Older Emergency Department Patients Research Articles

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

BackgroundCognitive impairment (CI) is common among older patients presenting to the emergency department (ED). The failure to recognize CI at ED presentation constitutes a high risk of additional morbidity, mortality, and functional decline. The Clock Drawing Test (CDT) is a well-established cognitive screening test. AimIn patients presenting to the ED with non-specific complaints (NSCs), we aimed to investigate the usability of the CDT and its prognostic value regarding length of hospital stay (LOS) and mortality. MethodSecondary analysis of the Basel Non-specific Complaints (BANC) trial, a prospective delayed type cross-sectional study with a 30-day follow-up. In three EDs, patients presenting with NSCs were enrolled. The CDT was administered at enrollment. ResultsIn the 1,278 patients enrolled, median age was 81 [74, 87] years and 782 were female (61.19%). A valid CDT was obtained in 737 (57.7%) patients. In patients without a valid CDT median LOS was higher (29 [9, 49] days vs. 22 [9, 45] days), and 30-day mortality was significantly higher than in patients with a valid CDT (n = 45 (8.32%) vs. n = 39 (5.29%)). Of all valid CDTs, 154 clocks (20.9%) were classified as normal, 55 (7.5%) as mildly deficient, 297 (40.3%) as moderately deficient, and 231 (31.3%) as severely deficient. Mortality and LOS increased along with the CDT deficits (p = 0.012 for 30-day mortality; p < 0.001 for LOS). ConclusionThe early identification of patients with CI may lead to improved patient management and resource allocation. The CDT could be used as a risk stratification tool for older ED patients presenting with NSCs, as it is a predictor for 30-day mortality and LOS.

Diagnostic and prognostic value of cardiac troponins in emergency department patients presenting after a fall: A prospective, multicenter study.

Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF. This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient. In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the goldstandard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both). A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.

Assessing dynamical resilience indicators in older adults: a prospective feasibility cohort study

Key summary pointsAimTo examine the feasibility of a prospective cohort study examining dynamical resilience indicators in acutely ill older adults who visited the Emergency Department (ED).FindingsThe intensive examination of dynamical resilience indiciators based on symptoms and physical activity measurements is feasible in older ED patients.MessageThe method of intensive dynamical resilience indicators assessment can be used to study resilience in older ED patients.

1995 Constructing a Frailty Index using routinely collected measures to study its relationship with adverse health outcomes

Abstract Introduction Any Frailty Index (FI) measures overall health. The FI-Lab employs common laboratory data and clinical measures to do so. Objective To examine how an FI-lab constructed from vital signs, laboratory tests, and electrocardiographic data is associated with in-patient admission and time to death. FI-Lab performance was compared with an FI from a Comprehensive Geriatric Assessment (FI-CGA), the Clinical Frailty Scale (CFS), and the Canadian Triage Acuity Scale (CTAS). Method Participants were Emergency Department (ED) patients aged 65+ years referred to Internal Medicine, staffed by a geriatrician (KR). Fifty-seven FI-Lab variables were binarized (0 = no deficit; 1 = deficit) using standard normal ranges. Each FI was calculated as the fraction of items present as deficits. Age- and sex-adjusted Cox proportional hazard and logistic regression models were used to assess relationships with all-cause mortality, and in-patient admission, respectively. Results Of 808 patients, an FI-Lab was calculable in 807. Median age was 81 years (IQR:13); 55.7% were female. FI-Lab values ranged from 0.05–0.78 (Mean: 0.51; Standard deviation (SD) 0.10). Females (0.50±0.11) had lower FI-Lab scores than males (Mean: 0.52±0.09; p=0.003). At 30 days, each 0.01 FI-Lab unit increase showed higher mortality Hazard Rate (HR) (95% Confidence Interval (CI):1.04 (1.02–1.06) and inpatient admission risk: Odds ratio (OR) 1.02 (1.00–1.03), as did the FI-CGA (1.04; 1.02-1.04) and CTAS (1.46; 1.02-2.10). Similar results held for inpatient admission, save for CTAS (0.95; 0.54-1.64). By two years, only the FI-lab and CFS significantly predicted mortality risk. Conclusion FI-Lab scores were associated with higher mortality rates and in-patient admission risk in older ED patients referred to Medicine. In acute care, the FI-Lab appears to integrate baseline frailty with illness severity. As such data often are routinely available, the FI-Lab might be an additional passive measure of frailty-related risk, potentially available in real time.

Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults.

We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients. We performed a retrospective case control study from June 1-August 31, 2019 (pre-program) to September 24, 2019-January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables. A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P < 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P < 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41-0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14-0.50). Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients.

Missed Opportunity to Diagnose Palliative Care Need Among Older Emergency Department Patients in a Middle-Income Country: A Retrospective Study.

This study aimed to determine the percentage of missed opportunities (MOs) to identify and treat older adults presenting with palliative care (PC) needs at one emergency department (ED). The secondary objective was to determine the rate of treatment interventions regardless of whether the patients received a PC plan as well as the direct cost of treatment. In this retrospective study, PC need was determined using broad and narrow criteria. The subjects comprised patients aged 65 or older who had out-of-hospital cardiac arrest and/or died in the ED (Group 1) or within 72 hours after ED disposition (Group 2) over a 3-year period (2016-2018). Overall, 17,414 older adults visited the ED, 60 died in the ED, and 400 died within 72 hours after ED disposition and admitted to in-hospital ward. In total, 200 patients were randomly selected; of these, 15 were excluded. Of the remaining 185 patients enrolled, 161/185 (87%) met the PC criteria and 60/161 (37.3%) were missed opportunities for PC planning. Group 1, had thirty patients, and 8 of those 30 (27%) were missed opportunities for PC planning. Group 2, 131/161 (81.4%), died within 72 hours, and there were 52 missed opportunities (39.7%) of ED PC planning. By comorbidity (Group 2), providers considered PC planning most often for cancer patients (PC: 41.8%; missed opportunities: 15.4%; p = 0.001) and there were more missed opportunities for PC planning among those with ischemic heart disease (PC: 19.0%; missed opportunities: 36.5%; p = 0.025). Of the older adults who visited the ED, 87% merited palliative care; further, 37% of opportunities for PC planning were missed. Providers considered PC planning most often for cancer patients. Recognizing PC needs and initiating care in the ED can improve end-of-life quality for dying patients.

Feasibility of cognitive assessments post‐emergency department (ED) discharge: A longitudinal pilot study of Medicare‐enrolled adults 65 +

AbstractBackground50% of US adults living with Alzheimer’s disease and related dementias (ADRD) never receive a formal diagnosis. This compromises the wellbeing of persons living with ADRD and their care partners, increases health services utilization, and the costs‐of‐care. Wider screening and assessment for ADRD may increase access to supportive care that prevents or delays disease progression, ameliorates care partner burden, and alleviates costs.MethodA sample of Medicare‐enrolled individuals 65+ (n = 149) presenting to the Oregon Health &amp; Sciences University (OHSU) emergency department (ED) in Portland, Oregon between May 2022 and January 2023 were recruited and administered the Telephone Interview for Cognitive Status (TICS) up to one‐month post‐discharge. Study participants were queried about their physical health via the modified cumulative illness rating scale (M‐CIRS), while their cognitive health was assessed via the PROMIS Cognitive Measure Questions on Mental Clarity. Care utilization patterns were measured via review of subjects’ electronic health records (EHR) for three years prior to study enrollment date focusing on total hospitalizations, ED visits, and primary care (PC) visits. These reviews measured health care utilization across three groups comparing individuals with (A) un‐diagnosed cognitive impairment with (B) cognitively healthy individuals, and (C) individuals with a formal ADRD diagnosis.ResultStudy enrollment rate was 25.8% (n = 149) of individuals meeting eligibility requirements. Enrollment was limited to patients with an OHSU PC affiliated provider excluding the majority (ineligible n = 1681, 74%) of Medicare‐enrolled ED patients (total ED users available for recruitment was n = 2,258). Of those contacted, 10% declined participation due to lack of interest and 4% declined due to cognitive or health restraints. Time to administer instrument suite ranged between 26‐33 minutes.ConclusionMedicare‐enrolled adults 65+ recently discharged from the ED appear to be an acceptable population to administer cognitive assessments. Findings during the recruitment process show success at enrolling this population to the study and administration times did not appear burdensome in duration for those enrolled. This study provides preliminary evidence supporting a focus on older ED patients to administer cognitive assessments, linking outcomes to the EHR, and ultimately providing a platform for future research on the impact of under‐diagnosed ADRD on health outcomes and utilization.

Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study

BackgroundThe Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting.MethodsThis was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis.ResultsA total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care.ConclusionMost emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment.RegistrationThe study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).

A Lethal Combination of Delirium and Overcrowding in the Emergency Department.

Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.

Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization

BackgroundComprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable.AimTo determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients’ subsequent healthcare utilization.MethodsSecondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914–20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously.ResultsThirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7–9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2–6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5–0.9, p = .01).Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1–16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission.ConclusionAbout one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness.

Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients. This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention. Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation. Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients

BackgroundPalliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED).MethodsThis prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1–3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan–Meier and log-rank tests.ResultsA total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16–8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 − 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03–19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84–3.77.ConclusionsAmong older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.

Delirium, confusion, or altered mental status as a risk for abnormal head CT in older adults in the emergency department: A systematic review and meta-analysis

BackgroundAltered mental status (including delirium) is a common presentations among older adults to the emergency department (ED). We aimed to report the association between altered mental status in older ED patients and acute abnormal findings on head computed tomogram (CT). MethodsA systematic review was conducted using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8th, 2021. We included citations if they described patients aged 65 years or older who received head imaging at the time of ED assessment, and reported whether patients had delirium, confusion, or altered mental status. Screening, data extraction, and bias assessment were performed in duplicate. We estimated the odds ratios (OR) for abnormal neuroimaging in patients with altered mental status. ResultsThe search strategy identified 3031 unique citations, of which two studies reporting on 909 patients with delirium, confusion or altered mental status were included. No identified study formally assessed for delirium. The OR for abnormal head CT findings in patients with delirium, confusion or altered mental status was 0.35 (95% CI 0.031 to 3.97) compared to patients without delirium, confusion or altered mental status. ConclusionWe did not find a statistically significant association between delirium, confusion or altered mental status and abnormal head CT findings in older ED patients.

A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review.

Older adults are at high risk of developing delirium in the emergency department (ED);however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs)translate evidence into recommendations to improve practice. To critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients. We conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II;and Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX)instruments. A threshold of 70% or greater in the AGREE-IIRigour of Development domain was used to define high-quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis. AGREE-IIRigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE-REXoverall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED-specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high-risk populations, and those at risk should be screened for delirium. The '4A's Test' was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short-term use of antipsychotic medication in urgent situations. This is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED. This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.

Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting

BackgroundDelirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 ‘A’s Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings.MethodsProspective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria.ResultsA total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting.ConclusionThe Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.

Resuscitation preferences of older acutely admitted medical and mentally competent patients with one and six months follow-up

AimDetermining patients’ cardiopulmonary resuscitation (CPR) preferences in the emergency department (ED) is common practice but the stability of these preferences and their recollection by patients has been questioned. Therefore, this study assessed the stability and recall of CPR preferences of older patients at and following ED discharge. MethodsThis survey-based cohort study was conducted between February and September 2020 at three EDs in Denmark. It consecutively asked mentally competent patients aged 65 years or older who were admitted to hospital through the ED and then one and six months later “In your current state of health, do you wish that physicians should try to intervene if your heart stops beating?” Possible responses were confined to “definitely yes”, “definitely no”, “uncertain”, and “prefer not to answer”. ResultsIn total, 3688 patients admitted to hospital via the ED patients were screened, 1766 were eligible and 491 (27.8%) were included: median age was 76 (IQR 71–82) years, and 257 (52.3%) were men. One third of patients who expressed definite yes or no preferences in ED had changed their preference at one month follow-up. Only 90 (27.4%) and 94 (35.7%) patients recalled their preferences at one and six months follow-up, respectively. Conclusion and RelevanceIn this study, one-in-three older ED patients who initially expressed definite resuscitation preferences had changed their minds at one month follow-up. Preferences were more stable at six months but only a minority were able to recall their preferences.

