Katherine M. Hunold

Motor Vehicle Collision-related Emergency Department Visits by Older Adults in the United States

OBJECTIVES Motor vehicle collisions (MVCs) are the second most common cause of nonfatal injury among U.S. adults age 65 years and older. However, the frequency of emergency department (ED) visits, disposition, pain locations, and pain severity for older adults experiencing MVCs have not previously been described. The authors sought to determine these characteristics using information from two nationally representative data sets. METHODS Data from the 2008 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to estimate MVC-related ED visits and ED disposition for patients 65 years and older. NHAMCS data from 2004 through 2008 were used to further characterize MVC-related ED visits. RESULTS   In 2008, the NEDS contained 28,445,564 patient visits, of which 760,356 (2.7%) were due to MVCs. The NHAMCS contained 34,134 patient visits, of which 1,038 (3.0%) were due to MVCs. National estimates of MVC-related ED visits by patients 65 years and older in 2008 are 226,000 (95% confidence interval [CI]=210,000 to 240,000) for NEDS and 270,000 (95% CI=185,000 to 355,000) for NHAMCS. Most older adults with MVC-related ED visits were sent home from the ED (proportion discharged NEDS 78%, 95% CI=78% to 79%; NHAMCS 77%, 95% CI=66% to 86%). During the years 2004 through 2008, of MVC-related ED visits by older adults not resulting in hospital admission, moderate or severe pain was reported in 61% (95% CI=52% to 70%) of those with recorded pain scores. Older patients sent home after MVC-related ED visits were less likely than younger patients to receive analgesics (35%, 95% CI=26% to 43% vs. 47%, 95% CI=44% to 50%) during their ED evaluations or as discharge prescriptions (52%, 95% CI=41% to 62% vs. 65%, 95% CI=61% to 68%). CONCLUSIONS In 2008, adults age 65 years or older made more than 200,000 MVC-related ED visits. Approximately 80% of these visits were discharged home from the ED, but the majority of discharged patients reported moderate or severe pain. Further studies of pain and functional outcomes in this population are needed.

Side Effects From Oral Opioids in Older Adults During the First Week of Treatment for Acute Musculoskeletal Pain

OBJECTIVES The authors sought to describe the frequency of short-term side effects experienced by older adults initiating treatment with opioid-containing analgesics for acute musculoskeletal pain. METHODS This was a cross-sectional study of individuals age 65 years or older initiating analgesic treatment following emergency department (ED) visits for acute musculoskeletal pain. Patients were called by phone 4 to 7 days after their ED visits to assess the intensity of six common opioid-related side effects using a 0 to 10 scale and to assess medication discontinuation due to side effects. Propensity score matching was used to compare side effects among patients initiating treatment with any opioid-containing analgesics to side effects among those initiating treatment with only nonopioids. RESULTS Of 104 older patients initiating analgesic treatment following ED visits for musculoskeletal pain, 71 patients took opioid-containing analgesics, 15 took acetaminophen, and 18 took ibuprofen. Among the patients who took opioids, at least one side effect of moderate or severe intensity (score ≥ 4) was reported by 62%. Among patients with matching propensity scores, those taking opioids were more likely to have had moderate or severe side effects than those taking only nonopioids (62%, 95% confidence interval [CI] = 48% to 74% vs. 4%, 95% CI = 1% to 20%) and were also more likely to have discontinued treatment due to side effects (16%, 95% CI = 8% to 29% vs. 0%, 95% CI = 0% to 13%). The most common side effects due to opioids were tiredness, nausea, and constipation. CONCLUSIONS Among older adults initiating treatment with opioid-containing analgesics for musculoskeletal pain, side effects were common and sometimes resulted in medication discontinuation.

Diagnosis of Elder Abuse in U.S. Emergency Departments

To estimate the proportion of visits to U.S. emergency departments (EDs) in which a diagnosis of elder abuse is reached using two nationally representative datasets.

Shared Decision Making to Support the Provision of Palliative and End‐of‐Life Care in the Emergency Department: A Consensus Statement and Research Agenda

BACKGROUND Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). OBJECTIVE The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. METHODS Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. CONCLUSION Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.

Randomized trials in emergency medicine journals, 2008 to 2011.

STUDY OBJECTIVE Knowledge of current areas of activity in emergency medicine research may improve collaboration among investigators and may help inform decisions about future research priorities. Randomized, controlled trials are a key component of research activity and an essential tool for improving care. We investigated the characteristics of randomized trials recently published in emergency medicine journals. METHODS This was a retrospective analysis of randomized trials published in the 5 highest impact emergency medicine journals. PubMed was searched for reports of randomized trials involving human subjects indexed to MEDLINE between January 1, 2008, and December 31, 2011. Included trials were classified with respect to study topic, funding source, presence of age-related inclusion criteria, and country of origin. RESULTS A total of 163 published studies were included for analysis. Pain management was the most commonly studied topic (n = 28, or 17%) followed by orthopedics (n = 24, or 15%), cardiovascular disease (n = 13, or 8%), and prehospital medicine (n = 13, or 8%). Less than half of studies received extramural funding support. Children were specifically examined in 22 (13%) of trials; only 5 trials (3%) specifically examined patients aged 60 or older. CONCLUSIONS Emergency medicine journals publish randomized trials addressing a wide range of clinical topics. Randomized trials focusing on geriatric patients are not commonly published in these journals.

