The medical structure that provides care to older adults in the United States can be divided into the acute care system and the long-term care system. Medicare has provided the funding for the majority of acute care and rehabilitation needs for adults older than 65. Long-term care (LTC), however, is funded primarily by the Medicaid program and private resources. Fewer than 5% of individuals older than 65 are in skilled nursing facilities (SNFs), yet a much larger number are part of the LTC system in the United States (an estimated 1.3 million vs. 5 million) (1).

Emergency room physicians, both psychiatrists and nonpsychiatrists, need to understand the levels of care this system offers to appropriately accept and return individuals to these facilities. SNFs are the most familiar to physicians. They provide care to the older adult who requires at least 7 hours a week of skilled nursing care. Although often understaffed, SNFs have a registered nurse and nursing aides available 24/7. Community-based residential facilities (CBRFs), in some areas called group homes, provide care to five or more adults unable to live independently by providing supervision and supportive services. Usually they are licensed by the state; some cater to specific populations, such as those requiring dementia care. Often different licensure levels exist, which separate CBRFs by the type of resident they can admit (e.g., ambulatory, nonambulatory, mentally capable of responding to a fire alarm or not). A nurse might be on call, but CBRFs generally use nonmedical personnel, with at least one staff member being present 24/7.

The phrase assisted living is used to describe a number of housing types and service arrangements. In most states, these are not licensed. Some provide personal services for extra cost (e.g., bathing assistance, medication monitoring). Mostly they are an apartment-like arrangement in which a nurse might be available for several hours during the day, and a manager might or might not be there overnight, with a nurse on call.

Behavioral emergencies in these facilities are always difficult but become even more so at night or over the weekends during periods of reduced staffing. SNFs can give as-needed medication and provide some short-term acute monitoring for a resident. CBRFs usually can give as-needed medication but rarely have the staff to provide extra monitoring for individuals. Assisted living is best thought of as a nonmedical housing situation with no monitoring available.

These differing levels of service must be taken into account when emergency departments (EDs) consider disposition decisions. Behavioral stability is a must for assisted living, whereas the SNF could have a resident return if he or she is somewhat better but still requires extra observation. It is frustrating for physicians when some long-term care facilities refuse to allow a resident to return from the ED or psychiatric emergency service (PES). However, if a facility feels it cannot deal with the older adult because of behavior, it is probably safer for the patient if he or she is not returned to that placement from the ED or PES. This chapter discusses the issues of geriatric behavioral assessment, acute treatment, and possible hospitalization.

In 2005, elderly individuals constituted 15.4% of total ED visits. In fact, increasing trends in ED visit rates were noted for individuals 65 years
and older (up by 26%) from 1993 to 2003, and were the highest among all age groups (2). Obtaining the geriatric history and the mental status is a time-intensive process because older patients rarely present with a single well-defined diagnosis and often experience multiple, comorbid medical and neurologic illnesses. However, the goals of a geriatric psychiatric evaluation in the ED are to complete a rapid assessment, investigate for underlying medical disorders, establish a provisional diagnosis and differential diagnosis, establish the patient’s cognitive and functional capacity, provide emergency treatment, and arrange an appropriate disposition in a short period of time. Although ED personnel are proficient in medical history taking and performing a physical examination, they are often not trained in recognizing common psychiatric manifestations in the elderly, including psychosis, depression, suicidality, behavioral disturbances, anxiety, and alcohol or drug intoxication and withdrawal. Also, appropriate medical evaluation is crucial in the free- standing PES because life-threatening medical emergencies can be easily misdiagnosed as mental disorders when the geriatric patient predominantly presents with psychiatric signs. A thorough evaluation is often compromised because of the need for rapid screening in the medical or psychiatric ED, which amplifies the risk for potential misdiagnosis and erroneous disposition planning.

The psychiatric evaluation should be modified to accommodate the needs of the geriatric psychiatric patient as outlined in Table 28.1. New-onset psychiatric symptoms in the elderly that trigger an ED visit should prompt the physician to assess for precipitating factors. Environmental and physical factors such as recent losses, relocation, changes in support networks, separations, recent change in medications, and various medical illnesses (ranging from urinary tract infection to recent diagnoses of potentially life-threatening illnesses) can be associated with the onset of an anxiety, affective, cognitive, or psychotic symptomatology. Also, new-onset psychosis can result from an undiagnosed dementia or acute delirium. A careful review of prescription and over-the-counter medications is essential because polypharmacy is common. A review of the medicine containers and a double-check between the written schedule and the pill containers should be performed. This might expose prescription drug noncompliance or overuse. Screening for alcohol, street drug, and prescription and over-the counter drug misuse or abuse in a geriatric patient is essential in the ED or PES but is often overlooked. Therefore, when suspicion arises, a blood alcohol level and urine toxicology screen should be obtained. Suicide risk assessment is a critical part of the ED geriatric psychiatric evaluation because suicide is more frequent in the elderly population compared with their younger counterparts. Moreover, approximately three fourths of elderly patients who commit suicide have seen a physician in the previous month, and over one third within the week of their suicide (3).

Cognitive evaluation is mandatory for all geriatric patients presenting to the ED. In general, an abrupt onset of cognitive impairment or a sudden decline in cognition and functional status from the baseline is highly indicative of an acute illness. Early detection of cognitive impairment in the elderly may aid medical and psychiatric differential diagnosis and result in requesting necessary laboratory and imaging studies and appropriate consultation (4,5). The most widely used cognitive screening instrument is the Folstein Mini Mental Status Examination (MMSE). The expert consensus panel for treatment of behavioral emergencies has endorsed the MMSE as the preferred cognitive instrument in ED settings (6). The Confusion Assessment Method (CAM), a brief screening instrument that is highly sensitive and specific for delirium, can be effectively administered by nonpsychiatrically trained ED staff. Functional assessment will provide the physician an understanding of how much care or supervision the patient requires upon discharge from the ED. Various scales have been developed for this purpose (7).

Most geriatric assessments in the ED or PES should include interviewing the significant other. The geriatric patient may not be a reliable historian as a result of cognitive and behavioral disturbances, and the collateral history will provide further insight into the patient’s condition. If the significant other is the caregiver, the ED staff will need to assess for caregiver burden and his or her health and ability to care for the patient. A systematic diagnostic approach as outlined in Table 28.1 and careful differential diagnoses will facilitate appropriate dispositional planning and treatment.