Cognitive impairment is a frequent problem among older patients attending the Emergency Department (ED) and can be the result of pre-existing cognitive impairment, delirium, or neurologic disorders. ...Another cause can also be acute disturbance of brain perfusion and oxygenation, which may be reversed by optimal resuscitation. This study aimed to assess the relationship between vital signs, as a measure of acute hemodynamic changes, and cognitive impairment in older ED patients.
Prospective cohort study.
ED's of two tertiary care and two secondary care hospitals in the Netherlands.
2629 patients aged 70-years and older.
Vital signs were measured at the moment of ED arrival as part of routine clinical care. Cognition was measured using the Six-Item Cognitive Impairment Test (6-CIT).
The median age of patients was 78 years (IQR 74-84). Cognitive impairment was present in 738 patients (28.1%). When comparing lowest with highest quartiles, a systolic blood pressure of <129 mmHg (OR 1.30, 95% confidence interval (95%CI) 0.98-1.73)was associated with increased risk of cognitive impairment. A higher respiratory rate (>21/min) was associated with increased risk of impaired cognition (OR 2.16, 95% CI 1.58-2.95) as well as oxygen saturation of <95% (OR 1.64, 95%CI 1.24-2.19).
Abnormal vital signs associated with decreased brain perfusion and oxygenation are also associated with cognitive impairment in older ED patients. This may partially be explained by the association between disease severity and delirium, but also by acute disturbance of brain perfusion and oxygenation. Future studies should establish whether normalization of vital signs will also acutely improve cognition.
BACKGROUND
Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, ...urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30‐day mortality in older ED patients.
DESIGN
Secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study.
SETTING
EDs within four Dutch hospitals.
PARTICIPANTS
Consecutive patients, aged 70 years or older, who were prospectively included.
MEASUREMENTS
Patients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30‐day mortality. Comparison was made between mortality within the geriatric high‐ and low‐risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R2.
RESULTS
We included 2,608 patients with a median age of 79 (interquartile range = 74‐84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30‐day mortality was threefold higher in geriatric high‐risk compared to low‐risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30‐day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener.
CONCLUSION
Combining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. J Am Geriatr Soc 68:1755‐1762, 2020.
Abstract
Background
During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty ...with poor outcome have been conflicting.
Objective
The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands.
Methods
This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality.
Results
A total of 1,376 patients were included (median age 78 years (interquartile range 74–84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6–9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1–3, patients with CFS 4–5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3–3.0)) and patients with CFS 6–9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8–4.3)).
Conclusions
The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms.
During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome ...have been conflicting.
The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands.
This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality.
A total of 1,376 patients were included (median age 78 years (interquartile range 74-84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6-9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1-3, patients with CFS 4-5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3-3.0)) and patients with CFS 6-9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8-4.3)).
The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms.
Abstract
Background
risk stratification tools for older patients in the emergency department (ED) have rarely been implemented successfully in routine care.
Objective
to evaluate the feasibility and ...acceptability of the ‘Acutely Presenting Older Patient’ (APOP) screener, which identifies older ED patients at the highest risk of adverse outcomes within 2 minutes at presentation.
Design and setting
2-month prospective cohort study, after the implementation of the APOP screener in ED routine care in the Leiden University Medical Center.
Subjects
all consecutive ED patients aged ≥70 years.
Methods
feasibility of screening was assessed by measuring the screening rate and by identifying patient- and organisation-related determinants of screening completion. Acceptability was assessed by collecting experienced barriers of screening completion from triage-nurses.
Results
we included 953 patients with a median age of 77 (IQR 72–82) years, of which 560 (59%) patients were screened. Patients had a higher probability of being screened when they had a higher age (OR 1.03 (95%CI 1.01–1.06), P = 0.017). Patients had a lower probability of being screened when they were triaged very urgent (OR 0.55 (0.39–0.78), P = 0.001) or when the number of patients upon arrival was high (OR 0.63 (0.47–0.86), P = 0.003). Experienced barriers of screening completion were patient-related (‘patient was too sick’), organisation-related (‘ED was too busy’) and personnel-related (‘forgot to complete screening’).
Conclusion
with more than half of all older patients screened, feasibility and acceptability of screening in routine ED care is very promising. To further improve screening completion, solutions are needed for patients who present with high urgency and during ED rush hours.
Falls in older Emergency Department (ED) patients may indicate underlying frailty. Geriatric follow-up might help improve outcomes in addition to managing the direct cause and consequence of the ...fall. We aimed to study whether fall characteristics and the result of geriatric screening in the ED are independently related to adverse outcomes in older patients with fall-related ED visits.
