Predicting a long hospital stay after admission to a geriatric assessment unit: Results from an observational retrospective cohort study

Prognostic value of cognitive impairment, assessed by the Clock Drawing Test, in emergency department patients presenting with non-specific complaints

BACKGROUND

Cognitive impairment (CI) is common among older patients presenting to the emergency department (ED). The failure to recognize CI at ED presentation constitutes a high risk of additional morbidity, mortality, and functional decline. The Clock Drawing Test (CDT) is a well-established cognitive screening test.

AIM

In patients presenting to the ED with non-specific complaints (NSCs), we aimed to investigate the usability of the CDT and its prognostic value regarding length of hospital stay (LOS) and mortality.

METHOD

Secondary analysis of the Basel Non-specific Complaints (BANC) trial, a prospective delayed type cross-sectional study with a 30-day follow-up. In three EDs, patients presenting with NSCs were enrolled. The CDT was administered at enrollment.

RESULTS

In the 1,278 patients enrolled, median age was 81 [74, 87] years and 782 were female (61.19%). A valid CDT was obtained in 737 (57.7%) patients. In patients without a valid CDT median LOS was higher (29 [9, 49] days vs. 22 [9, 45] days), and 30-day mortality was significantly higher than in patients with a valid CDT (n = 45 (8.32%) vs. n = 39 (5.29%)). Of all valid CDTs, 154 clocks (20.9%) were classified as normal, 55 (7.5%) as mildly deficient, 297 (40.3%) as moderately deficient, and 231 (31.3%) as severely deficient. Mortality and LOS increased along with the CDT deficits (p = 0.012 for 30-day mortality; p < 0.001 for LOS).

CONCLUSION

The early identification of patients with CI may lead to improved patient management and resource allocation. The CDT could be used as a risk stratification tool for older ED patients presenting with NSCs, as it is a predictor for 30-day mortality and LOS.

Frailty recommendations and guidelines: an evaluation of the implementability and a critical appraisal of clinical applicability by the ISPRM Frailty Focus Group

INTRODUCTION

Aging is associated with an increased burden of multi-morbidity and disease related functional loss and disability, widely impacting patients and health care systems. Frailty is a major actor in age-related disability and is an important target for rehabilitation interventions, considering that is a reversible condition.

EVIDENCE ACQUISITION

A working group of members of the ISPRM, responding to WHO 2030 call for action to strengthen rehabilitation, was established to assess the quality and implementability of the existing guidelines for the rehabilitation of frailty. Guidelines were retrieved using a systematic search on Pubmed, Scopus and Web of Science and from the reference lists of screened articles. The included guidelines were evaluated using the AGREE II to assess their quality and using the AGREE-REX to assess their clinical credibility and implementability. Guidelines with a score >4 in the AGREE II item evaluating the overall quality of the guideline were considered for endorsement. Finally, nine external reviewers evaluated the applicability of each recommendation from the endorsed guidelines, providing comments about the barriers and facilitators for their implementation in their country.

EVIDENCE SYNTHESIS

Ten guidelines were retrieved and evaluated by the working group, of which four guidelines, i.e. the WHO Guidelines on Integrated Care for Older People, the FOCUS guidelines, the Asia-Pacific Clinical Practice Guidelines for the Management of Frailty and the ICFSR International Clinical Practice Guidelines for Identification and Management of Frailty, were considered for endorsement. All these guidelines were rated as of adequate quality and implementability.

CONCLUSIONS

The WHO Guidelines on Integrated Care for Older people (24) the ICFSR International Clinical Practice Guidelines for Identification and management of Frailty (15), the FOCUS guidelines (25) and the Asia Pacific Clinical Practice Guidelines (14) for the Management of Frailty have the best quality and applicability of the existing guidelines on the management of frailty, we suggest that should be employed to define the standards of care for patients with frailty. There are barriers for their implementation, as stated by our experts, to take into account, and some of them are country- or region-specific. Screening for frailty, exercise, nutrition, pharmacological management, social and psychological support, management of incontinence, and an overall comprehensive clinical management are the best tools to face upon frailty.

Risk for short-term undesirable outcomes in older emergency department users: Results of the ER2 observational cohort study

BACKGROUND

The "Emergency Room Evaluation and Recommendations" (ER2) is a clinical tool designed to determine prognosis for the short-term Emergency Department (ED) undesirable outcomes including long length of stay (LOS) in ED and in hospital, as well as the likelihood of hospital admission during an index ED visit. It is also designed to guide appropriate and timely tailor-made geriatric interventions. This study aimed to examine whether ER2 assessment part was: 1) usable by ED healthcare workers (e.g. nurses) and 2) scoring system associated with long LOS in ED and in hospital, as well as hospital admission in older ED users on stretchers.

METHODS

Based on an observational, prospective and longitudinal cohort study 1,800 participants visiting the ED of the Jewish General Hospital (Montreal, Quebec, Canada) were recruited between September and December 2017. ER2 assessment determined three risk-levels (i.e., low, medium and high) for short-term ED undesirable outcomes. The rate of ER2 digital form completed, the time to fill ER2 items and obtain ER2 risk-levels, the LOS in ED and in hospital, and hospital admission were used as outcomes.

