Don Melady

Identification of older adults with frailty in the Emergency Department using a frailty index: results from a multinational study

Objectivenfrailty is a central concept in geriatric medicine, yet its utility in the Emergency Department (ED) is not well understood nor well utilised. Our objectives were to develop an ED frailty index (FI-ED), using the Rockwood cumulative deficits model and to evaluate its association with adverse outcomes.nnnMethodnthis was a large multinational prospective cohort study using data from the interRAI Multinational Emergency Department Study. The FI-ED was developed from the Canadian cohort and validated in the multinational cohort. All patients aged ≥75 years presenting to an ED were included. The FI-ED was created using 24 variables included in the interRAI ED-Contact Assessment tool.nnnResultsnthere were 2,153 participants in the Canadian cohort and 1,750 in the multinational cohort. The distribution of the FI-ED was similar to previous frailty indices. The mean FI-ED was 0.26 (Canadian cohort) and 0.32 (multinational cohort) and the 99th percentile was 0.71 and 0.81, respectively. In the Canadian cohort, a 0.1 unit increase in the FI-ED was significantly associated with admission (odds ratio (OR) = 1.43 [95% CI: 1.34-1.52]); death at 28 days (OR = 1.55 [1.38-1.73]); prolonged hospital stay (OR = 1.37 [1.22-1.54]); discharge to long-term care (OR = 1.30 [1.16-1.47]); and need for Comprehensive geriatric Assessment (OR = 1.51 [1.41-1.60]). The multinational cohort showed similar associations.nnnConclusionnthe FI-ED conformed to characteristics previously reported. A FI, developed and validated from a brief geriatric assessment tool could be used to identify ED patients at higher risk of adverse events.

A national survey of Canadian emergency medicine residents' comfort with geriatric emergency medicine.

BACKGROUNDnGeriatric patients represent a large and complex subgroup seen in emergency departments (EDs). Competencies in geriatric emergency medicine (EM) training have been established. Our objectives were to examine Canadian postgraduate year (PGY)-5 EM residents comfort with the geriatric EM competency domains, assess whether Canadian EM residents become more comfortable through residency, and determine whether geriatric educational exposures are correlated with resident comfort with geriatric EM.nnnMETHODSnA national, cross-sectional study of PGY-1 and PGY-5 Royal College EM residents was conducted to determine their comfort in geriatric EM clinical competency domains. Residents reported their level of comfort in satisfying each competency domain using a seven-point Likert scale. Residents were also asked about the location of their medical education as well as the type and number of different geriatric exposures that they had received to date.nnnRESULTSnOf the 141 eligible residents from across Canada, 77% (109) consented to participate. None of the PGY-1 EM residents and 34% (14) of PGY-5 EM residents reported that they were comfortable with all eight geriatric EM competency domains. PGY-5 EM residents were significantly more comfortable than PGY-1 EM residents. Residents reported a highly variable range of geriatric educational exposures obtained during training. No relationship was found between resident-reported comfort and the nature or number of geriatric exposures that they had received.nnnCONCLUSIONnCurrent Royal College EM residency training in Canada may not be adequately preparing graduates to be comfortable with defined competencies for the care of older ED patients.

Guidance when Applying the Canadian Triage and Acuity Scale (CTAS) to the Geriatric Patient: Executive Summary

The first of the baby boomers reached the historic retirement age of 65 in 2011, however, even prior to this emergency department (ED) visits by the elderly were on the rise, correlating with our expanding life span. The average life expectancy for Canadian males/females born in 1992, 2002, and 2012 respectively is 75/81; 77/82, and 80/84 years as reported by Statistics Canada (http://www. statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health26eng.htm). The proportion of the population over 65 is currently 12% and expected to rise to 20% by 2030, the year that all baby boomers will have reached the age of 65. Reductions in human mortality leading to extended lifespans reflect improved living standards, education, sanitation, housing, nutrition, public health, and advanced medical care. It has been proposed that medical advancements contributed 5 of the 30 year increase in life expectancy since 1900, and approximately 3.5 of the 7 year increase since 1950. From an ED perspective the impact of improved therapies for reversible life threatening conditions such as ST elevation infarcts (STEMIs), cerebrovascular accidents (CVAs) and severe trauma has complemented improved pre hospital care and ED processes to support rapid effective intervention vital to patient survival. More effective prevention and improved medical management has led to an increase in elderly ED patient complexity, often with multiple chronic diseases, varying degrees of cognitive impairment and mobility challenges. Older patient ED visits increased by greater than 30% in the decade between 1993 and 2003, with the number of ED visits over the age of 75 years of age relative to their proportion of the population even higher. This population is also subjected to prolonged ED lengths of stay, and have increased resource utilization and more frequent hospital admissions. Regarding triage and management challenges among older patients, the literature has identified a number of key differences from the general population, along with specific skills, knowledge and attitudes required to provide high quality care to older patients. Realities amongst elderly patients that make it more difficult to accurately triage and prioritize include:

Is Your Department's Quality Good Enough for Your Grandmother? Quality Indicators for Patients With Dementia and Delirium

