When the older patient meets the emergency department: paradigm shift for a super-aged Singapore

In 2026, Singapore will reach super-aged status, with 21% of its population aged 65 and older. This milestone prompts a critical question: are we delivering appropriate and effective care to our older patients in the emergency department (ED)? PARADIGM SHIFT IN THE EMERGENCY DEPARTMENT Traditional ED care prioritises rapid diagnosis and intervention within the constraints of time, space and resources. However, this model often falls short for older patients, whose presentations are frequently complex and atypical. Non-specific symptoms, multimorbidity and polypharmacy complicate diagnosis and increase the risk of adverse drug events.1,2,3,4 Moreover, frailty increases vulnerability to a host of complications, including delirium, falls, functional decline and other iatrogenic harms during ED stays and subsequent hospitalisation.5,6,7 Beyond clinical stabilisation during acute care, goals of care for older adults must also encompass preservation of function, autonomy and quality of life.6 Achieving such person-centred goals requires a shift away from episodic, diagnosis-driven models of care toward holistic, tailored multidisciplinary approaches that include comprehensive geriatric assessment (CGA) and team-based care. This growing awareness has spurred the development of the international geriatric emergency medicine (GEM) movement.8 Guidelines from American, European and International GEM societies and special interest groups have already laid the groundwork for good geriatric emergency care, addressing key areas, including geriatric screening, frailty and comprehensive assessment, medication safety, delirium and dementia management, fall prevention, geriatric trauma care, transitions of care, and palliative or end-of-life support.9,10,11,12,13 However, the integration of guidelines into clinical practice remains inconsistent, and bridging this ‘know-do’ gap requires the championing of system change, environmental adaptation and the right mindset for better care of older adults, even as evidence continues to evolve.14 This commentary draws from these frameworks and evaluates the current state of GEM in Singapore, highlighting necessary paradigm shifts across the ED care continuum—from triage and early frailty assessment (e.g. using the Clinical Frailty Scale CFS) to the structured assessment and management of geriatric syndromes, and finally to admission avoidance, discharge planning and transitional care. FRAILTY-FRIENDLY TRIAGE FOR OLDER ADULTS Older adults risk being under-triaged in overcrowded EDs when applying standard triage systems based on acuity alone.15,16,17,18 Incorporation of frailty scoring into triage tools is important, as it predicts outcomes such as mortality and institutionalisation more accurately in the older population when added to usual early warning scores.19,20,21,22,23,24,25 A higher score on the CFS predicts a higher risk of adverse outcomes regardless of the disease state, and should serve as an indicator to up-triage the patient to be assessed by a geriatric-trained clinician in a timely manner. A Delphi expert consensus involving participants from ten countries recommends frailty scoring, preferably within 4 hours of triage, to inform timely and appropriate clinical decisions. However, it also emphasises that frailty assessment should ideally be performed during the first point of contact in the ED or at triage.26 The CFS has emerged as a feasible and validated tool for EDs worldwide, including Singapore.23,27,28,29,30 While no studies to date have shown that earlier assessment directly leads to reduced morbidity, it is very likely that avoiding delays in vulnerable older patients will be beneficial. For example, prolonged ED duration for patients with delirium is linked to greater declines in cognition and function at 6 months,31 while septic patients presenting with non-specific presentations are at risk of longer time to antibiotics and higher in-hospital mortality.32 In line with Singapore’s National Frailty Strategy,33 once a patient is identified as frail (CFS ≥4), appropriate care pathways should be initiated. Those with CFS scores of 4–6 should receive a geriatric ED assessment, while those scoring 7–9 warrant holistic and palliative-focused care. While many EDs in Singapore already implement aspects of this model, we advocate for universal adoption across EDs—from the point of entry through to discharge—to ensure a consistently frailty-sensitive approach. GERIATRIC EMERGENCY DEPARTMENT ASSESSMENT AS STANDARD OF CARE Hospitalisation poses significant risks to frail older adults, including delirium, infections, falls and loss of function, which can shorten lifespan and reduce quality of life.3,5 To provide a safer alternative, collaborations between emergency and geriatric medicine specialists have enabled the development of front-door CGA in Singapore to provide holistic evaluation of the complex and multidisciplinary needs of frail older adults in the ED, facilitating appropriate and safe discharge.34,35,36 In Singapore, CGA was first introduced through the GEM team at Tan Tock Seng Hospital in 2007.34 Today, GEM teams are present in all adult public hospital EDs, supported by GEM nurses and dedicated clinical leads.37 While some are more established than others, all aspire to assess patients using the 5Ms framework: mind, mobility, medications, multi-complexity and what matters most to the patient.38 These teams are coordinated nationally by the Section of GEM under the College of Emergency Physicians, Academy of Medicine, Singapore. This structure strengthens efforts to improve care for older adults across the ED ecosystem. TARGETED SCREENING OF GERIATRIC SYNDROMES IN THE EMERGENCY DEPARTMENT A pragmatic approach in practice means that ‘mobility’, the most visible of the 5Ms, is often given the greatest weightage for triggering the selection of patients for CGA. Detection of the other 4 Ms has yet to catch up with the emphasis on restoring physical function, and patients may miss out on needed assessments and interventions. Moreover, although elements of screening for cognitive impairment, delirium, fall risk, pain, elder mistreatment and palliative care needs are embedded in some GEM protocols, they are not yet universally applied, particularly for patients not assessed by GEM teams. To address this, EDs should integrate ED-appropriate tools into standard protocols for all older patients, such as the 4AT for delirium detection,39 suitable screening questions for dementia40 and some of the aforementioned needs. This expanded approach can help identify time-sensitive geriatric emergencies, guide goals of care discussions and reduce both short- and long-term morbidity and mortality.2 Identifying ‘what matters’ at the initial visit helps to prioritise patient-centric outcomes and serve as a discussion point during follow-up.41 ADMISSION AVOIDANCE FOR OLDER ADULTS Given the well-documented risks of hospitalisation for older adults, the guiding question has shifted from ‘Is the patient safe for discharge?’ to ‘Is the patient safe for admission?’. This reframing emphasises the importance of viable alternatives to inpatient care. To support safe discharge, however, EDs require access to non-admission dispositions and services, such as emergency department observation units (EDOUs), transitional care nursing, ED case management, Mobile Inpatient Care at Home, and subacute or stepdown facilities or even virtual observation units.42 Some EDs, such as Sengkang General Hospital, have implemented pre-hospital collaborations with nursing homes to reduce ED conveyance and hospitalisation.43 While many of these services exist across Singapore, broader adoption and stronger physician buy-in are still required to move beyond the default option of hospital admission for frail older patients. Achieving safe admission avoidance also requires concurrent shifts in thinking: from a diagnosis-centred to a syndromic approach; from algorithmic single-provider assessment to multidisciplinary team-based evaluation; and from a mindset of single acute care episode management to a longer-term perspective that goes beyond the current ED encounter, taking into account the patient’s health trajectory, preferences and needs. This entails a change in emphasis on speed to a holistic approach for frail older adults —one that remains adapted for the ED using quick, easy and feasible assessments.44 TRANSITIONAL CARE AND DISCHARGE PLANNING: EMERGENCY DEPARTMENT AND EMERGENCY DEPARTMENT OBSERVATION UNITS MODELS Observation units have proven effective in reducing adverse outcomes for older patients who do not require inpatient admission.45,46 In Singapore, EDOUs are commonly used for CGA, falls and osteoporosis management, and for transitioning patients to community or stepdown care.34,37,47 Transitional care and CGA are also routinely conducted in the ED itself. These services often include allied health interventions and structured follow-up such as fast-tracked geriatric outpatient clinic access and post-discharge telephone support.34,35,48,49 Such interventions are critical for vulnerable patients, especially those facing social isolation, cognitive decline or caregiver burden,50 and have shown good results. For instance, Tan Tock Seng Hospital’s geriatrician-led Emergency Department Interventions for Frailty (EDIFY) CGA-based programme demonstrated reduced hospital admissions, improved functional outcomes and greater cost-effectiveness.35,51,52 Similarly, Ng Teng Fong General Hospital’s Case management for At-Risk patients in ED (CARED) initiative, a multidisciplinary programme targeting frail older adults, has led to reductions in post-discharge hospital admissions and ED re-attendances, resulting in significant cost avoidance.49 The CARED programme also reported higher healthcare-related quality of life scores 3 months after discharge and high patient satisfaction scores across all frailty groups.53 The EDs in the remaining restructured hospitals—Changi General Hospital, National University Hospital, Khoo Teck Puat Hospital, Sengkang General Hospital, Singapore General Hospital, Woodlands Hospital, as well as Alexandra Hospital Urgent Care Centre—which generally receive older patients, have all set up GEM nursing teams with multidisciplinary team support and non-admission pathways for appropriate community-based care,37 including hospital-at-home mobile inpatient care.54 CONCLUSION Geriatric emergency medicine in Singapore began in 2006, alongside the broader international movement toward specialised care for older adults in emergency settings. The community has grown steadily since, through strong collaboration among geriatricians, emergency physicians, nurses and allied health professionals. While the paradigm has started to shift and significant progress has been made, the question, “Have we done enough?” remains. Improving care for older adults in the ED will require ongoing changes to systems, physical environments and mindsets, as well as the application of implementation science approaches to translate evidence into practice.55Table 1 outlines these aspirational areas for improvement alongside the current landscape and achievements in Singapore.Table 1: Geriatric emergency medicine in Singapore: current state and future aspirations.Acknowledgment We thank Dr Foo Chik Loon for sharing how GEM started in Tan Tock Seng Hospital, Singapore, and for his continued support for the local GEM community. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.