1. Assessing risk of functional decline in emergency departments MS Bakken, MD PhD student X EAMA Advanced Postgraduate Course in Geriatrics Martigny, 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) Acute care Patients present without prior appointment Emergency Primary Health Care Emergency Department Medical or Geriatric Ward Settings vary! Norway Hospitalized Non-hospitalized

5. 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

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 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 Other parameters Biological parameters (IL-6, CRP, TNF) Physical parameters (muscle strength, walking stick, gait speed, TUG, one leg balance) No studies!? 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 ToolsItemsSettingsPerformanceOutcomes ISAR (1999)ADL(2), vision, cognition, hosp., 3+ drugs EDs 4 university hospitals (Can) N=676, 65+ ≥2/6 => Sens 72% Spec 58% Functional decline 6 m., institution- alization, 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.

10. 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 ObjectivePredict 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 ConclusionHeterogeneity limits synthesis. Moderate short- term 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

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 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.

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

13. 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!

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. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program. Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP). de Vos AJ et al. BMC Geriatr. 2012. Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP). 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) 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-practicalwww.smhc.qc.ca/en/research/our-research/research-made-practical