 2005;53:141-145.
  12. LaMascus AM, Bernard MA, Barry P, et al. Bridging the workforce gap for our aging society: how to increase and improve knowledge and training. Report of an expert panel. J Am Geriatr Soc 2005;53:343-347.
  13. Levine SA, Caruso LB, Vanderschmidt H, et al. Faculty development in geriatrics for clinician educators: a unique model for skills acquisition and academic achievement. J Am Geriatr Soc 2005;53:516-521.
  14. Potter JF, Burton JR, Drach GW, et al. Geriatrics for residents in the surgical and medical specialties: implementation of curricula and training experiences. J Am Geriatr Soc 2005;53:511-515.
  15. McNamara RM, Rousseau E, Sanders AB. Geriatric emergency medicine: a survey of practicing emergency physicians. Ann Emerg Med 1992;21:796-801.
  16. Leipzig RM. Evidence-based medicine in geriatrics. In Cassel CK, Leipzig RM, Cohen HJ, et al. (eds): Geriatric Medicine: An Evidence-Based Approach. New York, NY: Springer-Verlag, 2003, pp. 3-14.
  17. Meldon S, Ma OJ, Woolard R (eds): Geriatric Emergency Medicine. New York, NY: McGraw-Hill, 2004,
  18. Nerney MP, Chin MH, Jin L, et al. Factors associated with older patients’ satisfaction with care in an inner-city emergency department. Ann Emerg Med 2001;38:140-145.
  19. Boudreaux ED, O’Hea EL. Patient satisfaction in the emergency department: a review of the literature and implications for practice. J Emerg Med 2004;26:13-26.
  20. Magid DJ, Rhodes KV, Asplin BR, et al. Designing a research agenda to improve the quality of emergency care. Acad Emerg Med 2002;9:1124-1130.
  21. Wilber ST, Burger B, Gerson LW, Blanda M. Reclining chairs reduce pain from gurneys in older emergency department patients: a randomized controlled trial. Acad Emerg Med 2005;12:119-123.
  22. Jaslow D, Ufberg J, Marsh R. Primary injury prevention in an urban EMS system. J Emerg Med 2003;25:167-170.
  23. Fick DM, Kolanowski AM, Waller JL, Inouye SK. Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization. J Gerontol A Biol Sci Med Sci 2005;60:748-753.
  24. Elie M, Rousseau F, Cole M, et al. Prevalence and detection of delirium in elderly emergency department patients. CMAJ 2000;163:977-981.
  25. Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 2002;39:248-253.
  26. Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 2003;41:678-684.
  27. Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 2003;51:443-450.
  28. McCusker J, Cole M, Abrahamowicz M, et al. Delirium predicts 12-month mortality. Arch Intern Med 2002;162:457-463.
  29. Tierney MC, Charles J, Naglie G, et al. Risk factors for harm in cognitively impaired seniors who live alone: a prospective study. J Am Geriatr Soc 2004;52:1435-1441.
  30. McCusker J, Cole M, Dendukuri N, et al. The course of delirium in older medical inpatients: a prospective study. J Gen Intern Med 2003;18:696-704.
  31. Chiovenda P, Vincentelli GM, Alegiani F. Cognitive impairment in elderly ED patients: need for multidimensional assessment for better management after discharge. Am J Emerg Med 2002;20:332-335.
  32. Irons MJ, Farace E, Brady WJ, Huff JS. Mental status screening of emergency department patients: normative study of the quick confusion scale. Acad Emerg Med 2002;9:989-994.
  33. Laurila JV, Pitkala KH, Strandberg TE, Tilvis RS. Confusion assessment method in the diagnostics of delirium among aged hospital patients: would it serve better in screening than as a diagnostic instrument? Int J Geriatr Psychiatry 2002;17:1112-1119.
  34. McCusker J, Cole MG, Dendukuri N, Belzile E. The delirium index, a measure of the severity of delirium: new findings on reliability, validity, and responsiveness. J Am Geriatr Soc 2004;52:1744-1749.
