Some hospitals and EDs provide centers of excellence in the care of specific problems. It is common for hospitals to carry designations such as Trauma, Stroke, or Chest Pain Centers. Various levels of intensity exist in each of these center designations signifying increasing levels of service. Examples:

Various subcategories or levels of centers of excellence exist such as level one or level two trauma centers that signify differing availability or access to different surgical specialists or procedures. Prehospital providers have protocols designating that specific types of patients must be taken to specific levels of care. Patients are often unaware of these stipulations and may be transported to unexpected/undesired institutions when protocols designate they should be transported to specific centers.

Older patients are far more likely to present to the ED via ambulance compared to younger patients [3], and EMS personnel are often the first point of contact for these patients. EMS workers, however, receive little to no specialty training for this older population compared to other unique populations such as children [5]. There are compelling reasons, however, to train EMS personnel in care for the elderly. Paramedics are the first point of contact for elderly patients and can bridge a vital communication gap given the correct tools. Hearing or visual impairment, dementia, and limited understanding of a complex history are a few confounding factors that make communicating an accurate history challenging for elderly patients. EMS providers may be the only personnel who can obtain history from caregivers and witnesses to events such as syncope/falls/seizures. They are often the only link to establish a baseline mental status, goals of care, and medication lists. When transporting from nursing or skilled facilities, EMS personnel obtain standardized transport forms, and portable health information that can decrease redundant tests and delays in diagnoses. EMS deficiencies in geriatric-specific education have been acknowledged. The AGS and the National Council of State EMS Training Coordinators has developed an optional course, “Geriatrics Education for EMS,” which is now available to interested EMS providers [15].

The ED serves as an acute diagnosis and treatment center for its medical community. Complex elder patients often require advanced laboratory and imaging services unavailable in standard medical offices. Providers refer patients to the ED in large numbers to receive such services in a timely manner. Patients unwilling to wait for these services often present directly to the ED in an effort to receive immediate testing and treatment for their medical concerns. Treatments such as intramuscular or intravenous medications, blood transfusions, wound care, splinting, control of blood pressure, blood sugar, infectious symptoms, and pain management, to name a few, are often more available and accessible through the ED than in a clinic or private office setting. Some institutions are capable of obtaining subspecialist consultations in the ED. Sometimes the demand for ED evaluation and treatment is seen as more for convenience than necessity. However, even the most experienced emergency physicians are often unable to determine the urgency for care, until after significant evaluation and testing has been performed.

The ability to perform and the level of reimbursement for advanced diagnostics and treatments have shifted evaluations which historically took place in the inpatient setting, into the ED. Now a CT of the abdomen performed in the ED often prevents admission of patients for serial abdominal exams to exclude appendicitis, cholecystitis, or diverticular abscess. Initiation of IV antibiotics in the ED can prevent admission for conditions from cellulitis to pneumonia. Advanced imaging can exclude acute stroke, spinal cord compression, and intestinal ischemia. Such determinations allow safer dispositions of patients to outpatient evaluation and care. This is a huge driver of reimbursement, and hospital administrators now utilize the ED to ensure best allocation of resources to reimbursement for populations of patients in a strategy termed population health [16].

Understanding these changes is critical in managing a geriatric patient’s medication regimen, as well as underscoring the need to monitor hydration status.

Lower Urinary Tract : Increased collagen in the bladder, and benign prostatic hypertrophy in males lead to impaired bladder emptying in older adults. Urinary tract infections lead to 30–50 % of all community-acquired bacteremia in the elderly. These changes are impactful when seeking a source of infection in a febrile elderly patient.

Hepatobiliary : The liver realizes a decrease in the number of hepatocytes and hepatic blood flow up to 40 % after the age 60. The metabolism of some drugs is altered and elders may be increasingly sensitive to certain drugs requiring mediation regimen changes. Importantly, biliary disease is the most common reason for abdominal surgery in elders and up to 80 % of nursing home residents over 90 years have biliary stones.

Visual acuity, depth perception, sound sensitivity at high frequencies, and speech discrimination all decrease with age. Put into unfamiliar surroundings, and the typical noisy ED with monotone walls, curtain dividers, and fluorescent lighting; and many older patients will become confused and either lethargic or agitated.

The older patient presents atypically compared to a younger adult with the same disease process. However, within the older group, these ‘atypical’ presentations become typical for them. These variations must be understood to take optimal care of this population. For example, many frail elders manifest alteration of mental status as the primary symptom of systemic infections [18]. Emergency providers need to know these presentations but most do not receive specific training or practice according to this paradigm.

Older ED patients often take from 6 to 8 concurrent prescription and over-the-counter medications [19]. From 7 to 10 % of elder ED visits involve an adverse drug event. Additionally, from 13 to 25 % of ED prescriptions to older patients pose a potential drug–drug or drug–disease interaction, and one-fifth of ED patients report mild to moderate adverse drug events from ED prescriptions [20]. This is critical for both identification of drug related problems in elders and ensuring ED prescription treatments do no harm.

