Cumulative Incidence of Functional Decline After Minor Injuries in Previously Independent Older Canadian Individuals in the Emergency Department

Risk of falls is associated with 30-day mortality among older adults in the emergency department

OBJECTIVE

Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults.

METHODS

Observational cohort study of adults aged ≥ 75years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0-2 points), moderate (3-4 points), or high (≥5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087).

CONCLUSION

ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration.

Predicting posthospitalization falls in Brazilian older adults: External validation of the Carpenter instrument

OBJECTIVES

This study sought to explore and externally validate the Carpenter instrument's efficacy in predicting postdischarge fall risk among older adults admitted to the emergency department (ED) for reasons other than falls or related injuries.

METHODS

A prospective cohort study was conducted on 779 patients aged ≥ 65 years from a tertiary hospital in São Paulo, Brazil, who were monitored for up to 6 months post-ED hospitalization. The Carpenter instrument, which evaluates the four risk factors nonhealing foot sores, self-reported depression, inability to self-clip toenails, and prior falls, was utilized to assess fall risk. Follow-up by telephone occurred at 30, 90, and 180 days to identify falls and mortality. Fine-Gray models estimated the predictive power of Carpenter instrument for future falls, considering death as a competing event and sociodemographic factors, frail status, and clinical measures as confounders.

RESULTS

Among 779 patients, 68 (9%) experienced a fall within 180 days post-ED admission, and 88 (11%) died. The majority were male (54%), with a mean age of 79 years. Upon utilizing the Carpenter score, those with a higher fall risk (≥2 points) displayed more comorbidities, greater frailty, and increased clinical severity at baseline. Regression analyses showed that every additional point on the Carpenter score increased the hazard of falls by 73%. Two primary contributors to its predictive potential were identified: a history of falls in the preceding year and an inability to self-clip toenails. However, the instrument's discriminative accuracy was suboptimal, with an area under the curve of 0.62.

CONCLUSIONS

While the Carpenter instrument associated with a higher 6-month postadmission fall risk among older adults post-ED visit, its accuracy for individual patient decision making was limited. Given the significant impact of falls on health outcomes and health care costs, refining risk assessment tools remains essential. Future research should focus on enhancing these assessments and devising targeted proactive strategies.

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.

Individual and environmental variables related to outdoor walking among older adults: Verifying a model to guide the design of interventions targeting outdoor walking

OBJECTIVE

To estimate the relationships between individual and environmental variables and outdoor walking (OW) in older adults with OW limitations through verifying a conceptual model.

METHODS

Baseline data from 205 older adults participating in a randomized trial of a park-based OW program were analyzed using structural equation modeling. We evaluated a three latent factor model: OW (accelerometry and self-report); individual factors (balance; leg strength; walking self-confidence, speed and endurance; mental health; education; income; car access); and environmental factors (neighbourhood walkability components).

RESULTS

Mean age was 75 years; 73% were women. Individual factors was significantly associated with OW (β = 0.39, p < .01). Environmental factors was not directly associated with OW but was indirectly linked to OW through its significant covariance with the individual factors (β = 0.22, p < .01). The standardized factor loadings from the individual factors on walking self-confidence and walking capacity measures exceeded 0.65.

CONCLUSIONS

Better walking capacity and more confidence in the ability to walk outdoors are associated with higher OW in older adults. Better neighbourhood walkability is indirectly associated with more OW. The conceptual model demonstrates an individual and environment association; if the capacity of the individual is increased (potentially through walking interventions), they may be able to better navigate environmental challenges.

Community ambulation in older adults and people with OA - a model verification using Canadian Longitudinal Study on Aging (CLSA) data

BACKGROUND

There are health and well-being benefits of community ambulation; however, many older adults do not regularly walk outside of their home. Objectives were to estimate the associations between latent constructs related to community ambulation in older adults aged 65-85 (65+), and in adults with osteoarthritis (OA) aged 45-85.

METHODS

Secondary data analysis of the comprehensive baseline and maintaining contact questionnaire data from the Canadian Longitudinal Study of Aging (CLSA) was completed. Based on a previous model of community ambulation post-stroke, structural equation modeling (SEM) was used to develop measurement and structural models for two groups: older adults 65+ and people with OA. Multi-group SEM was conducted to test measurement invariance across sex and age groups. Measurement models were developed for the following latent factors: ambulation (frequency of walking outside/week, hours walked/day, ability to walk without help, frequency and aids used in different settings); health perceptions (general health, pain frequency/intensity); timed functional mobility (gait speed, timed up-and-go, sit-to-stand, balance). Variables of depression, falls, age, sex, and fear of walking alone at night were covariates in the structural models.

RESULTS

Data were used from 11,619 individuals in the 65+ group (mean age 73 years ±6, 49% female) and 5546 individuals in the OA group (mean age 67 ± 10, 60% female). The final 65+ model had a close fit with RMSEA (90% CI) = 0.018 (0.017, 0.019), CFI = 0.91, SRMR = 0.09. For the OA group, RMSEA (90% CI) = 0.021 (0.020, 0.023), CFI = 0.92, SRMR = 0.07. Health perceptions and timed functional mobility had a positive association with ambulation. Depression was associated with ambulation through negative associations with health perceptions and timed functional mobility. Multi-group SEM results reveal the measurement model was retained for males and females in the 65+ group, for males and females and for age groups (65+, < 65) in the OA group.

CONCLUSIONS

The community ambulation model post-stroke was verified with adults aged 65+ and for those with OA. The models of community ambulation can be used to frame and conceptualize community ambulation research and clinical interventions.

Decreasing hospitalizations through geriatric hotlines: a prospective French multicenter study of people aged 75 and above

BACKGROUND

The Emergency unit of the hospital (Department) (ED) is the fastest and most common way for most French general practitioners (GPs) to respond to the complexity of managing older adults patients with multiple chronic diseases. In 2013, French regional health authorities proposed to set up telephone hotlines to promote interactions between GP clinics and hospitals. The main objective of our study was to analyze whether the hotlines and solutions proposed by the responding geriatrician reduced the number of hospital admissions, and more specifically the number of emergency room admissions.

METHODS

We conducted a multicenter observational study from April 2018 to April 2020 at seven French investigative sites. A questionnaire was completed by all hotline physicians after each call.

RESULTS

The study population consisted of 4,137 individuals who met the inclusion and exclusion criteria. Of the 4,137 phone calls received by the participants, 64.2% (n = 2 657) were requests for advice, and 35.8% (n = 1,480) were requests for emergency hospitalization. Of the 1,480 phone calls for emergency hospitalization, 285 calls resulted in hospital admission in the emergency room (19.3%), and 658 calls in the geriatric short stay (44.5%). Of the 2,657 calls for advice/consultation/delayed hospitalization, 9.7% were also duplicated by emergency hospital admission.