  35. Monette J, Galbaud du Fort G, Fung SH, et al. Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room. Gen Hosp Psychiatry 2001;23:20-25.
  36. Nishiwaki Y, Breeze E, Smeeth L, et al. Validity of the Clock-Drawing Test as a screening tool for cognitive impairment in the elderly. Am J Epidemiol 2004;160:797-807.
  37. Wilber ST, Lofgren SD, Mager TG, et al. An evaluation of two screening tools for cognitive impairment in older emergency department patients. Acad Emerg Med 2005;12:612-616.
  38. Milisen K, Foreman MD, Abraham IL, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001;49:523-532.
  39. Flaherty JH, Tariq SH, Raghavan S, et al. A model for managing delirious older inpatients. J Am Geriatr Soc 2003;51:1031-1035.
  40. Christensen RC. Assessing new-onset mental status changes in patients with dementia. Am J Emerg Med 2004;22:228-229.
  41. Modawal A. Model and systems of geriatric care: “delirium rooms”—but where and at what cost? J Am Geriatr Soc 2004;52:1023; author reply 1024.
  42. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003;163:2716-2724.
  43. Caterino JM, Emond JA, Camargo CA, Jr. Inappropriate medication administration to the acutely ill elderly: a nationwide emergency department study, 1992-2000. J Am Geriatr Soc 2004;52:1847-1855.
  44. Gaddis GM, Holt TR, Woods M. Drug interactions in at-risk emergency department patients. Acad Emerg Med 2002;9:1162-1167.
  45. Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med 2001;38:666-671.
  46. Chung MK, Bartfield JM. Knowledge of prescription medications among elderly emergency department patients. Ann Emerg Med 2002;39:605-608.
  47. Stromski C, Popavetsky G, Defranco B, Reed J. The prevalence and accuracy of medication lists in an elderly ED population. Am J Emerg Med 2004;22:497-498.
  48. Meldon SW, Mion LC, Palmer RM, et al. A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med 2003;10:224-232.
  49. Dendukuri N, McCusker J, Belzile E. The Identification of Seniors at Risk screening tool: further evidence of concurrent and predictive validity. J Am Geriatr Soc 2004;52:290-296.
  50. Siebens H. The Domain Management Model—a tool for teaching and management of older adults in emergency departments. Acad Emerg Med 2005;12:162-168.
  51. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department—the DEED II study. J Am Geriatr Soc 2004;52:1417-1423.
  52. Guttman A, Afilalo M, Guttman R, et al. An emergency department-based nurse discharge coordinator for elder patients: does it make a difference? Acad Emerg Med 2004;11:1318-1327.
  53. McCusker J, Dendukuri N, Tousignant P, et al. Rapid two-stage emergency department intervention for seniors: impact on continuity of care. Acad Emerg Med 2003;10:233-243.
  54. McCusker J, Jacobs P, Dendukuri N, et al. Cost-effectiveness of a brief two-stage emergency department intervention for high-risk elders: results of a quasi-randomized controlled trial. Ann Emerg Med 2003;41:45-56.
  55. Mion LC, Palmer RM, Meldon SW, et al. Case finding and referral model for emergency department elders: a randomized clinical trial. Ann Emerg Med 2003;41:57-68.
  56. Fabacher DA, Raccio-Robak N, McErlean MA, et al. Validation of a brief screening tool to detect depression in elderly ED patients. Am J Emerg Med 2002;20:99-102.
  57. Raccio-Robak N, McErlean MA, Fabacher DA, et al. Socioeconomic and health status differences between depressed and nondepressed ED elders. Am J Emerg Med 2002;20:71-73.
  58. O’Connell H, Chin AV, Hamilton F, et al. A systematic review of the utility of self-report alcohol screening instruments in the elderly. Int J Geriatr Psychiatry 2004;19:1074-1086.
  59. Fink A, Tsai MC, Hays RD, et al. Comparing the alcohol-related problems survey (ARPS) to traditional alcohol screening measures in elderly outpatients. Arch Gerontol Geriatr 2002;34:55-78.
