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
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Definitions
Background
Why? How?
Current knowledge & trends
Conclusions
Questions
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!
Emergency Department (ED)
• Accident and Emergency (A&E)
• Emergency Room (ER)
• Acute care Settings vary!
• Patients present without prior appointment
Emergency
Primary
Health Care
Norway
Emergency
Department
Non-hospitalized
Medical or
Geriatric
Ward
Hospitalized
Background
• Patients 65+ ~ 20% of all consultations in EDs
• ED visits often followed by functional decline
(other adverse outcomes)
• Age, premorbid functional status and cognitive
function strong predictors of functional decline
• Studies in ED patients scarce
-studies in hospitalized patients abundant
Assessing risk of functional
decline in EDs – Why?
• Prevention possible
• Identification of patients at risk
Improved care. Two – step procedure?
Gatekeeping
Assessing risk of functional
decline in EDs – How?
Screening tools
• Easily and rapidly used
Other parameters
• Biological parameters
(IL-6, CRP, TNF)
• Most studied validated tools: • Physical parameters
(muscle strength, walking
Identification of Seniors at Risk
stick, gait speed, TUG, one
ISAR
leg balance)
Triage Risk Screening Tool
TRST
Both: 6 items, completed by
• No studies!?
patient/ caregiver/clinician
Graf 2012, de Saint-Hubert 2010
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
Screening tools to select
high risk ED patients
-validation studies
Tools
Items
Settings
Performance
Outcomes
ISAR (1999)
ADL(2), vision,
cognition, hosp.,
3+ drugs
EDs 4 university ≥2/6 =>
hospitals (Can) Sens 72%
N=676, 65+
Spec 58%
Functional decline
6 m., institutionalization, death
TRST (2003)
Walking, >5
drugs,cognition
hosp./ED use, no
caregiver, nurses
concern
EDs 2 urban
teaching
hospitals (USA)
N=647, 65+
≥2/6:
Sens 64/55%,
spes 63/66%
at 30/120 d
Institutionalization
& ED readmission,
30 + 120 days
Silver Code (2012)
(validated in
hospitalized
patients in 2010)
Age, sex, marital
status, day
hospital/hospital,
number of drugs
(0-8, 8+).
Geriatric ED
(Italy)
N=1632, 75+
Stratifies in 4
risk classes;
predictive
validity as for
ISAR
Need for
hospitalization, ED
return visit or
hospitalization or
death at 6 months
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.
Reviews
Tools appropriate to assess risk of functional decline in older patients
attending acute medical units (EDs in all reviews)
McCusker et al
2002
Hoogerduijn et al
2006
Sutton et al
2008
de Saint-Hubert
2010
Objective
Predict functional
decline in older
hospitalized
patients, >60yrs
physical decline,
nursing home adm
Identify valid,
reliable and
clinical userfriendly
tool for functional
decline in older
people
Identify screening
tools in ED,
elderly patients,
risk of functional
decline, >65yrs,
any condition
Identify tools to
detect risk of
functional
decline
at and after
discharge
Aspects of
functional
decline
considered
ADL ability,
NH adm,
Death
ADL ability
NH placement
Mortality
Hospital costs
ADL ability
Physical and
Cognitive function
NH adm, QoL
ADL ability
NH adm
Death
Conclusion
Heterogeneity
limits synthesis.
Moderate shortterm predictive
ability?
ISAR (HARP,
COMPRI) should be
further
investigated. ISAR
most userfriendly?
No «gold standard»
Only ISAR
acceptable
discrimination
(ROC 0.71).
Comparisons
difficult. Many
tools – because
no gives full
satisfaction.
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
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
Supporting clinical decision-making!
• ISAR & TRST high negative predictive values (NPVs)
Can be used to safely select patients for discharge (?)
*Silver Code, not included in reviews.
Edmans 2012.
Conclusions
Few studies focus on ED patients at
risk of functional decline
Tools, settings & outcomes vary
No gold standard
Questions
Assessing 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!
References
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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.
ISAR (yes/no)
1. Before the illness or injury that brought you to the Emergency,
did you need someone to help you on a regular basis?
2. Since the illness or injury that brought you to the Emergency,
have you needed more help than usual to take care of yourself?
3. Have you been hospitalized for one or more nights during the
past 6 months (excluding a stay in the Emergency Department)?
4. In general, do you see well?
5. In general, do you have serious problems with your memory?
6. Do you take more than three different medications every day?
2011/02 Version www.smhc.qc.ca/en/research/our-research/research-made-practical