CONCLUSION

This study revealed the value of hotlines in guiding the care of older adults. The results showed the potential effectiveness of hotlines in preventing unnecessary hospital admissions or in identifying cases requiring hospital admission in the emergency room. Hotlines can help improve the care pathway for older adults and pave the way for future progress.

TRIAL REGISTRATION

Registered under Clinical Trial Number NCT03959475. This study was approved and peer-reviewed by the Ethics Committee for the Protection of Persons of Sud Est V of Grenoble University Hospital Center (registered under 18-CETA-01 No.ID RCB 2018-A00609-46).

Older Adult Falls in Emergency Medicine, 2023 Update

Of 4 older adults, 1 will fall each year in the United States. Based on 2020 data from the Centers of Disease Control, about 36 million older adults fall each year, resulting in 32,000 deaths. Emergency departments see about 3 million older adults for fall-related injuries with falls having the ability to cause serious injury such as catastrophic head injuries and hip fractures. One-third of older fall patients discharged from the ED experience one of these outcomes at 3 months.

Differential screen and treatment of vestibular dysfunction in an elderly patient: A case report

BACKGROUND/PURPOSE

Concussion sequelae in the elderly is under recognized and negatively impacts quality of life. Labyrinthine concussion (LC) is an uncommon diagnosis, as is multiple canal (MC) benign paroxysmal positional vertigo (BPPV). This case report highlights physical therapist (PT) evaluation and treatment of an elderly male misdiagnosed with LC and successfully treated for MC BPPV.

CASE DESCRIPTION

A 72 year old male presented to his PT 23 days after falling off a ladder, resulting in a mild traumatic brain injury (mTBI). Diagnosed with LC, he was referred to PT due to ongoing symptoms of "falling backwards," poor gait, and diminished mobility. PT examination revealed an atypical BPPV. Thus, the patient was treated in two PT visits, which included canalith repositioning techniques and neuromuscular reeducation.

OUTCOMES

The PT diagnosis was MC BPPV, including the right lateral and left posterior semicircular canals. Initial positive findings of Head Impulse Test, Bow and Lean Test, Dix-Hallpike, and Roll Test were negative on the last visit. Patient-Specific Functional Scale improved from 0 to 9.9 (10 being no limitations). The patient progressed from minimum assistance to independence in bed mobility, transfers, gait, and previous activities.

DISCUSSION

The patient's presentation was atypical in signs and symptoms with a diagnosis of LC. PT examination and intervention successfully resolved the patient's signs and symptoms within two visits. Further research is needed regarding identification and treatment of elderly individuals with head injuries, such as MC BPPV, as well as the efficacy of a PT seeing patients shortly after mTBI.

Models of acute care for injured older patients-Australia and New Zealand practice

INTRODUCTION

The epidemiology of injured patients has changed, with an increasing predominance of severe injury and deaths in older (65 years and above) patients after low falls. There is little evidence of the models of care that optimise outcomes for injured older patients. This study aims to describe clinician perspectives of existing models of acute care for injured older patients in Australia and New Zealand.

METHODS

This cross-sectional online survey of healthcare professionals (HCP) managing injured older patients in Australia or New Zealand hospitals was conducted between November 2nd and December 12th, 2020. Recruitment was via survey link and snowball sampling to professional organisations and special interest groups via email and social media. HCP were asked, using a Likert scale, how likely four typical case vignettes were to be admitted to one of twelve options for ongoing care. Additional questions explored usual care components.

RESULTS

Participants (n=157) were predominantly Australian medical professionals in a major trauma service (MTS) or metropolitan hospital. The most common age defining "geriatric" was aged 65 years and older (43%). HCP described variability in the models and components of acute care for older injured patients in Australia and New Zealand. As a component of care, cognitive, delirium and frailty screening are occurring (60%, 61%, 46%) with HCP from non-major trauma services (non-MTS) reporting frailty and cognitive impairment screening more likely to occur in the emergency department (ED). Access to an acute pain service was more likely in a MTS. Participants described poor likelihood of a geriatrician (highest 16%) or physician (highest 12%) review in ED CONCLUSION: Despite a low response rate, HCP in Australia and New Zealand describe variability in acute care pathways for injured older patients. Given the change in epidemiology of injury towards older patients with low force mechanisms, models of acute injury care should be evaluated to define a cost-effective model and components of care that optimise patient-centred outcomes relevant to injured older patients. HCP described some factors they perceive to determine care, and outcomes of variability, offering guidance for future research and resource allocation in the Australia and New Zealand trauma system.

Is There Evidence of an Association Between Acute Health Care Utilization and Function in Older Adults Over Time? A Population-Based Cohort Study

Background and Objectives

Acute health care use varies by age, with older adults the highest users of acute health care services. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the association between acute health care utilization (emergency department [ED] visit with or without hospitalization) at baseline and subjective and objective measures of function measured at 4-year follow-up.

Research Design and Methods

This study represents a secondary analysis of a prospective cohort study, where data from Wave 1 (baseline) and Wave 3 of TILDA were analyzed in conjunction with a public and patient involvement group of older adults. Acute health care utilization was defined as an ED visit with or without hospitalization in the previous 12 months. Function was assessed objectively using the Timed Up and Go (TUG) test and a measure of grip strength, and subjectively using self-report limitations in activities of daily living (ADL) and instrumental ADL (IADL).

Results

A total of 1 516 participants met the study inclusion criteria. Mean age was 70.9 ± 4.6 years and 48% were male. At baseline, 1 280 participants reported no acute health care use. One hundred and eighteen indicated an ED visit but no hospitalization in the previous 12 months and 118 reported both an ED visit and hospitalization. Adjusting for all covariates, compared to those with no acute health care utilization, those with an ED visit with no hospital admission had poorer TUG performance at follow-up (β = 0.67, 95% confidence interval: 0.34, 1.29, p = .039).

Discussion and Implications

This paper supports previous research that acute health care events, specifically ED usage, are associated with reduced function for older adults as assessed by TUG at follow-up. No associations were observed for grip strength, ADL, or IADL. Further research is required in this area, exploring ED visits and the possible benefits of evaluating older adults at this stage.

Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association

Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.

Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine

BACKGROUND

In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service.

DISCUSSION

At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions.

CONCLUSIONS

In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.

Outdoor Community Ambulation Interventions to Improve Physical and Mental Health in Older Adults: A Systematic Review and Meta-Analysis

Limited community ambulation, defined as independent mobility outside the home, predicts adverse outcomes in older adults. We performed a systematic review and meta-analysis to examine outdoor community ambulation intervention effectiveness in older adults. We searched six databases until October 2021. Studies with an evaluative research objective, older adult population, and outdoor community ambulation interventions were eligible. After reviewing 23,172 records, five studies were included. The meta-analysis found no significant difference in walking endurance and depression outcomes between outdoor community ambulation and comparison interventions. For outcomes not suitable for meta-analysis, studies showed no significant difference in walking activity, anxiety, and general and health-related quality of life, and possible improvements in gait speed and lower extremity function and strength. Most evidence was of low to very low certainty. Considering the limited evidence base, the design, implementation, and evaluation of outdoor community ambulation interventions in older adults should be prioritized in primary research.

