K. Singler

European undergraduate curriculum in geriatric medicine developed using an international modified Delphi technique

Introduction: the rise in the number of older, frail adults necessitates that future doctors are adequately trained in the skills of geriatric medicine. Few countries have dedicated curricula in geriatric medicine at the undergraduate level. The aim of this project was to develop a consensus among geriatricians on a curriculum with the minimal requirements that a medical student should achieve by the end of medical school. Methods: a modified Delphi process was used. First, educational experts and geriatricians proposed a set of learning objectives based on a literature review. Second, three Delphi rounds involving a panel with 49 experts representing 29 countries affiliated to the European Union of Medical Specialists (UEMS) was used to gain consensus for a final curriculum. Results: the number of disagreements following Delphi Rounds 1 and 2 were 81 and 53, respectively. Complete agreement was reached following the third round. The final curriculum consisted of detailed objectives grouped under 10 overarching learning outcomes. Discussion: a consensus on the minimum requirements of geriatric learning objectives for medical students has been agreed by European geriatricians. Major efforts will be needed to implement these requirements, given the large variation in the quality of geriatric teaching in medical schools. This curriculum is a first step to help improve teaching of geriatrics in medical schools, and will also serve as a basis for advancing postgraduate training in geriatrics across Europe.

Geriatric syndromes predict postdischarge outcomes among older emergency department patients: findings from the interRAI Multinational Emergency Department Study.

OBJECTIVES Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. METHODS A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. RESULTS A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. CONCLUSIONS Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Considerations for the Development of an Undergraduate Curriculum in Geriatric Medicine

Background: Although the number of older patients is increasing in almost all medical specialties, the interest of medical students in geriatrics as a career is still low. Because quality of medical education and educators strongly influences student career decisions, it is important to develop curricula that motivate students to become self-directed, lifelong learners in the field of geriatric medicine. Objectives: We evaluated training aspects in terms of time, core content of teaching goals, and quality of undergraduate geriatric education in medical schools in Austria and Germany. Methods: A standardized paper questionnaire was sent to all 36 German and 4 Austrian medical faculties to evaluate quantitative aspects, content, and quality of pregraduate medical education in geriatrics. Results were compared to the recommendations of the Geriatric Medicine Section of the European Union of Medical Specialists (UEMS). Results: A total of 33/36 (92 of the German medical faculties) and 4/4 (100 of the Austrian medical faculties) responded to the questionnaire. In most of the faculties, geriatric medicine was taught as an independent discipline in the core curriculum, with learning objectives absent in almost one third of the faculties. A medical students first contact with geriatric medicine occurred on average during the second clinical year (median 8th semester). Although the content of geriatric curricula strongly varied among the faculties, core knowledge as recommended by the UEMS was integrated into most of the curricula. Teaching strategies regarding the development of attitudes and skills also recommended by the UEMS were identified in the curriculum of only some faculties. Conclusions: Geriatrics seems to be an established subject in most German and Austrian faculties. However, the current data clearly indicate highly variable quality in geriatric pregraduate training at German and Austrian universities. Because curricula should prepare young people using competence-based training and assessment methods, room for improvement remains not only in terms of structure, but also regarding quality of training to develop self-directed lifelong learners.

Diagnostic accuracy of three different methods of temperature measurement in acutely ill geriatric patients

