Systematic geriatric assessment for older patients with frailty in the emergency department: a randomised controlled trial

Abstract

Background Comprehensive geriatric assessment provided in hospital wards in frail patients admitted to hospital has been shown to reduce mortality and increase the likelihood of living at home later. Systematic geriatric assessment provided in emergency departments (ED) may be effective for reducing days in hospital and unnecessary hospital admissions, but this has not yet been proven in randomised trials. Methods We conducted a single-centre, randomised controlled trial with a parallel-group, superiority design in an academic hospital ED. ED patients aged ≥ 75 years who were frail, or at risk of frailty, as defined by the Clinical Frailty Scale, were included in the trial. Patients were recruited during the period between December 11, 2018 and June 7, 2019, and followed up for 365 days. For the intervention group, systematic geriatric assessment was added to their standard care in the ED, whereas the control group received standard care only. The primary outcome was cumulative hospital stay during 365-day follow-up. The secondary outcomes included: admission rate from the index visit, total hospital admissions, ED-readmissions, proportion of patients living at home at 365 days, 365-day mortality, and fall-related ED-visits. Results A total of 432 patients, 63 % female, with median age of 85 years, formed the analytic sample of 213 patients in the intervention group and 219 patients in the control group. Cumulative hospital stay during one-year follow-up as rate per 100 person-years for the intervention and control groups were: 3470 and 3149 days, respectively, with rate ratio of 1.10 (95 % confidence interval, 0.55–2.19, P = .78). Admission rates to hospital wards from the index ED visit for the intervention and control groups were: 62 and 70 %, respectively (P = .10). No significant differences were observed between the groups for any outcomes. Conclusion Systematic geriatric assessment for older adults with frailty in the ED did not reduce hospital stay during one-year follow-up. No statistically significant difference was observed for any secondary outcomes. More coordinated, continuous interventions should be tested for potential benefits in long-term outcomes. Trial registration The trial was registered in the ClinicalTrials.gov (registration number and date NCT03751319 23/11/2018).

Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review

“…Table 1 presents characteristics of the included studies. All studies were published in English and the primary author affiliation was mainly from North America [7,[30][31][32][33][34][35][36][37][38][39][40][41][42][43] (44%) and Europe [44][45][46][47][48][49][50][51][52][53][54][55] (35%). No papers had been published before 2015, and most of the papers (76%) were published beginning 2019.…”

“…Studies were published in emergency medicine journals (41%) [7, 30, 32, 33, 36, 40, 46, 48-50, 53, 54, 56, 57], geriatric journals (38%) [31,34,35,38,39,41,42,45,47,56,58,59] or other types of journals (21%) [37,43,51,52,55,60,61]. Two-thirds of the studies were prospective cohorts [7, 30, 33, 35-38, 40, 42, 43, 47-50, 52, 54-59, 62], while the remaining were retrospective cohorts (24%) [34,39,41,45,46,53,60,61], intervention studies (9%) [31,44,51] or cross-sectional studies (3%) [32] (Table 1). One study [45] was performed in pre-hospital setting only, and another one [43] included both pre-hospital and ED patients.…”

“…Table 2 shows the different types of assessors. Research staff (35%) [7,30,31,35,37,38,43,47,49,56,59,62], nurse (32%) [36,40,41,44,46,48,50,52,54,58,60] and ED physician (20%) [32,33,36,40,42,46,57] were the most frequent.…”

Critical Appraisal of the Concept Frailty: Rating of Frailty in Elderly People has Weak Scientific Basis and should not be Used for Managing Individual Patients

“…A Cochrane Library review from 2017 showed that a CGA carried out by a hospital for patients aged 65 and older does not affect mortality or i/p ADL capacity in the following year [26]. A recent RCT showed that systematic geriatric assessment for older (≥ 75 years) adults with frailty defined by CFS in the emergency department did not reduce hospital stay during one-year follow-up [27].…”

Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization

“…Comprehensive geriatric assessment (CGA) has been identified as a potentially useful approach to this aim as it was shown effective to improve functional trajectories and the likelihood of remaining at home up to 12 months after discharge from dedicated geriatric wards [ 9 ];[ 18 , 19 ]. Indeed, several studies that specifically examined CGA-based geriatric consultations performed by teams working within EDs reported promising results in detecting vulnerability and preventing admission [ 20 – 22 ]. However, evidence from these studies was less clear about their effect on length of stay or 30-day readmission [ 20 – 22 ].…”