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COMPREHENSIVE GERIATRIC ASSESSMENT IN THE EMERGENCY DEPARTMENT

2010; Wiley; Volume: 58; Issue: 10 Linguagem: Inglês

10.1111/j.1532-5415.2010.03090.x

1532-5415

Christophe Graf, Dina Zekry, Sandra Giannelli, Jean‐Pierre Michel, Thierry Chevalley,

Hip and Femur Fractures

To the Editor: Twenty percent of admissions to the emergency department (ED) are of older patients,1 who have longer stays in the ED, frequently have more-severe diseases, are five times as likely to be admitted, and have higher risk of adverse outcomes such as ED readmission, functional decline (reduced ability to perform tasks of everyday living because of a decrease in physical or cognitive functioning), nursing home admission, and death than younger people.1 However, some prevalent geriatric pathologies such as delirium and depression are frequently underdiagnosed, and functional impairment is underestimated in the ED.1 Comprehensive geriatric assessment (CGA) is a reproducible procedure that includes assessment of cognition, mood, comorbidities, polypharmacy, risk of falls, functional status (basic and instrumental activities of daily living), nutritional status, and social support. By recognizing up to two more geriatric problems than usual clinical evaluations, CGA can help ED physicians to improve management of older patients.2 However, CGA is time consuming and thus cannot be applied to every older patient admitted to the ED. As a consequence, the best compromise is the use of a two-step approach. The first step is the identification of patients at high risk for adverse outcomes, which can be performed using the Identification of a Senior at Risk (ISAR) screening tool, which has been validated in the ED.3 Its negative predictive value for ED readmission is 100%, 89%, and 82% at 14 days, 1 month, and 3 months, respectively. The second step is a CGA in patients that the ISAR identifies as being at high risk. The CGA was shown to decrease the incidence of adverse outcomes especially for patients at high risk.4 Even in selected patients, the CGA is time consuming, and some widely used tools such as the Mini-Mental-State Evaluation (MMSE) take too long in ED. Therefore, some shorter validated tools were developed. They are summarized in Table 1 and all together take approximately 25 minutes to administer. To detect delirium, the Confusion Assessment Method (CAM), requiring less than 5 minutes,5 has a positive predictive value of 100% and a negative predictive value (NPV) of 97%. For mental evaluation, the Quick Confusion Scale (QCS), which can be completed more quickly (∼2 minutes) than the MMSE and does not require writing and reading ability, has been validated.6 There is a significant correlation between a QCS score less than 11 out of 15 and a MMSE score of 23 or less out of 30 (correlation coefficient=.783). In a study of a two-questions screening test for depression in patients without cognitive impairment (defined as a MMSE score ≥26),7 a score of 1 or greater had a sensitivity of 84%, a specificity of 61%, and a NPV of 95% compared with a 15-item Geriatric Depression Scale (GDS-15) score of 5 or greater. To assess functional status, the Older Americans Resources and Services (OARS) questionnaire, with a score ranging from 0 to 288 and taking approximately 5 minutes to administer is the most used in North America. Although the cutoff is not clearly determined, each point under the maximum score indicates a functional disability that must be taken into account for further interventions or advises. The one-leg balance test is a short and simple test during which the patient has just to be able to stand up.9 The inability to perform this task doubles the risk for an injurious fall during the next 3 years. Concerning malnutrition, there is no validated test that can be routinely used in the ED, and the measurement of body mass index, frequently included in nutritional scores, is difficult to perform in the ED. It is also critical to take advantage of the ED visit to review and improve the medication list to reduce adverse drug events. The Beer's criteria are a widely accepted list that can help to identify potentially inappropriate medication in older patients and can be used to simplify treatments.10 In conclusion, older patients admitted to the ED should be screened for risk of adverse outcomes. In patients at high risk of adverse outcomes, the CGA should be administered with brief tools validated in the ED. This two-step intervention has been shown to decrease the rate of functional decline, readmission, and institutionalization. Further research is needed to validate this approach in different populations, such as in Europe or Asia. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Review of the literature: Graf CE. Drafting of the manuscript: Graf CE, Zekry D, Chevalley T. Critical revision of the manuscript for important intellectual content: Giannelli S, Michel JP. Sponsor's Role: None.