So your grandma is taken to your neighboring emergency department (ED) by ambulance because she’s “just not feeling right.” Once there she is as pleasant and sweet as she was when you visited her last Sunday (which you now do regularly because you’ve noticed that she’s “not as sharp as she used to be”). However, she’s also a “vague historian” and gives several different reasons why she called the ambulance. No one bothers to check on her ability to remember things or to execute basic tasks. And no one bothers to contact you to get some collateral history. She stays around for a long time and has a lot of investigations—but no food or water. Eventually she is discharged home to follow-up with her primary care provider—even though no one asked if she has one or sent any information to him or her. And things do not turn out so well. In fact, she, your grandmother, becomes the subject of that phrase, “remember that patient you sent home the other day . . .?” By 2030 the proportion of the population over age 65 years in the Western world is projected to increase to 25%; the proportion over 85, to 5%. EDs worldwide are challenged by mounting demands for services with increased attendances of up to 6% annually. The fastest growth in ED attendances in the United Kingdom, in the United States, and in Australia is for people over age 65 years, many of whom have high burdens of chronic disease, multiple comorbidities, and polypharmacy. Not only is the utilization of ED resources by older people substantial, it is expected to increase over the next three decades: ED presentations by older people have increased by 25% in the past 5 years, with the almost fourfold increase in patients over age 80 between 1990 and 2004 expected to continue. Cognitive impairment, principally dementia and delirium, is often underrecognized in the ED. Multiple studies in the United States and Canada report that 25% to 40% of community-dwelling older adults demonstrate cognitive impairment if formally tested, but over half of these cases are neither recognized nor documented. Since cognitive impairment is an independent predictor of ED returns and other postdischarge adverse outcomes, providing evidence-based quality care for these vulnerable patients should be a high-priority focus of both emergency medicine (EM) research and ED practice. Delirium (acute brain failure) is well established as a true medical emergency; “delirium not yet diagnosed” is no one’s idea of a suitable discharge diagnosis! Less obviously dementia (chronic brain failure), marked by impairment of memory and executive function, has an effect on every element of ED care, including getting an adequate history, engaging the patient in investigations, and establishing a safe discharge plan. Surely having indicators of quality care that are relevant to patients with cognitive impairment would be good for the institution of EM. Do we understand what those indicators are? In this issue of Academic Emergency Medicine, Schnitker et al. succeed in pushing the evidence base further and addressing our understanding of older people’s issues. Their two articles empirically and quantitatively evaluate quality care for older patients who present to the ED with cognitive impairment. These two comprehensive papers carry a remarkable “real-life” quality: they seem to make explicit and obvious what often is implicit and tacit. Quality health care is defined in six dimensions: patient-centeredness, safety, efficiency, effectiveness, timeliness, and equity. Quality improvement focuses on using systematic methods to change individual behavior and organizations to improve patient outcomes. Most providers seek to deliver the best outcomes for each patient. Because of the cost and technical difficulties of collecting information from patients directly, process and structural measures are frequently used as surrogates for outcomes. “Structure” in this usage relates to human resources (staff availability and training), the physical environment of care, and funding: the context in which care is provided. “Process” relates to how the system works: the policies and procedures by which care is provided. Schnitker et al. consider the indicators of quality that relate to the structures and the processes in the ED care of older people with cognitive impairment. Their results are both intuitive and startling at the same time, and they contribute a great deal to our understanding of The authors have no relevant financial information or potential conflicts of interest to disclose. Related articles appear on pages 273 and 285.

Discrepancy between information provided and information required by emergency physicians for long-term care patients

OBJECTIVESnThe primary objective of this study was to identify information included in long-term care (LTC) transfer documentation and to compare it to the information required by local emergency department (ED) physicians to provide optimal care and make decisions for LTC patients.nnnMETHODSnA retrospective chart review was conducted for a sample of LTC residents transferred by ambulance to the ED of an academic, tertiary care hospital over a 1-year period. All emergency physicians working at the institution were invited to complete an online questionnaire about information included in LTC transfer documentation and information required by emergency physicians to provide care for LTC patients.nnnRESULTSnOf the 200 charts reviewed, the most common information transferred to the ED with the LTC patient was the patients past medical history (n=184, 92.0%), name of family physician (n=182, 91.0%), a list of known allergies (n=179, 89.5%), the reason for transfer to the ED (n=155, 77.5%), the patients emergency contact information (n=152, 76.0%), and medication administration record (n=150, 75.0%). From a physicians perspective, the most frequently requested pieces of information included reason for transfer, past medical history, cognitive status, advanced directives for level of care and resuscitation, and the patients emergency contact information. This information was provided 77.5% (n=155), 92.0% (n=184), 24.0% (n=48), 62.0% (n=124), and 76.0% (n=152) of the time, respectively.nnnCONCLUSIONSnOur study demonstrates a clear discrepancy between information provided and information required by emergency physicians for LTC patients. Quality improvement initiatives at the local level may help reduce this discrepancy.

