Alexander X. Lo

Predicting geriatric falls following an episode of emergency department care: a systematic review.

BACKGROUND Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. OBJECTIVES This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factors accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. METHODS A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. RESULTS A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. CONCLUSIONS This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk.

Impact of Gait Speed and Instrumental Activities of Daily Living on All-Cause Mortality in Adults ≥65 Years With Heart Failure

Mobility and function are important predictors of survival. However, their combined impact on mortality in adults ≥65 years with heart failure (HF) is not well understood. This study examined the role of gait speed and instrumental activities of daily living (IADL) in all-cause mortality in a cohort of 1,119 community-dwelling Cardiovascular Health Study participants ≥65 years with incident HF. Data on HF and mortality were collected through annual examinations or contact during the 10-year follow-up period. Slower gait speed (<0.8 m/s vs ≥0.8 m/s) and IADL impairment (≥1 vs 0 areas of dependence) were determined from baseline and follow-up assessments. A total of 740 (66%) of the 1,119 participants died during the follow-up period. Multivariate Cox proportional hazards models showed that impairments in either gait speed (hazard ratio 1.37, 95% confidence interval 1.10 to 1.70; p = 0.004) or IADL (hazard ratio 1.56, 95% confidence interval 1.29-1.89; p <0.001), measured within 1 year before the diagnosis of incident HF, were independently associated with mortality, adjusting for sociodemographic and clinical characteristics. The combined presence of slower gait speed and IADL impairment was associated with a greater risk of mortality and suggested an additive relation between gait speed and IADL. In conclusion, gait speed and IADL are important risk factors for mortality in adults ≥65 years with HF, but the combined impairments of both gait speed and IADL can have an especially important impact on mortality.

Life-space mobility declines associated with incident falls and fractures

To determine the effect of falls and fractures on life‐space mobility in a cohort of community‐dwelling older adults.

Geriatric Dizziness: Evolving Diagnostic and Therapeutic Approaches for the Emergency Department

Dizziness affects one in five people over the age of 65 years and is associated with substantial healthcare costs. Serious causes of dizziness are found in 20% of patients over 50 years. The approach to the patient with dizziness is challenging as physical exam and diagnostic tests have suboptimal sensitivities. The risk of vascular events is higher in the first 30 days than after, suggesting some missed diagnoses. Medications and vestibular rehabilitation may serve as treatment options for dizziness, but data on their efficacy in older patients is lacking.

Life-Space Mobility Change Predicts 6-Month Mortality.

To examine 6‐month change in life‐space mobility as a predictor of subsequent 6‐month mortality in community‐dwelling older adults.

The Association Between Life-Space and Health Care Utilization in Older Adults with Heart Failure

BACKGROUND Life-space is associated with adverse health outcomes in older adults, but its role in health care utilization among individuals with heart failure is not well understood. We examined the relationship between life-space and both emergency department (ED) utilization and hospitalization. METHODS Participants were community-dwelling older adults with a verified diagnosis of heart failure who completed a baseline in-home assessment and at least one follow-up telephone interview. Life-space was measured at baseline and at follow-up every 6 months for 8.5 years. Poisson models were used to determine the association between life-space, measured at the beginning of each 6-month interval, and health care utilization, defined as ED utilization or hospitalization in the immediate ensuing 6 months, adjusting for sociodemographic and clinical confounders. RESULTS A total of 147 participants contributed 259 total health care utilization events involving an ED visit or a hospital admission. Multivariate analysis demonstrated an inverse association between life-space and health care utilization, where a clinically significant 10-point difference in life-space was independently associated with a 14% higher rate of ED utilization or hospitalization (incidence rate ratio 1.14, 95% CI 1.04-1.26, p = .004). CONCLUSIONS Life-space may be a useful identifier of community-dwelling older adults with heart failure at increased risk of ED visits or hospital admissions in the ensuing 6 months. Life-space may therefore be a potentially important component of intervention programs to reduce health care utilization.

Neighborhood Disadvantage and Life-Space Mobility Are Associated with Incident Falls in Community-Dwelling Older Adults

To determine the relationship between neighborhood‐level socioeconomic characteristics, life‐space mobility, and incident falls in community‐dwelling older adults.

Falling behind? Understanding implementation science in future emergency department management strategies for geriatric fall prevention

Recently published consensus guidelines for geriatric emergency departments (EDs)1 provide a significant milestone for the nascent subspecialty of geriatric emergency medicine, but real-world challenges reside between guidelines and bedside practice. In this issue of Academic Emergency Medicine, Tirrell et al.2 report a 1-year chart review of 350 randomly selected elderly patients presenting to an urban academic ED following falls. Their primary objective was to determine the extent to which the documented ED evaluation adhered to the Geriatric Emergency Department Guidelines1 and the American Geriatric Society (AGS) guidelines. Only two of the 16 fall-risk evaluation items recommended by the guidelines were reported over 80% of the time: fall location and cause of fall. Most (13 of 16) were reported fewer than 50% of the time, and nine of these fewer than 25% of the time. Four patient-level characteristics were significantly associated with better guideline adherence: older age, more comorbid conditions, residing in an assisted living facility, and admission to either an inpatient or an observation unit. While these findings offer reassurance that individuals deemed at higher risk were more likely to undergo more comprehensive evaluations for falls, there is clearly a missed opportunity to perform more complete risk assessments that may provide critical secondary prevention for falls in individuals at lower risk.

Defining Quality and Outcome in Geriatric Emergency Care

1. Gale SC, Donovan CM, Tinti M, et al. Organization and operations management at the health care facility. Ann Emerg Med. 2017;69:S29-S35. 2. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. 2017-2022 Health care preparedness and response capabilities. Available at: https://phe.gov/ Preparedness/planning/hpp/reports/Documents/2017-2022healthcare-pr-capablities.pdf. Accessed January 17, 2017. 3. Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59: 177-187. 4. Hanfling D. Role of regional healthcare coalitions in managing and coordinating disaster response, invited white paper, National Academies of Science, Engineering and Medicine. Available at: http://www. nationalacademies.org/hmd/w/media/Files/Activity%20Files/ PublicHealth/MedPrep/2013-JAN-23/Role%20of%20Regional% 20Healthcare%20Coalitions%20in%20Managing%20and% 20Coordinating%20Disaster%20Response_FINAL_01_2013.pdf. Accessed January 17, 2017.

Factors Associated with Hospital Admission for Older Adults Receiving Care in U.S. Emergency Departments

Background Emergency departments (EDs) play a growing role in hospital admissions for older adults, yet nationally representative data on predictors of admission from the EDs are limited. Methods We examined sociodemographic, clinical, and hospital characteristics associated with non-ICU admissions, using National Hospital Ambulatory Medical Care Survey data and multivariate Poisson regression models. Results There were an estimated 175 million ED visits by adults older than 65 years from 2001 to 2010. Overall, 32.5% were admitted to non-ICU beds. In multivariate analysis, non-ICU admission was associated with increasing age (16% higher per 10-year increase in age), white versus black race (35% vs 31%), and EDs in the Northeast (40%) or Midwest (38%) versus South (31%) or West (30%). Conclusion Non-ICU admission rates for older adults receiving care in U.S. EDs vary by age, race, and region. Understanding the reasons for these disparities in hospitalization rates may guide interventions to reduce hospitalizations in older adults.