Martha Jane Mohler

Advance Directives for Older Adults in the Emergency Department: A Systematic Review

BACKGROUND It has been more than two decades since the passage of the Patient Self-Determination Act (PSDA) of 1991, an act that requires many medical points of care, including emergency departments (EDs), to provide information to patients about advance directives (ADs). OBJECTIVE The study objective was to determine the prevalence of ADs among ED patients with a focus on older adults and factors associated with rates of completion. METHODS We searched PubMed, Embase, PsycINFO, CINAHL, Web of Science, Medline, and the Cochrane Library. Articles were selected according to the following criteria: (1) population: adult ED patients; (2) outcome measures: quantitative prevalence data pertaining to ADs and factors associated with completion of an AD; (3) location: EDs in the United States; and (4) date: published 1991 or later. RESULTS Of the 258 references retrieved as a result of our search, six studies met inclusion criteria. Rates of patient-reported AD completion ranged from 21% to 53%, while ADs were available to ED personnel for 1% to 44% of patients. Patients aged ≥65 years had ADs 21% to 46% of the time. Sociodemographics (e.g., older age, specific religion, white or African American race, being widowed, or having children) and health status related variables (e.g., poor health, institutionalization, and having a primary care provider) were associated with greater likelihood of having an AD. CONCLUSIONS Published rates of AD completion vary widely among patients presenting to U.S. EDs. Patient sociodemographic and health status factors are associated with increased rates of AD completion, though rates are low for all populations.

Emergency general surgery specific frailty index: A validation study.

INTRODUCTION Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in surgical cases. The aim of our study was to validate a modified 15-variable EGS-specific frailty index (EGSFI). METHODS We prospectively collected geriatric (age older than 65 years) EGS patients for 2 years. Postoperative complications were collected. Frailty index was calculated for 200 patients based on their preadmission condition using 50-variable modified Rockwood frailty index. Emergency general surgery–specific frailty index was developed based on the regression model for complications and the most significant factors in the frailty index. Receiver operating characteristic curve analysis was performed to determine cutoff for frail status. We validated our results using 60 patients for predicting complications. RESULTS A total of 260 patients (developing, 200; validation, 60) were enrolled in this study. Mean age was 71 ± 11 years, and 33% developed complications. Most common complications were pneumonia (12%), urinary tract infection (9%), and wound infection (7%). Univariate analysis identified 15 variables significantly associated with complications that were used to develop the EGSFI. A cutoff frailty score of 0.325 was identified using receiver operating characteristic curve analysis for frail status. Sixty patients (frail, 18; nonfrail, 42) were enrolled in the validation cohort. Frail patients were more likely to have postoperative complications (47% vs. 20%; p < 0.001) compared to nonfrail patients. Frail status based on EGSFI was a significant predictor of postoperative complications (odds ratio, 7.3; 95% confidence interval, 1.7–19.8; p = 0.006). Age was not associated with postoperative complications (odds ratio, 0.99; 95% confidence interval, 0.92–1.06; p = 0.86). CONCLUSION The 15-variable validated EGSFI is a simple and reliable bedside tool to determine the frailty status of patients undergoing EGS. Frail status as determined by the EGSFI is an independent predictor of postoperative complications and mortality in geriatric EGS patients. LEVEL OF EVIDENCE Prognostic study, level II.

HIV-Related Frailty Is Not Characterized by Sarcopenia.

Frailty is common in HIV-infected patients, but its causes are elusive. We assessed 122 clinic patients for frailty using the 5-measure Fried Frailty criteria. The prevalence of frailty was 19% (n = 23) and all frail patients reported exhaustion with a Center for Epidemiologic Studies Depression Scale score >16 indicating depression. The next most common criterion was low physical activity (expenditure of kcal/week). Markers of sarcopenia such as decreased grip strength and decreased gait speed, hallmarks of frailty in the elderly, were the least common of the 5 criteria. Frailty was reversible: 6 frail patients returned for reassessment and only 2 were frail. We conclude that frailty in the HIV-infected patients is potentially reversible and strongly associated with depression and low physical activity, whereas frailty in the elderly is associated with aging-related sarcopenia and is often irreversible.

Redefining the association between old age and poor outcomes after trauma: The impact of frailty syndrome.

BACKGROUND Frailty syndrome (FS) is a well-established predictor of outcomes in geriatric patients. The aim of this study was to quantify the prevalence of FS in geriatric trauma patients and to determine its association with trauma readmissions, repeat falls, and mortality at 6 months. METHODS we performed a 2-year (2012–2013) prospective cohort analysis of all consecutive geriatric (age, ≥ 65 years) trauma patients. FS was assessed using a Trauma-Specific Frailty Index (TSFI). Patients were stratified into: nonfrail, TSFI ⩽ 0.12; prefrail, TSFI = 0.1 to 0.27; and frail, TSFI > 0.27. Patient follow-up occurred at 6 months to assess outcomes. Regression analysis was performed to assess independent associations between TSFI and outcomes. RESULTS Three hundred fifty patients were enrolled. Frail patients were more likely to develop in-hospital complications (nonfrail, 12%; prefrail, 17.4%; and frail, 33.4%; p = 0.02) and an adverse discharge disposition compared with nonfrail and prefrail (nonfrail, 8%; prefrail,18%; and frail, 47%; p = 0.001). Six-month follow-up was recorded in 80% of the patients. Compared with nonfrail patients, frail patients were more likely to have had a trauma-related readmission (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2–3.6) and/or repeated falls (OR, 1.6; 95%CI, 1.1–2.5) over the 6-month period. Overall 6-month mortality was 2.8% (n = 10), and frail elderly patients were more likely to have died (OR, 1.1; 95% CI, 1.04–4.7) compared with nonfrail patients. CONCLUSION Over a third of geriatric trauma patients had FS. TSFI provides a practical and accurate assessment tool for identifying elderly trauma patients who are at increased risk of both short-term and long-term outcomes. Early focused intervention in frail geriatric patients is warranted to improve long-term outcomes. LEVEL OF EVIDENCE Prognostic study, level II.

Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialtys ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.

Clinical and Community Strategies to Prevent Falls and Fall-Related Injuries Among Community-Dwelling Older Adults

Falls in older adults are the result of several risk factors across biological and behavioral aspects of the person, along with environmental factors. Falls can trigger a downward spiral in activities of daily living, independence, and overall health outcomes. Clinicians who care for older adults should screen them annually for falls. A multifactorial comprehensive clinical fall assessment coupled with tailored interventions can result in a dramatic public health impact, while improving older adult quality of life. For community-dwelling older adults, effective fall prevention has the potential to reduce serious fall-related injuries, emergency room visits, hospitalizations, institutionalization, and functional decline.