Unseen Burdens: Social Drivers of Health in Older Adults in the Emergency Department

Case example: An 88-year-old woman presents to the ED, confused, cachectic, and severely dehydrated. She is quickly diagnosed with a UTI and sepsis. While the proximate cause of her illness is a bacterial infection, the true underlying causes are more complex: lack of social support, caregiver cognitive impairment, limited mobility, financial insecurity, and inadequate access to food and medications.

Social drivers of health (SDOH), the unseen burdens of our patients, play an outsized role in shaping health outcomes, especially for older adults. As emergency physicians, we often represent the last safety net for vulnerable patients. Recognizing and intervening on these social vulnerabilities can transform both immediate clinical care and help improve longer-term outcomes.

• Social drivers of health (SDOH) are often hidden contributors to emergency department (ED) presentations and poor outcomes in older adults.

• ED visits are a critical moment to identify unmet social needs and intervene. Even small actions can make a meaningful difference.

• Around the world, recognizing and addressing SDOH in the ED is increasingly vital to delivering comprehensive, patient-centered care.

Understanding Social Drivers of Health in Older Adults

• Older adults are particularly vulnerable due to higher rates of isolation, poverty, cognitive decline, and dependence on others for help with their activities of daily living.

• SDOH refers to non-medical factors that influence health. We can broadly frame the types of SDOH into four categories:

  1. Difficulty managing daily needs: Inability to manage activities of daily living (ADLs) such as toileting, bathing, feeding, and dressing; Inability to manage instrumental activities of daily living (iADLs) such as shopping, driving, managing finances, and attending appointments; Difficulty managing medications and taking them correctly.

  2. Social challenges: Financial insecurity, social isolation, food insecurity, shelter insecurity, language or literacy barriers, and marginalization.

  3. Substance use and mental health: These could include the disorders themselves, as well as a lack of mental health care or access to substance use disorder treatment.

  4. Abuse, neglect, and exploitation: Neglect, which could be intentional, unintentional, or self-neglect, financial exploitation, and physical or sexual abuse.

Global aging trends mean that emergency physicians across diverse healthcare systems will increasingly face these challenges. While available resources will vary significantly by location and hospital, the fundamental issues and opportunities for intervention are universal.

Why Emergency Physicians Should Care

• Unmet social needs drive ED visits, hinder recovery, and contribute to hospitalizations, functional decline, and mortality.

• Identifying these factors can optimize clinical outcomes, reduce repeat visits, and improve patient safety after discharge.

• In the U.S., new CMS regulations will soon require hospitals to screen for and address social vulnerabilities, a trend likely to expand internationally as health systems seek to improve elder care​.

How to Identify Unmet Social Needs in the ED

Even in busy departments, there are simple and effective ways to uncover social risks:

• Leverage EMS observations: Ask paramedics open-ended questions like, "Can you tell me about the patient's living environment?" This may bring to light unmet needs or concerns, such as a lack of electricity, food, or sanitary conditions.

• Screen selectively but thoughtfully. Using a comprehensive, formal screening tool for each item would be too time-consuming for most EDs. One option is to screen patients who are first identified as higher risk, such as those who have a higher ISAR (Identification of Seniors at Risk) score. Another option is to develop a short screening questionnaire that asks the patients if they have any concerns in areas such as:

  • Having meals every day

  • Having a safe place to live

  • Having enough money to get health care or medications

  • Access to transportation

  • Alcohol or substance use

  • Sadness or worry that is difficult to manage

  • Being hurt or neglected by anyone close to them

• Look for physical and historical clues. There are often few, if any, clear signs that patients are impacted by SDOH, but there may be clues, such as:

  • Malnutrition, dehydration, and poor hygiene

  • Pressure ulcers, repeated falls, and medication nonadherence

  • Delayed presentations or multiple recent ED visits​.

Practical Strategies for ED Teams

Just identifying the SDOH is not enough. The most important step is then to help intervene and connect the patient with services that can help them. Each hospital will have slightly different resources in-house and in their communities. It is helpful to know what services your own hospital and community have. For example, there may be paramedic home visit programs, or social services, or area agencies on aging that can provide help.

• Mobilize what you have: Partner with nurses, case managers, and EMS.

• Low-hanging fruit: Create handouts with information specific to your area such as food banks, transportation services, home care agencies, and helplines.

• Thoughtful disposition planning:

  • Ensure safe discharges by coordinating services like home health, outpatient rehab, and follow-up care when you can.

  • When in doubt about home safety, admission for "safety concerns" (rather than "social admission") may be appropriate​.

• International adaptations:

  • In resource-limited settings, there may be more opportunities to lean on community health workers, faith-based organizations, or local elders' groups.

  • In rural or remote areas, virtual visits can offer a glimpse into home environments and detect hidden hazards​.

  • Multilingual screening tools and culturally appropriate community partnerships are essential in diverse populations.

Pitfalls and Pearls

Pitfalls

• Ignoring SDOH as "not our job."

• Missing cognitively impaired caregivers as a risk factor for poor health.

• Focusing solely on medical stabilization without planning for a safe environment after discharge.

Pearls

• Think like a social worker: "Is this patient safe to go home?"

• Use simple tools: questions, observations, and local resource lists go a long way.

• Small interventions can prevent major harms, sometimes saving a life by arranging a meal delivery or a home safety visit.

Global Relevance

Around the world, emergency departments are facing a surge in older, medically complex patients. No matter where we practice, the challenges of unmet social needs—and the potential for ED-based intervention—are becoming more important.

While not every ED has a full array of social services, every ED can make a difference. Recognizing SDOH is not about creating unrealistic burdens for already-stretched physicians and nurses. It is about using the ED visit as a powerful opportunity to connect patients with resources, services, and care that may help them live healthier lives and prevent future ED visits and hospitalizations.

References

Shenvi C, Gottesman E, Rosen T. The Importance of Addressing Social Drivers of Health and Unmet Social Needs in Optimizing Geriatric Emergency Care. Emergency Medicine Clinics of North America, 2025​ 2025 May;43(2):281-301.doi: 10.1016/j.emc.2024.08.009.