Impaired cognition is associated with adverse outcome in older patients in the Emergency Department; the Acutely Presenting Older Patients (APOP) study

Detection and differentiation of undiagnosed dementia in the emergency department: A pilot referral pathway

INTRODUCTION

Cognitive impairment (CI) is under-recognized by emergency department (ED) clinicians, and processes for cognitive screening and outpatient referrals are limited.

METHODS

This pilot study tested the feasibility of ED clinicians referring older adult patients identified through CI screening and direct clinician referral for outpatient cognitive evaluation. Telephone interviews and chart reviews were conducted on 100 patients about their emergency care, cognitive function, and referral status.

RESULTS

A total of 9359 ED patients were screened for memory and thinking problems, with 650 (6.9%) reporting such issues. A total of 100 patients were discharged and referred for outpatient cognitive evaluation, consisting of 37 referred from screening and 67 through direct clinician referral. Of these, 26 (26.0%) scheduled and 19 (19.0%) completed outpatient evaluations within 100 days. Fifteen (78.9%) were formally diagnosed with dementia, CI, or memory loss.

DISCUSSION

ED clinicians are able to identify and appropriately refer older patients with CI for outpatient evaluation. Future studies can improve referral rates with solutions addressing detection and follow-up challenges.

HIGHLIGHTS

Screening for cognitive impairment and outpatient referral for cognitive evaluation is feasible in the emergency department. Nearly 80% of patients who completed follow-up were diagnosed with cognitive impairment, including probable dementia and Alzheimer's disease. Significant gaps and barriers remain in maintaining outpatient follow-up from initial referral from the emergency department, with less than one in five patients completing outpatient evaluations.

A simplified multidimensional scale approach is effective in predicting mortality in hospitalized older adults and highlights the role of nutrition

BACKGROUND & AIMS

Malnutrition and cognitive impairment are among the major contributors to frailty, that significantly increases the risk of mortality of older hospitalized patients. Multidimensional frailty assessment tools, such as the multidimensional prognostic index-MPI, a tool based on a standard comprehensive geriatric assessment (CGA), have proven valuable for predicting adverse outcomes, including mortality of older adults following acute illness but its application in everyday clinical practice is limited. We hypothesized that removing parameters not closely associated with mortality and sorting the patient population according to the presence or not of cognitive impairment with possible integration of common laboratory markers, could provide a simplified approach that could improve practicability in all settings with at least comparable 1-year mortality predictive value.

METHODS

A retrospective cohort study was conducted in patients consecutively admitted to the Geriatric Clinic of the Maggiore University Hospital in Trieste, Italy from January 1st 2018 to December 31st 2019. Their demographics, functional, clinical, laboratory parameters and 1-year mortality were recorded. In a development cohort of 1032 consecutive patients, best predictors of mortality were selected via systematic analysis and included in simplified prognostic models and algorithms and subsequently compared for prediction of 1-year mortality. The predictive relevance of the best algorithms was then validated, in comparison to MPI, in a separate cohort of 575 consecutive patients.

RESULTS

While all demographic and tested laboratory parameters as well as MPI domains correlated with 1-year mortality, exclusion from MPI calculation of Short Portable Mental Status Questionnaire (SPSMQ), Exton Smith scale (ESS) and Mini Nutritional Assessment (MNA) significantly reduced MPI mortality predictivity, suggesting that not all MPI domains have the same weight. Further analysis showed that in the whole study cohort and in subgroups according to cognitive function, selected models including up to 3 parameters were superior to MPI in predicting 1-year mortality. In particular, models including MNA and albumin, or Exton Smith scale proved to better predict mortality in patients without or with severe cognitive impairment, respectively. A derived diagnostic algorithm applying different models according to cognitive status showed improved predictive value compared to MPI while requiring shorter estimated assessment time. Internal validation confirmed these results [HR: 4.37 (3.02-6.31) vs 3.16 (2.18-4.61), p < 0.0001].

CONCLUSIONS

In older acutely ill patients, a simplified multidimensional algorithm approach based on the assessment of cognitive function followed by nutritional status with the addition of plasma albumin or of functional status in patients without or with severe cognitive impairment respectively, may significantly improve 1-year mortality prediction while reducing assessment time. Moreover, these results highlight the prognostic value of MNA in association with albumin for 1-year mortality risk screening in the hospital setting and, for the first time, demonstrate its differential performance according to the presence or not of cognitive impairment.