Prevalence and risk factors of burden among caregivers of older emergency department patients

The number of older individuals that live independently at home is rising. These older individuals often rely on caregivers who have a similar age and health status. Therefore, caregivers may experience a high burden. We determined the prevalence and associating factors of burden among caregivers of older patients in the emergency department (ED). A cross-sectional study of primary caregivers of patients aged ≥ 70 years visiting the ED of a Dutch teaching hospital was performed. Structured interviews were conducted with patients and their caregivers. Caregiver burden was measured using the caregiver strain index (CSI). Additionally, data from questionnaires and medical records were extracted to determine potential associating factors. Univariate and multivariate regression analyses were conducted to identify independent determinants for burden. Seventy-eight caregivers (39%) experienced a high burden. Multivariate analysis showed a significant association between high caregiver burden and patients with cognitive impairment or dependency for instrumental activities of daily living (IADL) and more self-reported hours of care per day. Almost 40% of older patients in the ED have a caregiver who experiences a high burden. Formal assessment in the ED may help provide adequate care to the patients and their caregivers.

Red cell distribution width and mortality in older patients with frailty in the emergency department

BackgroundThe red cell distribution width (RDW) reflects the degree of heterogeneity of red blood cells. Elevated RDW is associated both with frailty and with increased mortality in hospital-admitted patients. In this study we evaluate whether high RDW values are associated with mortality in older emergency department (ED) patients with frailty, and if the association is independent of the degree of frailty.MethodsWe included ED patients with the following criteria: ≥ 75 years of age, Clinical Frailty Scale (CFS) score of 4 to 8, and RDW % measured within 48 h of ED admission. Patients were allocated to six classes by their RDW value: ≤ 13%, 14%, 15%, 16%, 17%, and ≥ 18%. The outcome was death within 30 days of ED admission. Crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for a one-class increase in RDW for 30-day mortality were calculated via binary logistic regression analysis. Age, gender and CFS score were considered as potential confounders.ResultsA total of 1407 patients (61.2% female), were included. The median age was 85 with an inter-quartile range (IQR) of 80–89, median CFS score 6 (IQR: 5–7), and median RDW 14 (IQR: 13–16). Of the included patients, 71.9% were admitted to hospital wards. A total of 85 patients (6.0%) died during the 30-day follow-up. Mortality rate was associated with RDW increase (p for trend < .001). Crude OR for a one-class increase in RDW for 30-day mortality was 1.32 (95% CI: 1.17–1.50, p < .001). When adjusted for age, gender and CFS-score, OR of mortality for one-class RDW increase was still 1.32 (95% CI: 1.16–1.50, p < .001).ConclusionHigher RDW values had a significant association with increased 30-day mortality risk in frail older adults in the ED, and this risk was independent of degree of frailty. RDW is a readily available biomarker for most ED patients. It might be beneficial to include it in risk stratification of older frail ED patients to identify those who could benefit from further diagnostic assessment, targeted interventions, and care planning.

Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study

ObjectivesTo evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h).MethodsWe conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status).ResultsWe evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33–0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36–0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16–0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51–0.59) and the ED Screener (K = 0.32; 95% CI 0.2–0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57–0.61), full (c = 0.61–0.64), and adjusted forms (c = 0.63–0.65), and poor for all models when predicting extended length-of-stay.ConclusionED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.

Effect of ED-based transitional care interventions by healthcare professionals providing transitional care in the emergency department on clinical, process and service use outcomes: a systematic review

ObjectiveSuboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm...