Original Contributions
Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions*,*

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Abstract

Study Objective: We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. Methods: Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. Results: Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. Conclusion: Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients. [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. March 2002;39:238-247.]

Introduction

The steady increase in the size and age of the older population has had a major effect on health care delivery and costs. With the rapid growth of the oldest segment of the elderly population (≥85 years), the effect is expected to be even greater in the future. Emergency departments provide a critically important service to older people. They are used as a center for the treatment of emergencies, a point of entry into the high technology acute care and long-term health care services, a 24-hour accessible provider of primary medical care, and a safety net when a smooth transition between various systems of care is disrupted.1, 2 However, as the number of older persons presenting to overcrowded EDs increases, greater attention has focused on the appropriateness and the patterns of use of emergency services by older adults, their special care needs, and the effectiveness of the current models of service provision to elderly patients in EDs.

This systematic review provides a synthesis of the literature on the patterns of use of emergency services among older adults, the risk factors associated with adverse health outcomes in older ED patients, and the effectiveness of intervention strategies targeting this population.

Section snippets

Materials and methods

A computer-aided English-language search of the MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases was carried out by an experienced medical librarian to identify the relevant literature from January 1985 to January 2001. Appropriate subject headings and text words were used for each database, and the “exploding” technique was performed to ensure inclusion of all indexed articles. In MEDLINE, HealthSTAR, and CINAHL, the specific search terms used were as follows: exp

Results

Table 11, 6, 15 presents the findings of 11 international, large-scale ED use studies by using data from single-site, multicenter, or nationally representative samples.As shown, visits by older adults composed 12% to 21% of all ED encounters. In almost all of these studies, the rates consistently showed an overrepresentation of older adults in EDs compared with their proportions in the general population in the same geographic areas.1, 6, 7, 9, 13, 15 One exception was an American study of 3

Discussion

Older ED patients have distinct patterns of service use and care needs. They use emergency services at higher rates, require more resources, and are more likely to experience adverse health outcomes after an emergency visit compared with the rest of the adult population. However, to date, there is limited empiric research on the effectiveness of various clinical interventions targeting this group of ED patients. Therefore, the practice implications discussed below are based on a qualitative

Acknowledgements

We gratefully acknowledge the valuable assistance of Ursula Riendeau in identifying the relevant articles for this review. We also thank Barbara Power and Christine Gagne-Rodger for their review of the manuscript.

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    *

    Address for reprints: Faranak Aminzadeh, RN, MScN, Regional Geriatric Assessment Program of Ottawa Carleton, Geriatric Outreach Team, 39 Robertson Road, Suite 100, Nepean, Ontario, Canada, K2H 8R2; 613-721-4148, fax 613-820-6659; E-mail [email protected].

    *

    Author contributions are provided at the end of this article. Author contributions: FA and WBD conceived the research questions for the review. FA designed the methods of literature search and data extraction, conducted the review, and synthesized and analyzed the data. WBD participated in the review of selected literature and in the interpretation of the findings. FA drafted the manuscript and both authors contributed to its revision. FA takes responsibility for the paper as a whole.

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