Geriatric Assessment in the

Emergency Department

Thierry Chevalley

SIOG 2019 - Geneva

Geriatrics Liaison UnitService of Geriatrics

Department of Readaptation and GeriatricsGeneva University Hospitals

Emergency department use by oldest-old patients from 2005 to 2010 in a Swiss university hospital (Lausanne)

Vilpert et al. BMC Health Services Research 2013

+24%

+48%

Prediction of ageing (data from Canton de Vaud) Prediction of ageing (data from Canton de Vaud)

Rapport « Politique cantonale Vieillissement et Santé », 2012

As compared to younger patients:

– Use emergency services at a higher rate Use emergency services at a higher rate

– Longer lengths of stayLonger lengths of stay

– Higher Admission (5x) and re-admission ratesHigher Admission (5x) and re-admission rates

– Higher rates of adverse health outcomes after Higher rates of adverse health outcomes after

discharge (discharge (readmission, functional decline, mortalityreadmission, functional decline, mortality))

Aminzadeh et al. Ann Emerg Med 2002

Patients ≥ 75 years in the EDPatients ≥ 75 years in the ED

Adverse health outcomesAdverse health outcomes

At 3 months :At 3 months :

45% functional decline45% functional decline

24% readmission24% readmission

10% mortality10% mortality

Patients ≥ 75years in the ED and Patients ≥ 75years in the ED and return home return home the same day or the next daythe same day or the next day

Aminzadeh et al. Ann Emerg Med 2002Aminzadeh et al. Ann Emerg Med 2002

Rutschmann et al. Swiss Med Wkly 2005

Patients ≥ 75 ans in the EDPatients ≥ 75 ans in the ED

253 patients admitted for “home care impossible”253 patients admitted for “home care impossible”

Age 81y, 60% women Age 81y, 60% women

129 129 acute medical problem (51%) acute medical problem (51%)

26% “26% “undertriagedundertriaged””

Prevalence of geriatric syndromes in the EDPrevalence of geriatric syndromes in the EDPrevalence

in the ED

Recognition by the

ED physician

Impact on

LOS

Mortality

Delirium 10% 24% No HR 2.1 at 1 yr, RR 2.3 at 3 yrs

Cognitive disorders 20% 46% Yes RR 1.7 at 3 yrs

Depression 27% 33% No RR 1.6 after 27 yr s of follow-

up

Dependence 75% 25% Yes RR 2.1 at 3 yrs

Risk of falls 15% --- Yes RR 3.2 during the following

year

Malnutrition 20% --- Yes RR 2.8 at 4 yrs

Polimedication (≥ 5) 40% --- Yes OR 1.9 during hospitalization

Graf et al. Aging Clin Exp Res 2011LOS: length of stay

1141 patients, 60% women, 81.4 ± 7.6 yrs1141 patients, 60% women, 81.4 ± 7.6 yrs

CGA (FIM/MMSE/Lachs & Feinstein) detects in average CGA (FIM/MMSE/Lachs & Feinstein) detects in average

1.7 additional problem/standard clinical evaluation1.7 additional problem/standard clinical evaluation

Miller et al. Miller et al. JAGSJAGS 1996. 1996. Moore et al. Moore et al. Am Med JAm Med J 1996. 1996.Hustey et al. Ann Emerg Med 2003.Hustey et al. Ann Emerg Med 2003. Han et al. Han et al. Acad Emerg Med Acad Emerg Med 2009.2009.Inouye et al. Inouye et al. JAMAJAMA 1998. 1998. Chevalley et al. Karger 1999.Chevalley et al. Karger 1999.Elliot et al. Elliot et al. LancetLancet 1999 . 1999 . Reuben et al. Reuben et al. JAGSJAGS 1999. 1999.

Dependence (ADL): 2.8 x Mobility impairment: 2 x

Cognitif disorders: 2 x Delirium: 4 x

Depression: 3.3 x Sensory impairments: 5 x

Chronic pain: 2 x Urinary incontinence: 4.6 x

Efficacy of Comprehensive Geriatric Assessment Efficacy of Comprehensive Geriatric Assessment in the EDin the ED

1. Before the illness or injury that brought you to the Emergency, Before the illness or injury that brought you to the Emergency,

did you need someone to help you on a did you need someone to help you on a regular basis ?regular basis ?

2. 2. Since the illness or injury that brought you to the Emergency, Since the illness or injury that brought you to the Emergency,

have you needed more help than usual to take have you needed more help than usual to take care of yourself?care of yourself?

3. 3. Have you been hospitalized for one or more nights during the Have you been hospitalized for one or more nights during the

past 6 months (excluding a stay in the Emergency past 6 months (excluding a stay in the Emergency Department)Department)

4. 4. In general, do you see well ?In general, do you see well ?