The problem of controlling an acutely agitated elder patient is significant and sedatives from the ED often have unanticipated and long lasting effects. ED policies should include pathways for elder behavior control during acute change in mental status [21]. Use of Beers criteria improves risk of ED visit related adverse drug events. Targeting high-risk medications (e.g., warfarin, insulin, and digoxin) is also important in these patients [22]. See Chap. 5 Medication Management to learn more about managing this significant ED challenge.

Immobility leads to deconditioning, exacerbating the decline in body composition discussed above and increasing risk of falls. Additionally, falls are among the most common reason for geriatric ED presentations. However, in the typical ED flow, patients are carried or wheeled into and out of the ED, and providers must make a special effort to observe gait and mobility. Traumatic injuries and the resulting musculoskeletal injuries cause significant morbidity. Seemingly small injuries may make completing simple activities of daily living difficult or not possible and oftentimes otherwise healthy geriatric patients may require home assistance or temporary nursing home placement due to these seemingly minor issues. This awareness does not fit with the usual flow of the ED and providers often discharge elders home without attention to need for home services. See Chap. 8 Tools for Assessment for tips on quick and reliable gait assessments and identifying functional deficits.

Delirium is a change in cognition with an acute (hours to days) onset, fluctuating course, and disturbance in attention (the ability to direct, focus, sustain, and shift attention); or awareness [23]. Consciousness alteration is either hypoactive, hyperactive, or mixed. Hypoactive delirium is the most common presentation and it is missed in the ED setting in about 76 % of cases [21]. Metabolic abnormalities, stroke, seizure, infection, hypoxia, medications, and intoxication are a few of the most common causes of delirium and it is vital to keep a wide differential given the danger of missing a life-threatening condition. When missed in the ED delirium is nearly always missed by the hospital physician (internist or hospitalist) during admission [21]. Delirium is a harbinger of poor outcomes and carries a strong association with 12-month mortality independent of any other confounding comorbidities [24, 25]. Between 7 and 10 % of ED elders present with delirium and some studies estimate that the direct and indirect costs from the sequelae of delirium are as high as $100 billion annually [26]. Delirium in the ED is an independent predictor of 6-month mortality [27].

Up to 50 % of elders with delirium will also have underlying dementia. This emphasizes the need for accurate assessments that will capture shifts from a patient’s baseline mental status and minimize a delayed or missed diagnosis due to coexistence of the two states [21]. In the ED, a thorough history from caregivers or EMS is crucial in assessing the source of delirium. The ED evaluation includes rapid assessment of the ABCs, (Airway, Breathing, and Circulation). Recognition and treatment of abnormal vital signs, and a prompt point of care blood sugar are essential in any patient with altered mental states [28]. In addition to targeted labs and imaging that focus on treatable causes of delirium, EDs must complete a careful examination to identify the cause of delirium [21]. However, EDs often fail at the assessment of elder mental status or the recognition of it’s alteration, causing delays of care, missed diagnosis, and failure of rapid delirium treatment [29]. Many have argued that EDs must improve evaluation and treatment of acute delirium in the ED to decrease morbidity and mortality, and even further, that EDs should be actively screening for delirium and dementia [9]. When performed optimally, this screening can result in interventions that will enhance care and decrease length of hospitalization for elders admitted from the ED.

Dyspnea is a broad presenting complaint in ED elders that requires rapid assessment to rule out life-threatening emergencies such as myocardial infarctions/ischemia, pulmonary embolisms, and dysrhythmias while still keeping in mind more common causes such as pneumonia, COPD exacerbations, CHF exacerbations, and bronchitis. This acuity approach is a chief difference between dyspnea evaluations in the ED versus the office setting. Altered mental status, agitation, seizure, headache, and lethargy may indicate hypercarbia and/or impending respiratory failure in an older patient with dyspnea [30]. Elders often present with mixed pictures blending features of CHF and COPD. Clinical uncertainty between these diagnoses exists in about 30 % of ED elders with severe dyspnea and is associated with increased morbidity and mortality [31]. Differentiation often requires advanced diagnostic testing. Treatment is based on stabilization of breathing and ventilation which may blend treatments of both conditions before results of testing can be obtained. Bronchodilator use in patients with CHF is associated with need for aggressive interventions and monitoring [32].

The diagnosis of pulmonary embolism is often reserved for the ED as CT imaging is the diagnostic procedure of choice and making the diagnosis of PE in the ED is associated with a substantial survival advantage [33]. Dyspnea may be the only symptom of myocardial infarction (MI) in elders and is the most common presentation of MI in patients over 80 years of age. Nausea, disorientation, and lethargy can also be atypical presentations of an older patient with myocardial ischemia and ED providers should have a low threshold to rule out a cardiac etiology with such symptoms . Direction to EMS or ED with STEMI centers for these patients reduces treatment delays and improves long-term outcomes [34].

Correctly identifying a stroke sets into motion a cascade of diagnostic and therapeutic interventions that are time-critical. An accurate history establishes the timeline of a change in mental status or physical function and determines whether an otherwise eligible patient may benefit from thrombolytic therapy. The time from symptoms onset to thrombolytic therapy was recently increased to 4.5 h according to the 2012 AHA/ASA guidelines for the management of acute ischemic stroke but many centers have additional administration criteria [35].

