Navigating the demographic tipping point: the past, present and future of Geriatric Emergency Medicine in Singapore

Emergency departments (EDs) are often the bellwethers of the healthcare system, detecting the earliest signs of disasters or pandemics. As the frontline for acute illness and injuries, and the gateway to hospital-level care, EDs are particularly vulnerable to the rising tide of frail older adults needing comprehensive medical and social care, with emergency physicians becoming de facto gatekeepers to inpatient beds and resources. Since the early 1990s, specialists in Geriatric Emergency Medicine (GEM)—combining expertise in emergency care, ambulatory care, and geriatrics—have been addressing this ‘silver crisis’ in hospitals and communities.1 This GEM-themed issue aims to raise awareness about GEM and its impact on practice, policy and research, so that care for older adults in EDs and during care transitions can be improved fairly and sustainably. This issue highlights the progress of GEM over time, with GEM leaders in Singapore, Thailand, Malaysia and Indonesia describing community preparations through the provision of geriatric assessments, new services, education and research.2 A second commentary calls for a paradigm shift in caring for older adults in the EDs, urging the adoption of key elements of geriatric emergency care, including frailty-friendly triage, geriatric assessments, strategies to avoid unnecessary admissions and discharge planning guided by the ‘5Ms’ framework. It emphasises patients’ health trajectories, preferences and family involvement at each acute care encounter. Notably, it also reframes the ED question from ‘Is the patient safe for discharge?’ to ‘Is the patient safe for admission?’, highlighting that optimal care may lie in safe community-based alternatives rather than hospitalisation.3 The original articles show a marked increase in ED and hospital utilisation, and highlight higher patient acuity and longer ED stay among older adults in Singapore.4,5 A meta-analysis demonstrates that comprehensive geriatric assessments are associated with fewer hospital admissions, shorter stays and lower readmission rates, while a multidisciplinary protocol for older adults with falls shows success in hospital avoidance.6,7 Patient-centred research is also featured, including a quasi-experimental pre–post study of a geriatric-focused ED case management programme, which was associated with improved health-related quality of life after ED discharge.8 Finally, two educational articles—managing older adults with altered mental status, and falls and their complications—alongside a comprehensive review on pain management in the ED, round up the issue. Together, they provide essential guidance as we prepare for a ‘super-aged’ society.9,10,11