It had been a rough few months. Cynthia Tompkins was hospitalized in May for osteomyelitis, a bone infection, then spent six weeks in a rehabilitation facility. “It was a struggle,” she said. “I didn’t bounce back too well.”

Ms. Tompkins returned to her home in San Diego, but she was still taking antibiotics, along with a host of other drugs for diabetes, pain and blood clots. The deaths of her husband the previous year and her closest friend more recently had sapped her spirits.

In early July, a new symptom appeared: violent vomiting three times within about 24 hours. “I was so depleted,” she said. “I got weaker and weaker.” A friend who was visiting her called an ambulance.

“It’s the last place you think you want to go, the E.R.,” said Ms. Tompkins, 75, a retired teacher and family program director. She anticipated spending hours on an uncomfortable stretcher in a chilly hallway. Arriving at the emergency department at U.C. San Diego Health in La Jolla early in the morning, “I was in a knot,” she said.

But the place upended Ms. Tompkins’s expectations. Since 2022, this and every other adult E.R. in San Diego has been accredited as a geriatric emergency department, redesigned to address the specific risks and needs of older patients. It’s an approach, recent studies show, that can reduce hospital admissions and deaths among older adults and lower costs.

“They took me right to a room,” Ms. Tompkins said. She was transferred to a gurney with a thicker mattress to prevent bedsores and given blankets. “I got an I.V. right away because I needed fluids,” she said.

She was pleased that the small, curtained room, with sound-absorbing walls to lower the cacophony of emergency care, had a cushioned chair for her friend, who would stay with her, and a window looking out on trees.

The window served a medical purpose, too. Patients “can see whether it’s day or night,” said Denise Valenzuela, the geriatric emergency nurse assigned to Ms. Tompkins. “It prevents delirium,” the sudden change in mental status that can arise in hospitalized older patients and increase dementia risk.

Before long, “I just felt a calmness,” Ms. Tompkins said. “I felt, I’m where I need to be right now.”

Since 2017, the American College of Emergency Physicians has accredited 624 such geriatric emergency departments across the United States, including 73 in Veterans Affairs medical centers. “A fairly exponential rate of growth,” said Dr. Kevin Biese, the emergency doctor who directs the Geriatric Emergency Department Collaborative.

Few of these units are restricted to older patients. Instead, like the E.R. in La Jolla, they serve all ages but incorporate senior-friendly practices and protocols in an environment aimed at staving off disorientation, falls and other elder hazards. They’re classified from Level 1, for those fulfilling the highest number of criteria, to Level 3.

Adults 75 and older visit the emergency room at a higher rate than any other age group except infants: 76 visits per 100 people in 2022. Yet standard emergency care “wasn’t correctly designed for the needs of older adults,” Dr. Biese said.

The mission of a traditional E.R. is to speedily identify the central problem and either fix it or admit the patient to the hospital for ongoing care. “We ask, ‘What’s your chief complaint?’” Dr. Biese said. “You fell down the stairs and broke your leg.”

Older patients rarely arrive with a single ailment, however. Like Ms. Tompkins, most contend with several chronic conditions, take multiple prescriptions and need a variety of tests and assessments. Trained geriatric emergency teams focus not only on the broken leg but on determining what caused the fall, and how to prevent another one.

“An emergency department doesn’t routinely screen for delirium” and cognitive impairment, said Dr. Ula Hwang, an emergency doctor and researcher at N.Y.U. Langone Health. “But it’s one of the first things geriatric emergency departments will do,” along with a careful review of all the patient’s medications.

Geriatric E.R.’s also try to counter sensory impairment, another contributor to delirium, by distributing reading glasses and sound amplifying devices. They dim glaring lights and offer eye masks and ear plugs to promote sleep. If Ms. Tompkins had forgotten her walker, the unit would have lent her one.

These E.R.’s also aim to address a rising concern in emergency departments: hours or even days spent “boarding,” when admitted patients wait for open beds before they can leave the E.R.

“Prolonged boarding has increased among older adults,” said Dr. Cameron Gettel, an emergency doctor and researcher at the Yale School of Medicine, referring to waits that last over three hours. He is a co-author of a study on the topic in Health Affairs Scholar.

Spending more time boarding isn’t merely uncomfortable or inconvenient. Researchers studied patients 75 and older in emergency departments across France. They found that those kept there overnight before moving to an inpatient ward had a higher in-hospital mortality rate (15.7 percent) than those admitted to a ward before midnight (11.1 percent). Overnight boarding was associated with more falls and infections, too.