Geriatric screening, fall characteristics and 3- and 12 months adverse outcomes in older patients visiting the emergency department with a fall

BACKGROUND

Falls in older Emergency Department (ED) patients may indicate underlying frailty. Geriatric follow-up might help improve outcomes in addition to managing the direct cause and consequence of the fall. We aimed to study whether fall characteristics and the result of geriatric screening in the ED are independently related to adverse outcomes in older patients with fall-related ED visits.

METHODS

This was a secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study, of which a subset of patients aged ≥70 years with fall-related ED visits were prospectively included in EDs of two Dutch hospitals. Fall characteristics (cause and location) were retrospectively collected. The APOP-screener was used as a geriatric screening tool. The outcome was 3- and 12-months functional decline and mortality. We assessed to what extent fall characteristics and the geriatric screening result were independent predictors of the outcome, using multivariable logistic regression analysis.

RESULTS

We included 393 patients (median age 80 (IQR 76-86) years) of whom 23.0% were high risk according to screening. The cause of the fall was extrinsic (49.6%), intrinsic (29.3%), unexplained (6.4%) or missing (14.8%). A high risk geriatric screening result was related to increased risk of adverse outcomes (3-months adjusted odds ratio (AOR) 2.27 (1.29-3.98), 12-months AOR 2.20 (1.25-3.89)). Independent of geriatric screening result, an intrinsic cause of the fall increased the risk of 3-months adverse outcomes (AOR 1.92 (1.13-3.26)) and a fall indoors increased the risk of 3-months (AOR 2.14 (1.22-3.74)) and 12-months adverse outcomes (AOR 1.78 (1.03-3.10)).

CONCLUSIONS

A high risk geriatric screening result and fall characteristics were both independently associated with adverse outcomes in older ED patients, suggesting that information on both should be evaluated to guide follow-up geriatric assessment and interventions in clinical care.

Risk Factors for Disability After Emergency Department Discharge in Older Adults

OBJECTIVES

We have previously shown that older adults discharged from the emergency department (ED) experience an increased disability burden within a 6-month time period after ED discharge. The objective of this study was to identify risk factors associated with increased disability burden among older adults discharged from the ED.

METHODS

This study is part of an ongoing longitudinal study of 754 community-living persons aged ≥70 years. The analytic sample included 813 ED visits without hospitalization from 430 participants who had at least one visit to an ED during a 14-year follow-up period (1998-2012). Information on ED visits and disability burden in 13 functional activities was collected during monthly interviews. Twenty-nine candidate risk factors were evaluated for their independent associations with increased disability burden using a longitudinal multivariable model.

RESULTS

In the multivariable analyses, age ≥85 (adjusted risk ratio [aRR] = 1.14, 95% confidence interval [CI] = 1.05 to 1.24), being unmarried (aRR = 1.15, 95% CI = 1.05 to 1.27), lower-extremity weakness (aRR = 1.20, 95% CI = 1.07 to 1.34), and physical frailty (aRR = 1.25, 95% CI = 1.13 to 1.37) were associated with increased disability burden. As the number of risk factors increased, the predicted mean disability burden (on a scale of 0 to 13) also increased, ranging from a value of 1.80 (95% CI = 1.43 to 2.27) for 0 risk factors to a value of 8.59 (95% CI = 7.93 to 9.29) for four risk factors.

CONCLUSIONS

Among older adults discharged from the ED, several risk factors were associated with increased disability burden over the following 6 months, including age ≥85, being unmarried, lower-extremity weakness, and physical frailty. Further research is needed to evaluate whether risk stratification based on nonmodifiable factors or interventions targeting modifiable risk factors improve functional outcomes for older adults discharged from the ED.

Can an Emergency Department-Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial

STUDY OBJECTIVE

We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults.

METHODS

The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians.

RESULTS

Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed.

CONCLUSION

Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults.

Exercise Interventions for Community-Dwelling Older Adults Following an Emergency Department Consultation for a Minor Injury

This study compared effects of exercise-based interventions with usual care on functional decline, physical performance, and health-related quality of life (12-item Short-Form health survey) at 3 and 6 months after minor injuries, in older adults discharged from emergency departments. Participants were randomized either to the intervention or control groups. The interventions consisted of 12-week exercise programs available in their communities. Groups were compared on cumulative incidences of functional decline, physical performances, and 12-item Short-Form health survey scores at all time points. Functional decline incidences were: intervention, 4.8% versus control, 15.4% (p = .11) at 3 months, and 5.3% versus 17.0% (p = .06) at 6 months. While the control group remained stable, the intervention group improved in Five Times Sit-To-Stand Test (3.0 ± 4.5 s, p < .01). The 12-item Short-Form health survey role physical score improvement was twice as high following intervention compared with control. Early exercises improved leg strength and reduced self-perceived limitations following a minor injury.

Two-Item Fall Screening Tool Identifies Older Adults at Increased Risk of Falling after Emergency Department Visit

Introduction

Few emergency department (ED)-specific fall-risk screening tools exist. The goals of this study were to externally validate Tiedemann et al’s two-item, ED-specific fall screening tool and test handgrip strength to determine their ability to predict future falls. We hypothesized that both the two-item fall screening and handgrip strength would identify older adults at increased risk of falling.

Methods

A convenience sample of patients ages 65 and older presenting to a single-center academic ED were enrolled. Patients were asked screening questions and had their handgrip strength measured during their ED visit. Patients were given one point if they answered “yes” to “Are you taking six or more medications?” and two points for answering “yes” to “Have you had two or more falls in the past year?” to give a cumulative score from 0 to 3. Participants had monthly follow- ups, via postcard questionnaires, for six months after their ED visit. We performed sensitivity and specificity analyses, and used likelihood ratios and frequencies to assess the relationship between risk factors and falls, fall-related injury, and death.

Results

In this study, 247 participants were enrolled with 143 participants completing follow-up (58%). During the six-month follow-up period, 34% of participants had at least one fall and 30 patients died (12.1%). Fall rates for individual Tiedemann scores were 14.3%, 33.3%, 60.0% and 72.2% for scores of 0,1, 2 and 3, respectively. Low handgrip strength was associated with a higher proportion of falls (46.3%), but had poor sensitivity (52.1%).

Conclusion

Handgrip strength was not sensitive in screening older adults for future falls. The Tiedemann rule differentiated older adults who were at high risk for future falls from low risk individuals, and can be considered by EDs wanting to screen older adults for future fall risk.

Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study

BACKGROUND

Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a "Wiki-suite" (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders.

OBJECTIVE

The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools.

METHODS

Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools.

RESULTS

Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit.

CONCLUSIONS

This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17363.