OBJECTIVE we examined the diagnostic accuracy of different methods of body temperature measurement to diagnose infection in geriatric patients presenting to the emergency department (ED). METHODS this observational study was done in consecutive patients ≥75 years old presenting to the ED. Body temperature was determined by tympanal thermometry, temporal artery thermometry and rectal temperature measurement. Adjudicated final diagnosis of infection was done by two experts including patient history, clinical and laboratory findings as well as radiographic studies. RESULTS a total of 427 patients were included in the data analysis (age: 82.7 ± 5.1 years). Infection was present in 105 patients (24.6%). Respiratory rate, heart rate and body temperature were significantly higher in patients with infection, blood pressure was lower (P < 0.01). Body temperature measured by tympanal and temporal artery thermometry was correlated with rectal thermometry. Body temperature was significantly higher in patients with infection compared with those without infection independent of the method of body temperature measurement (P < 0.001). The diagnostic accuracy for infection quantified by the area under curve (AUC) was comparable among rectal [AUC: 0.72 (95% CI: 0.65-0.80)] and tympanal thermometry [AUC: 0.73 (95% CI: 0.66-0.81)], but significantly lower in temporal artery thermometry [AUC: 0.65 (95% CI: 0.57-0.73; P < 0.001)]. Compared with rectal measurement tympanal thermometry showed a higher bias than temporal artery thermometry (0.54 versus 0.03°C), while its limits of agreement were more narrow (-0.14 to 1.21°C versus -0.94-1.01°C). CONCLUSION diagnostic accuracy for the identification of infection was comparable among tympanal and rectal thermometry and lower for temporal artery thermometry. Different cut-off points should be used to identify infection using tympanal (37.3°C) or rectal (37.9°C) thermometry. In general, temperature measurement is an insensitive method to identify geriatric patients with infection. Registration number clinicaltrials.com: KSMC-tempger-1.

The Prevalence and Prognostic Significance of Near Syncope and Syncope: A prospective study of 395 cases in an emergency department (the SPEED Study)

BACKGROUND The prognostic significance of near-syncope has not yet been adequately characterized. METHOD We collected prospective data on a consecutive series of patients seen in an emergency department with syncope (brief loss of consciousness, usually with loss of muscle tone) or near-syncope (a feeling that syncope is about to occur, but without actual loss of consciousness or muscle tone). We report on the prevalence, etiology, and prognosis of such events (the SPEED study). Patients were followed up at 30 days and at 6 months after the event. RESULTS From 17 July to 31 October 2011, 395 patients were seen in the emergency department for a chief complaint of syncope or near-syncope (3% of all emergency patients). Their median age was 70 years, and 55% were men. 62% had experienced syncope, and 38% near-syncope. The patients with near-syncope were younger than those with syncope ( 63 vs. 72 years, p < 0.014) and were also more commonly male (63% vs. 49%, p = 0.006). The two patient groups did not differ significantly with respect to their measured laboratory values and vital parameters or their accompanying medical conditions. Hospitalizations were more common for syncope than for near-syncope (86% vs. 70%, p < 0.001). Etiologies were similarly distributed in the two patient groups, with the main ones being reflex syncope, orthostatic syncope, cardiac syncope, and syncope of uncertain origin. In all, 123 of 379 patients (32%) had further undesired events within 30 days of the event. Multivariable logistic regression revealed that age, heart rate, and renal dysfunction were independent predictors of undesired events, while the type of syncope was not. CONCLUSION Patients with near-syncope do not differ to any large extent from patients with syncope with respect to the features studied. The diagnostic evaluation should be similar for patients in the two groups.

Correlation between Age, Emergency Department Length of Stay and Hospital Admission Rate in Emergency Department Patients Aged ≥70 Years

Background: Interdisciplinary emergency departments (EDs) are confronted with trauma and nontrauma patients of any age group. Length of stay (LOS) and admission rates reflect both disease complexity and severity. Objective: To evaluate LOS and admission rates in different age groups according to traumatic and nontraumatic etiologies. Patients and Methods: During May 2011 a total of 4,653 adult patients (defined as ≥18 years old) seen in the ED of our municipal hospital were evaluated for their primary problem, Emergency Severity Index, LOS and admission rate. 1,841 trauma patients (mean age: 51.9 years; SD 22.5 years) and 2,812 nontrauma patients (mean age: 60.0 years; SD 20.4 years) were included. Results: Median LOS in the ED was 1:41 h (trauma) and 1:52 h (nontrauma). Trauma patients aged ≥70 years spent more time in the ED than nontrauma patients of this age group (patients aged ≥70 years median: 2:08 vs. 1:56 h; p < 0.0001). However, no significant difference was found in patients aged <70 years (1:33 vs. 1:48 h; p = 0.64). Comparing older with younger patients, median LOS within the ED was about 8 min longer in nontrauma patients aged ≥70 years (p = 0.22) and about 35 min longer in trauma patients aged ≥70 years (p < 0.00001). Conclusions: The correlation between age and LOS is stronger for trauma patients, which might indicate a special need for geriatric expertise in elderly trauma ED patients. Thus an interdisciplinary approach including surgical and geriatric expertise may be advantageous.

