Blog Harvey A. Friedman Center for Aging Infectious Disease

Emergency Departments, Older Adults & Coronavirus Part I: What are the Geriatric Emergency Department (GED) Guidelines?

Written by Tanner Meyer, Masters Research Fellow in Aging, Class of ‘21, Friedman Center for Aging

As we have written about before, ageism continues to rear its ugly head during the Coronavirus pandemic. The media has depicted older adults, ranging from age 60 to 100, as a homogeneous, frail group, destined to contract the virus. At the Harvey A. Friedman Center for Aging, we know the story is much more complex; we know that older adults are as diverse in ability as in age, and the majority live healthy, independent lives. We also know that with age comes a weakening of the immune system and an increase in the prevalence of multiple chronic conditions, like heart disease and diabetes. The presence of chronic conditions has more influence on an individual’s susceptibility to COVID-19, than age.

Keeping ageism and immuno-compromised older adults in mind, the Center for Aging team wanted to know how medical facilities are assessing and treating older adults during the pandemic. We were able to interview Dr. Christopher R. Carpenter, MD, MS, a Barnes-Jewish Emergency Department Physician who specializes in geriatric medicine. He explained how Barnes-Jewish Hospital, along with other medical facilities in the United States and Canada, have adopted geriatric-specific guidelines in the Emergency Department (ED) with his help. The GED guidelines were used in these particular medical facilities pre-Coronavirus, but since the spread of the virus, have been utilized to supplement the care and evaluation of older adults who may have contracted the virus and are experiencing symptoms.

Alongside other geriatricians, Dr. Carpenter has helped create The Geriatric Emergency Department Collaborative (GEDC), a nationwide collaborative dedicated to optimal emergency care for older adults. According to him, there are four top priorities when assessing an older adult when they enter an ED. They are as follows: functional assessment, cognitive assessment, medication assessment, and transitions of care. To learn more about these priorities, listen to this podcast interview with Dr. Carpenter.

Functional assessments look at ambulation; for example, is there a history of falls, and how can the physicians assist in preventing future falls? A cognitive assessment determines if the patient has dementia or a mild cognitive impairment. Cognitive assessments also aim to rule out delirium, a symptom for which a physician would need to find a cause. Medication assessments often use the Beers list of potentially high-risk medications and medication combinations that can harm a patient, a concept known as polypharmacy. These medications include, but are not limited to, NSAIDS, codeine, anti-cholinergics and benzos. Lastly, transitions of care assume that the ED is not the only place for treatment. The goal is to communicate with all providers involved in the patient’s care, like primary care physicians and neurologists, for a holistic and continual approach to care. The aforementioned podcast links in depth descriptions of evidenced-based assessments—for download—that can address the four priorities.

The GED Guidelines are specific to older adults, and therefore not applicable to younger populations. Dr. Carpenter explained, “the GED Guidelines provide rationale and obtainable metrics for conditions that are unique to aging adults (dementia, non-drug induced delirium, standing level falls).” In 2014, the GED Guidelines were endorsed by the American College of Emergency Physicians, Emergency Nurses Association, Society for Academic Emergency Medicine, and American Geriatrics Society. Since then, they have also been endorsed by the Canadian Association of Emergency Physicians and American Academy of Emergency Medicine. As of 2018, the American College of Emergency Physicians’ Board of Directors began accrediting hospitals for adhering to the GED Guidelines.

We asked Dr. Carpenter if the GED Guidelines were a “standard of care” model, to which he discouraged the use of the term. Resources vary hospital to hospital, for example, rural hospitals may not have an ED physician, or some may be without CT scanners. Therefore, one “standard of care” cannot apply to all hospitals. Hopefully, though, the GED Guidelines will be adopted and implemented by more physicians and hospitals in the future. This will be particularly important as the population ages and seeks healthcare.

“Geriatricians are in short supply and will be in even shorter supply over the next 30-years, so every medical and surgical specialty will need to develop expertise in geriatrics that is applicable to their specialty.”

The medial field must evolve. This would require specialties other than ED creating their own Geriatric Guidelines. Thankfully, St. Louis and Barnes-Jewish hospital have Dr. Chris Carpenter treating its older adults and paving the way in geriatrics for students in the medical field and helping professions.

Check back in the with the Center for Aging blog as we continue the conversation with Dr. Carpenter and how Coronavirus has impacted the ED and what older adults can expect from their ED physicians.