Fall prevention initiative: A fall screening and intervention pilot study on the ambulatory setting

BACKGROUND

Falling is the most common cause of trauma in the geriatric population. To identify patients that were at-risk for falling, we implemented a provider-directed fall prevention screening initiative in the ambulatory setting of a large tertiary care referral center. We used three clinician-directed questions from the Stopping Elderly Accidents, Death and Injuries toolkit. Our goal was to intervene on patients who were screened as at-risk for falling by referring them to our physical therapy program and evaluating its effects to these patients.

METHODS

Patients 55 years or older who live in the community were screened from June 2017 to June 2018. Patients who answered yes to any of the three questions were identified as at-risk for falling, and referred to the Fall Prevention Initiative Physical Therapy Program (FPIPTP). The FPIPTP is a program that establishes a quantifiable fall risk using the Time Up and Go (TUG) test, which then initiates PT treatments, designed to prevent future falls by improving, gait, balance, and fitness. The Wilcoxon signed rank test was used to determine significance (p < 0.05).

RESULTS

We identified 112 patients with a median age of 76.5 years (IQR, 68-82 years) to be at-risk for falling. The initial median TUG score in this group of patients is 15.85 seconds (12-20.33 seconds), which is consistent with a high fall-risk (time >12 seconds). After completing the FPIPTP, the median TUG score significantly improved to 12 seconds (9-15 seconds, p < 0.0001).

CONCLUSION

We conclude that a provider can use the three specific questions from the Stopping Elderly Accidents, Death and Injuries toolkit to identify patients (≥55 years) that are at-risk for falling. Additionally, the FPIPTP is able to significantly improve the TUG score in this group. We will need to confirm this conclusion with a larger population study.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Interventions to improve older adults' Emergency Department patient experience: A systematic review

STUDY OBJECTIVE

To summarize interventions that impact the experience of older adults in the emergency department (ED) as measured by patient experience instruments.

METHODS

This is a systematic review to evaluate interventions aimed to improve geriatric patient experience in the ED. We searched Ovid CENTRAL, Ovid EMBASE, Ovid MEDLINE and PsycINFO from inception to January 2019. The main outcome was patient experience measured through instruments to assess patient experience or satisfaction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the confidence in the evidence available.

RESULTS

The search strategy identified 992 studies through comprehensive literature search and hand-search of reference lists. A total of 21 studies and 3163 older adults receiving an intervention strategy aimed at improve patient experience in the ED were included. Department-wide interventions, including geriatric ED and comprehensive geriatric assessment unit, focused care coordination with discharge planning and referral for community services, were associated with improved patient experience. Providing an assistive listening device to those with hearing loss and having a pharmacist reviewing the medication list showed an improved patient perception of quality of care provided. The confidence in the evidence available for the outcome of patient experience was deemed to be very low.

CONCLUSION

While all studies reported an outcome of patient experience, there was significant heterogeneity in the tools used to measure it. The very low certainty in the evidence available highlights the need for more reliable tools to measure patient experience and studies designed to measure the effect of the interventions.

Toppling Oranges: Death, Disability, Decline, and Readmission of Community-Dwelling Elderly Patients After an Emergency Department Visit

BACKGROUND

Every emergency department (ED) faces both a rising tide and a revolving door of elderly patients. Unplanned short-term returns after a recent ED evaluation or hospital admission are sentinel events. Consequences include substantial functional decline, reduced health-related quality of life, and increased risk of dependency or death. Returning families, unaware of the significant likelihood of deterioration after an ED or hospital discharge, often harbor suspicions that something was missed. Literature describing the significant likelihood of functional decline in elderly patients after ED or hospital discharge is presented. Suggestions for incorporating the potential for subsequent deterioration into the evaluation of elderly ED patients and the discussions surrounding disposition decisions are included.

DISCUSSION

In addition to impacting patients and families, posthospitalization decline and short-term readmissions create serious burdens for hospitals and their EDs. Education, vigilance, specialized geriatric EDs, dedicated inpatient units, and ED access to outpatient services for the elderly can aid in the recognition and mitigation of postvisit functional decline and associated returns. Financial incentives for reducing short-term readmissions can translate into novel approaches and referral arrangements.

CONCLUSIONS

Currently, and for the foreseeable future, EDs are integral to predicting, identifying, and preventing functional decline in the elderly. For now, we are all Geriatric EDs.

GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data

OBJECTIVES

We aimed to describe a new multidisciplinary team fall prevention intervention for older adults who seek care in the emergency department (ED) after having a fall, assess its feasibility and acceptability, and review lessons learned during its initiation.

DESIGN

Single-blind randomized controlled pilot study.

SETTING

Two urban academic EDs PARTICIPANTS: Adults 65 years old or older (n = 110) who presented to the ED within 7 days of a fall.

INTERVENTION

Participants were randomized to a usual care (UC) and an intervention (INT) arm. Participants in the INT arm received a brief medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist (PT). INT participants received referrals to outpatient services (eg, home safety evaluation, outpatient PT).

MEASUREMENTS

We used participant, caregiver, and clinician surveys, as well as electronic health record review, to assess the feasibility and acceptability of the intervention.

RESULTS

Of the 110 participants, the median participant age was 81 years old, 67% were female, 94% were white, and 16.3% had cognitive impairment. Of the 55 in the INT arm, all but one participant received the pharmacy consult (98.2%); the PT consult was delivered to 83.6%. Median consult time was 20 minutes for pharmacy and 20 minutes for PT. ED length of stay was not increased in the INT arm: UC 5.25 hours vs INT 5.0 hours (P < .94). After receiving the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), 100% of participants and 97.6% of clinicians recommended the pharmacy consult, and 95% of participants and 95.8% of clinicians recommended the PT consult.

CONCLUSION

These findings support the feasibility and acceptability of the GAPcare model in the ED. A future larger randomized controlled trial is planned to determine whether GAPcare can reduce recurrent falls and healthcare visits in older adults. J Am Geriatr Soc 68:198-206, 2019.

180-Day functional decline among older patients attending an emergency department after a fall

OBJECTIVES

To determine functional changes and factors affecting 180-day functional prognosis among older patients attending a hospital emergency department (ED) after a fall.

STUDY DESIGN

Retrospective analysis from a prospective cohort study (FALL-ER Registry) spanning one year that included individuals aged ≥65 years attending four Spanish EDs after a fall. We collected 9 baseline and 6 fall-related factors.

MAIN OUTCOME MEASURES

Barthel Index (BI) was measured at baseline, discharge and 30, 90 and 180 days after the index fall. Absolute and relative BI changes were calculated. Absolute difference of ≥10 points between BI at baseline and at 180 days was considered a clinically significant functional decline.

