Geriatric Care Pearls: ACEP14

Published: Oct 31, 2014 | Updated: Nov 3, 2014

By Christopher R. Carpenter MD, MSc

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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Action Points

• Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
• Less than half of older adult alcohol users were accurately identified in the ER.

CHICAGO -- Can you cut your toenails? It's a question you might want to consider asking geriatric patients in your ED to assess fall risk. It's an indicator that researchers here at the American College of Emergency Physicians Scientific Assembly presented for post-ED fall risk stratification.

Between 2001 and 2009 the number of geriatric patient visits to U.S. emergency departments (EDs) increased 24.5%, which outpaced the growth in outpatient geriatric visits.

ACEP and the Society for Academic Emergency Medicine (SAEM) have lead the emergency medicine community to respond to this demographic "gray tsunami" by developing EM resident core competencies, ED geriatric quality indicators, and high-yield multidisciplinary research priorities. (1, 2) In 2013, the boards of directors of ACEP, SAEM, Emergency Nurses Association, and the American Geriatrics Society approved "Geriatric Emergency Department Guidelines."

Here are three notable abstracts presented at this session:

1. Post-ED Fall Risk Stratification

Standing level falls represent the leading cause of geriatric trauma mortality, and one-third of community-dwelling older adults over age 65 will fall every year. This well-designed meta-analysis explored the prognostic accuracy of ED-based falls studies to quantify the sensitivity, specificity, and likelihood ratios for individual fall-predictors from history and physical exam, as well as clinical decision models.

The investigators only identified three studies that met their inclusion criteria. Using positive (LR+) and negative likelihood (LR-) thresholds of 10 or greater and 0.1 or less, respectively, no single risk factor (such as past falls, number of medications, history of dementia) or objective test (get-up-and-go, tandem gait walk, chair stand) predicted falls at 1 to 6 months. Two ED-appropriate fall-risk prediction tools were identified (Tiedemann and Carpenter), neither of which accurately identified a subset of geriatric adults at increased risk for falls with LR+ of 3.76 and 2.40, respectively.

However, the Carpenter instrument (presence of nonhealing foot sore, falls within preceding 12-months, inability to cut toenails, self-reported depression) did identify a subset at reduced risk for falls with LR- 0.11 (95% CI 0.06-0.20). Although the Carpenter instrument awaits validation, this provides a new, evidence-based approach to ED fall risk stratification.

More on geriatric falls and these research results at the Skeptic's Guide to Emergency Medicine and this systematic review: "Predicting Geriatric Falls Following an Episode of Emergency Department Care."

2. Predict Post-ED Adverse Outcomes

Previously independent older adults frequently experience suboptimal outcomes after an episode of ED care, even when they are discharged home directly from the ED. For example, following blunt trauma (fall, motor vehicle accident), up to 35% of community dwelling older adults experience significant functional decline at 4 weeks. (1, 2) The challenge is to identify which 35% of patients are at-risk for these adverse outcomes, which also include preventable ED revisits, hospital admissions, and institutionalization.

This meta-analysis evaluated the prognostic accuracy of individual predictors and clinical stratification instruments for ED geriatric patients from 28 manuscripts, four abstracts and two published letters, all from North America and Europe. Twenty-six individual predictors were identified from five studies, but none accurately identified subsets of patients at increased or decreased risk for adverse outcomes at 1 to 6 months' post-ED discharge using LR+ and LR- thresholds of 10 or greater and 0.1 or less, respectively.

Seven risk stratification instruments were identified including the Identification of Seniors at Risk (ISAR)and Triage Risk Stratification Tool (TRST), but none identified any adverse outcome at any period following the index ED visit or any threshold for the test to be defined as "abnormal." Educators, ED nursing and physician leaders, guideline-developers, and policymakers need to be aware of these results in devising strategies to distinguish at-risk geriatric populations for subsequent preventative interventions.

3. Recognize Alcohol Misuse in ED Elderly

ED visits by older adults represent an opportunity to provide preventive interventions for falls, malnutrition, abuse, and smoking cessation, among other threats to sustained health (1, 2, 3). With 79,000 alcohol-related deaths and $223 billion excess medical-related costs, alcohol abuse among geriatric patients is yet another ED opportunity to proactively promote healthy lifestyles. (1, 2)

This study quantified the prevalence of hazardous alcohol use among older adults from one ED, noting that 10% met National Institute on Alcohol Abuse and Alcoholism criteria for alcohol misuse, but less than half had any documentation of alcohol use by the ED providers. If subsequent studies verify that ED-based interventions effectively reduce alcohol misuse in older adults, than further research will be needed to derive and validate ED-appropriate screening instruments for alcohol misuse.

Christopher R. Carpenter, MD, MSc is associate professor of emergency medicine at Washington University in St. Louis School of Medicine. Carpenter is also past-chair of the ACEP Geriatric Section and is on the editorial boards of the Journal of the American Geriatrics Society and Academic Emergency Medicine.

Follow him on Twitter: @GeriatricEDNews