White-haired hordes storming hospitals may be a comical image to conjure up, but it's not all that far-fetched. The number of Americans 65 and older is soaring, and the proportion 85 and up is climbing even more dramatically — at three times the rate of the general population. These folks are showing up at hospitals in ever-increasing numbers, more often than not in the emergency department, and many end up as inpatients. Geriatric emergency patients represent 43 percent of admissions, including 48 percent admitted to the intensive care unit, according to a set of guidelines for geriatric EDs released last week by a coalition of emergency medicine groups.

The guidelines create a template for everything from staffing and equipping a geriatric ED, to follow-up care and performance improvement. "Improved attention to the needs of this challenging population has the opportunity to more effectively allocate health care resources, optimize admission and readmission rates, while simultaneously decreasing iatrogenic complications [health care-associated conditions] and the resultant increased length of stay and decreased reimbursement," the guidelines state.

Keeping patients out of the hospital whenever possible ought to be a major goal of the geriatric ED. The guidelines note that hospitalization "is associated with increased rates of acute delirium, nosocomial infections, iatrogenic complications and functional declines in the geriatric adult." In non-emergent cases, patients should be directed to more appropriate care settings. When releasing patients, geriatric EDs should "have discharge protocols in place that facilitate the communication of clinically relevant information to the patient/family and outpatient care providers, including nursing homes." Moreover, clinical information should be presented in a format best suited for elderly adults, such as large-type discharge instructions.

The section on equipment and supplies calls for a "focus on structural modifications that promote improvements in safety, comfort, mobility, memory cues and sensorial modifications both with vision and hearing for elders in the ED."

And the section on staffing and administration describes how to build a geriatric ED team and urges robust geriatric training for team members. This section is particularly valuable to hospitals as they staff up with clinical professionals who understand the special needs of older patients, and can effectively communicate with them.

The coalition behind the guidelines includes the American College of Emergency Physicians, the American Geriatrics Society, the Emergency Nurses Association and the Society for Academic Emergency Medicine.