Deteriorating Functional Status in Older Adults After Emergency Department Evaluation of Minor Trauma—Opportunities and Pragmatic Challenges

The number of geriatric adults receiving emergency department (ED) care increased by 24.5% between 2001 and 2009, and readmissions after ED discharge increased from 2 to 4%.1 The number of tests and ED length of stay also increased during this period. These trends will continue for decades as baby boomers continue to age.2 Recently, the American Geriatrics Society and the Hartford Foundation prioritized the assessment of feasible functional assessment instruments in ED settings as one high-yield research objective.3 In this issue, Sirois and colleagues4 provide compelling evidence to support this focus on older adults during the ED assessment of seemingly minor trauma, but implementing this paradigm shift is the challenge.5, 6 Sirois and colleagues evaluated consecutively enrolled, previously functionally independent adults aged 65 and older who received ED care after trauma-related sprains, fractures, lacerations, or contusions that did not merit admission for longer than 48 hours. In-home follow-up occurred 3 and 6 months after injury to assess functional decline using a measure previously validated in ED settings.7 The investigators' definition of functional decline (loss of at least 2/28 points on the Older American Adult Resources and Service scale) is reasonable for this previously independent, community-residing population. Sirois and colleagues found functional decline in 14.9% at 3 months and 17% at 6 months. Wilber and colleagues noted higher rates of functional decline 4 weeks after blunt injuries (35%) and Shapiro and colleagues at 3 months (22% had a decrease in ability to perform instrumental activities of daily living (IADLs)).8, 9 Sirois and colleagues demonstrate that emergency physician gestalt is an independent predictor of functional decline, along with use of a walking aid, more than five concurrent comorbidities, and preinjury dependence in IADLs. Most of the initial injuries were falls (64%), but none of the fall-related mobility assessment tests were independent predictors of functional decline, which is consistent with prior ED-based falls research that suggests that these tests do not predict future falls in this population.10 Sirois and colleagues outline three important points for the multidisciplinary management of older adults during and after ED evaluations for minor trauma. First, ED physician gestalt predicts short-term functional decline. Although geriatric management strategies will need to be disseminated during emergency medicine training and continuing medical education while acute care providers are updated regarding the evolving scientific landscape, current ED physicians should not disregard their intuition when assessing the optimal disposition of these individuals.11 A second point from this research is that more-accurate risk stratification instruments need to be developed. Sirois and colleagues found that the Identification of Seniors at Risk (ISAR) instrument12 identified 39.7–77.9% of individuals as being at "high risk" depending upon the threshold used. In an era of scant resources, increasing ED patient volumes, and often unavailable ancillary providers such as case managers, a prognostic instrument that is better calibrated to the subset of individuals most likely to deteriorate (e.g., the 14.9% with 3-month functional decline) needs to be developed. The contemporary ED lacks the resources to manage 77% of the geriatric population that has been determined to be at "high risk," but multiple studies demonstrate that the ISAR and other prognostic instruments are not sufficiently accurate to distinguish this high-risk subset from the overall geriatric ED population.13-16 The ideal instrument would be accurate across a range of populations, including various strata of health literacy and illness acuity. In addition, the ideal prognostic screening instrument would be reliable and sufficiently brief without requiring personnel or equipment that is not universally available in the modern ED. Once sufficiently accurate prognostic instruments exist, efficient dissemination will be an exercise in disruptive innovation, including the use of electronic medical records and tablet computers so that busy clinicians can reliably translate prognostic data into action for these susceptible patients.17 The third issue derived from this research is the big picture of geriatric emergency care, because these individuals are often not sick or injured enough to be admitted, but there is a subset at risk of significant functional decline over the following few months. How will the future ED intervene to reduce functional decline and presumably the avoidable ED recidivism that is a direct consequence? One approach is the concept of the "geriatric ED." The current debate revolves around a "geriatric-friendly ED" with minimal quality indicators attainable in most acute care settings versus a geriatric-specific ED that includes alterations to infrastructure, personnel, and institutional support.5, 6, 18 To more fully assess functional status in the ED, others advocate for ED-based geriatric observation units to provide sufficient time to monitor and reassess these sometimes complex patients, time that is often missing from otherwise hectic, easily disrupted emergency care.19 Another approach focuses on nursing care. For example, in Ontario, Canada, every ED has at least one full-time geriatric nurse to facilitate geriatric syndrome screening and transitions of care between the ED and outpatient settings.20 Management of acute illness in potentially frail older adults requires multidisciplinary care, so some healthcare models are exploring unique ED interventions. For example, a mobile acute care for the elderly (ACE) unit would provide comprehensive geriatric assessment capabilities using geriatricians in the ED available as consultants for the subset of individuals who might otherwise fall between the cracks of inpatient and outpatient care.6, 21 The mobile ACE unit could be called to the ED before discharge for these individuals to provide adequate home-based follow-up or even hospital admission if unrecognized aging-related problems become apparent during their ED evaluation. Another alternative multidisciplinary approach is the concept of Hospital at Home, in which individuals receive traditional inpatient-level care, including nursing and physician coverage, at home. Although awaiting replication, early research in select older adults suggests that individuals and caregivers prefer the Hospital at Home model, which can be delivered at a lower cost with fewer iatrogenic events and otherwise equal outcomes.22, 23 Sirois and colleagues provide a rationale to identify older adults who are likely to lose functional independence after minor injuries. If these individuals are neglected, the consequences will be higher ED revisit rates with likely admissions for rehabilitation and possibly institutionalization.24 The pragmatic barriers to alter these individuals' postinjury trajectories are challenging and pertinent, but they can be overcome with cross-disciplinary expertise, commitment, and ingenuity. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Sole author. Invited editorial. Sponsor's Role: None.

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