EXECUTIVE SUMMARY
A new study suggests older patients are particularly vulnerable to functional decline in the six months following a visit to the ED. Investigators noted the findings suggest there are opportunities to short-circuit this trajectory with added assessment and arrangements for follow-up interventions at the time of the ED visit.
- Investigators compared 754 older patients who visited the ED with a matched group of 813 patients who did not visit an ED. They also studied an unmatched group of older patients who were hospitalized following an ED visit.
- At the beginning of the study, both the ED-visit and control groups exhibited similar functional abilities, with levels of disability ranging between 3 and 4 on a disability scale, where lower scores represented lower levels of disability.
- The ED-visit group scored an average of 14% higher than the control group participants on the disability scale during the six months following the ED visit. The group with participants who had ED visits followed by hospitalization demonstrated disability scores that were 17% higher than the ED-visit only group.
- Investigators pointed to studies showing that ED-based screening and follow-up of older patients can prevent the risk of functional decline, decrease readmissions, and potentially prevent admissions to the ICU.
New findings from a rigorously designed study suggest that older patients who visit the ED are at enhanced risk of disability for up to six months following the visit.1
To arrive at this conclusion, investigators evaluated what they refer to as the “burden of disability” in older persons during a six-month period after they were discharged from the ED, and they compared this group to a matched group of older persons who did not visit the ED, and an unmatched group of older patients who were hospitalized following an ED visit.
Investigators found that although an ED visit proved not as debilitating as a hospitalization on study participants, it was associated with statistically significant declines in functional status compared with the matched control group of participants who did not visit the ED. Researchers noted these outcomes reveal an opportunity to intervene and potentially mitigate functional declines in older patients who present to the ED for care.
Take Note of Post-visit Declines
The study is part of the Yale Precipitating Events Project, an ongoing investigation of older persons living in the community and initially nondisabled. Researchers are endeavoring to learn more about the epidemiology of disability as well as interventions that could be effective at maintaining or restoring function.
For this investigation, researchers compared 754 patients who went to the ED without being hospitalized with a control group of 813 individuals of similar characteristics who did not visit the ED. They also studied a group of non-matched older patients who visited the ED and then were hospitalized. The average age of participants in both the ED-only and the control groups was 84 years.
Between 1998 and 2012, participants completed assessments every 18 months, and they were interviewed every month to gauge their functional status and to note any illnesses or injuries that prompted ED visits and/or hospitalizations.
At the beginning of the study, both groups exhibited similar functional abilities, with levels of disability ranging between 3 and 4 on a disability scale, where lower scores represented lower levels of disability. However, the group with participants who visited the ED scored an average of 14% higher than the control group participants on the disability scale during the six months following the ED visit. The group with participants who had ED visits followed by hospitalization demonstrated disability scores that were 17% higher than the ED visit-only group.
The most common reason for an ED visit and for an ED visit followed by hospitalization was musculoskeletal followed by a cardiac event. Gastrointestinal and infectious issues were the next most common reasons. The authors noted that further analysis of the cohort is studying whether some conditions that lead older adults to visit the ED are more predictive of subsequent functional decline than others.
Consider Assessments, Follow-up
William Fleischman, MD, a co-author of the study and clinical assistant professor of emergency medicine at the University of Maryland Medical Center in Baltimore, stresses that the reason for an ED visit and/or hospitalization likely is responsible for the increase in disability observed in the study, and notes that such patients probably could benefit from the kind of discharge planning that typically takes place in the inpatient setting. Further, he states there are things that EDs could do to prevent functional decline in older patients.
“The first step would be screening older ED patients to identify who may be at risk for functional decline. If an older patient is to be discharged from the ED, there are ACEP guidelines on steps that can help reduce the risk of functional decline,” he says. “These include taking an active role in ensuring proper medical follow-up, arranging for home visits by a nurse and/or physical or occupational therapists, or arranging for appropriate equipment to be at home, such as a walker.” (For more information, please see: http://bit.ly/1fzmOix.)
Fleischman observes that randomized studies from EDs in Canada and Australia have demonstrated that such interventions reduce the risk of functional decline.2,3
“[They showed] good promise for the two-step intervention process of performing a screening exam in the ED and then coordinating outpatient follow-up by comprehensive care teams,” he says. “These interventions have been shown to reduce ED visits and readmissions, and may also reduce ICU admissions and improve a patient’s quality of life.4 I am not aware of a published cost-benefit analysis of these interventions, but there aren’t many interventions in medicine that can say they achieve [this much] in the older population.”
Although the creation of geriatric-focused EDs in the United States may provide value in helping prevent functional decline, Fleischman is not aware of any published studies that have looked specifically at outcomes in this area. He also observes that the trend toward geriatric EDs is limited at this point.
“Only about 36 out of 5,000 U.S. EDs have dedicated geriatric EDs,” he says.
REFERENCES
- Nagurney JM, Fleischman W, Han L, et al. Emergency department visits without hospitalization are associated with functional decline in older persons. Ann Emerg Med 2017;69:426-433.
- McCusker J, Verdon J, Tousignant P, et al. Rapid emergency department intervention for older people reduces risk of functional decline: Results of a multicenter randomized trial. J Am Geriatr Soc 2001;49:1272-1281.
- Caplan GA, Williams AJ, Daly B, Abraham K. A randomized controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department. The DEED II Study. J Am Geriatr Soc 2004;52:1417-1423.
- Grudzen C, Richardson LD, Baumlin KM, et al. Redesigned geriatric emergency care may have helped reduce admissions of older adults to intensive care units. Health Aff 2015;34:788-795.
SOURCE
- William Fleischman, MD, Clinical Assistant Professor, Emergency Medicine, University of Maryland Medical Center, Baltimore. Email: [email protected].
Investigators suggest ED-based assessments, interventions potentially can curb functional declines, reduce readmissions.
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