What geriatric emergency staff prefer, however, is to help patients avoid hospitalization altogether. “Admission may not be the best thing for an older adult,” Dr. Hwang said. “It might be the worst.”

Hospital patients, she said, are exposed to infections, staff errors and the rapid deconditioning that accompanies days spent in bed. All pose a greater threat to older patients.

Previous studies have found reduced admissions from geriatric emergency departments, but most of those studies involved one or two hospitals. Now, Dr. Hwang and her team have used nationwide data from the federal Health and Retirement Study and Medicare claims for nearly 4,600 adults over age 65, comparing those treated in geriatric emergency departments with a matched group seen in standard E.R.’s.

The differences were stark: Patients in the geriatric units had a 39 percent lower likelihood of hospital admission and a 38 percent reduction in mortality over 30 days. The geriatric E.R.’s also saved Medicare up to about $3,000 a visit, according to an earlier study Dr. Hwang led.

So having more than 600 accredited geriatric emergency departments nationwide represents both great strides and — in a country with more than 5,000 emergency departments — missed opportunities, Dr. Biese said.

“I’d encourage people to ask why their hospitals don’t have an accredited G.E.D.,” he added. “We should demand that.”

In La Jolla, Ms. Tompkins began feeling stronger. The intravenous fluids supplied anti-nausea medication and corrected the electrolyte abnormalities that her lab work revealed. She was able to sip water and juice and eat a few graham crackers.

A battery of other screens and scans found no serious concerns. After completing a geriatric assessment, Ms. Valenzuela, the nurse, suspected Ms. Tompkins hadn’t been eating well and was taking medications on a mostly empty stomach.

By about 6 p.m., Ms. Tompkins and her doctor agreed she could return home. She left the hospital with numbers to call for further help, and several staff members checked in by phone to see how she was doing.

Better, was her answer. “They took care of the whole me and put me on the right track,” Ms. Tompkins said. “I’m progressing. It’s slow, but I’m OK.”

The New Old Age is produced through a partnership with KFF Health News.

Channing House, a senior living community just a mile from Stanford University, is home to pioneering scientists, tech executives and inventors. But during a recent meeting, its residents confronted a problem they felt powerless to fix: the sudden loss of their caregivers to immigration policies.

“Our work force is being drastically disrupted, relationships are being severed and lives are being upended right now,” said Rhonda Bekkedahl, the center’s chief executive, who convened the gathering in June that was attended by about half of the 250 residents of the community in Palo Alto, Calif.

The Trump administration’s immigration crackdown is colliding with a demographic reality. Americans are aging rapidly and living longer, creating soaring demand for elder care when the industry is already buckling under the weight of chronic labor shortages.

Almost 70 million people in the United States are 65 or older, and government projections estimate that 70 percent of older adults will need care at some point in their lives.

Millions of immigrants, eligible to work in the United States, fill positions across the elder care industry such as nurses, dietitians, fitness instructors and maintenance technicians. And countless undocumented immigrants care for seniors in their homes, part of a vast informal economy.

Immigration enforcement is choking both labor pools.

Ms. Bekkedahl said that Channing House had already been forced to dismiss several beneficiaries of the Deferred Action for Childhood Arrivals program whose work permits had lapsed because the government has not processed their renewals. Many more dismissals at Channing House were looming, she added.

A recent Supreme Court ruling that upheld the Trump administration’s authority to end Temporary Protected Status for Syrian and Haitian nationals means Channing House could also soon lose workers who are stripped of that protection.

A handful of DACA and T.P.S. recipients, people who for years have fed, showered, dressed and dispensed medication to residents, shared their stories.

“Like many others, I am not demanding special treatment,” said Gloria Castellanos, the director of dining and a T.P.S. holder.

Ms. Castellanos, who has worked at Channing House for two decades and knows every resident’s dietary requirements, added: “I just want the opportunity to keep working.”

“If one of these days you don’t see me, you’ll know what happened,” she said.

Many residents expressed disbelief and outrage at the possibility that their caregivers, immigrants who have lived in the United States for the better part of their lives, could soon be forced to leave.

“What can be done, and who are we going to ask to do it?” said Lou Thompson, a high-speed rail expert who helped develop Amtrak’s Northeast corridor and was there with his wife, Alice Galenson, an economist who worked at the World Bank.

Responses ricocheted across the auditorium: Write to members of Congress. Send letters to the Department of Homeland Security. Help workers secure lawyers. Donate to an employee fund.

