Automating risk stratification for geriatric syndromes in the emergency department

Boarding in the Emergency Department: Specific Harms to Older Adults and Strategies for Risk Mitigation

Emergency department (ED) boarding, which refers to holding patients in the ED for prolonged periods while awaiting an inpatient bed, is linked to patient harm and is associated with worsening ED crowding. Evidence suggests that older patients are at increased risk of complications from boarding, including the development of delirium. By prioritizing the admission of at-risk older patients to inpatient beds, ED may improve the both the quality of care for these patients and reduce inpatient lengths of stay. Older patients who must board in the ED may benefit from targeted interventions to help mitigate risks from ED boarding.

Team-based, Multidisciplinary Care in the Emergency Department

Multidisciplinary care for older adults in the emergency department (ED) is endorsed by multiple national and international guidelines. There are numerous disciplines to consider including, each with different strengths and contributions, including social workers, case managers, pharmacists, physical, occupational, and speech therapists, hospice and palliative medicine teams, and the emergency deaprtment physicians and nurses themselves. The care team also extends beyond the ED walls and should include community services and the patient's family members and caregivers. There are many advantages to multidisciplinary care, including improved ED metrics, reduced length of hospitalization, and a reduction in repeat ED visits.

Practice and Impact of Using Fall Screening Tools in Emergency Medicine for Older Adults: A Scoping Review

Falls are a leading cause of injury among older adults in the United States which leads to significant morbidity and mortality. Though screening for fall risk is an important preventative measure in the emergency department (ED), fall screening tools' feasibility and utility remain a challenge in EDs. This scoping review aimed to identify the fall screening tools, their psychometric properties, their best practices, and their impact in the ED among patients aged 60 years and older. In the 25 publications included in this review, 6 functional assessments and 10 screening questionnaires were used. Even though this review found several tools that are easy to apply and have good psychometric properties in the ED setting, there is a need for increased feasibility, support, and effectiveness. Consistent education and resource allocation remains a challenge for fall screening. Future research needs to focus on optimizing fall screening tools and practices to improve fall prevention measures in ED.

Around the EQUATOR With Clin-STAR: AI-Based Randomized Controlled Trial Challenges and Opportunities in Aging Research

The CONSORT 2010 statement is a guideline that provides an evidence-based checklist of minimum reporting standards for randomized trials. With the rapid growth of Artificial Intelligence (AI) based interventions in the past 10 years, the CONSORT-AI extension was created in 2020 to provide guidelines for AI-based randomized controlled trials (RCT). The Clin-STAR "Around the EQUATOR" series features existing reported standards while also highlighting the inherent complexities of research involving research of older participants. In this work, we propose that when designing AI-based RCTs involving older adults, researchers adopt a conceptual framework (CONSORT-AI-5Ms) designed around the 5Ms (Mind, Mobility, Medications, Matters most, and Multi-complexity) of Age-Friendly Healthcare Systems. Employing the 5Ms in this context, we provide a detailed rationale and include specific examples of challenges and potential solutions to maximize the impact and value of AI RCTs in an older adult population. By combining the original intent of CONSORT-AI with the 5Ms framework, CONSORT-AI-5Ms provides a patient-centered and equitable perspective to consider when designing AI-based RCTs to address the diverse needs and challenges associated with geriatric care.

Optimizing physician-encounter frequency for type 2 diabetes patients in primary care based on cardiovascular risk assessment: A target trial emulation study

AIM

To investigate whether the physician-encounter interval for patients with type 2 diabetes (T2D) can be optimized from 2-3 to 4-6 months among those with a calculated 10-year cardiovascular disease (CVD) risk score of less than 20% without compromising their long-term outcomes.

MATERIALS AND METHODS

Using territory-wide public electronic medical records in Hong Kong, we emulated a target trial to compare the effectiveness of the physician-encounter intervals of 4-6 versus 2-3 months for T2D patients without prior CVDs and with a predicted risk for CVDs of less than 20% (i.e. those patients not in the high-risk category). Propensity score matching was used to emulate the randomization of participants at baseline, where 42 154 matched individuals were included for analysis. The marginal structural model was applied to estimate the hazard ratio (HR) for CVD incidence and all-cause mortality, the incidence rate ratio of secondary and tertiary care utilization, as well as the between-group differences in HbA1c, blood pressure and cholesterol levels.