  60. Fink A, Morton SC, Beck JC, et al. The alcohol-related problems survey: identifying hazardous and harmful drinking in older primary care patients. J Am Geriatr Soc 2002;50:1717-1722.
  61. Girard DD, Partridge RA, Becker B, Bock B. Alcohol and tobacco use in the elder emergency department patient: assessment of rates and medical care utilization. Acad Emerg Med 2004;11:378-382.
  62. Onen SH, Onen F, Mangeon JP, et al. Alcohol abuse and dependence in elderly emergency department patients. Arch Gerontol Geriatr 2005;41:191-200.
  63. Incorporating nutrition screening and interventions into medical practice: a monograph for physicians. The Nutritional Screening Initiative. American Academy of Family Physicians, American Dietetic Association, National Council on Aging, 1994.
  64. Detsky AS, Smalley PS, Chang J. The rational clinical examination: is this patient malnourished? JAMA 1994;271:54-58.
  65. Watson GR. Low vision in the geriatric population: rehabilitation and management. J Am Geriatr Soc 2001;49:317-330.
  66. Hastings OM, Zenko MM. Malnutrition and dehydration in the geriatric adult. Geriatr Emerg Med Rep 2000;1:41-50.
  67. Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. J Gerontol A Biol Sci Med Sci 2005;60:1071-1076.
  68. Hustey FM, Meldon SW, Banet GA, et al. The use of abdominal computed tomography in older ED patients with acute abdominal pain. Am J Emerg Med 2005;23:259-265.
  69. Esses D, Birnbaum A, Bijur P, et al. Ability of CT to alter decision making in elderly patients with acute abdominal pain. Am J Emerg Med 2004;22:270-272.
  70. Donaldson MG, Khan KM, Davis JC, et al. Emergency department fall-related presentations do not trigger fall risk assessment: a gap in care of high-risk outpatient fallers. Arch Gerontol Geriatr 2005;41:311-317.
  71. Gerson LW, Camargo CA, Jr., Wilber ST. Home modification to prevent falls by older ED patients. Am J Emerg Med 2005;23:295-298.
  72. Murray KJ, Hill K, Phillips B, Waterston J. A pilot study of falls risk and vestibular dysfunction in older fallers presenting to hospital emergency departments. Disabil Rehabil 2005;27:499-506.
  73. Close JC, Hooper R, Glucksman E, et al. Predictors of falls in a high risk population: results from the prevention of falls in the elderly trial (PROFET). Emerg Med J 2003;20:421-425.
  74. Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ 2004;328:676.
  75. Lord SR, Tiedemann A, Chapman K, et al. The effect of an individualized fall prevention program on fall risk and falls in older people: a randomized, controlled trial. J Am Geriatr Soc 2005;53:1296-1304.
  76. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004;328:680.
  77. Hendriks MR, van Haastregt JC, Diederiks JP, et al. Effectiveness and cost-effectiveness of a multidisciplinary intervention programme to prevent new falls and functional decline among elderly persons at risk: design of a replicated randomised controlled trial [ISRCTN64716113]. BMC Public Health 2005;5:6.
  78. Fontanarosa PB, Kaeberlein FJ, Gerson LW, Thomson RB. Difficulty in predicting bacteremia in elderly emergency patients. Ann Emerg Med 1992;21:842-848.
  79. Marco CA, Schoenfeld CN, Hansen KN, et al. Fever in geriatric emergency patients: clinical features associated with serious illness. Ann Emerg Med 1995;26:18-24.
  80. Mellors JW, Horwitz RI, Harvey MR, Horwitz SM. A simple index to identify occult bacterial infection in adults with acute unexplained fever. Arch Intern Med 1987;147:666-671.
  81. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-1310.
  82. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-873.
  83. Girard TD, Opal SM, Ely EW. Insights into severe sepsis in older patients: from epidemiology to evidence-based management. Clin Infect Dis 2005;40:719-727.
  84. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
  85. Pallin DJ, Muennig PA, Emond JA, et al. Vaccination practices in U.S. emergency departments, 1992-2000. Vaccine 2005;23:1048-1052.
