Emergency Department Case‐finding for High‐risk Older Adults: The Brief Risk Identification for Geriatric Health Tool (BRIGHT)

Abstract

Objective: The objective was to test the ability of the Brief Risk Identification for Geriatric Health Tool (BRIGHT) to identify older emergency department (ED) patients with functional and physical impairment.Methods: This was a cross-sectional study in which 139 persons ‡75 years, who presented to an urban New Zealand ED over a 12-week period, completed the 11-item BRIGHT case-finding tool. Then, within 10 days of their index ED visit, 114 persons completed a comprehensive geriatric assessment. A ''yes'' response to at least 3 of the 11 BRIGHT items was considered ''positive.'' Primary outcome measures were instrumental activities of daily living (IADL), cognitive performance scale (CPS), and activities of daily living (ADL).Results: The BRIGHT-identified IADL deficit (64% prevalence) with a sensitivity of 0.76, specificity of 0.79, and receiver operating characteristic (ROC) of 0.83 (95% confidence interval [CI] = 0.74 to 0.91, p < 0.01); cognitive deficit (35% prevalence) sensitivity of 0.78, specificity of 0.54, and ROC of 0.66 (95% CI = 0.55 to 0.76, p = 0.006); and ADL deficit (29% prevalence) sensitivity of 0.83, specificity of 0.53, and ROC of 0.64 (95% CI = 0.53 to 0.75, p = 0.020). Positive likelihood ratios (LR+) for the three outcomes of interest were 3.6, 1.7, and 1.8, respectively. Negative likelihood ratios (LR)) were 0.3, 0.4, and 0.3. Conclusions:The 11-item BRIGHT successfully identifies older adults in the ED with decreased function and may be useful in differentiating elder patients in need of comprehensive assessment. ACADEMIC EMERGENCY MEDICINE 2008; 15:598-606 ª 2008 by the Society for Academic Emergency MedicineKeywords: risk assessment, aged, emergency services, case finding, geriatric assessment O lder adult patients commonly present to the emergency department (ED) with a complex mix of health and psychosocial issues. Functional dependence at the time of ED admission is a risk factor for subsequent health and functional decline, ED and hospital readmission, institutionalization, and death.1-4 Other risk factors for adverse outcomes include living alone, lack of social support, multiple comorbidity, polypharmacy, and diagnoses such as cardiovascular disease, diabetes, cognitive impairment, and depression. 5,6 Research has demonstrated that systematic case-finding, assessment, and prompt intervention can forestall health and functional decline, decrease hospital length of stay and readmission, and decrease long-term care admission. 7,8 In the Discharge of Elderly from the Emergency Department (DEED) II trial, ED-based comprehensive geriatric assessment followed by multidisciplinary community outreach resulted in a lower rate of

Risk Factors and Screening Instruments to Predict Adverse Outcomes for Undifferentiated Older Emergency Department Patients: A Systematic Review and Meta‐analysis

“…The systematic review by Beaton and Grimmer 16 evaluated only functional decline and no meta-analysis is reported. They did identify two instruments that we did not include in our systematic review: the Brief Risk Identification for Geriatric Health Tool (BRIGHT) 94 and the Simplified PROFUNCTION index. 95 We excluded the BRIGHT because the validation trial assessed point-ofcare instrumental activities of daily living dependence rather than post-ED functional decline.…”

Frailty in Older Adults Using Pre-hospital Care and the Emergency Department: A Narrative Review

“…Risk-screening tools have been developed to identify patients at risk for re-admission to the ED, functional decline or death. (23)(24)(25)(26)(27) Although these tools are not attempting to quantify frailty, their components are related to a conceptualization of frailty (e.g., function, mobility, cognitive impairment). For older patients discharged from the emergency department, functional deficits and use of community services were predictive of re-admission.…”

“…Each brief screening instrument has demonstrated a moderate ability to predict functional decline in older ED patients. (27) These tools are not designed to grade frailty, and may lack the necessary precision to identify which patients may benefit most from specialized geriatric services.…”

“…It has been designed for use as a postal questionnaire or can be administered within the ED in order to detect older adults that might benefit from comprehensive geriatric assessment. (27) The BRIGHT requests the patient or caregiver to think about the previous three months and respond with "yes" or "no" to questions related to functional problems, shortness of breath, mobility problems, cognition, falls, self-rated health, and depression. (27) The final two screening tools identified were the sevenitem questionnaire developed by Rowland et al (26) and an eight-item questionnaire by Ruciman et al (25) The sevenitem screening primarily assesses function (activities of daily living (ADL) and instrumental activities of daily living (IADLs)) and mobility.…”

“…(23)(24)(25)(26)(27) The Triage Risk Screening Tool (TRST), a six-item tool comprised of yes/no questions that are completed during the triage process, has been evaluated for use in older patients being discharged from the ED. (24,28) It evaluates the presence of cognitive impairment, difficulty walking or transferring, recent falls, living alone with no available caregiver, taking five or more prescription medications, ED use in previous 30 days or hospitalization in previous 90 days, and registered nurse (assessor) concern.…”