Statement on Minimum Standards for the Care of Older People in Emergency Departments by the Geriatric Emergency Medicine Special Interest Group of the International Federation for Emergency Medicine

In 2015, the International Federation for Emergency Medicine (IFEM) established a geriatric emergency medicine special interest group, recognizing that older people are the fastest growing demographic population in the majority of countries, both developing and developed. The group was tasked with developing and promoting geriatric emergency medicine, including the establishment of a brief statement outlining minimum standards of care for older people in emergency departments (EDs) around the world. These minimum standards represent a first step on which future activities can be built. IFEM recognizes that, although these standards are global, the local solutions will be unique because they are dependent upon local, national, and regional factors. This statement applies to older people, a group who cannot be defined by age alone, but instead by the complex interactions of increased age and biopsychosocial vulnerability. Through this Statement of Minimum Standards, it is the goal of IFEM to catalyse change and improve care across emergency medicine for all older patients. Demographic changes, not limited to the developed world, have created an increase in older adults across all countries. This demographic shift is accompanied by an increased demand on health and social care resources, including EDs. For the well-being of patients and families, as well as national economies, continued improvements in the care of older people in EDs must be a priority for both clinical care and health policy. For many older people in higherand lower-resource settings, the ED is an important, if not the only, access point to the healthcare system. EDs function as an intersection point in the continuum of care. They represent a unique opportunity to influence the health experience and outcomes for older people, who place unique demands on healthcare systems. Older people often have complex care needs. They are more likely to be frail and are at increased risk of adverse events and health outcomes. For all older patients, acute illness or injury is a critical moment with an even greater risk of adverse outcomes. Integrated evaluation and management in the ED can lead to improved outcomes for older people not only through optimal immediate care, but also by preventing further morbidity and by providing more efficient and effective services across healthcare systems. To ensure that the needs of older people are met in every ED, IFEM mandates the following eight minimum standards. These are centred on the recognition that older people are a core population of emergency health service users whose care needs are often different from those of children and younger adults. These standards are

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients

Abstract In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time. Summit Participants Deb Adler1, Christopher Alban, MD, MBA2, Mark Bondi, PhD3, Michelle Braun, PhD4, Xavier Cagigas, PhD5, Morgan Daven6, Robert L. Denney, PsyD7,8, Lisa Drozdick, PhD9, Norman L. Foster, MD10,11, Ula Hwang, MD12–15, Laurie Ivey, PsyD16, Grant Iverson, PhD7,17, Joel Kramer, PsyD18, Laura Lacritz, PhD7,19, Melinda Lantz, MD20, Lisa Latts, MD, MSPH, MBA21, Shari M. Ling, MD22, Ana Maria Lopez, MD23–26, Michael Malone, MD27,28, Lori Martin-Plank, PhD, MSN, MSPH, RN29, Katie Maslow, MSW30, Don Melady, MSc(Ed), MD31–33, Melissa Messer34, John Meyers, PsyD7, Charles E. McConnel, PhD19, Randi Most, PhD36, Margaret P. Norris, PhD37, William Perry, PhD7,85,39, Neil Pliskin, PhD40, David Shafer, MBA41, Nina Silverberg, PhD42, Tresa Roebuck-Spencer, PhD43,44, Colin M. Thomas, MD, MPH45, Laura Thornhill, JD46, Jean Tsai, MD, PhD10,47, Nirav Vakharia, MD48, Martin Waters, MSW49 Organizations Represented Alzheimer’s Association, Chicago, IL AMA/CPT Health Care Professionals Advisory Committee, Chicago, IL American Academy of Clinical Neuropsychology (AACN), Ann Arbor, MI American Academy of Neurology (AAN), Minneapolis, MN American Association of Geriatric Psychiatry (AAGP), McLean, VA American Association of Nurse Practitioners (AANP), Austin, TX American Board of Professional Neuropsychology (ABN), Sarasota, FL American College of Emergency Physicians (ACEP), Philadelphia, PA American College of Physicians (ACP), Philadelphia, PA American Geriatrics Society (AGS), New York, NY American Psychological Association (APA), Washington, DC Beacon Health Options, Boston, MA Canadian Association of Emergency Physicians, Ottawa, ON, Canada Collaborative Family Healthcare Association (CFHA), Rochester, New York Gerontological Society of America, Washington, DC Hispanic Neuropsychological Society (HNS), Los Angeles, CA IBM Watson Health, Denver, CO International Federation of Emergency Medicine, West Melbourne, Australia International Neuropsychological Society (INS), Salt Lake City, UT National Academy of Neuropsychology (NAN), Denver, CO Optum of UnitedHealth Group, Minneapolis, MN Pearson, New York City, New York Psychological Assessment Resources, Inc, Lutz, FL Society for Clinical Neuropsychology, Washington, DC U.S. Department of Veterans Affairs, Washington, DC *Please note that participation in the Summit does not constitute organizational endorsement of this report

White Paper: Geriatric emergency medicine education: current state, challenges, and recommendations to enhance the emergency care of older adults

Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence‐based research and guidelines, including clear undergraduate and postgraduate GEM competencies.