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Assessing risk of functional decline in emergency departments MS Bakken, MD PhD student X EAMA Advanced Postgraduate Course in Geriatrics Martigny, Switzerland, January 2013. Outline. Definitions Background Why? How? Current knowledge & trends Conclusions Questions. Functional decline.

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Outline

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  1. Assessing risk of functional decline in emergency departmentsMS Bakken, MD PhD studentX EAMA Advanced Postgraduate Course in GeriatricsMartigny, Switzerland, January 2013

  2. Outline • Definitions • Background • Why? How? • Current knowledge & trends • Conclusions • Questions

  3. Functional decline • Reduced ability to perform tasks of everyday living, due to decreased physical and/or cognitive functioning. Inouye 2000 • New loss of independence in self-care activities, or detoriation in self-care skills. May include physical and psychosocial problems. De Vos 2012 • Measurements & outcomes vary!

  4. Emergency Department (ED) • Accident and Emergency (A&E) • Emergency Room (ER) • Acutecare • Patients present without prior appointment Settings vary! Hospitalized Non-hospitalized Norway

  5. Background • Patients 65+ ~ 20% of all consultations in EDs • ED visits often followed by functional decline (other adverse outcomes) • Age, premorbidfunctional status and cognitive function strong predictors of functional decline • Studies in ED patients scarce -studies in hospitalized patients abundant

  6. Assessing risk of functional decline in EDs – Why? • Prevention possible • Identification of patients at risk Improved care. Two – step procedure? Gatekeeping

  7. Assessing risk of functional decline in EDs – How? Screening tools Other parameters Biological parameters (IL-6, CRP, TNF) Physical parameters (muscle strength, walking stick, gait speed, TUG, one leg balance) No studies!? • Easily and rapidly used • Most studied validated tools: Identification of Seniors at Risk ISAR Triage Risk Screening Tool TRST Both: 6 items, completed by patient/ caregiver/clinician Graf 2012, de Saint-Hubert 2010

  8. An ideal tool • Clinically relevant • Easy to use • Accurate • The ROC*curve measures discriminating ability Takes both specificity and sensitivity into account Interpretation: 0.90-1.00 excellent 0.80-0.90 good 0.70-0.80 fair 0.60-0.70 poor 0.50-0.60 fail *ROC -Receiver Operating Characteristic

  9. Screening tools to select high risk ED patients -validation studies Excluded: Tools developed and validated for patients discharged ≥ 48 hours after attendance at ED: BRASS, Inouye, SHERPA; tool to assess complex care needs in hospital: COMPRI; tools for hospitalized patients: HARP, ISAR-HP.

  10. Reviews Tools appropriate to assess risk of functional decline in older patients attending acute medical units (EDs in all reviews) Umbrella review of tools to assess risk of poor outcome in older people attending acute medical units. Edmans 2012 Medical Crises in Older People. Discussion paper series

  11. Current knowledge & trends • ISAR only tool shown to predict decreased physical or cognitive function (readmission, resource use, institutionalization and mortality) • Validity, reliability, clinical utility • Fair predictive value according to systematic reviews* Poor-fair predictive value in more recent studies Potentially suitable selecting high risk patients Supportingclinicaldecision-making! • ISAR & TRST high negative predictive values (NPVs) Can be used to safelyselectpatients for discharge (?) *Silver Code, not included in reviews. Edmans 2012.

  12. Conclusions Few studies focus on ED patients at risk of functional decline Tools, settings & outcomes vary No gold standard

  13. QuestionsAssessing risk of functional decline • How? Sole instrument? Other (physical/biological) parameters? Two-step procedure: screening + CGA? • Where? • Gold standard? • Really assessing (an/several aspect/s of) frailty? Terminology!

  14. References • Identification of older patients at risk of unplanned readmission after discharge from the emergency department. Comparison of two screening tools. Graf C et al. Swiss Med Wkly. 2012. • Frailty in Older Adults Using Pre-hospital Care and the Emergency Department: A Narrative Review. Goldstein JP et al. Can Geriatr J. 2012. • Predicting functional adverse outcome in hospitalized older patients: a systematic review of screening tools. De Saint-Hubert M et al. J Nutr Health Aging 2010. • Screening tools to identify hospitalized elderly patients at risk of functional decline: a systematic review Sutton M et al. Int J Clin Pract 2008. • Screening for Frailty in the Elderly Emergency Department Patients by Using the Identification of Seniors at Risk (ISAR). Salvi F et al. J Nutr Health Aging. 2012. • The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program. Inouye SK et al. J Am Geriatr Soc. 2000. • Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP). de Vos AJ et al. BMC Geriatr. 2012. • Umbrella review of tools to assess risk of poor outcome in older people attending acute medical units. Edmans JA et al. Medical Crises in Older People. Discussion paper series. 2012.

  15. ISAR (yes/no)

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