COMPREHENSIVE GERIATRIC ASSESSMENT IN THE EMERGENCY DEPARTMENT

A 10-min Targeted Geriatric Assessment Predicts Mortality in Fast-Paced Acute Care Settings: A Prospective Cohort Study

OBJECTIVES

To estimate whether a 10-minute Targeted Geriatric Assessment (10-TaGA) adds utility to sociodemographic characteristics and comorbidities in predicting one-year mortality in busy acute care settings. We have also compared the performance of 10-TaGA with the Identification of Seniors at Risk (ISAR) scale.

DESIGN

Prospective cohort study.

SETTING

Geriatric day hospital specializing in acute care in Brazil.

PARTICIPANTS

751 older adults aged 79.4 ± 8.4 years (64% female), presenting non-surgical, medical illness requiring hospital-level care (e.g., intravenous therapy, laboratory test, radiology) for ≤ 12 hours.

MEASUREMENTS

The 10-TaGA, an easy-to-administer screening tool based on the comprehensive geriatric assessment (CGA), provided a measure of cumulative deficits ranging from 0 (no deficits) to 1 (highest deficit) on admission. Standard risk factors, including sociodemographics (age, gender, ethnicity, income) and the Charlson comorbidity index, were evaluated. The ISAR, a well-validated screening tool, was used for comparison.

RESULTS

During one year of follow-up, 130 (17%) participants died. Compared to the ISAR, 10-TaGA offered better accuracy in identifying older patients at risk of death (area under the receiver operating characteristic curve: [AUC] 0.70 vs 0.65; P = 0.03). In a Cox regression model adjusted for sociodemographics and comorbidities, each 0.1 increment in the 10-TaGA score (range 0-1) was associated with increased mortality (hazard ratio = 1.42, 95% confidence interval 1.27-1.59). The addition of 10-TaGA markedly improved the discrimination of the model, which already incorporated standard risk factors (AUC 0.76 vs 0.71; P = 0.005); adding ISAR (AUC 0.73 vs 0.71; P = 0.09) did not have this marked effect.

CONCLUSION

The 10-TaGA is an independent predictor of one-year mortality in acute care patients. This multidimensional screening tool offers better accuracy than ISAR when differentiating between older people at low and high risk of death in healthcare settings where providers have limited time and resources.

Geriatric support in the emergency department: a national survey in Belgium

Background

Older people in the emergency department (ED) represent a growing population and increasing proportion of the workload in the ED. This study investigated the support for frail older people in the ED, by exploring the collaboration between the geriatric services (GS) and the EDs in Belgian hospitals.

Methods

An electronic cross-sectional survey in all Belgian hospitals with an ED (n = 100) about care aspects, collaboration, education and infrastructure for older patients in the ED was collected. Descriptive analyses were performed at national level.

Results

Forty-nine of 100 surveys were completed by the GS. The heads of the ED returned only 12 incomplete questionnaires and these results are therefore not reported.

Twenty-six of the 49 heads of GSs (53%) indicated that there was an agreement, mainly informal, between the geriatric and the emergency department concerning the management of older people on the ED.

A geriatrician was available for specific problems, by phone or in person, in 96% of the EDs during daytime on weekdays. Almost all responding hospitals (96%) had an inpatient geriatric consultation team, of which 85% was available for specific problems at the ED, by phone or bedside during the daytime on weekdays. Twenty-nine heads of the GSs (59%) reported that older patients were screened at ED admission during the day to identify ‘at risk’ patients. The results of the screening were used in the context of further treatment (76%), to decide on hospital admission (27%), or to justify admission on a geriatric ward (55%). In the year preceding the survey, 25% of the responding hospitals had organised geriatric training for ED healthcare workers. Thirty-four heads of the GS (69%) felt that the infrastructure of the ED was insufficient to give high-quality care for older persons.

Conclusion

Collaborations between EDs and GS are emerging in Belgium, but are currently rather limited and not yet sufficiently embedded in the ED care. Exploratory studies are necessary to identify how these collaborations can be improved.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0458-8) contains supplementary material, which is available to authorized users.

Screening for elderly patients admitted to the emergency department requiring specialized geriatric care

BACKGROUND

There is a need for a brief geriatric assessment (BGA) tool to screen elderly patients admitted to the Emergency Department (ED) for their risk of a long hospital stay.

OBJECTIVE

To examine whether a BGA administered to elderly patients admitted to the ED may predict the risk of a long hospital stay in the geriatric acute care unit.

METHODS

This study had a prospective cohort study design, enrolling 424 elderly patients (mean age 84.0 ± 6.5 years, 31.6% male) who were evaluated in the ED using a BGA composed of the following items: age, gender, number of medications taken daily, history of falls during the past 6 months, Mini-Mental State Examination (MMSE) score, and non-use of home-help services (i.e., living alone without using any formal or informal home services or social help). The length of stay (LOS) was calculated in days. Patients were separated into three groups based on LOS: low (<8 days), intermediate (8-13 days), and high (>13 days).

RESULTS

The prevalence of male gender was higher among patients with the longest LOS compared to those with intermediate LOS (p = 0.002). There were more patients with a history of falls in the high LOS group compared to the intermediate LOS group (p = 0.001) and the low LOS group (p < 0.001). The classification tree showed that male patients with an MMSE score <20 who fell with age under 85 years formed the end node with the greatest relative risk (RR) of a long hospital stay (RR = 14.3 with p < 0.001).

CONCLUSIONS

The combination of a history of falls, male gender, cognitive impairment, and age under 85 years identified elderly ED patients at high risk of a long hospital stay.