The patient-reported outcome measure for older people living with frailty receiving acute care (PROM-OPAC): field-testing and validation

BACKGROUND

Current acute healthcare service metrics are not meaningful for older people living with frailty. Healthcare knowledge, situational security, and physical and psychosocial function are important outcomes typically not collected. The use of patient-reported outcome measures (PROMs) could support these assessments. Existing instruments are not comprehensive as they typically consider function, while older people with frailty also value enablement (self-determination and security in health and healthcare). This study field-tested and validated a PROM for older people with frailty receiving acute care (PROM-OPAC) to measure enablement.

METHODS

People aged 65+ with Clinical Frailty Scale 5-8 were recruited within seventy-two hours of an emergency attendance. Iterations of the novel instrument were administered over three stages: (1) preliminary field-testing for reliability (response distribution and internal consistency) and structure (exploratory factor analysis, EFA); (2) intermediate field-testing of an improved instrument for reliability and structure; (3) final draft validation assessing reliability, structure (confirmatory factor analysis, CFA), and construct validity based on a priori hypotheses. Feasibility was appraised throughout using data completeness and response rates and times.

RESULTS

241 people participated. Three items of a preliminary seven-item measure had poor response distribution or loading and were accordingly improved. The intermediate instrument had interpretability issues and three items required further improvement. The final eight-item draft had acceptable reliability (Cronbach's alpha: 0.71), structure (two factors for self-determination and security; RMSEA: 0.065; TLI: 0.917; CFI: 0.944), and construct validity (lower scores from respondents waiting longer and requiring admission). Feasibility was promising (response rate 39%; 98% responses complete; median completion time 11 (IQR: 12) minutes).

CONCLUSIONS

Administration of the PROM-OPAC appeared feasible and the instrument had acceptable psychometric properties. Further evaluation is required to assess generalisability.

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.

Geriatric Syndromes and Their Relationship with Mortality in a Population of Mexican Older Adults Aged 65 and Over, Admitted to the Emergency Department of a Second-Level Care Hospital

The main objective of this study was to analyze the relationship between Geriatric Syndromes (GSs) and in-hospital mortality in adults aged 65 and older admitted to the Emergency Department (ED). The study included 202 Older Adults (OAs) who met the inclusion criteria. We conducted a Comprehensive Geriatric Assessment and collected clinical and demographic data. A univariate analysis was carried out for each of the GSs analyzed. Those variables with p < 0.05 were entered into a multiple logistic regression using the backward stepwise entry method to analyze the independent predictor variables. The average number of GSs per individual was 4.65 (±2.76). Frailty syndrome was the most prevalent (70.2% of patients). Our study found an association between mortality and some GSs, such as frailty (p = 0.042), risk of falls (p = 0.010), delirium, cognitive impairment, dependence, and risk of ulcers (p < 0.001). We found that cognitive impairment (adjusted OR, 6.88; 95% CI, 1.41-33.5; p = 0.017) and dependence (adjusted OR, 7.52; 95% CI, 1.95-29.98; p = 0.003) were independent predictors associated with mortality in our population. It is necessary to develop new care strategies in the ED that respond to the needs of aging societies, including the use of new technologies and personnel with experience in gerontology.

Patient-reported outcome measure use among older adults after emergency department care: A systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care.

METHODS

With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments.

RESULTS

Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality.

CONCLUSIONS

PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.

Core requirements of frailty screening in the emergency department: an international Delphi consensus study

INTRODUCTION

Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study.

METHODS

A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors.

RESULTS

In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include.

CONCLUSIONS

Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

"You treat what you have to treat, and you don't care as much if they understand or if they feel good about it": Communication barriers and perceptions of moral distress among doctors in emergency departments

Doctors facing communication barriers when assessing patients in emergency departments (ED) is a frequent phenomenon, as the global prevalence of dementia and migration have increased. This study aims to explore how communication barriers influence moral distress as perceived by medical doctors working at emergency departments. Twelve doctors at 2 different EDs in Stockholm, Sweden, participated. Answers on communication barriers were collected from an interview guide on moral distress. Informants' responses were analyzed using qualitative thematic analysis. The results suggest that doctors experience moral distress when assessing patients with communication barriers due to an inability to mediate calm and safety and understand their patients, and due an increased need of resources and difficulties in obtaining consent before conducting examinations or interventions. In conclusion, communication barriers can be a cause of moral distress, which should be considered when developing tools and methods to mitigate and manage moral distress.

