The Missouri chapter of the American College of Emergency Physicians has prepared a survey asking emergency physicians if they would benefit from using a structured, 20-page form from the nursing home with all that information available in a "systematic fashion," Dr. Carpenter said. "So that, every time a patient goes to the ED, that chart goes with them. So the first step is determining that there is a need for that structured, 20-page tool, then having it mandated for nursing home transfers. That would take care of a big chunk of the problem with lack of information on nursing home transfers."

The survey was distributed about three months ago, but Dr. Carpenter hasn''t learned the results.

ER doctors also must deal with what Dr. Carpenter calls "polypharmacy" - seniors taking multiple and sometimes contraindicated medications.

"If they have diabetes and coronary disease, many of them are going to have an endocrinologist and a cardiologist in addition to their internal medicine physician," he said. "Many of them are seeing multiple physicians without each physician really knowing what the other physician is prescribing. So they end up coming to the ED with their entire bag of medications. We find out that they''re on, say, three ACE inhibitors and a couple different hypoglycemic agents. Probably they don''t need all those medications. What we end up doing a lot of the time is weaning down the number of medications that they''re on, and putting these physicians in touch with each other."

Emergency physicians consult the BEERS criteria, a list of medications considered unsafe for elderly patients.

"We kind of reference that as we try to figure out which medications patients should remain on, and which medications it might be safe to send that patient home on, from the emergency department," Dr. Carpenter said.

The growing geriatric impact on ERs can be addressed in other ways. About five years ago, Barnes-Jewish established an acute care for the elderly unit (ACE).

"Basically, you''re looking at a subset of the in-patient hospitalization," Dr. Carr said. "It''s not just being old, it''s being frail and old. So your reserve is diminished, kind of like the Pope. When you bring somebody in who has frailty and they have pneumonia, or they have a stroke, or MI, or heart failure, they''re probably going to take a little more time to come back. They''re also at risk for what we call iatrogenesis, or iatrogenic illness,... illness that we cause when they come into the hospital. Older adults are very susceptible to this."

The ACE model assembles a support staff for seniors that includes physical and occupational therapists, a geriatrician, a social worker, activities therapist, nutritionist and more. They meet daily to discuss patients'' needs and "see what we can do to get them out of bed early, avoid high-risk medicines, prevent pressure ulcers - maybe they need an extra three- or four-inch mattress," Dr. Carr said. "Maybe they need PT and OT, keep them from getting de-conditioned. Maybe they''ve been losing weight, they''re anorexic. Maybe they need a nutritional supplement. So it''s an interdisciplinary team approach to try and prevent further functional decline and to keep people in the best possible shape."

Where patients go after hospital discharge is also considered.

"Maybe they can go home. Maybe they''re not going to make it at home," he said. "Maybe they need to go to a rehab unit, or a nursing home for a couple weeks to get some rehab, in order to get back on their feet and give them the best chance. There are a lot of frail older adults who get booted out of the hospital after a few days. And guess what? A week later, they''re back in. Maybe we sent them out a little too early. Maybe they needed a little more time, a little TLC, a little more therapy, a little more nutrition, see how they''re going to react to their new medicines. So that''s the ACE concept."

A set agenda needs to be developed, Dr. Carpenter said, to prepare ERs for the various problems they will face treating elderly patients.

"Those are problems that are identified now that we need to address to make sure that when the baby boomers come of age and begin having these geriatric problems, that we''ve got a system in place to deal with them," he said. "And not have ED overcrowding that we cannot handle."