RESULTS

452 patients (mean age 80 ± 8 years; 70.8% women) were included. Baseline BI was 79.3 ± 23.1 points. Compared with baseline, functional status was significantly lower at the 4 follow-up time points (-8.7% at discharge; and -6.9%, -7.9% and -9.5% at 30, 90 and 180 days; p < 0.001 for all comparisons in relation to baseline; p = 0.001 for change over time). One hundred and thirty-three (29.6%) patients had a clinically significant functional decline at 180 days. Age ≥85 years (OR = 2.24, 95%CI 1.23-4.08; p = 0.008), fall-related fracture (OR = 2.45, 95%CI 1.43-4.28; p = 0.001), hospitalization (OR = 1.91; 95%CI 1.11-3.29; p = 0.019) and post-fall syndrome (OR = 1.77, 95%CI 1.13-2.77; p = 0.013) were independently associated with 180-day clinically significant functional decline.

CONCLUSION

Patients ≥65 years attending EDs after a fall experience a consistent and persistent negative impact on their functional status. Several factors may help identify patients at increased risk of functional impairment.

A theory-based, task-oriented, outdoor walking programme for older adults with difficulty walking outdoors: protocol for the Getting Older Adults Outdoors (GO-OUT) randomised controlled trial

INTRODUCTION

A theory-based, task-oriented, community walking programme can increase outdoor walking activity among older adults to optimise functional independence, social participation and well-being. The study objective is to determine if there is a difference in the change in outdoor walking activity from baseline to 10 weeks, 5.5 months and 12 months after receiving a 1-day interactive workshop and outdoor walking programme (Getting Older Adults Outdoors (GO-OUT)) compared with the workshop and weekly reminders (WR) in older adults with difficulty walking outdoors.

METHODS AND ANALYSIS

A randomised controlled trial is being conducted in four urban Canadian communities. We will stratify 240 individuals by site and participant type (ie, individual vs spousal/friend pair) and randomise to either the GO-OUT or WR intervention. The GO-OUT intervention involves a 1-day workshop, where participants complete eight interactive stations to build knowledge and skills to walk outside, followed by a 10-week group outdoor walking programme (two 1-hour sessions/week) led by a physiotherapist or kinesiologist in parks. The WR intervention consists of the same workshop and 10 weekly telephone reminders to facilitate outdoor walking. The primary outcome measure is mean outdoor walking time in minutes/week derived from accelerometry and global positioning system data. GO-OUT is powered to detect an effect size of 0.4, given α=0.05, β=0.20, equal number of participants/group and a 20% attrition rate. Secondary outcomes include physical activity, lifespace mobility, participation, health-related quality of life, balance, leg strength, walking self-efficacy, walking speed, walking distance/endurance and mood.

ETHICS AND DISSEMINATION

GO-OUT has received ethics approval at all sites. A Data Safety Monitoring Board will monitor adverse events. We will disseminate findings through lay summaries, conference presentations and journal articles.

TRIAL REGISTRATION NUMBER

NCT03292510 (Pre-results).

Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain

OBJECTIVES

Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain.

METHODS

This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes.

RESULTS

Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups.

CONCLUSION

In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.

Older Adult Falls in Emergency Medicine: 2019 Update

"Standing-level falls represent the most frequent cause of trauma-related death in older adults and a common emergency department (ED) presentation. However, these patients rarely receive guideline-directed screening and interventions during or following an episode of care. Reducing injurious falls in an aging society begins with prehospital evaluations and continues through definitive risk assessments and interventions that usually occur after ED care. Although ongoing obstacles to ED-initiated, evidence-based older adult fall-reduction strategies include the absence of a compelling emergency medicine evidence basis, innovations under way include validation of pragmatic screening instruments and incorporation of contemporary technology to improve fall detection rates."

Is the Drug Burden Index Related to Declining Functional Status at Follow-up in Community-Dwelling Seniors Consulting for Minor Injuries? Results from the Canadian Emergency Team Initiative Cohort Study

BACKGROUND

The Canadian Emergency Team Initiative (CETI) cohort showed that minor injuries like sprained ankles or small fractures trigger a downward spiral of functional decline in 16% of independent seniors up to 6 months post-injury. Such seniors frequently receive medications with sedative or anticholinergic properties. The Drug Burden Index (DBI), which summarises the drug burden of these specific medications, has been associated with decreased physical and cognitive functioning in previous research.

OBJECTIVES

We aimed to assess the contribution of the DBI to functional decline in the CETI cohort.

METHODS

CETI participants were assessed physically and cognitively at baseline during their consultations at emergency departments (EDs) for their injuries and up to 6 months thereafter. The medication data were used to calculate baseline DBI and functional status was measured with the Older Americans Resources and Services (OARS) scale. Multivariate linear regression models assessed the association between baseline DBI and functional status at 6 months, adjusting for age, sex, baseline OARS, frailty level, comorbidity count, and mild cognitive impairment.

RESULTS

The mean age of the 846 participants was 77 years and their mean DBI at baseline was 0.24. Complete follow-up data at 3 or 6 months was available for 718 participants among whom a higher DBI at the time of injury contributed to a lower functional status at 6 months. Each additional point in the DBI lead to a loss of 0.5 points on the OARS functional scale, p < 0.001. Among those with a DBI ≥ 1, 27.4% were considered 'patients who decline' at 3 or 6 months' follow-up, compared with 16.0% of those with a DBI of 0 (p = 0.06).

CONCLUSIONS

ED visits are considered missed opportunities for optimal care interventions in seniors; Identifying their DBI and adjusting treatment accordingly may help limit functional decline in those at risk after minor injury.

GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention for Emergency Department Patients - A Qualitative Evaluation

Background:

Three million US emergency department (ED) visits occur for falls each year. The mortality of falls is increasing and only one fourth of older adults report their fall to their primary care provider, suggesting that valuable preventative opportunities are missed. A fall prevention intervention initiated in the ED immediately after a fall has the potential to reduce subsequent falls, but ED providers lack the time and resources to complete fall risk assessments on their patients. GAPcare, the Geriatric Acute and Post-Acute Fall Prevention Intervention, was developed to address this need.

Methods:

GAPcare combines a pharmacist-led medication therapy management intervention with a physical therapist (PT)-administered fall risk assessment and disposition planning. A key objective of this pilot randomized controlled trial (RCT) was to create a patient and caregiver-centric intervention. This manuscript reports on the results of the qualitative companion study in which we conducted in-depth interviews with patients and caregivers to determine their lived experience with the intervention, barriers and perceived impact of the intervention, and to obtain their recommendations for the improvement of GAPcare. We recruited patients and their caregivers from the RCT into 30 minutes interviews in the participants’ home singularly or in dyads (patient and caregiver together). Interviews were audio-recorded, transcribed, and double-coded. We used applied thematic analysis to guide the data analysis.