Factors which Influence the Frequency of Cognitive Assessment in the Emergency Department

BACKGROUND

The practice of safe emergency medicine requires accurate and adequate assessments. However, screening for cognitive deficits is not performed regularly in the emergency department (ED). This study aimed to determine factors influencing the frequency of cognitive testing by ED doctors.

METHODS

This study included all doctors working in the EDs of three teaching hospitals. A 17-item online survey instrument that collected information on sex, experience, perceived prevalence, perception, and practice of cognitive assessment was distributed through electronic mail and data messaging services.

RESULTS

Of the 210 participants, 72 were male. The estimated mean with standard deviation prevalence of cognitive impairment in older patients in the ED was 39.5%±19.7%. Among the participating ED doctors, 75.8% performed cognitive testing up to 10% of the time. Moreover, the participants ranked cognitive impairment the lowest compared to the other four chronic conditions in terms of its impact on hospitalization outcomes. Multiple linear regression revealed that the doctors' perceptions of the responsible personnel and the importance of cognitive testing, as well as their lack of expertise, were independently associated with the frequency of testing.

CONCLUSION

Lack of expertise, perception of the importance of cognitive testing, and lack of consensus on which discipline is responsible for performing cognitive testing in older patients in the ED were the limiting factors in performing cognitive testing in the ED. Improving perception and awareness of the importance of cognitive assessment as a screening tool could improve the detection and overall management of older patients.

Measuring health-related quality of life of older people with frailty receiving acute care: feasibility and psychometric performance of the EuroQol EQ-5D

BACKGROUND

Although outcome goals for acute healthcare among older people living with frailty often include Health-Related Quality of Life (HRQoL) and other patient-reported outcome measures (PROMs), current quality metrics usually focus on waiting times and survival. Lay and patient review have identified the EuroQol EQ-5D as a candidate measure for this setting. This research appraised the EQ-5D for feasibility, psychometric performance, and respondents' outcomes in the acute frailty setting.

METHODS

People aged 65 + with Clinical Frailty Scale (CFS) 5-8 were recruited from eight UK hospitals' emergency care and acute admissions settings. They completed the five-level EQ-5D and the EQ-VAS. Feasibility was assessed with completion times and completeness. For reliability, response distributions and internal consistency were analysed. Finally, EQ-Index values were compared with demographic characteristics and service outcomes for construct validity.

RESULTS

The 232 participants were aged 65-102. 38% responded in emergency departments and 62% in admissions wards. Median completion time was 12 (IQR, 11) minutes. 98% responses were complete. EQ-5D had acceptable response distribution (SD 1.1-1.3) and internal consistency (Cronbach's alpha 0.69). EQ-VAS demonstrated a midpoint response pattern. Median EQ-Index was 0.574 (IQR, 0.410) and was related positively with increasing age (p = 0.010) and negatively with CFS (p < 0.001). Participants with higher CFS had more frequent problems with mobility, self-care, and usual activities.

CONCLUSIONS

Administration of the EQ-5D was feasible in these emergency and acute frailty care settings. EQ-5D had acceptable properties, while EQ-VAS appeared problematic. Participants with more severe frailty had also poorer HRQoL.

Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairment

INTRODUCTION

After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions.

METHODS

We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner-completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi-structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations.

RESULTS

Care partners' mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners.

DISCUSSION

Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner-reported outcome measures as well as ED discharge care transition interventions targeting care partners.

Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review

OBJECTIVES

We aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

ED patients with cognitive impairment and/or their care partners.

METHODS

Informed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations.

RESULTS

From 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage.

CONCLUSIONS AND IMPLICATIONS

This scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.

Care transitions intervention reduces ED revisits in cognitively impaired patients

Introduction

About half of older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We tested the effect of an adapted Care Transitions Intervention (CTI) at reducing ED revisits in this vulnerable population.

Methods

We conducted a pre-planned subgroup analysis of community-dwelling, cognitively impaired older (age ≥60 years) participants from a randomized controlled trial testing the effectiveness of the CTI adapted for ED-to-home transitions. The parent study recruited ED patients from three university-affiliated hospitals from 2016 to 2019. Subjects eligible for this sub-analysis had to: (1) have a primary care provider within these health systems; (2) be discharged to a community residence; (3) not receive care management or hospice services; and (4) be cognitively impaired in the ED, as determined by a score >10 on the Blessed Orientation Memory Concentration Test. The primary outcome, ED revisits within 30 days of discharge, was abstracted from medical records and evaluated using logistic regression.