RESULTS

ER2 was usable by ED nurses in charge of older ED users. High-risk group was associated with both increased ED stay (coefficient of regression β = 3.81 with P≤0.001) and hospital stay (coefficient of regression β = 4.60 with P = 0.002) as well as with hospital admission (HR = 1.32 with P≤0.001) when low ER2 risk level was used as referent level. Kaplan-Meier distributions showed that the three risk groups of participants differed significantly (P = 0.001). Those with high-risk level (P≤0.001) were discharged later from hospital to a non-hospital location compared to those with low risk. There was no significant difference between those classified in low-risk and in medium-risk groups (P = 0.985) and those in medium and high-risk groups (P = 0.096).

CONCLUSION

The ER2 assessment part is usable in daily practice of ED care and its risk stratifications may be used to predict adverse outcomes including prolonged LOS in ED and in hospital as well as hospital admission.

TRIAL REGISTRATION

NCT03964311.

Frailty and adverse outcomes in older adults being discharged from the emergency department: A prospective cohort study

BACKGROUND

A growing number of frail older adults are treated in the emergency department (ED) and discharged home. There is an unmet need to identify older adults that are predisposed to functional decline and repeat ED visits so as to target them with proactive interventions.

METHODS

A prospective cohort study was conducted in patients 75 years or older who were being discharged from the ED. The objective was to test the value of frailty screening tests, namely 5-meter gait speed and handgrip strength, to predict repeat ED visits at 1 and 6 months and functional decline at 1 month using multivariable logistic regression.

RESULTS

After excluding 7 patients lost to follow-up, 150 patients were available for analysis. The mean age was 81.1 ± 4.9 years with 51% females, 13% arriving by ambulance, and 67% having at least two comorbid conditions. At ED discharge, 41% of patients were found to have slow gait speed, whereas 23% had weak handgrip strength. After adjustment, only slow gait speed was independently associated with functional decline at 1 month (odds ratio [OR] 1.39 per 0.1 meters/second decrement, 95% confidence interval [CI], 1.12 to 1.72) and repeat ED visits at 6 months (OR 1.20 per 0.1 meters/second decrement, 95% CI, 1.01 to 1.42).

CONCLUSIONS

Gait speed can be feasibly measured at the time of ED discharge to identify frail older adults at risk for early functional decline and subsequent return to the ED. Conversely, grip strength was not found to be associated with functional decline or ED visits.

Current nutritional status assessment tools for metabolic care and clinical nutrition

PURPOSE OF REVIEW

The aim of this report is to critically review existing questionnaires and tools to assess nutritional status in different populations and pathological conditions.

RECENT FINDINGS

A total of 16 instruments to evaluate nutritional status were recorded, which were based on anthropometrical determinations, biochemical markers, clinical examinations and subjective questionnaires, depending on the nutritional assessment focus, involving different concepts: screening of the risk, diagnosis and severity of malnutrition, as well as the consequences of undernutrition or overnutrition.

SUMMARY

A variety of questionnaires, equations and tools were found with ability to assess nutritional status for metabolic care or clinical nutrition purposes, but apparently there is no optimal, universal and reliable nutritional status screening system for all metabolic conditions. Novel assessment instruments should provide high sensibility and specificity, be precise and reliable as well as inexpensive and simple, in order to avoid the additional burden of excessive loads of costs, work and time while dynamically overcoming the influence of disease diversity.

Screening for older inpatients at risk for long length of stay: which clinical tool to use?

Background

Screening for inpatients at risk for long length of stay (LOS) is the first step of an effective hospital care plan for older inpatients. This study aims, in older adults admitted to a geriatric acute care ward, to examine and compare the 6-item brief geriatric assessment (BGA) and the “Programme de Recherche sur l’Intégration des Services pour le Maintien de l’Autonomie” (PRISMA-7) risk levels with long LOS, and to establish their performance criteria (i.e., sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios) for LOS.

Methods

Based on an observational, retrospective, cohort design, 166 inpatients aged ≥75 admitted to a geriatric acute care ward of a McGill University-affiliated hospital (Montreal, Quebec, Canada) were recruited. The risk levels of the 6-item BGA (low, moderate and high) and the PRISMA-7 (low versus high) were calculated from a baseline assessment. The LOS was subsequently calculated in number of days.

Results

Only the 6-item BGA high risk level was associated with a long LOS (Odds ratio = 1.1 with P = 0.028 and Hazard ratio = 2.1 with P = 0.004). Kaplan-Meier distributions showed that there was no significant difference in the delay of hospital discharge between the low and high-risk level reported by the PRISMA-7 (P = 0.381), whereas the 6-item BGA three risk levels differed significantly (P = 0.008), with individuals at high risk levels being discharged later when compared to those with low (P = 0.001) and moderate (P = 0.019) risk levels. Both tools’ performance criteria were poor (i.e., < 0.70), except for PRISMA-7’s sensitivity which was 100%.

Conclusion

The 6-item BGA risk levels were associated with LOS, low risk-level being associated with short LOS and high-risk level with long LOS, but no association was reported with the PRISMA-7 risk levels. Both tools had poor performance criteria for long LOS, suggesting that they cannot be used as prognostic tools with current scientific knowledge.