  86. Greci LS, Katz DL, Jekel J. Vaccinations in pneumonia (VIP): pneumococcal and influenza vaccination patterns among patients hospitalized for pneumonia. Prev Med 2005;40:384-388.
  87. Rudis MI, Stone SC, Goad JA, et al. Pneumococcal vaccination in the emergency department: an assessment of need. Ann Emerg Med 2004;44:386-392.
  88. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington DC: U.S. Department of Health and Human Services. U.S. Government Printing Office, 2000.
  89. Manthey DE, Stopyra J, Askew K. Referral of emergency department patients for pneumococcal vaccination. Acad Emerg Med 2004;11:271-275.
  90. Talan DA, Abrahamian FM, Moran GJ, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med 2004;43:305-314.
  91. Lee PY, Alexander KP, Hammill BG, et al. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA 2001;286:708-713.
  92. Ball SG. Thrombolysis: too old and too young. Heart 2002;87:312-313.
  93. Estess JM, Topol EJ. Fibrinolytic treatment for elderly patients with acute myocardial infarction. Heart 2002;87:308-311.
  94. Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al. Effectiveness of thrombolytic therapy for acute myocardial infarction in the elderly: cause for concern in the old-old. Arch Intern Med 2002;162:561-568.
  95. Stenestrand U, Wallentin L. Fibrinolytic therapy in patients 75 years and older with ST-segment-elevation myocardial infarction: one-year follow-up of a large prospective cohort. Arch Intern Med 2003;163:965-971.
  96. Thiemann DR, Coresh J, Schulman SP, et al. Lack of benefit for intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation 2000;101:2239-2246.
  97. Barchielli A, Buiatti E, Balzi D, et al. Age-related changes in treatment strategies for acute myocardial infarction: a population-based study. J Am Geriatr Soc 2004;52:1355-1360.
  98. Alter DA, Manuel DG, Gunraj N, et al. Age, risk-benefit trade-offs, and the projected effects of evidence-based therapies. Am J Med 2004;116:540-545.
  99. Magid DJ, Masoudi FA, Vinson DR, et al. Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients. Ann Emerg Med 2005;46:14-21.
  100. Rathore SS, Mehta RH, Wang Y, et al. Effects of age on the quality of care provided to older patients with acute myocardial infarction. Am J Med 2003;114:307-315.
  101. Rathore SS, Wang Y, Radford MJ, et al. Quality of care of Medicare beneficiaries with acute myocardial infarction: who is included in quality improvement measurement? J Am Geriatr Soc 2003;51:466-475.
  102. Grossman SA, Brown DF, Chang Y, et al. Predictors of delay in presentation to the ED in patients with suspected acute coronary syndromes. Am J Emerg Med 2003;21:425-428.
  103. Lee DC, Pancu DM, Rudolph GS, Sama AE. Age-associated time delays in the treatment of acute myocardial infarction with primary percutaneous transluminal coronary angioplasty. Am J Emerg Med 2005;23:20-23.
  104. Bach RG, Cannon CP, Weintraub WS, et al. The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med 2004;141:186-195.
  105. Cohen M, Gensini GF, Maritz F, et al. Prospective evaluation of clinical outcomes after acute ST-elevation myocardial infarction in patients who are ineligible for reperfusion therapy: preliminary results from the TETAMI registry and randomized trial. Circulation 2003;108:III14-III21.
  106. de Boer MJ, Ottervanger JP, van’t Hof AW, et al. Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol 2002;39:1723-1728.
  107. Goldenberg I, Matetzky S, Halkin A, et al. Primary angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction. Am Heart J 2003;145:862-867.
  108. Kotamaki M, Strandberg TE, Nieminen MS. Clinical findings, outcome and treatment in patients > or = 75 years with acute myocardial infarction. Eur J Epidemiol 2003;18:781-786.