Results

Of our sub-sample (N = 81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.07 to 0.90) but not 14 days (OR 1.01, 95% CI 0.26 to 3.93). Multivariate analysis of outpatient follow-up found no significant effects.

Discussion

Community-dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.

Delirium in Older Adults: What a Surgeon Needs to Know

Delirium remains a challenging clinical problem in hospitalized older adults, especially for postoperative patients. This complication, with a high risk of postoperative mortality and an increased length of stay, frequently occurs in older adult patients. This brief narrative paper aims to review the recent literature regarding delirium and its most recent update. We also offer physicians a brief and essential clinical practice guide to managing this acute and common disease.

Psychological and Social Factors Associated with Coexisting Frailty and Cognitive Impairment: A Systematic Review

Those living with coexistent frailty and cognitive impairment are at risk of poorer health outcomes. Research often focuses on identifying biological factors. This review sought to identify the association psychological and social factors have with coexisting physical and cognitive decline. Six databases were systematically searched in July 2020. Studies included individuals aged 60 years or older identified as being both frail and cognitively impaired. A narrative synthesis examined patterns within the data. Nine studies were included, most employed a cross-sectional design. Depression was investigated by all nine studies, those with coexistent frailty and cognitive impairment had higher levels of depressive symptoms than peers. Findings were mixed on social factors, although broadly indicate lower education, living alone and lower material wealth were more frequent in those living with coexistent decline. Further research is needed to explore potentially modifiable psychological and social factors which could lead to the development of supportive interventions.

Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study

BACKGROUND

Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients' perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits.

METHODS

This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached.

RESULTS

In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients' untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit.

CONCLUSIONS

This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.

Emergency department outcome of elderly patients assisted by professional home services, the EPIGER study

BACKGROUND

For the elderly population living at home, the implementation of professional services tends to mitigate the effect of loss of autonomy and increases their quality of life. While helping in avoiding social isolation, home services could also be associated to different healthcare pathways. For elderly patients, Emergency Departments (EDs) are the main entrance to hospital where previous loss of autonomy is associated to worst hospital outcomes. Part of elderly patients visiting EDs are still admitted to hospital for having difficulties coping at home without presenting any acute medical issue. There is a lack of data concerning elderly patients visiting EDs assisted by home services. Our aim was to compare among elderly patients visiting ED those assisted by professional home services to those who do not in terms of emergency resources' use and patients' outcome.

METHODS

A multicenter, prospective cohort study was performed in 124 French EDs during a 24-h period on March 2016.Consecutive patients living at home aged ≥80 years were included. The primary objective was to assess the risk of mortality for patients assisted by professional home services vs. those who were not. Secondary objectives included admission rate and specific admission rate for "having difficulties coping at home". The primary endpoint was in-hospital mortality. Cox proportional-hazards regression model was used to test the association between professional home services and the primary endpoint. Multi variables logistic regressions were performed to assess secondary endpoints.

RESULTS

One thousand one hundred sixty-eight patients were included, median age 86(83-89) years old,32% were assisted by professional home services. The overall in-hospital mortality rate was 7%. Assisted patients had more investigations performed. Home services were not associated with increased in-hospital mortality (HR = 1.34;95%CI [0.68-2.67]), nor with the admission rate (OR = 0.92;95%CI [0.65-1.30]). Assisted patients had a lower risk of being admitted for "having difficulties coping at home" (OR = 0.59;95%CI [0.38-0.92]).

CONCLUSION

Professional home services which assist one-third of elderly patients visiting EDs, were not associated to lower in-hospital mortality or to an increased admission rate. Assisted patients were associated to a lower risk of being admitted for «having difficulties coping at home».Professional home services could result in avoiding some admissions and their corollary complications.

TRIAL REGISTRATION

Clinicaltrial.gov - NCT02900391 , 09/14/2016, retrospectively registered.

Frailty Index and functional level upon admission predict hospital outcomes: an interRAI-based cohort study of older patients in post-acute care hospitals

BACKGROUND

Geriatric assessment upon admission may reveal factors that contribute to adverse outcomes in hospitalized older patients. The purposes of this study were to derive a Frailty Index (FI-PAC) from the interRAI Post-Acute Care instrument (interRAI-PAC) and to analyse the predictive ability of the FI-PAC and interRAI scales for hospital outcomes.