Results:

We conducted 20 interviews; patients (n=12), caregivers (n=11). Patients were on average 83 years old, 7/12 were female, and 2/14 had cognitive impairment. 6/11 caregiver interviews were in reference to a patient with dementia. Patients and caregivers reported they embraced the experience of motivational interviewing elements, citing its collaborative and inclusive nature. Caregivers in particular said they felt that PT helped their loved one recognize and overcome functional limitations. Barriers included lack of time, the burden of coordinating multiple service providers once home, and concerns that PT would be ineffective or increase pain. Areas for improvement included better screening for those who would benefit from the individual components (pharmacy vs. PT consultation), improving identification of GAPcare pharmacists and PTs vs. other hospital staff in the ED, and expanding the role of GAPcare personnel to provide culturally competent, comprehensive care to improve adherence and medication education.

Conclusions:

We found that GAPcare, a new team-based intervention for fall prevention in the ED, was welcomed by patients and their caregivers. Several suggestions to improve the intervention were made that will inform the screening, content, and communication with patients in GAPcare.

Safety and feasibility of an interactive workshop and facilitated outdoor walking group compared to a workshop alone in increasing outdoor walking activity among older adults: a pilot randomized controlled trial

Background

Limited outdoor walking is a marker of frailty and a risk factor for decline in mobility and self-care functioning, social isolation, and reduced health-related quality of life (HRQL). Objectives were to evaluate the safety, feasibility, and preliminary effect of a supervised outdoor walking group and interactive workshop compared to the workshop alone in increasing outdoor walking activity and identify an optimal method for estimating outdoor walking activity among older adults who infrequently walk outdoors.

Methods

A pilot 2-parallel-group randomized controlled trial was conducted. Adults aged ≥ 65 years who reported walking ≤ 20 min/week outdoors were randomized in a 2:1 ratio to receive the GO-OUT program (1-day workshop and 9-week outdoor walking group), or the workshop alone. An external site conducted the randomization after workshop completion. The eight workshop activity stations aimed to build knowledge and skills to safely walk outdoors. The group-based outdoor walking program consisted of repetitive practice of mobility tasks at local parks. The primary outcome of outdoor walking activity used an activity monitor and GPS; secondary outcomes included aerobic, balance, and walking capacity; physical activity; participation; mood; and HRQL. Blinded outcome assessors evaluated participants at 0, 3, and 6 months. Qualitative interviews occurred after 3 months; data were analyzed with qualitative description. Quantitative data were summarized using descriptive statistics.

Results

Forty-eight individuals were screened; 9 were eligible and randomized to the GO-OUT (n = 6) or workshop (n = 3) group. Data from 9 participants were analyzed. Mean age was 77 and 74 years in the GO-OUT and workshop groups, respectively. No falls occurred during the workshop and outdoor walking program. Average attendance of the walking group was 61%. All participants attended the evaluations and workshop. An analysis method combining data from activity monitors and GPS was developed to estimate outdoor walking. Themes from the qualitative analysis included the barriers to outdoor walking, impact of the workshop and GO-OUT walking group, and feasibility and acceptance of the assessment and intervention strategies.

Conclusions

The trial protocol was deemed safe and feasible. Results were used to inform changes to the protocol to conduct a full-scale study.

Trial registration

Clinical Trials.gov: NCT02339467.

Characteristics and outcomes of older adults presented to Spanish emergency departments after a fall

PURPOSE

To study patient profile, fall-related characteristics and immediate outcomes according to age and to determine the effect of age in the outcomes among older patients presenting to ED after a fall.

METHODS

Cross-sectional analysis of the FALL-ER registry that included patients aged ≥ 65 years old that presented to five Spanish EDs after a fall. Patients were classified into three age categories, and demographic, comorbidity, chronic medication, fall-related characteristics, health care resources and immediate outcomes data were analysed.

RESULTS

We included 1610 patients, 541 (28%) aged 65-74, 647 (40.2%) aged 74-84 and 512 (31.8%) aged ≥ 85 years old. Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. Medications related to risk of falling and antithrombotic therapy significantly increased with age category. Physical, functional and psychological consequences and healthcare resource use increased significantly with age group. Age was independently associated with severe injury (adjusted OR 1.02; IC 95% 1.01-1.04), fear of falling (adjusted OR 1.02; IC 95% 1.01-1.04) and acute functional impairment (adjusted OR 1.02; IC 95% 1.00-1.04).

CONCLUSIONS

Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. The probability of presenting with severe injury, fear of falling and acute functional impairment increases with age.

Use of the STTGMA Tool to Risk Stratify 1-Year Functional Outcomes and Mortality in Geriatric Trauma Patients

OBJECTIVES

To determine whether a novel inpatient mortality risk assessment tool designed to be calculated in the emergency department setting can risk stratify patient-reported functional outcomes and mortality at 1 year.

DESIGN

Prospective cohort.

SETTING

Academic level 1 trauma center.

PATIENTS

Six hundred eight-five patients >55 years of age who were orthopaedic surgery consults or trauma surgery consults in the emergency department between January 10, 2014, and September 30, 2015.

INTERVENTION

Calculation of the validated score for trauma triage in the geriatric and middle-aged (STTGMA) using each patient's demographics, injury severity, and functional status.

MAIN OUTCOME MEASUREMENTS

Mortality, EQ-5D questionnaire, and percent return to baseline function since their hospitalization at 1-year after hospitalization.

RESULTS

Forty-five (6.6%) patients died within the year after hospitalization. Of remaining 639 patients available for follow-up, 247 (38.7%) were successfully contacted. There was no observed difference between patients who were successfully contacted and those who were not. The mean STTGMA score was 2.1% ± 3.6%. Patients reported on average a 76.4% ± 27.5% return to baseline function. When comparing patients between risk groups, there was a significant difference in EQ-5D scores and percent return to baseline. The Kaplan-Meier survival curve shows that high-risk patients had pronounced decreased survival within the initial days after discharge compared with other cohorts.

CONCLUSIONS

This study demonstrates that patients identified with the STTGMA tool as having an increased risk of inpatient mortality after trauma correlate with poorer functional outcomes at 1 year. The STTGMA risk score is also a valuable tool to stratify risk of mortality up to 1 year after discharge.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Patients With Syncope and Suspected Dementia

OBJECTIVES

Syncope and near-syncope are common in patients with dementia and a leading cause of emergency department (ED) evaluation and subsequent hospitalization. The objective of this study was to describe the clinical trajectory and short-term outcomes of patients who presented to the ED with syncope or near-syncope and were assessed by their ED provider to have dementia.

METHODS

This multisite prospective cohort study included patients 60 years of age or older who presented to the ED with syncope or near-syncope between 2013 and 2016. We analyzed a subcohort of 279 patients who were identified by the treating ED provider to have baseline dementia. We collected comprehensive patient-level, utilization, and outcomes data through interviews, provider surveys, and chart abstraction. Outcome measures included serious conditions related to syncope and death.

RESULTS

Overall, 221 patients (79%) were hospitalized with a median length of stay of 2.1 days. A total of 46 patients (16%) were diagnosed with a serious condition in the ED. Of the 179 hospitalized patients who did not have a serious condition identified in the ED, 14 (7.8%) were subsequently diagnosed with a serious condition during the hospitalization, and an additional 12 patients (6.7%) were diagnosed postdischarge within 30 days of the index ED visit. There were seven deaths (2.5%) overall, none of which were cardiac-related. No patients who were discharged from the ED died or had a serious condition in the subsequent 30 days.

