Geriatric Emergency Geriatric Emergency Medicine: Research Medicine: Research

Update - Tried and True Update - Tried and True to Somewhat newto Somewhat new

Jacques Lee MD, MSc, FRCPC

ObjectivesObjectives

• To review existing research literature on “Geriatric Emergency Medicine”

- Tried and (probably) True

- Somewhat New!

• To finish before Christmas!

GEM Literature Search: MethodsGEM Literature Search: Methods

1. Geriatric.m_titl.

2. elder.m_titl.

3. older.m_titl.

4. senior.m_titl.

5. 1 or 2 or 3 or 4

6. Emergency.m_titl.

7. (accidents and emergencies).m_titl.

8. ER.m_titl.

9. ED.m_titl.

10. 6 or 7 or 8 or 911.5 and 10 = 32312.Limit English & Human =

299

GEM Research Update: Tried & GEM Research Update: Tried & TrueTrue

• Important reviews:

• Grief et al. J Em Nurse 2003

• Aminzadeh et al. Ann Em Med 2002

• Samaras et al. Ann Em Med 2010

GEM Research Update: GEM Research Update: Epidemiology & Descriptive Epidemiology & Descriptive StudiesStudies• Older patients:

- Higher users of ED- More Frequently arrive by Ambulance- More likely to be admitted- More likely to require Critical Care- More likely to develop delirium- More likely to die

GEM Research Update: GEM Research Update: Epidemiology & Descriptive Epidemiology & Descriptive StudiesStudies• Older patients:

- Receive More Tests / More resources- Have longer ED lengths of stay- Less likely to understand discharge

instructions- More likely to return for the same

problem

GEM Research Update: GEM Research Update: Epidemiology & Descriptive Epidemiology & Descriptive StudiesStudiesEmergency physicians with:

• Less experience

• Less training

• Lower pay

• Higher perceived volume of older patients,

• Associated with higher perceived “burden of care” 6

GEM Research Update: Prediction GEM Research Update: Prediction and Screeningand Screening

Good data on clinical prediction tools for use in the ED

• ISAR

• TRST

• PERIL

GEM Research Update: Prediction GEM Research Update: Prediction and Screeningand Screening

Good data on clinical prediction tools for use in the ED

• ISAR

• TRST

• PERIL

GEM Research Update: Prediction GEM Research Update: Prediction and Screeningand Screening

• Any studies comparing screening tool? 10

• Are screening tools being used? 11

GEM Research Update: Prediction GEM Research Update: Prediction and Screeningand Screening

Something New?

• Any studies comparing screening tool? 10

• Are screening tools being used? 11

GEM Research Update: GEM Research Update: InterventionsInterventions

• McCusker J, Verdon J. Do geriatric interventions reduce emergency department visits? A systematic review..

GEM Research Update: GEM Research Update: InterventionsInterventions

Something New?

• Courtney et al.12

• 24 Weeks case management and customized exercise program

• Cost Effective ? 13

GEM Research Update: DeliriumGEM Research Update: Delirium

Tried & True

• Delirium increases length of stay 14

• Prolonged ED stay increases Delirium

• Delirium is an independent risk factor for mortality

• Delirium can takes months to clear and can be permanent

GEM Research Update: DeliriumGEM Research Update: Delirium

Something New?

• Genetic markers for delirium “predisposition”?

• Computerized testing for delirium?

ReferencesReferences

1. Grief CL. Patterns of ED use and perceptions of the elderly regarding their emergency care: a synthesis of recent research. J Emerg Nurs. Apr 2003;29(2):122-126.

2. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med Mar 2002;39(3):238-247

3. Samaras N, Chevalley T, Samaras D, Gold G. Older patient in the Emergency Department. Ann Emerg Med Sept 210;56(3):261-269.

4. Singal BM, Hedges JR, Rousseau E, et al. Geriatric patient emergency visits. Part I: comparison of visits by geriatric and younger patients. Ann Emerg Med. 1992;21:802-807.

5. Hedges J, Singal B, Rousseau E. Geriatric patient emergency visits. Part II: Perceptions of visits by geriatric and younger patients. Ann Emerg Med. July 1992;21((7)):808-813.

ReferencesReferences

6. Schumacher JG, Deimling GT, Meldon S, Woolard B. Older adults in the Emergency Department: predicting physicians' burden levels. Journal of Emergency Medicine. 2006;30(4):455-60.

7. McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool.. Journal of the American Geriatrics Society. 1999;47(10):1229-37.

8. Meldon SW, Mion LC, Palmer RM, Drew BL, Connor JT, Lewicki LJ, Bass DM, Emerman CL. A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department.. Acad Emerg Med. 2003;10(3):224-32.

ReferencesReferences

9. Lee JS, Schwindt G, Langevin M, Moghabghab R, Alibhai SM, Kiss A, Naglie G. Validation of the triage risk stratification tool to identify older persons at risk for hospital admission and returning to the emergency department.. JAGS. 2008;56(11):2112-7.

10.McCusker J, Verdon J, Veillette N, Berg K, Emond T, Belzile E. Standardized screening and assessment of older patients in the emergency department: a survey of implementation in Quebec.. Canadian Journal on Aging. 2007 [cited 2007];26(1):49-57.

11.McCusker J, Verdon J. Do geriatric interventions reduce emergency department visits? A systematic review. J Geront Series A. 2006;61(1):53-62.

ReferencesReferences

12.Courtney M, Edwards H, Chang A, Parker A, Finlayson K, Hamilton K. Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.. Journal of the American Geriatrics Society. 2009 [cited 2009 Mar];57(3):395-402.

13.Graves N, Courtney M, Edwards H, Chang A, Parker A, Finlayson K. Cost-effectiveness of an intervention to reduce emergency re-admissions to hospital among older patients.. PLoS ONE [E- Resource]. 2009;4(10):e7455.

14.McCusker J, Cole MG, Dendukuri N, Belzile E. Does Delirium increase hsopital stay? JAGS, 2003;51(11):