Background Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. Objectives This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor’s accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. Methods A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. Results A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the...
Background / Objective Limited mobility in the community, measured by life-space, is associated with long-term mortality; but little is known about changes in life-space over time predicting short-term mortality. We examined 6-month change in life-space mobility as a predictor of subsequent 6-month mortality for community-dwelling older adults. Design Prospective cohort study. Setting Community-dwelling older adults from five Alabama counties in the University of Alabama at Birmingham (UAB) Study of Aging. Participants A random sample of 1000 Medicare beneficiaries, stratified by gender, race, and rural/urban residence, recruited between November 1999 and February 2001, followed by telephone interview every 6 months for the subsequent 8.5 years. Interventions None. Measures Mortality data was determined from informant contacts and confirmed by the National Death Index and Social Security Death Index. Life-space was measured at each interview using the UAB Life-Space Assessment, a validated instrument for assessing community mobility. A total of 11,817 6-month life-space change scores were calculated over 8.5 years of follow-up. Generalized linear mixed models were used to test predictors of mortality in subsequent 6-month intervals. Results There were 354 deaths that occurred within 6 months of two sequential life-space assessments. Controlling for age, gender, race, rural/urban residence, and comorbidity, life-space score and life-space decline over the preceding 6-month interval predicted mortality. A 10-point decrease in life-space resulted in a 72% increase in odds of dying over the subsequent 6 months (OR = 1.723, p < 0.001). Conclusions Both life-space score at the beginning of a 6-month interval and life-space decline over 6 months were associated with significant increases in subsequent 6-month mortality. Life-space assessment may assist clinicians to identify older adults at risk for short-term mortality.
OBJECTIVES To determine the impact of falls and fractures on life-space mobility in a cohort of community-dwelling older adults. DESIGN Prospective, observational study with a baseline in-home assessment and 6-month telephone follow-up interviews over 4 years. SETTING Central Alabama, U.S.A. PARTICIPANTS Nine hundred seventy community-dwelling adults age ≥ 65 years, recruited from a random sample of Medicare beneficiaries were stratified by sex, race, and urban/rural residence. MEASUREMENTS Sociodemographic factors, medical history, depressive symptoms (using the Geriatric Depression Scale), cognitive function (using the Mini-Mental State Examination), mobility-related symptoms, transportation difficulty, and healthcare utilization were assessed during a baseline in-home interview of participants. Life-space mobility, as well as any falls or injuries (including fractures) were assessed both at the baseline interview and at six-month intervals by follow-up telephone calls. RESULTS Four hundred and fifty-four (47%) participants reported at least one fall during the 4-year follow-up. The life-space score decreased 3.2 points from the beginning to the end of the six-month interval during which a fall occurred, adjusting for other known predictors of decline in life-space mobility. The decrease in interval life-space score was progressively greater for a fall and an injury (−4.7 points), a fall and a fracture (−14.2 points), and was highest for a fall and a hip fracture (−23.6 points). CONCLUSION Falls, whether associated with an injury or not, were independently associated with a decrease in life-space mobility in the ensuing six months. Further studies are needed to determine reasons for life-space mobility decline among community-dwelling older adults with incident falls without any injuries.
Mobility and function are important predictors of survival. However, their combined impact on mortality in adults ≥65 years of age with heart failure (HF) is not well understood. This study examined the role of gait speed and instrumental activities of daily living (IADL) in all-cause mortality in a cohort of 1,119 community-dwelling Cardiovascular Health Study participants ≥65 years of age with incident HF. Data on HF and mortality were collected through annual examinations or contact during the 10-year follow-up period. Slower gait speed (<0.8m/s vs. ≥0.8m/s) and IADL impairment (≥1 vs. 0 areas of dependence) were determined from baseline and follow-up assessments. A total of 740 (66%) of the 1119 participants died during the follow-up period. Multivariate Cox proportional hazards models showed that impairments in either gait speed (hazard ratio 1.37, 95% CI 1.10-1.70; p=0.004) or IADL (HR 1.56, 95% CI 1.29-1.89; p<0.001), measured within 1 year before the diagnosis of incident HF, were independently associated with mortality, adjusting for socio-demographic and clinical characteristics. The combined presence of slower gait speed and IADL impairment was associated with a greater risk of mortality and suggested an additive relationship between gait speed and IADL. In conclusion, gait speed and IADL are important risk factors for mortality in adults ≥65 years of age with HF, but the combined impairments of both gait speed and IADL can have an especially important impact on mortality.
In 2018, the American College of Emergency Physicians began accrediting facilities as "Geriatric Emergency Departments" (GEDs) based on adherence to the multi-organizational guidelines published in 2014. The guidelines were developed in order to help every emergency department (ED) improve its care of older adults. The GED guideline recommendations span the care continuum from pre-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric-friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-
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