  109. Minai K, Horie H, Takahashi M, et al. Long-term outcome of primary percutaneous transluminal coronary angioplasty for low-risk acute myocardial infarction in patients older than 80 years: a single-center, open, randomized trial. Am Heart J 2002;143:497-505.
  110. Moriel M, Behar S, Tzivoni D, et al. Management and outcomes of elderly women and men with acute coronary syndromes in 2000 and 2002. Arch Intern Med 2005;165:1521-1526.
  111. Niebauer J, Sixt S, Zhang F, et al. Contemporary outcome of cardiac catheterizations in 1085 consecutive octogenarians. Int J Cardiol 2004;93:225-230.
  112. Yagi M, Nakao K, Honda T, et al. Clinical characteristics and early outcomes of very elderly patients in the reperfusion era. Int J Cardiol 2004;94:41-46.
  113. Kaye P. Early prediction of individual outcome following cardiopulmonary resuscitation: systematic review. Emerg Med J 2005;22:700-705.
  114. Bunch TJ, White RD, Khan AH, Packer DL. Impact of age on long-term survival and quality of life following out-of-hospital cardiac arrest. Crit Care Med 2004;32:963-967.
  115. Herlitz J, Eek M, Engdahl J, et al. Factors at resuscitation and outcome among patients suffering from out of hospital cardiac arrest in relation to age. Resuscitation 2003;58:309-317.
  116. Herlitz J, Engdahl J, Svensson L, et al. Can we define patients with no chance of survival after out-of-hospital cardiac arrest? Heart 2004;90:1114-1118.
  117. Swor R, Compton S, Farr L, et al. Perceived self-efficacy in performing and willingness to learn cardiopulmonary resuscitation in an elderly population in a suburban community. Am J Crit Care 2003;12:65-70.
  118. Swor R, Fahoome G, Compton S. Potential impact of a targeted cardiopulmonary resuscitation program for older adults on survival from private-residence cardiac arrest. Acad Emerg Med 2005;12:7-12.
  119. Demetriades D, Murray J, Martin M, et al. Pedestrians injured by automobiles: relationship of age to injury type and severity. J Am Coll Surg 2004;199:382-387.
  120. Schulman AM, Claridge JA, Young JS. Young versus old: factors affecting mortality after blunt traumatic injury. Am Surg 2002;68:942-947; discussion 947-948.
  121. Clark DE, DeLorenzo MA, Lucas FL, Wennberg DE. Epidemiology and short-term outcomes of injured Medicare patients. J Am Geriatr Soc 2004;52:2023-2030.
  122. Hannan EL, Waller CH, Farrell LS, Rosati C. Elderly trauma inpatients in New York state: 1994-1998. J Trauma 2004;56:1297-1304.
  123. Nirula R, Gentilello LM. Futility of resuscitation criteria for the “young” old and the “old” old trauma patient: a national trauma data bank analysis. J Trauma 2004;57:37-41.
  124. Grossman M, Scaff DW, Miller D, et al. Functional outcomes in octogenarian trauma. J Trauma 2003;55:26-32.
  125. Inaba K, Goecke M, Sharkey P, Brenneman F. Long-term outcomes after injury in the elderly. J Trauma 2003;54:486-491.
  126. McKevitt EC, Calvert E, Ng A, et al. Geriatric trauma: resource use and patient outcomes. Can J Surg 2003;46:211-215.
  127. Richmond TS, Kauder D, Strumpf N, Meredith T. Characteristics and outcomes of serious traumatic injury in older adults. J Am Geriatr Soc 2002;50:215-222.
  128. Sieling BA, Beem K, Hoffman MT, et al. Trauma in nonagenarians and centenarians: review of 137 consecutive patients. Am Surg 2004;70:793-796.
  129. Jacobs DG, Plaisier BR, Barie PS, et al. Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group. J Trauma 2003;54:391-416.
  130. Demetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg 2002;89:1319-1322.
  131. Liberman M, Mulder DS, Sampalis JS. Increasing volume of patients at level I trauma centres: is there a need for triage modification in elderly patients with injuries of low severity? Can J Surg 2003;46:446-452.