CONCLUSIONS

Patients with perceived dementia who presented to the ED with syncope or near-syncope were frequently hospitalized. The diagnosis of a serious condition was uncommon if not identified during the initial ED assessment. Given the known iatrogenic risks of hospitalization for patients with dementia, future investigation of the impact of goals of care discussions on reducing potentially preventable, futile, or unwanted hospitalizations while improving goal-concordant care is warranted.

Optimization of the APOP screener to predict functional decline or mortality in older emergency department patients: Cross-validation in four prospective cohorts

INTRODUCTION

Many screening instruments to predict adverse health outcomes in older patients visiting the emergency department (ED) have been developed, but successful implementation has been hampered because they are insufficiently validated or not tailored for the intended use of everyday clinical practice. The present study aims to refine and validate an existing screening instrument (the APOP screener) to predict 90-day functional decline or mortality in older ED patients.

METHODS

Consecutive older patients (≥70 years) visiting the EDs of four hospitals were included and prospectively followed. First, an expert panel used predefined criteria to decide which independent predictors (including demographics, illness severity and geriatric parameters) were suitable for refinement of the model predicting functional decline or mortality after 90 days. Second, the model was cross-validated in all four hospitals and predictive performance was assessed. Additionally, a pilot study among triage nurses experiences and clinical usability of the APOP screener was conducted.

RESULTS

In total 2629 older patients were included, with a median age of 79 years (IQR 74-84). After 90 days 805 patients (30.6%) experienced functional decline or mortality. The refined prediction model included age, gender, way of arrival, need of regular help, need help in bathing/showering, hospitalization the prior six months and impaired cognition. Calibration was good and cross-validation was successful with a pooled area under the curve of 0.71 (0.69-0.73). In the top 20% patients predicted to be at highest risk in total 58% (95%CI 54%-62%) experienced functional decline or mortality. Triage nurses found the screener well suited for clinical use, with room for improvement.

CONCLUSION

In conclusion, optimization of the APOP screener resulted in a short and more simplified screener, which adequately identifies older ED patients at highest risk for functional decline or mortality. The findings of the pilot study were promising for clinical use.

Preventing emergency department (ED) visits and hospitalisations of older adults with cognitive impairment compared with the general senior population: what do we know about avoidable incidents? Results from a scoping review

OBJECTIVES

Older cognitively impaired adults present a higher risk of hospitalisation and mortality following a visit to the emergency department (ED). Better understanding of avoidable incidents is needed to prevent them and the associated ED presentations in community-dwelling adults. This study aimed to synthetise the actual knowledge concerning these incidents leading this population to ED presentation, as well as possible preventive measures to reduce them.

DESIGN

A scoping review was performed according to the Arksey and O'Malley framework.

METHODS

Scientific and grey literature published between 1996 and 2017 were examined in databases (Medline, Cumulative Index of Nursing and Allied Health, Ageline, Scopus, ProQuest Dissertations/theses, Evidence-based medecine (EBM) Reviews, Healthstar), online library catalogues, governmental websites and published statistics. Sources discussing avoidable incidents leading to ED presentations were included and then extended to those discussing hospitalisation and mortality due to a lack of sources. Data (type, frequency, severity and circumstances of incidents, preventive measures) was extracted using a thematic chart, then analysed with content analysis.

RESULTS

67 sources were included in this scoping review. Five types of avoidable incidents (falls, burns, transport accidents, harm due to self-negligence and due to wandering) emerged, and all but transport accidents were more frequent in cognitively impaired seniors. Differences regarding circumstances were only reported for burns, as scalding was the most prevalent mechanism of injury for this population compared with flames for the general senior population. Multifactorial interventions and implications of other professionals (eg, pharmacist, firefighters) were reported as potential interventions to reduce avoidable incidents. However, few preventive measures were specifically tested in this population.

CONCLUSIONS

Primary research that screens for cognitive impairment and involves actors (eg, paramedics) to improve our understanding of avoidable incidents leading to ED visits is greatly needed. This knowledge is essential to develop preventive measures tailored to the needs of older cognitively impaired adults.

Prognostic Value of S-100β Protein for Prediction of Post-Concussion Symptoms after a Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to determine the prognostic value of S-100β protein to identify patients with post-concussion symptoms after a mild traumatic brain injury (mTBI). A search strategy was submitted to seven databases from their inception to October 2016. Individual patient data were requested. Cohort studies evaluating the association between S-100β protein level and post-concussion symptoms assessed at least seven days after the mTBI were considered. Outcomes were dichotomized as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies including between seven and 223 patients (n = 2505) were included. Post-concussion syndrome (PCS) (16 studies) and neuropsychological symptoms (9 studies) were the most frequently assessed outcomes. The odds of having persistent PCS (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.34-1.12, p = 0.11, I² 0% [n = five studies]) in patients with an elevated S-100β protein serum level were not significantly different from those of patients with normal values while the odds of having early PCS (OR 1.67, 95% CI: 0.98-2.85, p = 0.06, I² 38% [n = five studies]) were close to statistical significance. Similarly, having an elevated S-100β protein serum level was not associated with the odds of returning to work at six months (OR 2.31, 95% CI: 0.50-10.64, p = 0.28, I² 22% [n = two studies]). Overall risk of bias was considered moderate. Results suggest that the prognostic biomarker S-100β protein has a low clinical value to identify patients at risk of persistent post-concussion symptoms. Variability in injury to S-100ß protein sample time, mTBI populations, and outcomes assessed could potentially explain the lack of association and needs further evaluation.

Feasibility, Acceptability and Effects of a Home-Based Exercise Program Using a Gerontechnology on Physical Capacities after a Minor Injury in Community-Living Older Adults: A Pilot Study

CONTEXT

Several studies have demonstrated that physical activity can help limit decline in functional capacities of older adults. Nevertheless, many adults aged 65 and over are inactive.

OBJECTIVE

To explore the feasibility, the acceptability and the effects of a home-based exercise program (HEP) using a motion capture gerontechnology in independent community-living older adults at risk of function decline.

DESIGN

Interventionnal clinical trial.

PARTICIPANTS

Sixteen previously independent individuals aged 65 and older recruited at the Emergency Department after being treated for a minor injury and discharged home were assigned to a home-based exercise program group (HEP=8) or to a control group (CONTR=8). Twelve participants completed the study, 6 in each group Setting: Canadian Community-dwelling in Montreal area.

INTERVENTION

The HEP group engaged in a twelve-week physical activity intervention using a gerontechnology while the CONTR group continued with discharge plan from ED.

MEASUREMENTS

Participants were evaluated for functional status using validated questionnaires and objective physical measures at baseline, three and six months later. Feasibility and acceptability of the HEP was assessed using data reports from the gerontechnology and from self-reported assessments.