5. 5. In general, do you have serious In general, do you have serious problems with your memory ?problems with your memory ?

6. 6. Do you take more than three different Do you take more than three different medication everyday ?medication everyday ?

Patients at risk if ≥ 2/6Patients at risk if ≥ 2/6 McCusker et al. J Am Geriatr Soc 1999 and 2001McCusker et al. J Am Geriatr Soc 1999 and 2001

Sensibility 72%Sensibility 72%Specificity 58%Specificity 58% Mortality, InstitutionalizationMortality, Institutionalization, Functional decline at 6 months, Functional decline at 6 months

ISAR: Identification of a Senior at Risk (2mn)

Readmission rates of 25% at 1 month and 38% at 3 months (in accordance to previous publications)(in accordance to previous publications)

Graf et al. Swiss Med Wkly 2011

ISAR et TRSTISAR et TRSTIndividual Prediction of Readmission Individual Prediction of Readmission after discharge after discharge

at home from the at home from the emergency departmentemergency department

AUC: area under the curve, NPV: negative predictive value, PPV: positive predictive value

4 4 itemsitems:: 1) 1) ACUTE ONSET AND FLUCTUATING COURSEACUTE ONSET AND FLUCTUATING COURSE2) 2) INATTENTIONINATTENTION3) 3) DISORGANIZED THINKINGDISORGANIZED THINKING4) 4) ALTERED LEVEL OF CONSCIOUSNESSALTERED LEVEL OF CONSCIOUSNESS

Suggested if 1 + 2 + (3 or 4)Suggested if 1 + 2 + (3 or 4)

- vs psychiatric evaluation:- vs psychiatric evaluation:VPP 91-94% - VPN 90-100%VPP 91-94% - VPN 90-100%

- 906 patients > 66 yrs in ED, nurse vs geriatrician :- 906 patients > 66 yrs in ED, nurse vs geriatrician :VPP 97% - VPN 100%VPP 97% - VPN 100%Excellent reproducibility (k 0.91)Excellent reproducibility (k 0.91)

Confusion Assessment Method (CAM)Confusion Assessment Method (CAM)

Smith et al. J Pain Symptom Manage1995.Monette J et al. Gen Hosp Psychiatry 2001.

Delirium Frequency Among Advanced Cancer Patients Presenting to an Emergency Department: a Prospective Randomized Observational Study

Elsayem et al. Cancer 2016

243 advanced cancer patients, median age 62 yrs (range 19-89 yrs)

22(9%) had CAM-positive delirium, and a median MDAS score of 14 (range, 9-21 of 30).

- Physicians correctly identified delirium in 13 (59%) of the CAM-positive delirious patients

- Delirium is relatively frequent and underdiagnosed in ED patients with advanced cancer

Cognitive impairmentCognitive impairmentMini-COGMini-COG

Borson et al. Int J Geriatr Psychiatry 2000.Wilber at al. Acad Emerg Med 2005.

• Episodic memory:Episodic memory:

3 words (1 pt/word)3 words (1 pt/word)

• Clock drawing test:Clock drawing test:

numbers + hands (2 pts if ok)numbers + hands (2 pts if ok)

149 patients in the ED (mean age 75 yrs)149 patients in the ED (mean age 75 yrs)• 2 minutes2 minutes• Sensibility 73% and NPV 93% / MMS ≤ 23/30 Sensibility 73% and NPV 93% / MMS ≤ 23/30

The Six-item Screener to Detect Cognitive Impairment in Older Emergency Department Patients

Wilber ST ACADEMIC EMERGENCY MEDICINE 2008

- 352 patients, either the SIS or the MMSE, followed by the other test 30 minutes later.

- An MMSE ≤ 23 and SIS ≤ 4 used as cutoff for cognitive impairment.

- 111 were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%)

- SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%)

- Area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83)

Mood DisorderMood Disorder

Hustey FM et al. Acad Emerg Med 2005

• 2 questions:2 questions:

• During the past month, have you often been bothered by feelingDuring the past month, have you often been bothered by feeling

down, depressed, or hopeless? down, depressed, or hopeless?

• During the past month, have you often been bothered by littleDuring the past month, have you often been bothered by little

interest or pleasure in doing things? interest or pleasure in doing things?

