Enhancing Emergency Department Care for Older Adults in Australia and New Zealand: Evidence Since April 2021

1. Executive Summary

Older adults represent a significant and growing proportion of emergency department (ED) presentations in Australia and New Zealand, often presenting with complex health and social needs that challenge traditional ED models. Evidence generated since April 2021 highlights multifaceted efforts across both countries to improve geriatric emergency care, though significant challenges remain. Specialized models of care, such as Queensland’s Geriatric Emergency Department Intervention (GEDI), demonstrate potential benefits including reduced ED length of stay (LoS) and hospital costs, but successful implementation is complex and context-dependent, requiring sustained funding, leadership, and fidelity. Comprehensive Geriatric Assessment (CGA) principles are being adapted, but evidence for community-based CGA significantly impacting ED use remains limited. Interface services supporting aged care facilities (e.g., NSW’s ACE service) and primary care admission avoidance programs (e.g., NZ’s Waikato POAC scheme) show promise in reducing avoidable ED transfers.

Management of key geriatric syndromes remains a priority. Delirium screening is increasingly mandated (e.g., ACSQHC Standard), with tools like the 4AT widely used, though implementation barriers persist. Evidence linking delirium to long-term cognitive decline underscores the urgency of effective ED management, yet proven ED-initiated prevention strategies are scarce. Falls prevention relies on multifactorial assessment and interventions, but validated predictive models for ED use are lacking, and Australia faces a gap in national policy coordination. Medication management focuses on reconciliation (mandated in both countries) and review, particularly addressing polypharmacy and potentially inappropriate medications (PIMs). While pharmacist involvement shows benefits, passive deprescribing interventions face implementation hurdles, whereas IT tools offer potential for targeted identification.

Optimizing care transitions is crucial but challenging. Older patients and their carers report communication gaps and feeling unprepared post-discharge. Effective strategies require structured processes, clear communication tailored to individual needs, genuine patient/family partnership, and robust links with primary/community care. Systematic reviews since 2021 reveal limitations in the evidence base for many ED-specific interventions, often due to study quality issues, suggesting a need for strategies extending beyond the ED.

Comparing Australia and New Zealand, both nations are actively developing geriatric ED initiatives, utilizing specialized roles, focusing on frailty, and mandating medication reconciliation. Australia demonstrates evaluated models like GEDI (QLD) and ACE (NSW), alongside state-level initiatives (WA, SA, VIC). New Zealand shows strong national guidance on frailty care, primary care-led admission avoidance models, and research into IT-supported medication review and delirium outcomes. Common challenges include funding sustainability, implementation fidelity, workforce development, data integration, and effectively bridging the ED-community interface. Recommendations focus on strengthening integrated models, prioritizing evidence-based syndrome management, enhancing care transitions through improved communication and patient partnership, investing in implementation science, fostering AU-NZ collaboration, and addressing policy gaps, particularly in Australian falls prevention.

2. Introduction

Context: The Demographic Imperative and ED Challenges

Australia and New Zealand, like many high-income countries, are experiencing significant population ageing.¹ This demographic shift has profound implications for healthcare systems, particularly emergency departments (EDs). Older adults (typically defined as those aged 65 years and over, though lower thresholds apply for Indigenous populations ²) constitute a disproportionately large and growing percentage of ED presentations.¹ In Australia, for instance, individuals aged 65 and older account for approximately 21% of ED presentations despite comprising only 16% of the population.¹ This cohort often presents with complex health profiles characterized by multiple comorbidities, polypharmacy (the use of multiple medications), age-related sensory impairments, cognitive decline (including dementia and delirium), functional limitations, atypical symptom presentations, and intricate psychosocial needs.⁵

The traditional ED model, primarily designed for rapid assessment and management of acute, often single-system, conditions and trauma, frequently struggles to adequately address the multifaceted needs of older patients.⁵ ED environments can be challenging for older adults due to noise, pace, and potential communication barriers.⁶ Consequently, ED visits for older people are associated with a higher risk of adverse outcomes following discharge, including functional decline, unplanned hospital readmissions, institutionalization, and increased mortality.⁶ Studies indicate that a substantial proportion of older adults discharged from the ED experience functional decline within months, and many return to the ED within 30 days, often with the same presenting complaint, suggesting potential gaps in initial assessment or continuity of care.⁶ Furthermore, transfers from residential aged care facilities (RACFs) to EDs occur at significantly higher rates compared to older people living at home, reflecting the high care needs of this vulnerable group but also potentially indicating issues with care provision within RACFs or challenges in accessing alternative acute care pathways.⁷ These ED transfers can impose burdens on residents, increasing risks of delirium and hospital-acquired complications.⁷

Rationale for Report

The confluence of an ageing population, the unique complexities of geriatric presentations, and the limitations of standard ED care models underscores the critical need for evidence-based strategies to optimize emergency care for older adults.¹ Improving the quality, safety, and appropriateness of ED care for this population is essential not only for enhancing patient outcomes and experiences but also for ensuring the sustainability of healthcare systems.¹ Research priorities identified by emergency physicians and patients alike emphasize the need for improvements in areas such as medication management, falls prevention, delirium care, and discharge planning.¹ This report synthesizes the most current evidence (since April 2021) from Australia and New Zealand to inform practice, policy, and future research directions in geriatric emergency care.

Scope and Methodology

This report focuses on evidence published or released between April 2021 and the present day concerning interventions, models of care, clinical guidelines, official statements, research studies, and evaluations aimed at improving the care provided to older persons (generally ≥65 years, acknowledging the younger threshold for Aboriginal and Torres Strait Islander peoples ² and Māori ⁴) within, or directly impacting, EDs in Australia and New Zealand. The evidence reviewed encompasses systematic reviews and meta-analyses, clinical practice guidelines from relevant authorities (e.g., Australasian College for Emergency Medicine [ACEM], Australian & New Zealand Society for Geriatric Medicine, government health departments), evaluations of specific models (e.g., GEDI, CGA), strategies for managing key geriatric syndromes (delirium, falls, medication issues), approaches to discharge planning and communication, and reports from government or research institutions on relevant initiatives. A key objective is to compare approaches between Australia and New Zealand and synthesize findings into evidence-based recommendations.

3. Models of Geriatric Emergency Care in Australia and New Zealand

Overview

Recognizing the limitations of standard ED care for older adults, specialized models of geriatric emergency care have emerged globally and within Australia and New Zealand.¹⁰ These models aim to provide more comprehensive, person-centred care by incorporating principles such as targeted geriatric assessment, interdisciplinary teamwork, early intervention for geriatric syndromes, improved care coordination across settings, and enhanced discharge planning to prevent adverse outcomes.⁹ While various tailored geriatric-specific models exist internationally, such as the Acute Care for Elders (ACE) program adapted for EDs ¹¹, recent evidence from Australia and New Zealand highlights specific initiatives being implemented and evaluated locally.

Geriatric Emergency Department Intervention (GEDI) Model (Australia – QLD Focus)

Description: The Geriatric Emergency Department Intervention (GEDI) model, developed and trialled initially in Queensland, Australia, represents a significant local innovation.¹² It is characterized as a nurse-led, physician-championed intervention embedded within the ED structure.¹² Advanced practice nurses, typically with substantial experience in geriatrics (e.g., at least five years ¹³), form a subspecialty team that assists the primary ED clinicians.¹² Core components include:

• Frontloaded Geriatric Assessment: Rapid screening and assessment upon ED presentation, often using tools like the interRAI ED Screener to gauge physical and cognitive dependence as a proxy for frailty, helps prioritize patients.¹³ Priority groups include residents from aged care facilities, those with high frailty scores, and high-functioning older adults with potentially incapacitating injuries (e.g., hip fractures).¹³
• Multidisciplinary Shared Decision-Making: Facilitating collaboration between the patient, family/carers, ED clinicians, and the GEDI team to inform care plans.¹²
• Care Coordination: Initiating specialist referrals (internal and external) and improving communication pathways to facilitate appropriate and timely care progression, whether discharge or admission.¹²
• Targeted Population: Primarily focusing on frail older adults (often defined as ≥70 years) presenting to the ED.¹²
• Service Integration: Operating as a service managed within the ED, responsive to its timelines, but fundamentally acting as a ‘border spanning’ role to improve inter-disciplinary communication and transitions.¹²

Implementation Evaluation (QLD): Following its initial success, the GEDI model received funding for implementation in additional Queensland hospital EDs.¹² A multi-method evaluation examined this translation process in two sites.¹²

• Qualitative Findings: Interviews with staff revealed crucial factors influencing implementation.¹²Facilitators included the presence of passionate “grass roots” clinicians driving the change, general support for the GEDI concept, the adaptability of the model to local contexts, and the perceived utility of the provided implementation toolkit.¹² However, significant barriers emerged. Persistent challenges with resourcing and securing ongoing funding created uncertainty.¹² The planned structured support from experienced external facilitators was severely disrupted due to staffing constraints at the host site, leading to a lack of consistent mentoring and guidance for the new teams.¹² While adaptability was a strength, some adaptations (e.g., staffing the GEDI role with ED nurses lacking specific gerontology experience) were perceived as less effective, and the breakdown in facilitation meant these deviations weren’t adequately evaluated or addressed.¹² Staff turnover, including the loss of key champions, shifting priorities under new middle management less familiar with or supportive of the model, inconsistent physician champion involvement due to role changes, and a lack of clear fiscal accountability for the implementation funds further hampered progress.¹² Challenges in accessing and analyzing data for evaluation and insufficient orientation for some GEDI staff were also noted.¹²
• Quantitative Findings: Despite implementation challenges, the evaluation demonstrated successful translation of the GEDI model.¹³ At both implementation sites, compared to the pre-GEDI period or patients not seen by GEDI, the intervention was associated with an increased likelihood of patients being discharged home directly from the ED, decreased ED LoS, and reduced hospital costs for those patients who were admitted.¹³ There was also an associated reduction in the risk of all-cause in-hospital mortality within 28 days.¹³ Interestingly, patients seen by the GEDI team who were subsequently admitted tended to have a longer hospital LoS compared to those not seen by GEDI.¹³This finding, coupled with the GEDI team’s prioritization of patients with higher physical and cognitive dependency (higher frailty scores), suggests the model successfully targeted more complex patients requiring more intensive inpatient care, whose needs might otherwise have been underestimated.¹³The overall positive effects on discharge rates and ED LoS were, however, noted to be more subtle than those observed in the original single-site trial, likely reflecting the real-world complexities and barriers encountered during broader implementation.¹⁶

The detailed qualitative findings from the GEDI implementation study underscore that translating an evidence-based model into routine practice is a highly complex undertaking.¹² Success is heavily contingent not just on the model itself, but on critical contextual factors. Sustained funding, consistent leadership and managerial support, robust implementation facilitation (as intended by frameworks like i-PARIHS mentioned in the study ¹²), and maintaining fidelity to the model’s core principles are paramount. The adaptations made at the implementation sites highlight another critical aspect: while local tailoring is often necessary, modifications made without careful consideration or evaluation, particularly regarding staff expertise or core processes, risk diluting the intervention’s effectiveness.¹² This emphasizes the need for structured approaches to adaptation within implementation frameworks.

Comprehensive Geriatric Assessment (CGA) in ED Context

Principles: Comprehensive Geriatric Assessment (CGA) is a well-established multidimensional, interdisciplinary diagnostic process used to determine an older person’s medical, psychological, and functional capabilities to develop a coordinated care plan.¹⁷ While its benefits are well-documented for older inpatients ¹⁷, its application in the ED setting typically involves a more targeted approach, focusing on key domains relevant to the acute presentation and disposition planning.¹³ This targeted CGA is a core element within models like GEDI.¹³ The broader relevance of CGA is reflected in its use in preoperative settings ¹⁸and specific populations like older adults with cancer, for whom ANZSGM released a position statement in April 2023.²⁰

Community CGA Evidence: A 2022 Cochrane review examined the effectiveness of CGA delivered to frail, older people living in the community.¹⁷ Based on data largely preceding April 2020, the review found moderate-certainty evidence that community CGA probably leads to little or no difference in mortality or nursing home admission compared to usual care. It found low-certainty evidence that it may decrease the risk of unplanned hospital admissions. Crucially, the effect on ED visits was uncertain, with very low-certainty evidence.¹⁷

The weak or uncertain evidence regarding the impact of community-based CGA on ED utilization (based on pre-April 2020 data) contrasts with the premise of ED-embedded models like GEDI, which incorporate targeted CGA within the acute care pathway.¹³ This disparity suggests that the effectiveness of CGA in influencing acute care use likely depends heavily on the specific setting, timing, and integration of the assessment relative to the patient’s acute event and ED presentation. CGA delivered proactively in the community may have different impacts compared to CGA performed reactively within or immediately adjacent to the ED visit.

Frailty-Focused Initiatives

Concept: Frailty, characterized by reduced strength, endurance, and physiological reserve, leading to increased vulnerability to stressors and adverse health outcomes, is increasingly recognized as a critical geriatric syndrome relevant to ED care.⁴ Identifying frailty can help predict outcomes and guide appropriate care intensity and goals.⁴

NZ Frailty Care Guides (2023): The Health Quality & Safety Commission New Zealand (HQSC) released Frailty Care Guides in 2023.⁴ These guides emphasize the importance of standardized frailty assessment using recognized tools, recommending the Clinical Frailty Scale (CFS) for its ease of use and visual format helpful for discussing goals of care, and the FRAIL-NH tool for aged residential care settings.⁴ The guides highlight that frailty is multidimensional (physical, cognitive, social) and progressive, and importantly, note that Māori may experience frailty at a younger age, necessitating culturally appropriate assessment and care planning.⁴ Recommended interventions focus on physical activity, nutrition, medication review (polypharmacy), and optimizing chronic condition management.⁴ This national guidance signals a strategic focus in New Zealand on systematically identifying and managing frailty across care settings.

Australian Tools/Pathways: In Australia, frailty screening is also being incorporated into ED pathways. The GEDI model in Queensland utilizes the interRAI ED screener as a proxy measure for frailty to prioritize patients.¹³ Queensland Health provides resources on using the Clinical Frailty Scale to assess frailty level and predict outcomes like LoS and need for residential care.¹⁵ There is also exploration of roles for Advanced Nurse Practitioners (ANPs) in improving frailty identification.²⁴

Interface Services and Admission Avoidance Models

Several initiatives focus on the interface between the ED and other care settings (community, aged care) to prevent unnecessary ED presentations or facilitate smoother transitions.

Aged Care Emergency (ACE) Service (Australia – NSW): The ACE service in the Hunter New England and Central Coast regions of NSW is a nurse-led, multi-agency model specifically targeting residents of aged care facilities.²⁵ It provides 24/7 telephone triage, clinical support, and advice to RACF staff, aiming to manage acutely unwell residents within the facility where appropriate and avoid unnecessary hospital transfers.²⁵ Key components include agreed clinical pathways, emphasis on structured communication using ISBAR for handovers, and a strong focus on clarifying the resident’s goals of care before transfer is considered.²⁵ The service fosters a collaborative network between RACFs, GPs, ambulance services, and the hospital.²⁵ Reported outcomes include a significant (20%) reduction in ED transfers and hospital admissions from participating facilities, alongside improved communication and empowerment of RACF staff.²⁵ This model demonstrates the potential impact of providing proactive support and clear communication pathways at the RACF-ED interface before a transfer occurs, addressing potential root causes of avoidable presentations.²⁵

WACHS Older Patient Initiative (OPI) (Australia – WA Regional): The Western Australia Country Health Service (WACHS) operates the Older Patient Initiative (OPI) Program.³ This program targets older adults (≥65 years or ≥50 years for Aboriginal people) following an ED presentation. Identification occurs via an automated OPI Dashboard populated from ED data using eligibility criteria and trigger words, supplemented by referrals.³ With patient consent, the OPI team conducts a follow-up functional assessment (using the MR42A form) either by phone or face-to-face.³ Based on this assessment, the team coordinates care and makes referrals to community-based services and supports, aiming to prevent future avoidable ED presentations and hospital admissions.³ This initiative represents a strategy of proactive intervention afteran ED visit but before a potential re-presentation, using data-driven identification and focusing on community linkage, particularly suited to regional contexts.³

NZ Primary Care Admission Avoidance (Waikato): In the Waikato region of New Zealand, a Primary Health Organisation (PHO)-led initiative provides an alternative pathway for frail older adults experiencing an acute event that compromises their function but may not require hospital admission.²⁶ General Practitioners (GPs) can refer eligible patients (≥65 years, acute event, borderline function, unsafe for immediate discharge home) to a central triage coordinator.²⁶ This coordinator then links the patient to the most appropriate short-term community service, such as acute home-based support, respite care in a rest home, or the START rehabilitation service, utilizing Primary Options for Acute Care (POAC) funding.²⁶ This model empowers GPs with funded alternatives to ED referral, operating further upstream in the care pathway and leveraging primary care coordination.²⁶

Other Health Service Initiatives

Beyond these specific models, state and territory health services are implementing broader strategies and resources:

• Queensland Health: Provides ED-specific training modules on care of the older person, a clinical practice framework for trauma in older adults ¹⁵, and supports active research programs within hospitals like the Royal Brisbane and Women’s Hospital (RBWH). RBWH research since 2021 includes studies on delirium prevalence and care standards, frailty, fundamental care delivery (‘Eat Walk Engage’ program), incontinence outcomes, and ED end-of-life care for older people.²⁷ A statewide survey of hospital managers on how “older person friendly” Queensland hospitals are was also funded in 2023.²⁷
• SA Health (Southern Adelaide LHN): Explicitly lists dedicated ED/Acute Medical Unit (AMU) Older Persons Services as part of its integrated network of aged care services.²⁸
• NSW Health (Agency for Clinical Innovation – ACI): Provides resources such as a curated list of 55 screening and assessment tools for identifying cognitive and mental health needs in older people across the NSW Health system, covering domains like delirium, dementia, and depression.²⁹

Summary of Models

The table below summarises key evaluated or described geriatric ED models and initiatives in Australia and New Zealand based on evidence since April 2021.

