Post-acute care for frail older people decreases 90-day emergency room visits, readmissions and mortality: An interventional study

Comprehensive geriatric assessment for older adults admitted to the hospital as emergencies: a meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effects of comprehensive geriatric assessment (CGA) on mortality, readmission, activities of daily living (ADL) improvement, and length of hospital stay in acutely hospitalized older patients.

METHODS

In accordance with the guidelines from the Cochrane recommendations and PRISMA guidelines, we conducted a search of seven databases: PubMed, Web of Science, Embase, CINAHL, ProQuest, ScienceDirect, and Cochrane Library, aiming to identify eligible studies published from the time of database inception up to February 23, 2024. The quality of the included studies was assessed using the Cochrane Risk of Bias (RoB) 2.0. Following the literature search, two researchers independently performed data extraction and quality assessment, and conducted meta-analysis using Review Manager 5.4 software, pooling risk ratios (RR) and 95 % confidence intervals (CI). Heterogeneity among studies was evaluated using the I2 statistic.

RESULTS

Twenty-three trials involving 9,477 participants were identified. The final meta-analysis showed that CGA did not significantly reduce mortality overall. However, subgroup analyses revealed that older patients living alone who underwent CGA had a lower risk of mortality at 6 months (RR 0.43, 95 % CI 0.21 to 0.90; P = 0.03). At six months post-discharge, CGA reduced readmission rates (RR 0.49, 95 % CI 0.36 to 0.68; P < 0.0001), and improved ADL outcomes in targeted populations (RR 3.04, 95 % CI 1.05 to 8.79; p = 0.04), though no differences were observed in length of stay (MD 0.50, 95 % CI -1.98 to 2.98; P = 0.69).

CONCLUSION

CGA may improve short-term survival and reduce rates of readmission following acute hospitalization. These findings highlight CGA's potential to enhance geriatric nursing practice through comprehensive evaluations addressing both functional status and social vulnerabilities. Further research is needed to explore multicenter, standardized CGA frameworks with long-term follow-up, which are essential for establishing evidence-based clinical guidelines to facilitate seamless integration of CGA into routine geriatric care pathways.

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.

The association of biological sex and long-term outcomes in older patients with physical restraint at the emergency department

BACKGROUND

The worldwide population is ageing and self-arm can be prevented with many techniques. Among them coercive measure consisting of physical restraint (PR) is one of the techniques. This study aims to assess the effects of the biological sex on the long-term survival after PR in geriatric patients during the initial emergency department (ED) visit.

METHODS

This retrospective study included patients between November 2019 to March 2021. All consecutive hospitalized patients after emergency department visit older than 75 years with PR were included. The population was compared according to the biological sex. One-year all-cause mortality was plotted with the Kaplan-Meier curve. Hazard ratios (HRs) for 1-year mortality were calculated using a Cox proportional hazards regression model. Mortality was monitored over a 3-year period.

RESULTS

PR was used in 149 patients representing 4.6% of 3210 hospitalized patients older than 75 years after ED visit. Women represented 52% of the study population. Compared to men, women were older [median (IQR) age 89 (85-93) vs. 85 (81-90) years, P = 0.002]. Women more often presented dementia (93 vs. 80%, P = 0.031). Both sexes presented the same limited independence. All-cause mortality was significantly lower for women than men after one year (25 vs. 51%, respectively, P = < 0.001). Likewise, adjusted HR of 1-year all-cause mortality was higher in men [a HR 3.4 (95% confidence interval 1.7-7.1), P < 0.001].

CONCLUSION

This study suggested that the use of physical restraint in older adults was a more related factor of mortality in men than women. Women were older with lower expectancy life but PR use seemed to be a sign of global health decline in men. Further prospective studies are needed to assess if mortality after PR use is a cause or a consequence of a global health decline.

Revisits and frailty in older patients in the emergency department - a prospective observational multicenter study

BACKGROUND

An increased number of revisits may signal that the immediate medical needs of patients seeking care at Emergency Departments (EDs) are not being met. The prevalence and characteristics of revisits to the EDs in Sweden among older patients, and its association to frailty, are unknown. We aimed to investigate the prevalence of ED revisits among patients over 65 years of age, living with or without frailty, and its association with rate of admission, and mortality; in the Swedish ED setting.

METHODS

This was a prospective, multicentre study of patients over 65 years of age with an index visit to one of three Swedish EDs during May-Nov 2021. Frailty was assessed in conjunction with standard triage, using the 9-level Clinical Frailty Scale (CFS) with a CFS score of 5 to 8 as cut-off for identifying frailty. For all patients who made a revisit within 90 days of their index visit, we collected information about the revisit, admission, and mortality.

RESULTS

A total of 1835 patients made an index visit which were included, and out of those, 595 patients made a revisit within 90 days of the index visit. Patients living with frailty (CFS 5 to 8) were more likely to make a revisit to the ED at 8 to 30 days (17% vs. 11%, diff 6%, 95% CI 2-10%, p < 0.001) and at 31 to 90 days (19% vs. 12%, diff 7%, 95% CI 3-10%, p < 0.001) and be admitted to in-hospital care during their revisit (57% vs. 47%, diff 10%, 95% CI, 1-18%, p < 0.05), compared to patients living without frailty. Results also show that patients living with frailty had a higher overall mortality rate (17% vs. 5%, diff 12%, 95% CI 7-18%, p < 0.001). However, among patients living without frailty, making a revisit slightly increased the mortality rate compared to those who did not (5% vs. 2%, diff 3%, 95% CI 1-10%, p < 0.05).

CONCLUSIONS

Patients living with frailty make more revisits, are more often admitted to in-hospital care, and have a higher overall mortality rate than patients not living with frailty. Frailty, assessed with the CFS may be a simple and useful indicator of increased risk of adverse events, including revisits, in the ED.

Does post acute care reduce the mortality of octogenarian and nonagenarian patients undergoing hip fracture surgery?

BACKGROUND

With the increasing number of elderly individuals worldwide, a greater number of people aged 80 years and older sustain fragility fracture due to osteopenia and osteoporosis.

METHODS

This retrospective study included 158 older adults, with a median age of 85 (range: 80-99) years, who sustained hip fragility fracture and who underwent surgery. The patients were divided into two groups, one including patients who joined the post-acute care (PAC) program after surgery and another comprising patients who did not. The mortality, complication, comorbidity, re-fracture, secondary fracture, and readmission rates and functional status (based on the Barthel index score, numerical rating scale score, and Harris Hip Scale score) between the two groups were compared.

RESULTS

The patients who presented with fragility hip fracture and who joined the PAC rehabilitation program after the surgery had a lower rate of mortality, readmission rate, fracture (re-fracture and secondary fracture), and complications associated with fragility fracture, such as urinary tract infection, cerebrovascular accident, and pneumonia (acute coronary syndrome, out-of-hospital cardiac arrest, or in-hospital cardiac arrest.

CONCLUSIONS

PAC is associated with a lower rate of mortality and complications such as urinary tract infection, bed sore, and pneumonia in octogenarian and nonagenarian patients with hip fragility fracture.