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      Acute care of older patients in the emergency department: strategies to improve patient outcomes

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          Abstract

          Older patients in the emergency department (ED) are a vulnerable population who are at a higher risk of functional decline and hospital reattendance subsequent to an ED visit, and have a high mortality rate in the months following an ED attendance. The delivery of acute care in a busy environment to this population presents its own unique challenge. The purpose of this review is to detail the common geriatric syndromes encountered in the ED as well as the appropriate strategies and instruments, which can be utilized to support the clinical decision matrix and improve outcomes.

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          Risk factors for falls among elderly persons living in the community.

          Mary E. Tinetti, Mark Speechley, Sandra F. Ginter (1988)
          To study risk factors for falling, we conducted a one-year prospective investigation, using a sample of 336 persons at least 75 years of age who were living in the community. All subjects underwent detailed clinical evaluation, including standardized measures of mental status, strength, reflexes, balance, and gait; in addition, we inspected their homes for environmental hazards. Falls and their circumstances were identified during bimonthly telephone calls. During one year of follow-up, 108 subjects (32 percent) fell at least once; 24 percent of those who fell had serious injuries and 6 percent had fractures. Predisposing factors for falls were identified in linear-logistic models. The adjusted odds ratio for sedative use was 28.3; for cognitive impairment, 5.0; for disability of the lower extremities, 3.8; for palmomental reflex, 3.0; for abnormalities of balance and gait, 1.9; and for foot problems, 1.8; the lower bounds of the 95 percent confidence intervals were 1 or more for all variables. The risk of falling increased linearly with the number of risk factors, from 8 percent with none to 78 percent with four or more risk factors (P less than 0.0001). About 10 percent of the falls occurred during acute illness, 5 percent during hazardous activity, and 44 percent in the presence of environmental hazards. We conclude that falls among older persons living in the community are common and that a simple clinical assessment can identify the elderly persons who are at the greatest risk of falling.
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            Clock-drawing: is it the ideal cognitive screening test?

            Kenneth I Shulman (2000)
            The clock-drawing test has achieved widespread clinical use in recent years as a cognitive screening instrument and a significant amount of literature relates to its psychometric properties and clinical utility. This review aims to synthesize the available evidence and assess the value of this screening test according to well-defined criteria. A Medline and Psycho-info literature search of all languages was done from 1983 to 1998 including manual cross-referencing of bibliographies. A brief summary of all original scoring systems is provided as well as a review of replication studies. Psychometric data including correlations with other cognitive tests were recorded. Qualitative aspects of the test are also described. Among published studies, the mean sensitivity (85%) and specificity (85%) of the clock-drawing test are impressive. Correlations with the Mini-Mental State Examination and other cognitive tests was high, generally greater than r = 0.5. High levels of inter-rater and test-re-test reliability and positive predictive value are recorded and despite significant variability in the scoring systems, all report similar psychometric properties. The clock test also shows a sensitivity to cognitive change with good predictive validity. The clock-drawing test meets defined criteria for a cognitive screening instrument. It taps into a wide range of cognitive abilities including executive functions, is quick and easy to administer and score with excellent acceptability by subjects. Together with informant reports, the clock-drawing test is complementary to the widely used and validated Mini-Mental State Examination and should provide a significant advance in the early detection of dementia and in monitoring cognitive change. A simple scoring system with emphasis on the qualitative aspects of clock-drawing should maximize its utility. Copyright 2000 John Wiley & Sons, Ltd.
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              Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions.

              Faranak Aminzadeh, William Dalziel (2002)
              We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Open Access Emerg Med
                Journal ID (iso-abbrev): Open Access Emerg Med
                Journal ID (publisher-id): Open Access Emergency Medicine
                Title: Open Access Emergency Medicine : OAEM
                Publisher: Dove Medical Press
                ISSN (Electronic): 1179-1500
                Publication date Collection: 2015
                Publication date (Electronic): 04 September 2015
                Volume: 7
                Pages: 45-54
                Affiliations
                Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
                Author notes
                Correspondence: Sean P Kennelly, Department of Age-Related Health Care, Tallaght Hospital, Tallaght, Dublin 24, Ireland, Email sean.kennelly@ 123456amnch.ie
                Article
                Publisher ID: oaem-7-045
                DOI: 10.2147/OAEM.S69974
                PMC ID: 4806806
                PubMed ID: 27147890
                SO-VID: e5bc94f7-2b5f-4eb3-a70b-8642423a6e5b
                Copyright © © 2015 McCabe and Kennelly. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License
                License:

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                History
                Categories
                Subject: Review

                Keywords: delirium,dementia,emergency department,comprehensive geriatric assessment
                Data availability:
                Keywords: delirium, dementia, emergency department, comprehensive geriatric assessment

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