Table 1: Summary of Selected Geriatric ED Models/Initiatives in AU/NZ (Evidence post-April 2021)

Model/Initiative	Location	Target Population	Key Features	Reported Outcomes/Focus (since Apr 2021)	Supporting Snippets
GEDI (Geriatric Emergency Dept Intervention)	QLD, Australia	Older adults (≥70yrs) presenting to ED, esp. frail, RACF residents	Nurse-led (geriatric expertise), physician-championed ED team; targeted geriatric assessment (interRAI); shared decision-making; care coordination (internal/external referrals); focus on safe disposition	Evaluation (2 sites): Increased discharge home, decreased ED LoS, decreased hospital costs (admitted), reduced 28-day mortality risk. Longer hospital LoS for complex patients seen. Implementation challenges identified (funding, facilitation).	15–12
ACE (Aged Care Emergency) Service	NSW, Australia	Residents of aged care facilities (RACFs) acutely unwell	Nurse-led, multi-agency; 24/7 phone triage/support for RACF staff; clinical pathways; ISBAR handover; goals of care focus; community of practice	Reported 20% reduction in ED transfers/admissions from RACFs; improved communication; RACF staff empowerment.	25
WACHS OPI(Older Patient Initiative)	WA Regional, AU	Older adults (≥65yrs, ≥50yrs Aboriginal) post-ED presentation, identified as at risk	Proactive identification (dashboard/referral); follow-up functional assessment (MR42A); care coordination; referral to community supports to prevent re-presentation	Program guideline outlines process for identification, assessment, and short-term care coordination to prevent future ED use.	3
Frailty Admission Avoidance (POAC)	Waikato, NZ	Frail older adults (≥65yrs) with acute event, borderline function, referred by GP	GP referral to triage coordinator; links patient to community support (home care, respite, rehab) as alternative to ED; uses POAC funding	Program description outlines GP-initiated pathway to avoid ED presentation by leveraging community services.	26
ED/AMU Older Persons Service	SA (SALHN), AU	Older adults presenting to ED/AMU	Dedicated service within ED/AMU as part of integrated aged care network	Service listed as part of LHN’s aged care provision.	28
NZ Frailty Care Guides	National, NZ	Older adults, particularly those with frailty	HQSC guidance; recommends standardized frailty assessment (CFS, FRAIL-NH); recognizes earlier onset in Māori; promotes multidimensional care planning (activity, nutrition, meds, chronic conditions)	National guideline promoting systematic approach to frailty identification and management.	4
QLD Health Geriatric Resources / RBWH Research	QLD, Australia	Older adults in ED/hospital	Training modules for ED staff; trauma framework; active research (delirium, frailty, fundamental care, EOL care); statewide survey on age-friendly hospitals	Provision of resources and active research programs aimed at improving care.	15
NSW ACI Cognitive/Mental Health Tools	NSW, Australia	Older adults within NSW Health	Curated list of 55 validated screening/assessment tools provided for clinical use	Resource provision to support standardized assessment.	29

4. Addressing Key Geriatric Syndromes in the ED

Introduction

Geriatric syndromes are multifactorial health conditions common in older adults that do not fit into discrete disease categories. They include conditions like delirium, falls, incontinence, frailty, and pressure injuries. These syndromes often share risk factors and can significantly impact an older person’s function and quality of life. Recognizing and managing these syndromes effectively in the ED is crucial, as they are often indicators of underlying illness or vulnerability and predictors of adverse outcomes. This section focuses on recent evidence (since April 2021) regarding the management of three key syndromes frequently encountered in Australian and New Zealand EDs: delirium, falls, and medication-related issues (including polypharmacy).

4.1 Delirium

Prevalence and Impact: Delirium, an acute change in mental state characterized by disturbances in attention, awareness, and cognition ², is a common and serious condition in older ED patients. Meta-analysis suggests an overall pooled prevalence of around 15.2% in geriatric ED patients.³¹ It is frequently under-recognized or misdiagnosed (e.g., as dementia) despite being a medical emergency.² Delirium is associated with significantly worse outcomes, including increased mortality, longer hospital LoS, higher rates of injurious falls, increased risk of subsequent institutionalization, and persistent cognitive and functional decline.³⁰ In Australia, delirium is the most common hospital-acquired complication (HAC) identified by the Australian Commission on Safety and Quality in Health Care (ACSQHC), occurring at a rate of 42.2 per 10,000 episodes in 2021-22, with associated costs estimated at $8.8 billion annually (in 2016-17).³⁰ Recent large-scale Australian hospital data further underscores the gravity of delirium, finding it to be a strong risk factor for both death (39% higher risk) and incident dementia (three times higher risk) over five years of follow-up.³³ This potential causal link between delirium episodes and subsequent dementia development elevates the importance of ED detection and management beyond addressing the acute event, positioning it as critical for potentially mitigating long-term cognitive decline.³³

Screening and Assessment: Early identification is paramount.

• Guidelines: The ACSQHC’s Delirium Clinical Care Standard (revised 2021) mandates identifying patients with key risk factors on presentation and using a validated tool to screen for cognitive impairment.³⁴ Health services are expected to have systems for risk identification within 24 hours of presentation.³⁴ The standard also requires prompt assessment using a validated tool by a trained clinician if cognitive impairment is present on arrival or if an acute change occurs during the hospital stay.³⁴ Local health districts, like South Eastern Sydney LHD (SESLHD) in NSW, have developed procedures to operationalize these standards, specifying local pathways and tools (e.g., Delirium Risk Assessment Tool and 4AT).² A proposed international delirium care pathway model, ‘STOP DELIRIUM’, also emphasizes spotting risk factors and planned cognitive assessments.³⁵
• Tools in Use/Mentioned: Several validated screening tools are mentioned in recent literature relevant to AU/NZ EDs:
  • 4AT: This brief tool is widely used and recommended in Australia and New Zealand.³³ Large UK studies demonstrate its feasibility for routine use at scale in emergency admissions (completion rates 49-77%).³⁶ Importantly, 4AT scores obtained in routine practice strongly predict key outcomes: scores ≥4 (possible delirium) were associated with 3.4-5.5 fold increased 30-day mortality, more than doubled LoS, and significantly reduced time spent at home in the year post-admission compared to scores of 0.³⁶ This elevates the 4AT beyond a simple detection tool to a valuable prognostic indicator usable from the point of ED admission. A recent study evaluated a similar tool, RMA (RADAR + Months Backwards + Acute change), finding it non-inferior to 4AT in research settings but noting challenges with staff adherence in routine practice.³⁸
  • CAM (Confusion Assessment Method): Used as a diagnostic reference in NZ research ³² and forms the basis of the widely used CAM-ICU for ventilated patients.³⁹
  • interRAI ED Screener: Used in the QLD GEDI model as a proxy for frailty, incorporating cognitive elements.¹³
  • DRAT (Delirium Risk Assessment Tool): Mentioned alongside 4AT in a NSW educational resource.³⁰
  • Other tools: Nu-DESC and bCAM are mentioned in US-based resources cited.⁴⁰
• Implementation Challenges: Despite mandates and available tools, achieving consistent screening remains challenging. A retrospective study in two NZ hospitals found that while integrating the 4AT into electronic admission forms was feasible, completion was often hindered by practical barriers.³⁷Common reasons for non-completion included reduced patient alertness (making assessment difficult), communication barriers (language, deafness, aphasia), clinical prioritization (addressing critical illness, managing symptoms, end-of-life care), the presence of pre-existing cognitive disorders, and unstructured assessment processes.³⁷ These findings suggest that successful implementation requires not just a mandate but also clear protocols and workflow integration to manage these common ED scenarios. Even in specialized settings like the ICU, adherence can be low; one Australian study found CAM-ICU assessments were performed in only 7.2% of instances where a RASS score indicated it was possible.³⁹ Nurse knowledge and perceived barriers (patient, individual, organizational factors) also influence assessment behaviours.⁴¹