  132. Grossman MD, Miller D, Scaff DW, Arcona S. When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma. J Trauma 2002;52:242-246.
  133. McGwin G, Jr., MacLennan PA, Fife JB, et al. Preexisting conditions and mortality in older trauma patients. J Trauma 2004;56:1291-1296.
  134. Coronado VG, Thomas KE, Sattin RW, Johnson RL. The CDC traumatic brain injury surveillance system: characteristics of persons aged 65 years and older hospitalized with a TBI. J Head Trauma Rehabil 2005;20:215-228.
  135. Mosenthal AC, Lavery RF, Addis M, et al. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J Trauma 2002;52:907-911.
  136. Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. J Trauma 2003;54:492-496.
  137. Susman M, DiRusso SM, Sullivan T, et al. Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma 2002;53:219-223; discussion 223-214.
  138. Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2005:CD000356.
  139. Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med 2005;143:798-808.
  140. Ricauda NA, Bo M, Molaschi M, et al. Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial. J Am Geriatr Soc 2004;52:278-283.
  141. Thorsen AM, Holmqvist LW, de Pedro-Cuesta J, von Koch L. A randomized controlled trial of early supported discharge and continued rehabilitation at home after stroke: five-year follow-up of patient outcome. Stroke 2005;36:297-303.
  142. Lyman S, Ferguson SA, Braver ER, Williams AF. Older driver involvements in police reported crashes and fatal crashes: trends and projections. Inj Prev 2002;8:116-120.
  143. Morrisey MA, Grabowski DC. State motor vehicle laws and older drivers. Health Econ 2005;14:407-419.
  144. Brown LB, Ott BR, Papandonatos GD, et al. Prediction of on-road driving performance in patients with early Alzheimer’s disease. J Am Geriatr Soc 2005;53:94-98.
  145. Ott BR, Anthony D, Papandonatos GD, et al. Clinician assessment of the driving competence of patients with dementia. J Am Geriatr Soc 2005;53:829-833.
  146. Physician’s guide to assessing and counseling older drivers. Washington, DC: National Highway Traffic Safety Administration, 2003.
  147. Fitten LJ. Driver screening for older adults. Arch Intern Med 2003;163:2129-2131; discussion 2131.
  148. Li I, Smith RV. Driving and the elderly. Clin Geriatr 2003;11:40-46.
  149. Wardlaw JM, Zoppo G, Yamaguchi T, Berge E. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2003:CD000213.
  150. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995;333:1581-1587.
  151. Clark WM, Wissman S, Albers GW, et al. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 1999;282:2019-2026.
  152. Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998;352:1245-1251.
  153. Simon JE, Sandler DL, Pexman JH, et al. Is intravenous recombinant tissue plasminogen activator (rt-PA) safe for use in patients over 80 years old with acute ischaemic stroke?—the Calgary experience. Age Ageing 2004;33:143-149.
  154. Tanne D, Gorman MJ, Bates VE, et al. Intravenous tissue plasminogen activator for acute ischemic stroke in patients aged 80 years and older: the tPA stroke survey experience. Stroke 2000;31:370-375.
  155. Allen KR, Hazelett SE, Palmer RR, et al. Developing a stroke unit using the acute care for elders intervention and model of care. J Am Geriatr Soc 2003;51:1660-1667.
  156. Anetzberger GJ. Elder abuse identification and referral: the importance of screening tools and referral protocols. J Elder Abuse Neglect 2001;13:3-22.
  157. Dong X. Medical implications of elder abuse and neglect. Clin Geriatr Med 2005;21:293-313.
  158. Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc 2004;52:297-304.
  159. Gorbien MJ, Eisenstein AR. Elder abuse and neglect: an overview. Clin Geriatr Med 2005;21:279-292.
  160. Harrell R, Toronjo CH, McLaughlin J, et al. How geriatricians identify elder abuse and neglect. Am J Med Sci 2002;323:34-38.
  161. Lachs MS, Pillemer K. Elder abuse. Lancet 2004;364:1263-1272.