• geriatrics
• emergency department
• assessment

An ageing population is straining reliable and timely access to emergency department (ED) care for all patients worldwide.1–6 Compared with younger populations, older adults have lengthier ED evaluations are more frequently admitted, and if discharged, return to the ED more often but still leave the ED dissatisfied with the care delivered.7–9 In response to an ageing demographic, Emergency Medicine and Geriatric organisations in the UK and USA released evidence-based and consensus-based guidelines to optimise the care and outcomes for this population.10 ,11 Over the past decade, professional organisations,10 ,12 residency educators13 and quality improvement experts have advocated that geriatric risk stratification instruments be widely employed in adult EDs worldwide, while researchers simultaneously supported development of more accurate instruments.14 One immediately palpable challenge for clinicians (physicians, mid-level providers, nurses) and policy-makers is to identify accurately the most vulnerable older adults, real time in the busy ED and have them receive more intensive, geriatric-focused ED care.15 ,16

One recommendation from the US guidelines highlighted the need for risk-stratification of older adults using instruments like the Identification of Seniors at Risk (ISAR) tool.12 ,17 In the ED environment, an ideal geriatric ‘vulnerability’ screening instrument would be precise and reliable for a broad spectrum of presenting illnesses and injuries, including illnesses and injuries of variable severity managed across heterogeneous healthcare settings, and for patients with differing levels of socioeconomic and health literacy states.18 The original ISAR was developed as a six-item, self-report screening tool to identify older people in the ED at increased risk of 6-month adverse health outcomes (death, admission to nursing home or long-term care, or clinically significant decrease in functional status).17 Such screening tools could theoretically maximise allocation of ED-based interventions focused on care transitions and care coordination to those in greatest need, at highest risk and most likely to benefit.

A prospective study in two US hospitals by Suffoletto et al19 evaluated the prognostic accuracy of the ISAR tool to predict ED revisit, post-ED discharge hospitalisation or death at 1 month. The EMJ study compared the accuracy of the original ISAR tool, whereby patients self-respond to six yes/no responses, with an objective version based on researchers’ point-of-care risk factor assessments of mobility, vision and cognitive function, as well as a structured chart review to identify unreported evidence of polypharmacy or prior hospitalisations within 6 months. The authors reported that neither the subjective self-report nor the objective versions of the ISAR accurately predict which patients were more likely or less likely to return to the ED, have a subsequent admission or die within 30 days. In comparison, prior studies evaluating the prognostic accuracy of the ISAR with a cut-off of ≥2, reported sensitivities varying from 47% to 100%, and specificities of 10–50% for 30-day ED returns20–22 and 61–92% and 18–30% for 30-day hospitalisations.23–25 More recently, a systematic review and meta-analysis by Carpenter et al, compared 23 individual risk factors, 5 constructs of frailty and 7 geriatric ED screening tools for prognostic accuracy at various thresholds and different post-ED intervals to predict adverse outcomes following ED visits. No individual or combined risk factors, or screening tools were able to differentiate accurately either high-risk or low-risk patients.26

Despite ample efforts over the last two decades, an ideal instrument does not yet exist. In addition to the ISAR, at least six other ED instruments to risk-stratify geriatric patient ‘vulnerability’ for postdischarge adverse outcomes have been ‘validated’, including the Triage Risk Screening Tool,27 Variables Indicative of Placement Risk,28 the Silver Code,29 Mortality Risk Index,30 Rowland31 and Runciman.32 Other instruments also continue to be developed.33 Based upon the meta-analysis,26 and this paper by Suffoletto et al, it is disappointing to understand that none of the instruments had the predictive ability proposed in their original papers. A significant challenge in the development of vulnerability assessment tools may be the definitions, criteria and outcomes measured. It will be necessary to standardise what and where the targets and goals are when assessing geriatric patient risk factors in the ED setting. Without a common understanding of the patient populations, settings, unmeasured intrinsic markers of vulnerability, extrinsic factors within the culture of a healthcare system that may affect observed patient or provider responses to acute illness, and philosophical issues associated with defining meaningful and actionable items, development of geriatric vulnerability assessment tools will continue to be inaccurate. Future investigations are still needed to develop ED-validated instruments assessing geriatric syndromes like falls, frailty, dementia or delirium. Without objective and common measures for these geriatric syndromes, subsequent attempts to demonstrate the impact of geriatric emergency care may continue to be mixed or largely disappointing.34 ,35 Understanding why prior instruments lack sufficient prognostic accuracy will be essential to inform future investigators and accelerate the process of developing truly accurate instruments moving forward. Until better risk-stratification tools are developed, instruments such as the ISAR, Triage Risk Screening Tool (TRST) Silver Code and others should continue to be considered. There is merit to the use of any tool—the geriatricising of emergency care is a critical first step to improving the quality of geriatric emergency care. The processes of implementing ED screening for geriatric-specific risk factors in themselves promote a system-wide awareness that: (A) older adults require a different approach and assessment than younger patients, (B) older patients face unique challenges to recovery, and (C) ED protocols and linkages to appropriate outpatient resources to facilitate illness/injury recovery can be developed and implemented. Current ED models of patient care and education do not include geriatric-specific evaluations.13 ,15 No segment of the emergency clinical assessment currently accounts for the special care needs of older adults. If specialised emergency care protocols and settings exist for paediatric and psychiatric patients, why are older adults evaluated and treated the same way as younger patients with a one-size-fits-all approach?

Instruments like the ISAR, though blunt, at least differentiate assessment of the older adult. We can enter the challenge of caring for our ageing population equipped with some guidance, rather than blindfolded. Studies that find poor sensitivity and specificity to predict suboptimal post-ED outcomes using existing geriatric risk assessment tools demonstrate to clinicians, educators, funders and policy-makers that we still have a long way to go in to improve our approach, evaluation and care for these patients. It should be noted, the geriatric emergency guidelines endorsed in the UK and the USA were evidence-based on studies from the inpatient and outpatient settings, and not in the ED setting. The guidelines nonetheless are recommended because they provide a basis for what should be considered when geriatric emergency care is delivered.

Attempts to optimise our ability to discern which patients would maximally benefit from geriatric-specific care remains necessary. Geriatric vulnerability screening instruments such as the ISAR and others enhance our awareness and understanding of geriatric patients beyond just the ED presenting complaint. These screening tools force us to take into consideration the older adult as a whole, deliberating on their medical condition, and on their functional and psychosocial problems.36 More accurate tools must be developed. Until better ones are established, however, imperfect instruments such as the ISAR that incorporate the assessment of geriatric-specific needs should continue to be incorporated into routine ED care when assessing older adults in the ED.