Diagnostic and Prognostic Value of High-sensitivity Cardiac Troponin T in Patients with Syncope

OBJECTIVE We examined the diagnostic and predictive value of high-sensitivity cardiac troponin T (cTnThs) in patients with syncope. METHODS We performed an analysis of consecutive patients with syncope presenting to the emergency department. The primary end point was the accuracy to diagnose a cardiac syncope. In addition, the study explored the prognostic relevance of cTnThs in patients with cardiac and noncardiac syncope. RESULTS A total of 360 patients were enrolled (median age, 70.5 years; male, 55.8%; 23.9% aged >80 years). Cardiac syncope was present in 22% of patients, reflex syncope was present in 40% of patients, syncope due to orthostatic hypotension was present in 20% of patients, and unexplained syncope was present in 17.5% of patients. A total of 148 patients (41%) had cTnThs levels above the 99% confidence interval (CI) (cutoff point). The diagnostic accuracy for cTnThs levels to determine the diagnosis of cardiac syncope was quantified by the area under the curve (0.77; CI, 0.72-0.83; P < .001). A comparable area under the curve (0.78; CI, 0.73-0.83; P < .001) was obtained for the predictive value of cTnThs levels within 30 days: Patients with increased cTnThs levels had a 52% likelihood for adverse events, patients with cTnThs levels below the cutoff point had a low risk (negative predictive value, 83.5%). Increased cTnThs levels indicate adverse prognosis in patients with noncardiac causes of syncope, but not in patients with cardiac syncope being a risk factor for adverse outcome by itself. CONCLUSIONS Patients with syncope presenting to the emergency department have a high proportion of life-threatening conditions. cTnThs levels show a limited diagnostic and predictive accuracy for the identification of patients with syncope at high risk.

Instruments to identify elderly patients in the emergency department in need of geriatric care

AbstractThe number of people with functional limitations, cognitive impairment and disability with unscheduled, unintended contact to emergency departments seeking acute medical care is increasing. With this, the problem of how to identify elderly people in need for acute geriatric care has evolved. The best solution to the problem would be to perform comprehensive geriatric assessment during the initial contact; however, comprehensive geriatric assessment is considered too complex and therefore not feasible for emergency departments. Instead, screening instruments have been developed and proposed. In this narrative review, selected screening instruments are discussed. The instrument best studied in various settings and countries is the Identification of Seniors At Risk (ISAR) screening tool which contains six simple questions that are easy to administer and can be assessed even in urgent situations. In recent years, several studies have examined the validity of ISAR in different European countries. Most of these studies, including one German study and a recent systematic review, confirmed the validity of ISAR. Unfortunately, evidence is conflicting, as some studies found only weak or even no association between ISAR and negative health outcomes. Other instruments have been investigated to a lesser extent and do not indicate obvious advantages over ISAR. Despite growing evidence in the field, there are still many uncertainties. Further research is needed to solve existing inconsistencies and to assess how elderly patients screened positive for acute geriatric care needs can best be managed further.ZusammenfassungDie Anzahl an Patienten mit funktionellen Einschränkungen, kognitiver Einschränkung oder Behinderung, die ungeplant in Kontakt mit der Notaufnahme eines Krankenhauses kommen und akutmedizinischer Versorgung bedürfen, nimmt zu. Damit stellt sich zunehmend das Problem, wie ältere Patienten mit Bedarf einer akut-geriatrischen Behandlung identifiziert werden können. Die Durchführung eines umfassenden geriatrischen Assessments bei Erstkontakt könnte eine Lösung sein. Allerdings gilt das umfassende geriatrische Assessment als zu aufwendig und komplex, um sinnvoll in der Notaufnahme umsetzbar zu sein. Deshalb wurden verschiedene Screening-Instrumente entwickelt und vorgeschlagen. Das in verschiedenen Versorgungszusammenhängen und unterschiedlichen Ländern am besten untersuchte Instrument ist derzeit das ‚Identification of Seniors At Risk‘ (ISAR) Screening Instrument. Es besteht aus sechs einfachen Fragen, die rasch angewendet und auch in dringlichen Situationen erhoben werden können. In den letzten Jahren wurde die Validität des ISAR-Instruments in verschiedenen europäischen Ländern getestet. Die meisten Studien, eine Studie aus Deutschland und eine aktuelle systematische Übersicht eingeschlossen, bestätigen die Validität. Die Ergebnisse sind aber nicht widerspruchsfrei. Einige Studien haben nur einen schwachen oder gar keinen Zusammenhang zwischen ISAR und negativen Gesundheitsfolgen gefunden. Andere Instrumente wurden deutlich weniger gut untersucht und scheinen keinen offensichtlichen Vorteil zu bieten. Trotz der zunehmenden Evidenz zum Thema bleiben etliche Unsicherheiten bestehen. Weitere Studien werden benötigt, um bestehende Inkonsistenzen aufzulösen und zu klären, wie im Screening positive Patienten am besten weiter behandelt werden können.