•267 patients in the ED (mean age 78 yrs)267 patients in the ED (mean age 78 yrs)•Se 84%, Sp 61%, NVP 95% vs GDS-15 ≥ 5Se 84%, Sp 61%, NVP 95% vs GDS-15 ≥ 5

One-leg balance is an important predictor One-leg balance is an important predictor of injurious falls in older personsof injurious falls in older persons

Vellas B et al. Vellas B et al. J Am Geriatr Soc.1997J Am Geriatr Soc.1997

• Ability to stand unassisted for 5 Ability to stand unassisted for 5 seconds on one legseconds on one leg

• Healthy, community-living volunteers Healthy, community-living volunteers older than age 60 (N = 316; mean age older than age 60 (N = 316; mean age 73 years)73 years)

• 3 years follow-up:3 years follow-up:

• Fall: 71%Fall: 71%

• Injurious Fall: 22%Injurious Fall: 22%

• One leg balance impossible:One leg balance impossible:

• RR: 2.13 (p = 0.03)RR: 2.13 (p = 0.03)

Mobility assessments of geriatric emergency department patients: A systematic review

Eagles D Canadian Journal of Emergency Medicine 2018

Mobility assessment prior to ED discharge for older patients were neither associated with nor predictive of adverse outcomes (hospitalization, return visits, falls)

Delirium/Cognition : CAM (Delirium/Cognition : CAM (Confusion Assessment Method)Confusion Assessment Method)

Mini-COG or Six-item ScreenerMini-COG or Six-item Screener

Depression:Depression: HusteyHustey’’s questionnaire s questionnaire

Functional status:Functional status: ADL / IADL ADL / IADL

Falls:Falls: One leg balance or get up and go test One leg balance or get up and go test

Malnutrition:Malnutrition: MNA-SF or DETERMINEMNA-SF or DETERMINE

Polypharmacy: Polypharmacy: STOPP (Screening Tool of Older STOPP (Screening Tool of Older People’s potentially inappropriate People’s potentially inappropriate

Prescriptions)Prescriptions)

Time

<5 mn

2 mn

2 mn

5 mn

5 mn

5 mn

3 mn

Proposed Validated Tools for CGA in the EDProposed Validated Tools for CGA in the ED

Graf CE et al. JAGS 2010

Proposed Algorithm to apply in ED for Patients > 75 yrsProposed Algorithm to apply in ED for Patients > 75 yrsGraf CE et al. Aging Clin Exp Res 2011

Safe to send home? Discharge risk assessment in the emergency department

Southerland LT Emergency Medicine Australia 2019

Foo CL et al. Australasian Journal on Ageing, 2012

Geriatric assessment and intervention in an emergency department observation unit reduced re-attendance and hospitalisation rates

172 control and 315 intervention group patients

40% reduction of ED re-attendance and hospitalisation at 3, 6, 9 and 12 months40% reduction of ED re-attendance and hospitalisation at 3, 6, 9 and 12 months

Mean monthly figure Age category Control group (%) Intervention group (%)

ED conversion rate 75–84 507/830 (61.1) 520/962 (54.1)85+ 444/638 (69.6) 461/753 (61.2)

Seven days readmission rate (all attendees) 75–84 38/830 (4.6) 37/962 (3.8)85+ 30/638 (4.7) 25/753 (3.3)

Thirty day readmission rate (all attendees) 75–84 95/830 (11.4) 85/962 (8.8)85+ 79/638 (12.4) 69/753 (9.2)

Ninety day readmission rate (all attendees) 75–84 181/830 (21.8) 176/962 (18.3)85+ 166/638 (26.0) 150/753 (19.9)

A controlled evaluation of comprehensive geriatric assessment A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’in the emergency department: the ‘Emergency Frailty Unit’

Conroy SP et al. Age and Ageing 2013

Complete coverage by geriatricians, 08.00 – 18.00, 7 days a weekComplete coverage by geriatricians, 08.00 – 18.00, 7 days a week

-10%

-25%

-25%

Impact of a New Senior Emergency Departmenton Emergency Department Recidivism,

Rate of Hospital Admission, and Hospital Length of Stay

Keyes DC et al. Ann Emerg Med. 2014

Pre-post design with two 6-month time blocks and roughly 12,000 patients aged ≥ 55 yrs

The Geriatric Emergency Department Intervention model of care: a pragmatic trial

Wallis M et al. BMC Geriatrics 2018

- GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention, 7 days from 0700h to 1730h - 3 implementations periods: pre-(2012), developmental phase (2013 to 2015) and full implementation (Sept. 2015 to 2016)

When the GEDI team were working :

- Increased likelihoods of discharge (HR = 1.19; 95% CI: 1.13–1.24)

- Reduced ED length of stay (HR = 1.42; 95% CI: 1.33–1.52)

- Average cost savings per ED presentation of $35 [95% CI, $21, $49] and of $1469 [95% CI, $1105,

$1834]

per hospital admission.

Take Home Messages

• Elderly patients in ED are at greater risk of unfavorable clinical course

• CGA supplements standard clinical evaluation and improves identification of geriatric syndromes

• CGA needs to be applied to patients at high risk of unfavorable clinical course

• Multidisciplinary geriatric teams increase discharge rates from ED, but impact on readmission rates or inpatient length of stay are less clear

• Need to improve linkages between ED and relevant community care and services

Thank you for your attention!