Table 3: Comparison of Delirium Screening Tools Mentioned in Recent AU/NZ Literature (post-April 2021)

Tool Name	Description/Features	Mentioned Use/Context (AU/NZ)	Key Findings/Notes (since Apr 2021)	Supporting Snippets
4AT (4 ‘A’s Test)	Brief (4 items: Alertness, AMT4, Attention, Acute change); Score based (0, 1-3, ≥4)	Widely used/recommended in AU/NZ EDs & admission pathways; Mandated assessment in some NZ hospitals (≥75yrs); Used as reference in Australian study; Mentioned in NSW resources.	Feasible for routine use at scale; Scores strongly predict mortality, LoS, home time; Implementation barriers identified (patient factors, communication, workflow).	30
CAM(Confusion Assessment Method)	Diagnostic algorithm (4 features: acute onset/fluctuating, inattention, disorganized thinking, altered LoC)	Used as diagnostic reference in NZ Memory Service/hospital study.	Basis for CAM-ICU; Requires trained assessor based on interview/observation.	32
interRAI ED Screener	Rapid measure of physical & cognitive dependence (proxy for frailty)	Used in QLD GEDI model to screen and prioritize older ED patients.	Incorporates cognitive assessment as part of broader frailty screen.	13
DRAT(Delirium Risk Assessment Tool)	Not specified	Mentioned alongside 4AT in NSW educational presentation on delirium screening.	No specific evaluation data provided.	30
RMA(RADAR + MOYB + Acute)	Combines nurse-administered RADAR test + physician-administered Months Backwards test + check for acute change	Evaluated vs 4AT in an international study (not AU/NZ specific but cited).	Non-inferior to 4AT in research setting; Adherence challenges in routine practice noted.	38

Prevention and Management: Prevention is considered the most effective strategy.²

• Guidelines: The ACSQHC Standard emphasizes offering a set of preventative interventions to at-risk patients and regular monitoring.³⁴ SESLHD procedure outlines local implementation.² The HIGN protocol provides detailed non-pharmacological strategies targeting risk factors: optimizing cognition/orientation (clocks, calendars, communication), sensory input (glasses, hearing aids), sleep (noise reduction, routine), mobility (avoiding restraints/catheters, encouraging ambulation), hydration/nutrition, infection control, and medication management.⁴⁰ The STOP DELIRIUM model proposes a similar bundle approach.³⁵
• Evidence for ED Interventions: A 2022 systematic review specifically examined interventions initiated in the ED to prevent or treat delirium.⁴² It found that such trials are rare. Only four studies showed a significant impact: one RCT found melatonin reduced delirium incidence, and two studies (one non-RCT) on multi-factorial programs showed reductions in prevalence or incidence. A pooled analysis of three multifactorial programs suggested a benefit (OR 0.46).⁴² Crucially, one case-control study found that the use of ED Foley catheters was associated with an increased duration of delirium.⁴² This highlights the potential for common ED practices to be iatrogenic in this population and underscores the need for ED-specific evidence to guide practice, as interventions proven effective in other settings may not translate directly.
• Antipsychotic Use: While sometimes necessary for severe agitation posing safety risks, guidelines emphasize cautious use as a last resort after non-pharmacological strategies fail.⁴⁰ An Australian ICU audit found 17% of patients received antipsychotics (APMs) for suspected/diagnosed delirium, with quetiapine and haloperidol most common. Notably, over a third of those receiving APMs had not been screened for delirium, and 9% receiving APMs had screened negative, suggesting potential inappropriate use.³⁹

4.2 Falls

Scale of Problem: Falls are a major public health issue for older adults in Australia and New Zealand. They are the leading cause of unintentional injury hospitalisation and injury-related death among older Australians.⁴³ In Western Australia, falls account for 24% of injury hospitalisations and 35% of injury deaths.²² Falls are strongly linked with increasing age and frailty.²² Beyond physical injuries (fractures, head trauma), falls can lead to a debilitating fear of falling, reduced activity levels, loss of confidence and independence, social isolation, and potentially precipitate admission to residential aged care.⁴³

Risk Assessment: Identifying those at high risk is a key prevention step.

• Assessment Tools: Various tools are used in Australian clinical practice. The Victorian Department of Health highlights the Falls Risk Assessment Tool (FRAT), a three-part tool including risk status screening, a risk factor checklist, and an action plan.⁴³ They also describe the Falls Risk for Older People: Community Setting (FROP-Com) tool and its shorter version, the FROP-Com Screen. The FROP-Com Screen uses three items to predict falls risk over 12 months and has shown moderate ability to predict falls in older people presenting to an ED after a fall.⁴³
• Predictive Models: While assessment tools are used, recent evidence casts doubt on the clinical utility of more complex falls risk prediction models for hospitalized older adults.⁴⁶ A 2024 systematic review examining 13 such models concluded that due to a high risk of bias across all included studies ( stemming from issues like retrospective design, lack of blinding, inadequate statistical analysis, and lack of robust external validation), none could be recommended for clinical use at present.⁴⁶ Common predictors identified in these models included mobility issues, fall history, specific medications, and psychiatric disorders.⁴⁶ One model included ‘Admission to emergency department’ as a predictor.⁴⁶This distinction between clinical assessment tools (like FRAT, FROP-Com) used to guide multifactorial assessment and complex predictive algorithms is important; while tools can aid clinical judgment, current evidence does not support relying on the scores generated by these unvalidated models for clinical decision-making.⁴⁶

Prevention Strategies: Evidence strongly supports a multifactorial approach, tailoring interventions to individual risk factors.²²

• Key Interventions: Effective strategies identified in guidelines and reviews include:
  • Exercise: Programs targeting balance and strength are crucial. Tai Chi and specific programs like the Otago Exercise Programme are often recommended.⁴³ General brisk walking may not be sufficient for high-risk individuals.⁴⁵ NZ promotes community strength and balance classes (‘Live Stronger for Longer’) and the Nymbl balance app.⁴⁷
  • Medication Review: Reducing or withdrawing psychoactive medications is effective.⁴³Polypharmacy management is key.
  • Vision: Regular eye checks and appropriate spectacle use are important. Cataract surgery can reduce falls.⁴³ Bifocals may increase risk.⁴⁷
  • Home Safety: Assessing and modifying the home environment to remove hazards (e.g., clutter, poor lighting, loose rugs) and install safety features (e.g., grab bars) is recommended.⁴³Occupational therapist-led home visits are effective.⁴³
  • Vitamin D/Calcium: Supplementation is effective in reducing falls and fractures, particularly for those with deficiency or in residential care.⁴³
  • Other Factors: Managing underlying medical conditions (e.g., cardiovascular issues ⁴⁸, incontinence ⁴⁵), ensuring safe footwear ⁴⁷, and limiting alcohol ⁴⁷ are also important.
• Patient Education in Hospital: Educating hospitalized patients about their fall risk and prevention strategies is considered essential.⁴⁹ Studies have explored using structured approaches like scripted conversations combined with brochures.⁴⁹ However, successful implementation requires empowering patients, ensuring health professionals have effective tools and training, fostering interprofessional collaboration, and overcoming barriers such as time constraints and organizational factors.⁴⁹ A patient-centred approach engaging patients in decision-making is crucial for adherence.⁵⁰

Policy and Implementation:

• Australian Policy Gap: A 2024 analysis highlighted the absence of a dedicated national policy framework specifically for preventing falls in older adults in Australia, despite falls being a major public health issue.⁴⁴ Existing policy documents touching on falls were found within broader aged care or health strategies, suggesting falls may not be prioritized as a distinct public health problem requiring dedicated policy resources.⁴⁴ The Australian and New Zealand Falls Prevention Society (ANZFPS) has called for urgent national action.⁵¹ This lack of a cohesive national strategy may contribute to fragmented efforts and inadequate resourcing for prevention across jurisdictions.⁴⁴
• International Policy Quality: A systematic scoping review of international falls prevention policies (2005-2020) found significant deficiencies.⁵² Many policies lacked key components deemed necessary for effectiveness according to WHO and NZ government frameworks, such as quantified objectives, prioritized interventions based on evidence, dedicated budgets, ministerial approval, and robust monitoring and evaluation plans.⁵² This suggests a potential disconnect between policy intent and effective implementation globally.
• Hospital Implementation Challenges: Implementing falls prevention effectively in acute hospital settings (relevant for patients post-ED admission) faces hurdles beyond just having guidelines.⁵³ A UK realist investigation identified challenges related to leadership roles (senior nurses vs. link practitioners), difficulties in truly sharing responsibility beyond nursing staff due to supervision demands, staff perceptions of assessment tools (e.g., viewing them as audit requirements rather than practice aids), and insufficient time or processes for meaningful patient participation and education.⁵³ These organizational and cultural factors likely resonate in Australian and New Zealand hospitals and indicate that successful implementation requires a systems approach addressing leadership, teamwork, workflow integration, and patient engagement strategies.⁵³

Table 4: Falls Risk Assessment Tools Mentioned in Recent AU/NZ Literature (post-April 2021)

Tool Name	Description/Features	Mentioned Use/Context (AU/NZ)	Key Findings/Notes (since Apr 2021)	Supporting Snippets
FRAT (Falls Risk Assessment Tool)	3 parts: Risk status screen, Risk factor checklist, Action plan	Highlighted by VIC Health for hospital use.	Standardized tool for guiding multidisciplinary interventions.	43
FROP-Com(Falls Risk for Older People: Community Setting)	Assessment tool for community settings.	Highlighted by VIC Health for community use.	Guidelines include scoring and intervention options.	43
FROP-Com Screen	Short version of FROP-Com (3 items).	Highlighted by VIC Health; use in community or ED post-fall.	Moderate ability to predict falls in older people presenting to ED after a fall. High reliability.	43
(Generic Multifactorial Assessment)	Not a specific tool, but a process.	Recommended approach in guidelines and reviews.	Key components: falls history, medication review, physical exam (gait/balance), assessment of various risk factors (vision, cognition, continence, environment etc.).	22
(Predictive Models – Various)	Complex algorithms using multiple variables to predict risk.	Subject of systematic review (international studies).	Systematic review (2024) found current models have high risk of bias and lack validation; not recommended for clinical usecurrently.	46

4.3 Medication Management (Polypharmacy, Reconciliation, Review)

The Problem: Suboptimal medication management is a major concern for older adults, particularly during transitions of care involving the ED. Polypharmacy, commonly defined as the concurrent use of five or more medications, is highly prevalent, affecting a large proportion of older adults ⁵⁴ and reaching rates over 90% in hospitalized people with dementia.⁵⁷ While polypharmacy itself isn’t inherently harmful and may be necessary for managing multimorbidity ⁵⁸, it significantly increases the risk of adverse drug events, medication errors, non-adherence due to complex regimens, harmful drug interactions, and the use of potentially inappropriate medications (PIMs) ⁵⁹-.⁵⁶ These issues contribute to poor clinical outcomes, including falls, confusion, functional decline, and increased healthcare utilization (e.g., ED visits, hospital admissions).⁵⁹ Medication-related errors are a substantial burden, contributing to over 250,000 hospital admissions annually in Australia at an estimated cost of $1.4 billion.⁶² It is also important to note that while polypharmacy and multimorbidity often co-occur, they are distinct concepts; many individuals with multimorbidity do not have polypharmacy, although polypharmacy almost always occurs in the context of multimorbidity.⁵⁴

Medication Reconciliation:

• Definition and Importance: Medication reconciliation is the formal, systematic process of creating the most accurate list possible of all medications a patient is currently taking (Best Possible Medication History – BPMH) and comparing this list against the physician’s admission, transfer, and discharge orders.⁶⁰ The goal is to identify and resolve any unintended discrepancies (e.g., omissions, duplications, dosing errors, interactions) and document any intentional changes.⁶⁰ This process is crucial for preventing medication errors that commonly occur during transitions of care.⁶²
• Mandated Practice (AU/NZ): Recognizing its importance for patient safety, medication reconciliation is a core action mandated by national safety and quality standards in both countries. In Australia, it falls under the National Safety and Quality Health Service (NSQHS) Standard 4 – Medication Safety.⁶³ In New Zealand, it is mandated by the Health Quality & Safety Commission (HQSC) Standards for Medicines Reconciliation.⁶⁴
• Key Transitions: The process is critically important at multiple points of transition involving the ED, including admission to hospital from the community or aged care, transfer from the ED to inpatient wards or intensive care, and discharge from the ED or hospital back to home or other care settings.⁶⁰
• Process: Obtaining an accurate BPMH involves interviewing the patient and/or their family/carer, asking about current medications (including over-the-counter and complementary therapies), dosing schedules, indications, allergies, and past adverse reactions.⁶⁰ This information should be confirmed using multiple sources, such as the patient’s own medications, medication lists, GP records, community pharmacy dispensing history, and information from other health services.⁶⁰ The reconciliation step involves meticulously comparing the BPMH to newly written medication orders, identifying discrepancies, discussing them with the prescriber, and documenting the resolution or rationale for changes.⁶⁰Western Australia utilizes a standardized WA Medication History and Management Plan (WA MMP) tool to support this process.⁶³
• Effectiveness: Evidence indicates that medication reconciliation, particularly when led by pharmacy staff (pharmacists or trained technicians), is effective in reducing medication discrepancies and errors at admission and discharge.⁶² Comprehensive programs that include reconciliation at discharge coupled with post-discharge follow-up have shown reductions in adverse drug event-related hospital revisits, ED visits, and readmissions.⁶²
• Implementation Challenges: Despite mandates and proven benefits, ensuring complete and timely reconciliation can be challenging in busy clinical environments. A quality improvement project in a NZ hospital found that while pharmacists were identifying discrepancies, the crucial step of getting junior doctors to review, rectify, and formally document the reconciliation was often missed (initial completion rate of 0%).⁶⁴ Interventions focused on improving communication (e.g., standardized notification labels, direct text messaging to doctors) significantly improved the rate of completed reconciliations (to 37%) and pharmacist uptake of texting (to 88%).⁶⁴ This highlights that a major bottleneck often lies in closing the loop – ensuring physician review and sign-off occurs after discrepancies are identified. Systems improvements and streamlined communication pathways are needed to address this gap between identification and documented resolution.⁶⁴ Timely completion, ideally within 24 hours of admission, is also crucial to prevent in-hospital adverse events.⁶²

Medication Review and Deprescribing: Beyond ensuring accuracy through reconciliation, optimizing medication regimens often involves medication review and deprescribing (the planned cessation of inappropriate medications).

• Pharmacist Role: Pharmacists play a key role. Evidence supports pharmacist-led medication review services post-discharge in reducing medication-related problems (MRPs) and subsequent ED visits.⁶²Pharmacist involvement in medication reconciliation and review during hospital admission for people with dementia was associated with reductions in PIMs and anticholinergic burden at discharge in one Australian study, although differences between intervention and control sites were not significant.⁵⁷
• Targeting Interventions: Identifying patients most likely to benefit from review and deprescribing is important. This might involve considering medication complexity (using tools like the Medication Regimen Complexity Index developed in Australia ⁶⁵) rather than just the number of medications. However, one study suggested that patients taking a moderate number of medications (5-9) might derive particular benefit from medication changes in terms of reduced ED visits and readmissions.⁵⁹Key targets for deprescribing often include specific classes of PIMs, identified using explicit criteria (e.g., Beers Criteria, STOPP/START) or implicit judgment, and medications contributing to high anticholinergic or sedative load (quantified using tools like the Drug Burden Index).⁵⁷
• Deprescribing Challenges: Implementing successful deprescribing interventions can be difficult. A significant recent pragmatic randomized controlled trial (RCT) conducted in New Zealand tested a pharmacist-led intervention targeting frail older adults in the community.⁶¹ Pharmacists reviewed medications and provided specific deprescribing recommendations for anticholinergic/sedative drugs (based on DBI) to the participants’ GPs. However, the intervention failed to demonstrate any reduction in DBI score compared to usual care at 6 months, across all levels of frailty.⁶¹ This important negative finding suggests that simply providing passive recommendations from a pharmacist to a GP may be insufficient to overcome clinical inertia or other barriers to deprescribing high-risk medications in this vulnerable population. The study authors suggest that implementation science principles need to be considered, pointing towards the need for more active, collaborative, multi-component, or patient-centred deprescribing strategies rather than relying solely on informing the prescriber.⁶¹
• IT Support for Targeting: Technology offers potential solutions for identifying patients for review. A primary care information technology tool called PolyScan has been developed and validated in New Zealand.⁵⁸ PolyScan uses algorithmic logic applied to routinely collected health data (hospital records, pharmaceutical claims) to identify older adults (≥65 years) with polypharmacy who also meet criteria for potentially inappropriate prescribing based on 21 indicators adapted from NZ PIM criteria. Validation against manual record review showed 100% accuracy in identifying individuals meeting indicators.⁵⁸Such validated IT tools can efficiently screen large populations, enabling targeted allocation of resources for medication reviews (e.g., GP-initiated Home Medicines Reviews in Australia ⁶⁰, clinical pharmacist reviews) to those at highest risk, potentially overcoming limitations of manual identification processes.⁵⁸
• Patient Education and Communication: Effective medication management requires clear communication. Patients and carers need education before discharge covering medication lists, correct usage, potential side effects, missed dose instructions, and when to seek advice.⁶⁰ Providing written information and assessing the patient’s ability to manage their regimen (potentially via in-hospital trials or post-discharge outreach pharmacy services where available) is important.⁶⁰ Crucially, clear communication with the patient’s GP upon discharge is essential, detailing medication changes, reasons for changes, required follow-up, and explicitly recommending HMRs if appropriate.⁶⁰ Intraprofessional communication activities, like the medication review task undertaken by medical students and GP supervisors in NZ, can foster reflection on prescribing practices beyond simply choosing a drug, emphasizing polypharmacy risks and deprescribing opportunities.⁶⁶

Table 5: Key Medication Management Strategies and Evidence (post-April 2021)

Strategy	Description	Key Evidence/Guidance (AU/NZ, post-Apr 2021)	Supporting Snippets
Medication Reconciliation	Formal process of creating BPMH, comparing to orders, resolving discrepancies at transitions.	Mandated by NSQHS St 4 (AU) & HQSC Stds (NZ). Reduces errors/discrepancies. Pharmacist-led effective. Crucial at ED admission/transfer/discharge. WA MMP tool used. Implementation challenge: completing doctor review/sign-off loop.	60
Pharmacist-led Medication Review (Post-discharge)	Pharmacist reviews medication regimen after hospital discharge.	Effective for reducing MRPs and ED visits.	62
Pharmacist-led Medication Review (Inpatient – PWD)	Pharmacist reconciliation & review during admission for people with dementia.	Associated with reduced PIMs & anticholinergic burden at discharge (though no significant intervention vs control difference in one study).	57
Targeted Deprescribing Recommendations (Pharmacist to GP)	Pharmacist identifies PIMs (e.g., high DBI) & sends recommendations to GP.	Ineffective in NZ RCT for reducing DBI load in frail older community dwellers. Suggests passive approach insufficient.	61
IT-based Patient Identification (PolyScan)	Algorithm uses health data to identify older adults with polypharmacy + PIM indicators.	Validated NZ tool; 100% accuracy vs manual review. Enables targeted allocation of review resources in primary care.	58
Medication Complexity Assessment (MRCI)	Tool to quantify medication regimen complexity beyond just pill count.	Developed in Australia; helps identify regimens posing adherence risks.	65
Patient/Carer Medication Education	Providing clear verbal/written info on meds, use, side effects, follow-up before discharge.	Essential component of safe discharge planning.	60
GP Communication at Discharge	Detailed handover to GP including med changes, reasons, follow-up needs, HMR recommendation.	Critical for continuity of care post-discharge.	60

5. Optimizing Care Transitions: Discharge Planning and Communication

Importance: Transitions of care, particularly discharge from the ED or hospital, represent periods of high vulnerability for older adults.⁶² Effective discharge planning is the critical link between hospital treatment and ongoing care in the community.⁸ However, reviews indicate that hospital discharges often suffer from insufficient planning, poor patient instruction, inadequate information sharing, lack of coordination among providers, and poor communication between hospital and community services.⁸ These deficiencies are particularly problematic for older adults, who may have complex ongoing needs ⁶⁷, and for their care partners, especially those supporting persons living with cognitive impairment (PLWCI) who face unique challenges navigating post-ED care.⁶⁸

Patient/Carer Perspectives: Understanding the lived experience of discharge is crucial for identifying areas for improvement.

• Older Adult Experience: Qualitative research interviewing older adults after ED discharge reveals significant dissatisfaction and challenges.⁶⁷ Patients often perceive the discharge process as abrupt and lacking adequate explanation regarding their symptoms, the cause of their problem, or the results of tests performed in the ED.⁶⁷ Discharge paperwork is frequently described as cumbersome, lengthy, and unhelpful, sometimes containing conflicting instructions that create uncertainty.⁶⁷ Accessing timely follow-up appointments with their usual clinicians can be a barrier.⁶⁷ Many express a desire for a follow-up phone call from the ED or hospital to check on their progress and answer questions.⁶⁷ The lack of clear guidance leaves patients feeling they need to infer next steps and take charge of navigating their own follow-up care, often leading to anxiety and fear, particularly regarding new physical limitations or symptom recurrence.⁶⁷ These findings point to a substantial gap between the information and support older patients need during the discharge transition and what is typically provided by EDs.⁶⁷
• Care Partner Experience (PLWCI): Care partners of PLWCI face additional hurdles during ED discharge transitions.⁶⁸ Qualitative interviews with care partners identified four major barriers: unique care considerations for the PLWCI while in the ED impacting the transition; poor communication and lack of engagement from ED staff during the discharge process; feeling unprepared to manage the complex care needs (medical, functional, social) of the PLWCI after returning home; and experiencing significant emotional and physical burden associated with managing the post-ED care transition.⁶⁸ This highlights that the ED discharge process often fails to adequately involve, prepare, or support essential informal caregivers, particularly for vulnerable patient groups like PLWCI, placing considerable strain on them during a critical period.⁶⁸

Components of Effective Discharge Planning: Evidence suggests that comprehensive, structured discharge planning tailored to the individual can improve outcomes for older people, potentially reducing LoS and readmissions, although impacts on mortality and overall health status remain less certain.⁸ Key components include:

• Structured Process: Discharge planning should be an interdisciplinary process involving early identification of needs, assessment, collaborative goal setting, planning, implementation, coordination, and evaluation.⁸ Models involving specialized discharge planners or case coordinators may be employed.⁸ Research indicates structured planning is more effective than informal approaches for older adults.⁸
• Communication Strategies: Effective communication is paramount, requiring clinicians to adapt their approach to accommodate potential sensory (vision, hearing), cognitive, speech, or cultural/linguistic diversity among older patients.⁶⁹ Strategies include ensuring patients have access to and use their glasses and hearing aids, using alternative communication methods or aids if speech is impaired, and involving interpreters when needed.⁶⁹ For patients with cognitive impairment, using positive approaches, addressing the person directly, allowing time for expression, and involving family/carers (who often have valuable insights) is crucial.⁶⁹ Specific communication techniques like using teach-back methods to confirm understanding of instructions (e.g., new prescriptions, reasons to return to ED) ⁶⁷, providing clear, geriatric-friendly written materials (e.g., large font) ⁶⁷, and explicitly summarizing test results and linking them back to the patient’s presenting complaint are recommended.⁶⁷ Innovative approaches like ‘Care Transfer Video’, where ward round discussions are recorded for patients to review later with family or GPs, have been trialled in Victoria to aid recall and communication.⁶⁹Establishing and clearly communicating goals of care is also vital, particularly when transferring from settings like aged care.²⁵ Structured handover tools like ISBAR should be used consistently between providers and settings.²⁵
• Patient/Family Engagement: Moving beyond simply informing patients, effective discharge planning requires genuine shared decision-making and partnership with the older person and their family/carers (as appropriate).⁶⁹ While hospitals may implement various ‘best practice’ discharge interventions, studies suggest more work is needed to truly engage patients and families as active team members in the planning process, rather than passive recipients of information.⁷¹ This requires a cultural shift towards viewing patients and families as collaborators in care.⁷¹
• Coordination: Seamless transitions depend on effective coordination between the ED/hospital and subsequent care providers.⁸ This involves clear communication pathways with primary care (GPs) and community services.⁶⁰ Specialized roles, such as Geriatric Emergency Management (GEM) nurses involved in creating care transition plans ¹⁴, and interface services like NSW’s ACE service ²⁵, play a crucial role in bridging gaps. Proactive post-discharge follow-up, as seen in WA’s OPI program ³ or pharmacist-led medication reviews ⁶², can also enhance coordination and prevent downstream problems.

Role of Specific Models/Initiatives: Many of the specialized models discussed earlier (Section 3) explicitly aim to improve care transitions. GEDI nurses focus on assessment and coordination to facilitate safe discharge or admission.¹² The ACE service directly addresses the RACF-ED transition through improved communication and support.²⁵ The WACHS OPI program targets post-ED follow-up to ensure linkage with community support.³ These models recognize that optimizing transitions is integral to improving overall geriatric emergency care outcomes.

6. Guiding Frameworks: Recent Systematic Reviews and Clinical Guidelines

Synthesizing higher-level evidence from recent systematic reviews and key clinical guidelines provides a broader perspective on the current state of knowledge and recommended practices for geriatric emergency care in Australia and New Zealand since April 2021.