METHODS

This retrospective cohort study was conducted by combining patient data from interRAI-PAC with discharge records from two post-acute care hospitals. The FI-PAC was derived from 57 variables that fulfilled the Frailty Index criteria. Associations of the FI-PAC and interRAI-PAC scales (ADLH for activities of daily living, CPS for cognition, DRS for mood, and CHESS for stability of health status) with hospital outcomes (prolonged hospital stay ≥90 days, emergency department admission during the stay, and in-hospital mortality) were analysed using logistic regression and ROC curves.

RESULTS

The cohort included 2188 patients (mean age (SD) 84.7 (6.3) years) who were hospitalized in two post-acute care hospitals. Most patients (n = 1691, 77%) were discharged and sent home. Their median length of stay was 35 days (interquartile range 18-87 days), and 409 patients (24%) had a prolonged hospital stay. During their stay, 204 patients (9%) were admitted to the emergency department and 231 patients (11%) died. The FI-PAC was normally distributed (mean (SD) 0.34 (0.15)). Each increase of 0.1 point in the FI-PAC increased the likelihood of prolonged hospital stay (odds ratio [95% CI] 1.91 [1.73─2.09]), emergency admission (1.24 [1.11─1.37]), and in-hospital death (1.82 [1.63─2.03]). The best instruments for predicting prolonged hospital stay and in-hospital mortality were the FI-PAC and the ADLH scale (AUC 0.75 vs 0.72 and 0.73 vs 0.73, respectively). There were no differences in the predictive abilities of interRAI scales and the FI-PAC for emergency department admission.

CONCLUSIONS

The Frailty Index derived from interRAI-PAC predicts adverse hospital outcomes. Its predictive ability was similar to that of the ADLH scale, whereas other interRAI-PAC scales had less predictive value. In clinical practice, assessment of functional ability is a simple way to assess a patient's prognosis.

SPMSQ for risk stratification of older patients in the emergency department : An exploratory prospective cohort study

Background

Risk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated.

Objective

To estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality).

Method

This was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment.

Results

The SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46–0.63) but at 3 months (AUC 0.61, 95% CI 0.54–0.68), 6 months (AUC 0.63, 95% CI 0.56–0.70) and 12 months (AUC 0.63, 95% CI 0.56–0.70) after initial contact.

Conclusion

For longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.

Electronic supplementary material

The online version of this article (10.1007/s00391-019-01626-z) contains supplementary material, which is available to authorized users.

Vital signs and impaired cognition in older emergency department patients: The APOP study

BACKGROUND/OBJECTIVES

Cognitive impairment is a frequent problem among older patients attending the Emergency Department (ED) and can be the result of pre-existing cognitive impairment, delirium, or neurologic disorders. Another cause can also be acute disturbance of brain perfusion and oxygenation, which may be reversed by optimal resuscitation. This study aimed to assess the relationship between vital signs, as a measure of acute hemodynamic changes, and cognitive impairment in older ED patients.

DESIGN

Prospective cohort study.

SETTING

ED's of two tertiary care and two secondary care hospitals in the Netherlands.

PARTICIPANTS

2629 patients aged 70-years and older.

MEASUREMENTS

Vital signs were measured at the moment of ED arrival as part of routine clinical care. Cognition was measured using the Six-Item Cognitive Impairment Test (6-CIT).

RESULTS

The median age of patients was 78 years (IQR 74-84). Cognitive impairment was present in 738 patients (28.1%). When comparing lowest with highest quartiles, a systolic blood pressure of <129 mmHg (OR 1.30, 95% confidence interval (95%CI) 0.98-1.73)was associated with increased risk of cognitive impairment. A higher respiratory rate (>21/min) was associated with increased risk of impaired cognition (OR 2.16, 95% CI 1.58-2.95) as well as oxygen saturation of <95% (OR 1.64, 95%CI 1.24-2.19).

CONCLUSION

Abnormal vital signs associated with decreased brain perfusion and oxygenation are also associated with cognitive impairment in older ED patients. This may partially be explained by the association between disease severity and delirium, but also by acute disturbance of brain perfusion and oxygenation. Future studies should establish whether normalization of vital signs will also acutely improve cognition.