N-active: a new comanaged, orthogeriatric ward: observations and prospects.

The incidence of hip fractures increases with increasing age. Besides the actual trauma, it is mainly the comorbidities and an increased postoperative complication rate in old patients that lead to increased mortality in this patient population. Around 25% of patients who had previously been living independently continue to need long-term care after a hip fracture. Given this situation, the comanaged orthogeriatric unit “N-active” was opened at the Nuremberg Hospital in December 2010. The following article describes implementation of the ward and preliminary data. These show a positive impact of comanagement in terms of patient outcome, staff satisfaction, and also financial aspects.ZusammenfassungDie Inzidenz hüftgelenknaher Frakturen steigt mit zunehmendem Alter an. Neben dem eigentlichen Trauma führen bei den betagten Patienten vor allem die Komorbiditäten und eine erhöhte postoperative Komplikationsrate zu einer erhöhten Mortalität. Ein Viertel der zuvor selbstständig lebenden Patienten bleibt zudem langfristig pflegebedürftig. Vor diesem Hintergrund wurde am Klinikum Nürnberg im Dezember 2010 eine interdisziplinär (unfallchirurgisch-geriatrisch) geführte alterstraumatologische Station „N-Aktiv“ eröffnet. Der vorliegende Artikel beschreibt die Implementierung der Station sowie erste Daten. Diese zeigen einen positiven Effekt der unfallchirurgisch-geriatrischen Kooperation hinsichtlich Patientenoutcome, Mitarbeiterzufriedenheit sowie ökonomischer Aspekte.

Bedeutung der demographischen Entwicklung für die Notfallmedizin

ZusammenfassungHintergrundDer demographische Wandel führt zu einer Zunahme von geriatrischen Patienten mit all ihren Besonderheiten in der präklinischen und innerklinischen Notfallversorgung. Dadurch verändern sich zunehmend die Ansprüche an die Struktur und das Management von Krankenhäusern sowohl in der Notaufnahme als auch in der stationären Versorgung.MethodenRecherche und Analyse aktueller Literatur.Ergebnisse und SchlussfolgerungDieser Entwicklung gerecht zu werden und hierbei eine optimale Versorgung zu gewährleisten, stellt eine große Herausforderung an alle in der Notfallversorgung Tätigen dar. Neben der akuten medizinischen Problematik mit Wertung der medizinischen Diagnose spielen in der Gruppe der geriatrischen Patienten auch psychische und soziale Aspekte eine wichtige Rolle im Patientenmanagement. Es ist zwingend erforderlich, neben dem geriatrisch geschulten Arzt, im Idealfall dem Geriater, auch speziell ausgebildete Pflegekräfte in der Notaufnahme vorzuhalten, um den häufig komplexen Problemstellungen gerecht zu werden.AbstractBackgroundDemographic shift is leading to an increasing number of geriatric patients with all their associated characteristics in preclinical and emergency departments (ED). Thus, this increasingly changes the demands on structural requirements and management in hospitals, both in EDs and inhouse.MethodResearch and analysis of the current literature.Results and conclusionsTo cope with the growing responsibility and to provide optimal treatment is a major challenge for emergency staff. In addition to acute medical problems and diagnosis, psychosocial aspects play an important role in managing geriatric patients. It is imperative that a physician trained in geriatrics, being in the ideal case a geriatrician, as well as a specialized nurse be available in order to be able to adequately treat the often complex problems of these patients.