Synthesis of Recent Systematic Reviews (post-April 2021): Several systematic reviews published since April 2021 have examined interventions and issues relevant to older adults in the ED:

• Overall ED Interventions: Two reviews assessed the effectiveness of various interventions initiated in the ED for older adults.⁵ Both concluded that the evidence base is limited, with low to moderate quality studies and significant heterogeneity making firm conclusions difficult.⁵ While some specific interventions like care coordination with additional support, early assessment, and transitional care interventions showed potential promise in some studies, many interventions failed to consistently demonstrate significant improvements in key outcomes such as ED revisits, hospitalizations, LoS, costs, or functional decline.⁵ One review explicitly suggested that the lack of impact on revisits might imply many are unavoidable manifestations of frailty and disease progression, suggesting efforts should also focus outside the ED.⁵ The collective findings from these reviews temper expectations about the impact of interventions solely initiated and contained within the ED. They imply that substantially improving outcomes for this complex population likely requires more comprehensive strategies that extend beyond the ED encounter itself, focusing on better integration with community services, addressing underlying frailty, and improving care transitions.⁵ Furthermore, the recurring issue of low study quality and high risk of bias identified in these reviews ⁵, as well as in reviews focusing on specific areas like falls prediction models ⁴⁶, significantly hampers the ability to draw definitive conclusions and underscores the need for more rigorous research in geriatric emergency care.
• ED End-of-Life (EOL) Care: A large retrospective cohort study using data from 177 hospitals in Australia and New Zealand (data from 2018, published 2024) examined deaths occurring within 48 hours of ED presentation for people aged ≥65.¹ It found a 48-hour mortality rate of 6.43 per 1,000 ED presentations, with over a quarter (28.1%) dying within the ED itself.¹ Notably, about 26% of those who died had been triaged into less urgent categories (ATS 3-5), highlighting challenges in recognizing imminent death in older ED patients.¹ Factors associated with dying in the ED included arrival by ambulance and higher acuity triage categories, but also younger age within the cohort (65-74 years).¹The study supports recommendations for national advance care planning registers and suggests a review of triage systems with an older person-focused lens.¹
• Early Warning System (EWS) Scores: A systematic review and meta-analysis assessed the predictive ability of common EWS scores (NEWS, MEWS, RAPS, CART) applied in ED or prehospital settings.⁷³It found that these scores performed better at predicting in-hospital deterioration (ICU admission, short-term mortality) when applied in the ED setting compared to the prehospital setting. However, their ability to predict longer-term (30-day) mortality was limited, particularly when used prehospital.⁷³
• Delirium Prevalence: A meta-analysis focusing on delirium in geriatric ED patients confirmed its high prevalence, estimating an overall pooled rate of 15.2%.³¹
• Delirium ED Interventions: As previously discussed (Section 4.1), a systematic review found limited high-quality evidence supporting specific ED-initiated interventions for delirium prevention or treatment, though multifactorial programs and potentially melatonin showed some promise.⁴² It also highlighted the potential harm of routine Foley catheter use in the ED for this population.⁴²
• Community CGA: As noted (Section 3), the 2022 Cochrane review on community-based CGA (using pre-April 2020 data) found low-certainty evidence for reduced hospital admissions but uncertain effects on ED visits.¹⁷
• Falls Prediction Models: As detailed (Section 4.2), the 2024 systematic review concluded that current prediction models for falls in hospitalized older adults suffer from high risk of bias and lack sufficient validation for clinical use.⁴⁶

Key Clinical Guidelines and Standards (post-April 2021):

• ACSQHC Delirium Clinical Care Standard (Australia, 2021): This national standard provides evidence-based quality statements covering the prevention, identification, assessment, and management of delirium in hospital settings, including specific indicators for health services.³⁴ It emphasizes early risk identification and screening on presentation, preventative interventions, patient/family engagement, prompt assessment with validated tools, identifying underlying causes, and planning for transition from hospital.³⁴ Its principles are directly applicable to the ED setting.³⁴
• ACEM Geriatric Emergency Medicine (GEM) Network Resources (Australia/NZ): While ACEM’s core policies on elderly care (P51) and EOL care (P455) predate April 2021, the GEM Network continues to be active, promoting quality care, education, and research.²³ Since 2021, they have highlighted resources including an Acute Geriatric series in EMA covering topics like delirium, frailty, falls, RACF transfers, and EOL care.²³ They also promote webinars and external resources like Geri-EM and ED Dementia Care Training.²³ The network serves as a liaison group advising ACEM on geriatric issues and collaborates with ANZSGM.²³ Recent articles in ACEM’s YourED publication discuss GEM initiatives and research trends.²³
• ANZSGM Position Statements (Australia/NZ): Since April 2021, ANZSGM has released relevant position statements, including a revision on Abuse of the Older Person (Oct 2022) and a new statement on Comprehensive Geriatric Assessment in Older Adults with Cancer (Apr 2023).²⁰ While not ED-specific, these inform geriatric practice broadly.
• HQSC Frailty Care Guides (NZ, 2023): These guides provide specific recommendations for identifying and managing frailty in older New Zealanders, including guidance on assessment tools (CFS, FRAIL-NH), recognizing disparities for Māori, and multidimensional care planning.⁴ They also include guidance on recognizing and responding to acute deterioration in frail older people, relevant for ED and pre-hospital settings.⁷⁰
• State/LHD Guidelines & Resources (Australia): Various Australian states provide resources. QLD Health offers ED training modules and frailty resources.¹⁵ NSW ACI provides curated lists of cognitive assessment tools.²⁹ SESLHD (NSW) has a detailed procedure for delirium prevention and management.² VIC Health provides extensive online resources on falls prevention, including tool guidance (FRAT, FROP-Com) ⁴³, and medication management for older people in hospital, covering BPMH, reconciliation, and discharge communication.⁶⁰ WA Health provides guidance on medication reconciliation (including the WA MMP tool) ⁶³ and falls prevention strategies.²² The WACHS OPI program guideline details processes for that specific initiative.³
• Medication Safety Guidance (Australia): The ACSQHC provides resources related to NSQHS Standard 4, including an evidence briefing on strategies for safer medication management at transitions of care (covering reconciliation, pharmacist charting, post-discharge reviews).⁶² The Australian Government Department of Health has released a handbook of tools to support medicine management in multimorbidity and polypharmacy, including the MRCI.⁶⁵

7. Comparison of Approaches: Australia vs. New Zealand

Based on the evidence reviewed since April 2021, both Australia and New Zealand demonstrate a clear recognition of the need to improve ED care for older adults and are actively pursuing various strategies. However, some differences in emphasis and approach emerge.

Common Themes and Strategies:

• Focus on Geriatric Syndromes: Both countries prioritize addressing key syndromes like delirium, falls, and polypharmacy. Delirium screening and prevention are guided by national standards (ACSQHC in AU ³⁴, implied in NZ frailty/deterioration guides ⁴) and local implementation efforts. Falls prevention emphasizes multifactorial assessment and interventions, drawing on similar evidence bases.⁴³Medication safety, particularly reconciliation at transitions, is mandated by national quality bodies in both countries.⁶³
• Specialized Roles and Models: Both utilize specialized nursing roles (e.g., GEDI nurses in QLD ¹², ACE nurses in NSW ²⁵, GEM nurses cited in Canadian context but relevant ¹⁴) and geriatrician input, often incorporating principles of targeted CGA.¹³
• Frailty Recognition: Frailty is increasingly recognized as a key concept guiding assessment and care planning in both nations.⁴
• Interface Care: Both countries have initiatives targeting interfaces between ED and other settings (e.g., ACE in NSW ²⁵, WACHS OPI in WA ³, Waikato POAC admission avoidance in NZ ²⁶).
• Research Activity: Active research into geriatric emergency care, including models of care, specific conditions (delirium, falls, EOL care), and medication management, is evident in both countries.¹
• Professional Collaboration: Bodies like ACEM and ANZSGM operate across both countries, facilitating shared standards, education (GEM Network ²³), and advocacy.⁷⁴ Joint research is also conducted.¹

Differences in Emphasis or Approach:

• Evaluated ED-Specific Models: Australia (specifically Queensland) has formally evaluated and published on the implementation of a specific ED-embedded model (GEDI) since 2021, providing detailed insights into its effectiveness and implementation challenges.¹² While NZ likely has local ED initiatives, similar large-scale published evaluations of specific NZ ED models were not prominent in the reviewed evidence post-April 2021.
• National Frailty Guidance: New Zealand has published clear national Frailty Care Guides (2023) from its Health Quality & Safety Commission, providing standardized recommendations for assessment and management, including explicit consideration of Māori health equity.⁴ While frailty is addressed in Australia, similar recent, dedicated national-level clinical guidance specifically on frailty assessment and management across settings was less evident in the reviewed materials.
• Primary Care Admission Avoidance: The Waikato PHO initiative in NZ represents a distinct model focused on empowering primary care (GPs) to divert appropriate frail older patients from the ED via a structured triage and community support pathway, utilizing specific funding mechanisms (POAC).²⁶While Australia has interface services (ACE, OPI), this specific GP-initiated, PHO-coordinated admission avoidance model appears unique in the reviewed evidence.
• IT Tools for Medication Review: New Zealand research has specifically developed and validated an IT tool (PolyScan) using routinely collected data to identify older adults with polypharmacy and PIMs for targeted review in primary care.⁵⁸ While Australia uses IT in health, evidence for a similar validated, nationally-focused tool for this specific purpose was not identified in the review period.
• National Falls Policy: Australia has an identified gap regarding a dedicated national falls prevention policy framework ⁴⁴, whereas international reviews (including NZ frameworks) inform discussions on policy quality.⁵²
• State vs. National Initiatives: Much of the specific program implementation evidence in Australia comes from state-level initiatives (QLD GEDI, NSW ACE, WA OPI, SA Older Persons Service, VIC resources) ³, reflecting its federated health system. New Zealand evidence includes national guidelines (HQSC Frailty/Deterioration Guides ⁴) and PHO-level initiatives ²⁶, alongside DHB/Te Whatu Ora level research and implementation.³²

Persistent Challenges: Despite progress, both countries face common challenges:

• Funding and Sustainability: Securing ongoing, dedicated funding for specialized geriatric ED services and interface programs remains a barrier.¹²
• Implementation Fidelity and Adaptation: Effectively translating models like GEDI into diverse settings while maintaining core components is difficult.¹² Balancing fidelity with necessary local adaptation requires careful management.¹²
• Workforce: Recruiting and retaining staff with geriatric expertise (nurses, physicians, allied health) for ED and related roles is challenging.¹² Ensuring adequate training for existing ED staff in geriatric principles is ongoing.⁴¹
• Data Integration and Use: Accessing, integrating, and utilizing data effectively for risk stratification (e.g., frailty, delirium risk), care coordination (e.g., shared care plans), and evaluation remains complex.¹²
• ED-Community Interface: Effectively bridging the communication and coordination gap between busy EDs and fragmented primary/community/aged care services is a persistent hurdle.⁸
• Evidence Quality: As noted, the evidence base for many interventions is limited by study quality and heterogeneity, making it difficult to definitively recommend specific approaches.⁵

8. Synthesis: Evidence-Based Practices, Innovations, and Recommendations

Synthesizing the evidence from Australia and New Zealand since April 2021 reveals several key evidence-based practices, innovations, and recommendations for enhancing ED care for older persons.

Current Evidence-Based Practices and Innovations:

1. Specialized Geriatric ED Models: Models like Queensland’s GEDI, incorporating nurse-led geriatric assessment, multidisciplinary input, and care coordination within the ED, demonstrate potential to improve outcomes (discharge rates, ED LoS, costs, mortality).¹³ However, their success hinges on addressing complex implementation factors like funding, leadership, facilitation, and fidelity.¹²
2. Interface Services: Proactive services bridging the gap between EDs and aged care facilities (e.g., NSW ACE) or community settings (e.g., WACHS OPI, NZ Waikato POAC) are effective strategies. Supporting RACFs pre-transfer ²⁵, proactive post-ED follow-up ³, and empowering primary care with alternatives ²⁶ can reduce avoidable ED presentations and improve care coordination.
3. Systematic Delirium Screening: Routine screening for delirium on ED presentation using validated tools (like the 4AT) is feasible at scale and provides crucial prognostic information beyond simple detection.³⁶ National standards (ACSQHC) mandate this approach.³⁴ Addressing implementation barriers related to patient factors and workflow is key.³⁷
4. Multifactorial Delirium Prevention/Management: While ED-specific evidence is limited ⁴², guideline-recommended non-pharmacological bundles targeting orientation, sleep, mobility, hydration, sensory aids, and medication review remain best practice.⁴⁰ Caution regarding potentially harmful routine practices (e.g., Foley catheters ⁴²) is warranted.
5. Multifactorial Falls Prevention: A comprehensive approach addressing individual risk factors (exercise, medication review, vision, home safety, Vitamin D) is the most effective strategy.⁴³ Validated assessment tools (FRAT, FROP-Com) can guide this process ⁴³, but complex predictive models currently lack sufficient validation for ED use.⁴⁶
6. Mandated Medication Reconciliation: Formal medication reconciliation at all transitions of care, including ED admission, transfer, and discharge, is a mandated safety standard in both countries.⁶³Pharmacist involvement improves accuracy ⁶², but system improvements are needed to ensure timely physician review and documentation.⁶⁴
7. Targeted Medication Review: Pharmacist-led reviews, particularly post-discharge, can reduce MRPs and ED visits.⁶² IT tools like NZ’s PolyScan show promise for efficiently identifying high-risk patients (polypharmacy + PIMs) for targeted review.⁵⁸
8. Structured Communication and Handover: Using standardized tools (e.g., ISBAR) for clinical handover ²⁵ and ensuring clear, patient-centred communication during discharge planning ⁶⁷ are essential for safe transitions.

Recommendations for Enhancing Care:

Based on the synthesized evidence, the following recommendations are proposed for health services, policymakers, and researchers in Australia and New Zealand:

1. Invest in Integrated Models of Care: Support the development, implementation, and rigorous evaluation of integrated geriatric care models that span the ED, hospital, and community interface. This includes:
   • Providing sustained funding and strong organizational support for models like GEDI, ACE, and primary care admission avoidance programs.
   • Utilizing implementation science frameworks (e.g., i-PARIHS) to guide adaptation and ensure fidelity during rollout.¹²
   • Focusing on building robust communication and data-sharing pathways between EDs, GPs, aged care facilities, and community services.
2. Prioritize Evidence-Based Geriatric Syndrome Management in ED:
   • Delirium: Strengthen systems for routine delirium risk assessment and screening on ED presentation using validated tools (e.g., 4AT). Implement multi-component prevention bundles based on guidelines.⁴⁰ Address identified implementation barriers through workflow redesign and staff training.³⁷ Conduct rigorous research into effective ED-specific delirium interventions.⁴²
   • Falls: Implement multifactorial falls risk assessment (using tools like FRAT/FROP-Com) for high-risk older adults in the ED, leading to tailored prevention strategies (including appropriate referrals for exercise, medication review, home safety). Advocate for coordinated national falls prevention policy in Australia.⁴⁴
   • Medication Safety: Ensure consistent, timely, and complete medication reconciliation at all ED transitions, leveraging pharmacy expertise and addressing system bottlenecks (e.g., doctor sign-off).⁶⁴ Promote targeted medication reviews, potentially using IT tools for identification ⁵⁸, focusing on deprescribing PIMs and high-risk combinations. Support research into effective, active deprescribing strategies beyond passive recommendations.⁶¹
3. Enhance Care Transitions through Patient Partnership and Communication:
   • Redesign ED discharge processes to be patient-centred, involving older adults and their carers as active partners.⁷¹
   • Provide clear, concise, jargon-free communication (verbal and written, using large font/teach-back) tailored to individual needs (sensory, cognitive, cultural).⁶⁷
   • Ensure discharge summaries explicitly address presenting problems, investigations, management changes, follow-up plans, and red flags.⁶⁷
   • Establish reliable pathways for communication between ED/hospital and primary/community care providers.⁶⁰
4. Strengthen Workforce Capacity: Invest in training and education for all ED staff (medical, nursing, allied health) on core geriatric principles, including assessment techniques (delirium, frailty), communication strategies, and management of common syndromes. Support the development and integration of specialized geriatric roles within or interfacing with the ED.¹²
5. Improve Evidence Base and Knowledge Translation:
   • Fund high-quality research, including pragmatic trials and implementation studies, to evaluate the effectiveness and cost-effectiveness of different geriatric ED models and interventions in the local context. Address the methodological weaknesses identified in previous studies.⁵
   • Foster collaboration between researchers, clinicians, policymakers, and consumers to ensure research addresses priority areas and findings are effectively translated into practice and policy.
6. Promote Trans-Tasman Collaboration: Leverage existing collaborations (ACEM, ANZSGM) and establish mechanisms for sharing best practices, innovations, data, and research findings related to geriatric emergency care between Australia and New Zealand to accelerate improvements in both countries.