A door to needle time of <60 min is now being established as the standard of care for thrombolytic therapy and unsurprisingly a lack of corroborating information from bystanders can lead to delays and disqualification for therapy if a correct time of onset of symptoms cannot be established [36]. The proliferation of primary stoke centers starting in 2000, meant that by 2010 49 % of all stroke patients had access to stroke center care [37].

Typical symptoms include unilateral paralysis of the face, arms, legs, acute changes in mental status, difficulty speaking or severe headache and dizziness. Atypical presenting symptoms may include pain, palpitations, confusion, or shortness of breath [38]. It is equally important to rule out other etiologies of illness that may mimic the symptoms of a stroke including seizure, ingestions, hypoglycemia, and hemorrhagic intracranial bleeding. Appropriate EMS activation and rapid delivery of patients to the ED of a primary stroke center are associated with improved evaluation and treatment of acute ischemic strokes [39].

In the elderly atypical presentations of infection can delay identification and treatment of the source. Older patients may not have a white count elevation (although a left shift will typically still be present) in response to an infection. They may be either hypo, normo, or hyperthermic, they may not have chills or rigors, and their tachycardia may be blunted by beta-blocker therapy or aging physiology [40]. Immune senescence and comorbidities also make the elderly more prone to infection [41]. In elders, normal vital signs and lab values do not rule out serious infections and non-specific findings such as shaking chills, altered mental status, abdominal pain, and vomiting are all predictive of bacterial infection as are the presence of diabetes mellitus and other major comorbidities. [42, 43]. Pneumonia, urinary tract infection, and bacteremia are the most common causes of infection in this population [44]. After the primary evaluation for vital sign instability a thorough physical exam should search for signs of hypoperfusion including altered mental status, poor capillary refill, and dry mucus membranes, and decreased urine output. Most ED practice guidelines regarding sepsis agree on the benefits of early fluid resuscitation and antibiotic therapy [45].

Syncope is defined as a transient loss of consciousness and postural tone due to rapid global cerebral hypoperfusion with prompt return to full pre-event function. Syncope in the older patient can be difficult to distinguish from seizure, stroke, hypoglycemia, hypoxia, or drug effect. Older patients present more often, are hospitalized at higher rates, and have increased mortality associated with syncope [46, 47]. Nearly 60 % of older patients who present with syncope will be admitted to the hospital but in a third of cases no clear etiology is discovered even after full hospital evaluation [46]. The most common causes in older people include neurally mediated syncope, orthostatic hypotension, dysrhythmia, and carotid sinus hypersensitivity [48].

A focused history looking to determine etiology of syncope, with an evaluation of medication regimen, and potential resulting trauma or contributory illness should be included in the initial survey.

The goal of the initial evaluation should be to:

There are a number of ED clinical decision rules and risk-stratification tools including the San Francisco Syncope Rule to guide focused evaluations and predict high-risk patients who would benefit from admission although none have been universally adopted as accurate predictors of outcomes [50]. Excellence in elder ED syncope care generally requires cooperation with a multidisciplinary hospital team and assurance of prompt follow up.

Traumatic injuries are a leading cause of death among older people and one contributing cause could be the failure to transport patients to a trauma center. Failure of EMS trauma-center transport in elders is well documented and usually based on an inaccurate index of suspicion for traumatic injury. However, even obviously severely injured elders are less likely than younger patients to receive care in a trauma center [51].

Because of widely acknowledged physiologic changes that occur with aging such as cerebral atrophy, thinning skin and osteoporosis, even relatively benign mechanisms of injury can cause intracranial hemorrhages, intra-thoracic or intra-abdominal organ injuries, with hemodynamic compromise, and significant fractures [52, 53]. This is especially true in a patient on anticoagulants [54].

The second challenge is recognizing that elder’s vital signs can be deceptively normal in trauma [55], and could in fact be signs of shock compared to baseline vital signs that may be unknown to paramedics. Not only is hypotension not always an accurate predictor of shock, but there is a phenomenon of poor end-organ perfusion in the setting of normotension referred to as occult hypotension [56].

Guidelines for field triage now have updated standards that take into account the physiologic differences of the older patient [57]. They highlight the following issues:

Older patients have special EMS transport needs. Padding is often required under areas prone to skin tears or pressure ulcers. In elders, cervical injuries can occur with seemingly minimal mechanisms. EMS providers determine need for backboards and cervical collars and can ensure additional padding and stabilization allowing for more comfortable and safe transport.

As with younger patients, the “golden hour” between a traumatic injury occurring and presenting to a trauma surgeon is crucial and missing subtle signs of a traumatic injury could significantly delay lifesaving interventions. Just as in pediatric patients, adjusted vital sign parameters are required for geriatric patients. EMS workers need additional training to recognize these abnormalities and to adjust their index of suspicion for traumatic injuries based on low-impact mechanisms. Bringing the patient to the right place for the right evaluation on the initial transport should be the standard for every patient regardless of age.