David Golden, an award-winning chemist who has published hundreds of papers, including on pollution and ozone depletion, aired his frustration.

“I think there’s a certain amount of naïveté being bounced around here,” said Mr. Golden, a former vice president of the nonprofit research institute SRI who has taught at Stanford University. So long as the current administration was in office, he opined, pushing for a change in immigration policy would be fruitless.

The Trump administration has intensified scrutiny of people brought to the United States as children, who have been shielded from deportation and allowed to work under the Obama-era DACA program. Renewals of their status, required every two years, now take several months instead of several weeks, forcing thousands to exit the work force, at least temporarily.

In May, the administration issued a “policy alert” stating that DACA would no longer be applied in a blanket manner. Instead, “detailed case-by-case scrutiny or review” would be required for renewals.

Compounding the DACA bottleneck is the Supreme Court’s decision last month on T.P.S., a program that has allowed people from countries in crisis to remain in the United States. The ruling, which ended protection for 350,000 people from Haiti and Syria, could clear the way for the Trump administration to dismantle the protection for more than a million more people.

Many recipients have lived and worked in the United States for years, and the administration has said that T.P.S. has turned into a de facto permanent immigration program.

Katie Smith Sloan, chief executive of LeadingAge, which represents more than 5,000 aging service providers, called the recent Supreme Court ruling and the Trump administration immigration policies “a government-mandated disservice to older adults and families in need of care and services.”

“There is no work force waiting in the wings capable of replacing the longstanding relationships, in some cases built over years and even decades, that are so vital to quality care,” she said.

The senior-care sector was already under strain. More than half of 400 nursing homes surveyed in 2023 said they had turned away prospective residents because they lacked enough staff, according to the American Health Care Association and the National Center for Assisted Living. Nearly all reported asking employees to work overtime or extra shifts.

Like many providers, Hebrew SeniorLife, which has seven campuses in the Boston area, including independent living communities and long-term care facilities, has hired many immigrants with T.P.S., said Adam Scott, SeniorLife’s chief executive.

Since President Trump began his second term, policy changes have cost SeniorLife 60 immigrant workers. After the Supreme Court’s T.P.S. ruling, the nonprofit is preparing to terminate 40 Haitian workers whose work permits are set to expire on Friday.

Many of those workers — housekeepers, kitchen staff, certified nursing assistants and registered nurses — have been employed by SeniorLife since an earthquake devastated Haiti in 2010 and the United States first designated the country for T.P.S.

“No matter their job, they are all caregivers,” Mr. Scott said. “The effect of losing them will be felt by the 4,500 seniors we care for every day.”

“These are the people that clean their rooms, serve their food, lift them to take them to the bathroom and to shower,” Mr. Scott added.

Senior-care workers already suffer from burnout, and the industry has a high turnover rate. Industry pay is also a factor, with low Medicaid reimbursement rates leaving no room to raise wages.

“Normally, an economist would say the solution is to pay more to draw more people,” said Brian McGarry, a health economist at the University of Rochester who studies long-term care. “That is hard to do in this area because the primary payer is Medicaid.”

On average, nursing homes receive only 82 cents in Medicaid reimbursement for every dollar they spend per resident, according to a 2024 study.

“There is a lot of concern, rightly so, that roadblocks to legally working are only exacerbating,” Mr. McGarry said. “When staffing goes down at nursing homes, bad things happen to residents.”

The human toll of the roadblocks was painfully clear in the Channing House auditorium that June afternoon.

“Many people assume that there is a simple pathway to citizenship for individuals who have earned degrees, built careers, pay taxes and follow the rules,” said Yadira Aldana, a DACA recipient who oversees more than 120 nurses and other health staff. “Unfortunately, that is not the case.”

“I am one of the people wondering whether my renewal will arrive in time,” she said. “For many of us, it has meant sleepless nights, anxiety and the constant fear that the lives we have spent decades building could be disrupted by circumstances beyond our control.”

Last to speak was Marlene Vasquez, a licensed nurse who filed her DACA renewal late last year.

“Because my work authorization expired,” she said, holding back tears, “I am no longer legally allowed to work and had to leave a job that I loved, caring for others.”

Way in the back, sitting on a mobility scooter, was Kent Mather, 88, a retired architect who has Parkinson’s disease. Ms. Vasquez had been his caregiver.

Mr. Mather had been constantly asking about what had happened to Ms. Vasquez, but Channing House does not disclose information about workers who depart.

Now he knew.