This was a secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study, of which a subset of patients aged ≥70 years with fall-related ED visits were prospectively included in EDs of two Dutch hospitals. Fall characteristics (cause and location) were retrospectively collected. The APOP-screener was used as a geriatric screening tool. The outcome was 3- and 12-months functional decline and mortality. We assessed to what extent fall characteristics and the geriatric screening result were independent predictors of the outcome, using multivariable logistic regression analysis.
We included 393 patients (median age 80 (IQR 76-86) years) of whom 23.0% were high risk according to screening. The cause of the fall was extrinsic (49.6%), intrinsic (29.3%), unexplained (6.4%) or missing (14.8%). A high risk geriatric screening result was related to increased risk of adverse outcomes (3-months adjusted odds ratio (AOR) 2.27 (1.29-3.98), 12-months AOR 2.20 (1.25-3.89)). Independent of geriatric screening result, an intrinsic cause of the fall increased the risk of 3-months adverse outcomes (AOR 1.92 (1.13-3.26)) and a fall indoors increased the risk of 3-months (AOR 2.14 (1.22-3.74)) and 12-months adverse outcomes (AOR 1.78 (1.03-3.10)).
A high risk geriatric screening result and fall characteristics were both independently associated with adverse outcomes in older ED patients, suggesting that information on both should be evaluated to guide follow-up geriatric assessment and interventions in clinical care.
Objective
The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) ...care shortly after implementation.
Methods
We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate.
Results
Two comparable groups of patients (median age 77 years) were included before (
n
= 920) and after (
n
= 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after;
p
= 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after;
p
= 0.152) or hospital admission rate (40% before vs. 39% after;
p
= 0.410).
Conclusion
Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.
Abstract
Background
as the coronavirus disease of 2019 (COVID-19) pandemic progressed diagnostics and treatment changed.
Objective
to investigate differences in characteristics, disease presentation ...and outcomes of older hospitalised COVID-19 patients between the first and second pandemic wave in The Netherlands.
Methods
this was a multicentre retrospective cohort study in 16 hospitals in The Netherlands including patients aged ≥ 70 years, hospitalised for COVID-19 in Spring 2020 (first wave) and Autumn 2020 (second wave). Data included Charlson comorbidity index (CCI), disease severity and Clinical Frailty Scale (CFS). Main outcome was in-hospital mortality.
Results
a total of 1,376 patients in the first wave (median age 78 years, 60% male) and 946 patients in the second wave (median age 79 years, 61% male) were included. There was no relevant difference in presence of comorbidity (median CCI 2) or frailty (median CFS 4). Patients in the second wave were admitted earlier in the disease course (median 6 versus 7 symptomatic days; P < 0.001). In-hospital mortality was lower in the second wave (38.1% first wave versus 27.0% second wave; P < 0.001). Mortality risk was 40% lower in the second wave compared with the first wave (95% confidence interval: 28–51%) after adjustment for differences in patient characteristics, comorbidity, symptomatic days until admission, disease severity and frailty.
Conclusions
compared with older patients hospitalised in the first COVID-19 wave, patients in the second wave had lower in-hospital mortality, independent of risk factors for mortality.
The better prognosis likely reflects earlier diagnosis, the effect of improvement in treatment and is relevant for future guidelines and treatment decisions.
Objective
Recent studies suggest that hypotension thresholds in current guidelines might be too low for older patients due to arterial stiffening, possibly leading to insufficient fluid resuscitation
....
We compared intravenous (IV) fluid volumes that older (≥ 70 years) and younger (< 70 years) patients with suspected infection with similar initial systolic blood pressure (SBP) received in the emergency department (ED) and investigated whether this was associated with in-hospital mortality in older patients.
Methods
This was an observational multicenter study using an existing database in which consecutive ED patients hospitalized with suspected infection were prospectively included. We first compared the fluid volumes older and younger ED patients received per initial SBP category. Patients were then stratified into two SBP categories (≤ or > 120 mmHg; 120 has been suggested to be a better threshold) and thereafter into three fluid volume categories: 0–1 L, 1–2 L, or > 2 L. In each SBP and fluid category, case-mix-adjusted in-hospital mortality was compared between older and younger patients, using multivariable logistic regression analysis.
Results
The included 981 (37%) older and 1678 (63%) younger ED patients received similar IV fluid volumes per initial SBP category. Older patients with an initial SBP > 120 mmHg had a higher adjusted OR of 2.06 (95% CI 1.02–4.16), in the 0–1 L category, while this association was not found in the higher fluid categories of 1–2 L or > 2 L. In the SBP ≤ 120 mmHg category, this association was also absent.
Conclusion
This hypothesis-generating study suggests that older patients with suspected infection may need higher fluid volumes than younger patients, when having a seemingly normal initial SBP.
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