Acute geriatrics at the front door

Abstract

Older people with frailty and urgent care needs are major uses of health and social care services. Comprehensive geriatric assessment (CGA) is an evidence-based approach to improving their outcomes, as well as improving service outcomes. Geriatricians form a small proportion of the overall workforce and cannot address the population need alone, so all clinicians (doctors, nurses, therapists and so on) need to engage in delivering CGA as a process of care, underpinned by specifi c competencies -which can be developed. Delivery of this care pathway needs to be measured and improved as rigorously as campaigns like those for improving sepsis or eradicating methicillin-resistant Staphylococcus aureus . IntroductionFor many older people -in the UK at least -the emergency department (ED) is the main portal of entry to urgent care. In many cases, the older person's urgent care needs can be quickly assessed and managed within a short period of time (the 4-hour standard); in the UK, about one-third of people over the age of 85 years accessing EDs are able to return home directly. But for many others, a more detailed assessment and management plan is required, delivered in either observation wards in the ED (typically for people with an anticipated stay of less than 24 hours; variously termed clinical decision units, emergency decision units and other such acronyms) or an acute medical unit (for post-ED management of medical patients, initially for up to 72 hours) -staffed by acute physicians trained in acute assessment of a wide range of conditions. 1 While older people (65 or 75+ years) form a significant proportion of patients at all of these axes of care, and around two-thirds of all those receiving ongoing care in acute hospitals, there is a discrete subset of people aged 75+ who account for the bulk of bed days. Emerging data from the Nuffield Trust indicate about 20% of all those aged 75+ account for 85% of bed days and 85% of readmission or deaths within 90 days of an urgent care episode. It appears that this 20% resemble older people with frailty.Frailty is a distinctive late-life health state in which apparently minor stressor events are associated with adverse health outcomes. The two established international models are the ABSTRACT Acute geriatrics at the front door frailty phenotype 2 and the cumulative deficit model, 3 both of which have been validated in large population cohort studies. The models identify people at increased risk of a range of adverse outcomes, including dependency, institutionalisation and premature death. Frailty can be measured; the cumulative deficit model of frailty expresses frailty as a ratio of deficits present to a total list of deficits that have been pre-defined using a standard procedure. 4 This model maps well onto the Clinical Frailty Scale, 5 which is quick (<1 minute), simple and easy to use in urgent care settings. 6Frailty identification is important at several levels. Older people with frailty will often present with so-called nonspecific presentations, multiple comorbid...

Disability and morbidity among older patients in the emergency department: a Danish population-based cohort study

“…However, how to identify the patients in need of geriatric assessment remains unclear. Using frailty scales as risk stratification tools might be a possibility 54 55. Several frailty rating scales exist19 and screening appears to predict the risk of mortality,56 length of admission57 and risk of readmission57 depending on the frailty scale used.…”

Identification and acceptance of suggested therapeutic alternatives of potentially inappropriate medications amongst hospitalised geriatric patients in Iran

“…An estimated 22% of the global population will be aged ≥65 years by 2050 . Older frail people and those with urgent care needs are major users of health and social care services . Criteria to identify inappropriate medication for older people have been developed in North America, Europe and Asia .…”

“…1 Older frail people and those with urgent care needs are major users of health and social care services. 2 Criteria to identify inappropriate medication for older people have been developed in North America, Europe and Asia. 3 Azoulay et al 4 evaluated prescriptions from 3000 elderly patient visits in Isfahan, Iran, and reported that 27.6% of geriatric patients recorded at least one potentially inappropriate medication (PIM).…”

Emergency Department Staff Perceptions of Emergency Department Interventions for Frailty (EDIFY)

“…EDIFY was designed for the dual purpose of reducing the number of potentially avoidable acute admissions and delivering interprofessional geriatric interventions through comprehensive geriatric assessments, and promoting awareness and education on frailty. 2,3 The program significantly reduced acute admissions without escalating the risk of rehospitalization, ED re-attendance, or mortality. 1 We conducted a survey among ED staff aimed at assessing their perceptions of knowledge and confidence in managing older persons and to explore their satisfaction with current geriatric expert This work was supported by the Ng Teng Fong Healthcare Innovation Programme (Project Code: NTF_JUL2017_I_C2_CQR_02), National Healthcare Group, Singapore, which had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.…”

“…Because of time pressures at the ED, addressing complex multidimensional needs of older persons often do not take precedence. 2,3 Hence, care models designed specifically to deliver frailty-centric care at the ED are needed to improve functional outcomes and reduce ED re-attendance among older persons. 1,4e7 Our study had a number of limitations.…”