SEE RELATED ARTICLE , P. 426 .

Hospitalizations have long been recognized as sentinel events in the lives of older adults. Recovery from the illness or injury that prompts hospitalization may be prolonged or may not occur at all. Adverse events during hospitalization are common, as are factors such as immobilization, sleep disruption, impaired nutrition, and polypharmacy that may impede patients’ return to their baseline level of independence. Among hospitalized patients, the persistence of acquired disability occurs in predictable patterns, with increased age, cardiovascular disease, dementia, the presence of cancer, decreased albumin levels, and dependency in instrumental activities of daily living at baseline all heralding worse functional outcomes. Although optimizing the types and duration of rehabilitation needed to reverse this disability remains a subject of study, efforts to protect older adults from hospital-associated functional decline have been widely incorporated into clinical practice. Physical rehabilitation is now routinely provided to patients who experience myocardial infarction or stroke or undergo orthopedic surgery. Discharge planners begin working, often on the day of admission, to ensure that in-home resources and follow-up appointments are arranged. Alternatives to hospitalization, including hospital-at-home and brief periods of observation, rather than admission, have also been developed to reduce admissions among older adults.

These efforts to improve outcomes for hospitalized patients are critically important, but they raise lingering and largely unanswered questions about the outcomes of the 65% of older adults who are not hospitalized after seeking care in the emergency department (ED). Among both clinicians and researchers, there is increasing concern that these discharged older ED patients may also experience functional decline.

The notion that ED visits for older adults are associated with subsequent functional decline is not novel. More than 30 years ago, Currie et al described the development of functional decline after an ED visit and reported increased dependence among 52 of 100 discharged patients. Since then, others have endeavored to predict and prevent the development of functional decline among older adults discharged after an ED visit. However, the evidence for an association between an ED visit by an older adult and subsequent functional decline has been circumstantial and constrained by 2 limitations: the absence of a control group of individuals who did not seek ED care and the lack of prospectively obtained information about patients’ functional status before the ED visit.

In this issue of Annals , Nagurney et al present compelling longitudinal data from the Yale Precipitating Events Project that overcome both of these limitations. By following a large cohort of community-dwelling older adults, some of whom visited the ED and some of whom did not, the authors provide the natural control group lacking in earlier studies and thus a window into the functional trajectories of seniors after an ED visit. In collecting functional data from study participants monthly, the investigators also capture pre-ED visit health data that obviate the potential recall bias present in earlier work. Nagurney et al observe that older adults who sought ED care and were discharged had greater functional decline, increased nursing home admissions, and higher mortality in the 6 months after an ED visit than matched older adults who did not go to the ED.

Having identified this inflection point in the functional trajectories of our older patients, we must ask ourselves an essential clinical question: can we intervene to preserve function among these patients? Existing evidence indicates that we can improve outcomes for older adults discharged from the ED. Successful interventions tend to have the following components: a screening or assessment instrument to identify needs, establishment of connections to community resources that can perform further evaluation and care provision at home, and close follow-up with a primary provider. In 2001 in Montreal, McCusker et al tested the ability of the Identifying Seniors at Risk screening instrument plus an ED nursing assessment combined with referral to post-ED services to prevent functional decline. Patients randomized to the intervention were significantly less likely to experience functional decline at 4 months. Similarly, in an Australian study, Caplan et al demonstrated the efficacy of a multidisciplinary, comprehensive geriatric assessment intervention among older adults who were discharged from the ED to reduce subsequent hospitalizations and improve mental and physical function. These foundational studies have been the backbone for implementation of these models in Canada and Australia. In a 2006 survey of Quebec EDs, McCusker et al reported that “even among large EDs serving higher-risk seniors, only about half did any systematic geriatric screening, about one third used standardized tools to assess patient function or cognition, and 12% had a discharge planning protocol.” But by 2014, there had been significant improvements in screening of cognitive status, functional status, and medications, as well as in the adoption of discharge planning protocols. Similarly, Caplan’s work in Australia has been widely adopted in the state of New South Wales with the development of Aged Care Services in Emergency Teams.

In the United States, comprehensive evaluation and treatment programs for older adults discharged from the ED are nascent. Guidelines for optimizing care for older ED patients have been published: screening and connecting patients to community resources are central components of these guidelines. But guideline compliance is low, even by EDs that self-designate as geriatric EDs, and the essential connection between discharged patients and comprehensive care services is inconsistent. Geriatric or senior EDs may one day be a central part of the solution, but with more than 5,000 US EDs and only an estimated 36 geriatric EDs, that day has not yet arrived. In some settings, partnerships between EDs and specialty care programs may provide a means to optimize care for discharged older adults. In other settings, opportunities may exist to partner with disease-specific programs that seek to coordinate services for older adults across the care continuum. Indiana University’s Aging Brain Care program and the University of California–Los Angeles’s Alzheimer and Dementia care program focus on providing high-quality care to older adults with cognitive impairment. In other areas, potential partners such as Vermont’s Support and Services at Home program or the Geriatric Resources for Assessment and Care of Elders model focus more generally on high-risk individuals and are becoming more widespread as a result of replication and dissemination efforts supported by federal and private insurance sources. A hallmark of these programs is their ability to use geriatric-competent, nonphysician providers and community health workers to extend the reach of the medical system into patients’ homes and address the myriad issues faced by older adults that have not traditionally been considered “medical” in nature (eg, isolation, neglect, limited food access, poor oral health, housing insecurity) but have outsized influence on patient outcomes.

To be certain, further research needs to be conducted. In the United States, although the conceptual approach of screening and linking high-risk older ED patients to community services makes sense, work is needed to define how to implement and scale these programs, particularly in the many parts of the country with limited access to social services. Second, disease-specific discharge pathways for common conditions are needed. Although there are many issues faced by older adults that span all disease states (eg, reduced mobility, sensory impairments, polypharmacy), there are also issues that are disease specific. Congestive heart failure, chronic obstructive pulmonary disease, mental health problems, and musculoskeletal pain are common reasons for ED visits and potentially amenable to outpatient treatment. For these common complaints, we need condition-specific tools to help us determine which patients can be safely discharged and provide the essential patient education and links to resources and outpatient care needed to optimize outcomes. Finally, we need payment mechanisms that either directly reimburse the additional work of comprehensive evaluation and treatment or a reimbursement system in which the money saved from doing this extra work is returned to providers.

These steps are by no means simple, but they are imperative. Ten thousand baby boomers celebrate their 65th birthday every day in America and will do so through 2029, and as we transition to population-based payments, the percentage of older ED patients who are not hospitalized is likely to increase. Our patients deserve to be cared for by health care systems that are designed to preserve their independence. Avoiding Medicare insolvency, currently predicted to occur in 2028, will also depend in part on these solutions. There is no time like the present to starting bending those curves.