Primary care availability and emergency department use by older adults: a population-based analysis.

To assess the relationship between the number of primary care providers (PCPs) in an area and emergency department (ED) visits by older adults.

Constipation Prophylaxis Is Rare for Adults Prescribed Outpatient Opioid Therapy From U.S. Emergency Departments

OBJECTIVES Constipation is a common and potentially serious side effect of oral opioids. Accordingly, most clinical guidelines suggest routine use of laxatives to prevent opioid-induced constipation. The objective was to characterize emergency provider prescribing of laxatives to prevent constipation among adults initiating outpatient opioid treatment. METHODS National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2010 were analyzed. Among visits by individuals aged 18 years and older discharged from the emergency department (ED) with opioid prescriptions, the authors estimated the survey-weighted proportion of visits in which laxatives were also prescribed. A subgroup analysis was conducted for individuals aged 65 years and older, as the potential risks associated with opioid-induced constipation are greater among older individuals. To examine a group expected to be prescribed laxative medication and confirm that NHAMCS captures prescriptions for these medications, the authors estimated the proportion of visits by individuals discharged with prescriptions for laxatives among those who presented with constipation. RESULTS Among visits in 2010 by adults aged 18 years and older discharged from the ED with opioid prescriptions, 0.9% (95% confidence interval [CI] = 0.7% to 1.3%, estimated total n = 191,203 out of 21,075,050) received prescriptions for laxatives. Among the subset of visits by adults aged 65 years and older, 1.0% (95% CI = 0.5% to 2.0%, estimated total n = 18,681 out of 1,904,411) received prescriptions for laxatives. In comparison, among visits by individuals aged 18 years and older with constipation as a reason for visit, 42% received prescriptions for laxatives. CONCLUSIONS In this nationally representative sample, laxatives were not routinely prescribed to adults discharged from the ED with prescriptions for opioid pain medications. Routine prescribing of laxatives for ED visits may improve the safety and effectiveness of outpatient opioid pain management.

Ambulance transport rates after motor vehicle collision for older vs. younger adults: A population-based study

Older adults are at greater risk than younger adults for life-threatening injury after motor vehicle collision (MVC). Among those with life-threatening injury, older adults are also at greater risk of not being transported by emergency medical services (EMS) to an emergency department. Despite the greater risk of serious injury and non-transportation among older adults, little is known about the relationship between patient age and EMS transportation rates for individuals experiencing MVC. We describe transport rates across the age-span for adults seen by EMS after experiencing MVC using data reported to the North Carolina Department of Motor Vehicles between 2008 and 2011. Of all adults aged 18 years and older experiencing MVC and seen by EMS (n=484,310), 36.3% (n=175,768) were transported to an emergency department. Rates of transport for individuals seen by EMS after MVC increased only a small amount with increasing patient age. After adjusting for potential confounders of the relationship between patient age and the decision to transport (patient gender, patient race, air bag deployment, patient trapped or ejected, and injury severity), transport rates were: age 18-64=36.0% (95% confidence interval [CI], 35.9-36.2%); age 65-74=36.6% (95% CI, 36.0-37.1%); age 75-84=37.3% (95% CI, 36.5-38.1%), and age 85-94=38.2% (95% CI, 36.7-39.8%). In North Carolina between 2008 and 2011, the transportation rate was only slightly higher for older adults than for younger adults, and most older adults experiencing MVC and seen by EMS were not transported to the emergency department. These findings have implications for efforts to improve the sensitivity of criteria used by EMS to determine the need for transport for older adults experiencing MVC.

Increase in older adults reporting mountaineering-related injury or illness in the United States, 1973-2010.

