From Gerodontology to Geriatric Emergency Medicine

Liz Maloney, Ireland

I am a geriatrician working in the ED of a city centre hospital in Cork city, Ireland. My official title is clinical lead for the acute floor. I would love to say my career path to this post was well planned, but in reality it was more circuitous and providential.

I began life as a dentist, providing a mobile dental service to older adults in rural, long term residential care centres as part of my job. It was a much needed but underdeveloped service at the time. I enjoyed providing such practical and beneficial care, however my interactions with these older adults made me question my career path. I observed that some residents were lonely and isolated, despite living among a large group of people. Others appeared frail and vulnerable. I left feeling that these older adults needed help with many issues but I could only assist with a small part of that list. After several years in public and private dental practice, I decided to return to university to study medicine.

Fast forward through University College Cork medical school and my initial postgraduate years involved regular geriatric medicine rotations in large tertiary-referral and smaller, provincial hospitals around Cork city and county. These 3 formative years cemented my interest in the speciality, particularly when I observed the benefits that a comprehensive geriatric assessment could offer. This patient group involved some of the most acutely unwell, medically and socially complex people to present to the ED on any given day, providing challenges to all healthcare staff involved in their care.

I went on to complete a further 7 years of higher specialist training in geriatric medicine in hospitals all around Ireland, gaining experience in acute stroke care, falls and syncope, movement disorders, memory disorders, frailty, bone health, and incontinence.

My involvement in a Geriatric Emergency Medicine Service (GEMS) began in the latter part of my training. I undertook doctoral research on frailty screening in ED, which involved a clinical commitment as senior medical support to a Frailty Intervention Team (FIT). This is a multi-disciplinary team who screen adults aged ≥65 years for frailty syndromes, with the purpose of earlier identification of at-risk people on the ED pathway. This allows targeted, specialist geriatric medicine reviews to be undertaken in order to optimize hospital outcomes and facilitate community support services post discharge. Early identification of frailty allows proactive care options to be explored, potentially reducing adverse hospital outcomes. I collaborated and engaged with ED healthcare staff more closely than at any stage in my training up to that point and discovered an enthusiastic and progressive attitude to both my research and my clinical role in ED. Positive patient feedback to our FIT service, improved admission avoidance metrics for older adults in ED and opportunities to provide GEMS education sessions for ED staff proved a rewarding combination that has led me to this point.

The sub-speciality of GEMS has grown rapidly as an holistic model of care for acutely unwell older adults in ED, particularly in the last 20 years, with increasing international collaboration across disciplines. There are many GEMS stalwarts, such as Professor Simon Mooijaart, Professor Christopher R. Carpenter, Professor Simon Conroy and Professor Don Melady, who have assisted in international developments in the area for many years. Such strong inter-disciplinary advocates for improved standards of care for older adults in ED bodes well for future achievements.

It is both exciting and rewarding to be involved in this global GEMS development and to strive to support ongoing clinical research that may influence future practice. The future of GEMS is bright with dedicated courses, fellowships, and guidelines now established. Further developments will hopefully include defined sub-specialty routes from both EM and geriatric medicine and expanded international collaboration on education and research priorities. Our specialties are forging strong partnerships that will not doubt continue to strive for better care for all older adults in our care. Wishing everyone a happy and healthy 2023.