RESULTS

During a follow-up period of up to 12 (average: 5.1) years, there was no significantly increased risk of CVD in patients with physician-encounter intervals of 4-6 months compared with those patients with physician-encounter intervals of 2-3 months (HR [95% confidence interval {CI}]: 1.01 [0.90, 1.14]; standardized 10-year risk difference [95% CI]: -0.1% [-0.7%, 0.6%]), nor for all-cause mortality (HR: 1.00 [0.84, 1.20]; standardized 10-year risk difference: -0.1% [-0.5%, 0.3%]). Additionally, there was no observable difference in the utilization of secondary and tertiary care or key clinical parameters between these two follow-up frequencies.

CONCLUSIONS

For T2D patients with a calculated 10-year CVD risk of less than 20%, the interval of regular physician encounters can be optimized from 2-3 to 4-6 months without compromising patients' long-term outcomes and saving substantial service resources in primary care.

Enhancing healthcare access for an older population: The age-friendly emergency department

Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.

A machine learning approach to evaluate the impact of virtual balance/cognitive training on fall risk in older women

Introduction

Novel technologies based on virtual reality (VR) are creating attractive virtual environments with high ecological value, used both in basic/clinical neuroscience and modern medical practice. The study aimed to evaluate the effects of VR-based training in an elderly population.

Materials and methods

The study included 36 women over the age of 60, who were randomly divided into two groups subjected to balance-strength and balance-cognitive training. The research applied both conventional clinical tests, such as (a) the Timed Up and Go test, (b) the five-times sit-to-stand test, and (c) the posturographic exam with the Romberg test with eyes open and closed. Training in both groups was conducted for 10 sessions and embraced exercises on a bicycle ergometer and exercises using non-immersive VR created by the ActivLife platform. Machine learning methods with a k-nearest neighbors classifier, which are very effective and popular, were proposed to statistically evaluate the differences in training effects in the two groups.

Results and conclusion

The study showed that training using VR brought beneficial improvement in clinical tests and changes in the pattern of posturographic trajectories were observed. An important finding of the research was a statistically significant reduction in the risk of falls in the study population. The use of virtual environments in exercise/training has great potential in promoting healthy aging and preventing balance loss and falls among seniors.

Recruiting patients for falls prevention in the emergency department - worth the challenge

BACKGROUND

Severe falls escalate the risk of future falls and functional decline as indicated by recent global guidelines. To establish effective falls prevention, individuals at highest risk must be thoroughly studied and, therefore, successfully recruited.

OBJECTIVE

Recruiting from an emergency department (ED) may mitigate common selection biases, such as overrepresentation of individuals with a higher social status and healthier lifestyle. However, this approach presents unique challenges due to ED-specific conditions. Hence, we present the successes and challenges of an ED-based recruitment for an observational study.

METHODS

The SeFallED study targets older adults aged ≥60 years, who present to either of two hospitals in Oldenburg after a fall without subsequent admission. A study nurse addressed individuals in the EDs. Subsequently, potential participants were contacted by phone to arrange a home visit for obtaining written consent. Data of participants were compared with total admissions during the recruitment period to determine recruitment rate and compare patients' characteristics.

RESULTS

Over 1.500 individuals met the inclusion criteria. Of these, 288 participants were successfully recruited. Most patients presented to the ED outside of the study team's working hours, and some opted not to participate (main reason: too unwell (40%)). Compared to working hours, a participant was recruited every 14 h. Comparing characteristics, a trend towards better health and younger age was observed.

CONCLUSION

ED-based recruitment offers the opportunity to include more diverse individuals in falls prevention. To achieve adequate sample sizes, flexibility in working days and hours of the research team are obligatory.

TRIAL REGISTRATION

DRKS00025949.