RESULTS

There was no differences between groups at baseline except for the fallrelated self-efficacy: HEP=8.33/28±1.51 vs CONTR=7/28±0 p=0.022. The HEP was found to be feasible and acceptable (adherence rate at 86% and average quality of movements at 87.5%). Significant improvement in walking speed on 4m was observed three months after baseline for HEP vs CONTR group (+0.25 vs +0.05 m/sec, p=0.025). Effects remained at follow-up. Only CONTR group resulted in a significant increase in SF-36 global score.

CONCLUSION

This twelve-week HEP intervention using the Jintronix® gerontechnology is feasible, acceptable and safe for community-living older adults who sustained a minor injury. This intervention could increase walking speed, the most important predictor of adverse events in the elderly population, and that the improvement could be maintained over time.

Slipping through the cracks: A cross-sectional study examining older adult emergency department patient fall history, post-fall treatment and prevention

Falls are the leading cause of emergency department (ED) visits for fatal and non-fatal injuries among adults 65 years old and older. We aimed to better understand the fall history, risk for further falls, and actions taken to prevent further falls among this higher fall risk population. This cross-sectional study included older adults without cognitive impairment presenting to the Rhode Island Hospital ED from February to May 2017. Of the 76 participants, 35 self-reported no prior falls, and 41 self-reported at least one prior fall, of whom 20 fell on the day of ED presentation. Participants with vs. without self-reported prior falls were similar in age, gender, race, and substance use. Participants with prior falls scored lower on cognitive testing and had more comorbidities associated with falls. Only one quarter of those with prior falls reported making changes and few were evaluated by professionals to prevent future falls. This study highlights that older adult ED patients who sustain a fall are at higher risk for subsequent falls, and that greater fall prevention efforts are needed to protect this vulnerable group. [Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

Prognostic value of neuron-specific enolase (NSE) for prediction of post-concussion symptoms following a mild traumatic brain injury: a systematic review

BACKGROUND

This systematic review aimed to determine the prognostic value of neuron-specific enolase (NSE) to predict post-concussion symptoms following mild traumatic brain injury (TBI).

METHODS

Seven databases were searched for studies evaluating the association between NSE levels and post-concussion symptoms assessed ≥ 3 months (persistent) or ≥ 7 days < 3 months (early) after mild TBI. Two researchers independently screened studies for inclusion, extracted data and appraised quality using the Quality in Prognostic Studies (QUIPS) tool.

RESULTS

The search strategy yielded a total of 23,298 citations from which 8 cohorts presented in 10 studies were included. Studies included between 45 and 141 patients (total 608 patients). The outcomes most frequently assessed were post-concussion syndrome (PCS, 12 assessments) and neuropsychological performance deficits (10 assessments). No association was found between an elevated NSE serum level and PCS. Only one study reported a statistically significant association between a higher NSE serum level and alteration of at least three cognitive domains at 2 weeks but this association was no longer significant at 6 weeks. Overall, risk of bias of the included studies was considered moderate.

CONCLUSIONS

Early NSE serum level is not a strong independent predictor of post-concussion symptoms following mild TBI.

Using the Bergman-Paris Question to screen seniors in the emergency department

OBJECTIVES

In the fast pace of the Emergency Department (ED), clinicians are in need of tailored screening tools to detect seniors who are at risk of adverse outcomes. We aimed to explore the usefulness of the Bergman-Paris Question (BPQ) to expose potential undetected geriatric syndromes in community-living seniors presenting to the ED.

METHODS

This is a planned sub-study of the INDEED multicentre prospective cohort study, including independent or semi-independent seniors (≥65 years old) admitted to hospital after an ED stay ≥8 hours and who were not delirious. Patients were assessed using validated screening tests for 3 geriatric syndromes: cognitive and functional impairment, and frailty. The BPQ was asked upon availability of a relative at enrolment. BPQ's sensitivity and specificity analyses were used to ascertain outcomes.

RESULTS

A response to the BPQ was available for 171 patients (47% of the main study's cohort). Of this number, 75.4% were positive (suggesting impairment), and 24.6% were negative. To detect one of the three geriatric syndromes, the BPQ had a sensitivity of 85.4% (95% CI [76.3, 92.0]) and a specificity of 35.4% (95% CI [25.1, 46.7]). Similar results were obtained for each separate outcome. Odds ratio demonstrated a higher risk of presence of geriatric syndromes.

CONCLUSION

The Bergman-Paris Question could be an ED screening tool for possible geriatric syndrome. A positive BPQ should prompt the need of further investigations and a negative BPQ possibly warrants no further action. More research is needed to validate the usefulness of the BPQ for day-to-day geriatric screening by ED professionals or geriatricians.

Characteristics of patients included and enrolled in studies on the prognostic value of serum biomarkers for prediction of postconcussion symptoms following a mild traumatic brain injury: a systematic review

OBJECTIVE

Mild traumatic brain injury (mTBI) has been insufficiently researched, and its definition remains elusive. Investigators are confronted by heterogeneity in patients, mechanism of injury and outcomes. Findings are thus often limited in generalisability and clinical application. Serum protein biomarkers are increasingly assessed to enhance prognostication of outcomes, but their translation into clinical practice has yet to be achieved. A systematic review was performed to describe the adult populations included and enrolled in studies that evaluated the prognostic value of protein biomarkers to predict postconcussion symptoms following an mTBI.

DATA SOURCES

Searches of MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, PsycBITE and PsycINFO up to October 2016.

DATA SELECTION AND EXTRACTION

Two reviewers independently screened for potentially eligible studies, extracted data and assessed the overall quality of evidence by outcome using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

A total of 23 298 citations were obtained from which 166 manuscripts were reviewed. Thirty-six cohort studies (2812 patients) having enrolled between 7 and 311 patients (median 89) fulfilled our inclusion criteria. Most studies excluded patients based on advanced age (n=10 (28%)), neurological disorders (n=20 (56%)), psychiatric disorders (n=17 (47%)), substance abuse disorders (n=13 (36%)) or previous traumatic brain injury (n=10 (28%)). Twenty-one studies (58%) used at least two of these exclusion criteria. The pooled mean age of included patients was 39.3 (SD 4.6) years old (34 studies). The criteria used to define a mTBI were inconsistent. The most frequently reported outcome was postconcussion syndrome using the Rivermead Post-Concussion Symptoms Questionnaire (n=18 (50%)) with follow-ups ranging from 7 days to 5 years after the mTBI.

CONCLUSIONS

Most studies have recruited samples that are not representative and generalisable to the mTBI population. These exclusion criteria limit the potential use and translation of promising serum protein biomarkers to predict postconcussion symptoms.

Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma†

Background

there is no standardised test for assessing mobility in the Emergency Department (ED).

Objective

we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma.

Methods

this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated.

Results

TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5).

Conclusion

in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.