To the Editor: Older adults are a growing injury population in the United States.1 We analyzed US climbing and mountaineering- related injuries and illness including fatalities recorded in Accidents in North American Mountaineering2 as an indirect assessment of changes during the past several decades in the proportion of older adults involved in mountaineering accidents. Statistical tables from this source summarize mountaineering accidents occurring in the United States from 1951 to 2010. From 1973 onward, cases were grouped into 7 age categories, with the oldest age group being individuals older than 50. Before 1973, the oldest age group recognized was individuals older than 35. Data from Canada were not included in the analysis because data were not available from 2006 onward. Cases are identified by the editors of Accidents in North American Mountaineering for possible inclusion in the tables in a number of ways. The most common means of case identification are reports submitted by climbers and members of search and rescue organizations. In national parks with a large volume of climbing activity (eg, Yosemite, Denali, Grand Teton), accident reports are submitted by climbing rangers. During the past decade, cases have also been identified by editors using searches of online sources including general climbing websites such as The Mountain Project (www.themountainproject.com) and Supertopo (www.supertopo.com) as well as area-specific websites (eg, www.redriverclimbing.org). Cases are included in the statistical tables and used for this analysis if they occur in the United States and involved people participating in climbing and mountaineering activities including rock or ice climbing, mountain climbing, and ski mountaineering. Duplicate recording of cases is avoided because the details of each case are reviewed by the editor. Accidents occurring during bouldering, climbing indoors, or climbing buildings are not included in the tables used for this analysis. We calculated the annual percentage of cases involving individuals older than 50 by dividing the number of individuals older than 50 by the total number of individuals of known age; individuals of unknown age were not included in the denominator. Temporal changes in the percentage of cases occurring in individuals older than 50 are summarized and presented graphically for years 1973 through 2010. For descriptive purposes, a loess procedure was used to fit a locally weighted regression line and graphed using Sigma Plot 12 (Systat Software Inc, Chicago, IL). Between 1973 and 2010, there were 6603 US climbing and mountaineering accidents reported; 1281 (19%) of these were fatalities. Most accidents occurred on rock (63%) as opposed to snow or ice (37%); during ascent (77%); and during the months of June, July, August, and September (63%). More than half of the US accidents occurred in California (21%), Washington (18%), and Colorado (12%). For years in which type of accident was recorded (1984–2010), the most common types of accident were injury (83%), frostbite or hypothermia (6%), and altitude-related illness (3%). Of the 6603 accidents reported, age was known for 5513 cases (83%). The number of accidents involving climbers older than 50 each year ranged from 0 in 1975 to 31 in 2010. Among the 5513 cases for which the age of the victim was known, the percentage of injured climbers older than 50 ranged from 0% in 1975 to 22% in 2008 (Figure). The mean percentage of injuries or fatalities occurring in individuals older than 50 increased from 3% between 1973 and 1989 to 16% between 2006 and 2010. Figure Percentage of US mountaineering-related injuries and illnesses involving climbers older than 50 reported in Accidents in North American Mountaineering, 1973–2010.2 We observe a large increase in the percentage of adults older than 50 with mountaineering-related injury or illness as reported during the last 4 decades in Accidents in North American Mountaineering. Accidents in North American Mountaineering depends on the voluntary submission of information by injured parties and rescuers and captures only a fraction of the total number of US mountaineering accidents. Further, the purpose of these reports is to understand the etiology of injuries, not to quantify the total number of injuries occurring each year. As a result, the data used for this analysis do not represent the actual number of accidents that occurred each year, and interpretation of trends from this source of data must be made with caution. Additionally, changes in reporting practices with time have the potential to introduce bias in temporal trends. Despite these important limitations, we think the observed trend is not simply a result of changes in reporting practices. Increased use of Internet-based communication would not be anticipated to favor older adults. Similarly, although reporting of accidents by climbing rangers from national parks may be biased toward older climbers, we would not expect that such a bias would favor reports regarding older adults during the past decade but not in the 1970s and 1980s. Given the magnitude of the change observed and its agreement with trends in other forms of recreational trauma in older adults,3,4 we think it likely that the observed increase in reporting in Accidents in North American Mountaineering represents an actual increase in the number of older US adults experiencing climbing or mountaineering-related injury or illness. Between 1980 and 2010, the percentage of the US population age 50 and older increased from 26% to 32%.5 Thus, the approximately fivefold increase in reports of older adults experiencing mountaineering accidents from Accidents in North American Mountaineering during the same time is not explained solely by the increase in the population of older adults. We think that the most likely explanation for the observed trend is a disproportionate increase in mountaineering activity by older adults. Whether this increase reflects a general increase in climbing activities of older adults that will be sustained or reflects the aging of a cohort that began climbing in the 1970s is unknown. The data presented are not coupled with information about the age distribution of participants in climbing and mountaineering activities, so our analysis is unable to determine the rate of accidents in older vs younger adults. However, even if the risk of injury is lower in older than younger climbers, 6 the results suggest that older adults are now a substantial US climbing and mountaineering accident population. If representative of actual trends in the epidemiology of mountaineering accidents, these findings are important because age is a risk factor for adverse outcomes after trauma.7–9 Further, because targeted education and additional rescue resources can reduce mountaineering-related fatalities,10 a better understanding of these trends has potential implications for prevention and rescue preparedness. Further work is needed to confirm these observations and, if confirmed, to identify and implement practices to minimize mountaineering-related injury and illness in older adults. The National Center for Research Resources had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.

Willingness and Ability of Older Adults in the Emergency Department to Provide Clinical Information Using a Tablet Computer.

To estimate the proportion of older adults in the emergency department (ED) who are willing and able to use a tablet computer to answer questions.