Post-Traumatic Stress Disorder among Older Adults Experiencing Motor Vehicle Collision: A Multicenter Prospective Cohort Study.

OBJECTIVE: To characterize risk factors for and consequences of post-traumatic stress disorder (PTSD) among older adults evaluated in the emergency department (ED) following motor vehicle collision (MVC). DESIGN: Prospective multicenter longitudinal study (2011-2015). SETTING: 9 EDs across the United States. PARTICIPANTS: Adults aged 65 years and older who presented to an ED after MVC without severe injuries. MEASUREMENTS: PTSD symptoms were assessed 6 months after the ED visit using the Impact of Event Scale-Revised. RESULTS: Of 223 patients, clinically significant PTSD symptoms at 6 months were observed in 21% (95% CI 16%-26%). PTSD symptoms were more common in patients who did not have a college degree, had depressive symptoms prior to the MVC, perceived the MVC as life-threatening, had severe ED pain, and expected their physical or emotional recovery time to be greater than 30 days. Three factors (ED pain severity [0-10 scale], perceived life-threatening MVC [0-10 scale], and pre-MVC depressive symptoms [yes to either of two questions]), predicted 6-month PTSD symptoms with an area under the curve of 0.76. Compared to patients without PTSD symptoms, those with PTSD symptoms were at higher risk for persistent pain (72% versus 30%), functional decline (67% versus 42%), and new disability (49% versus 18%). CONCLUSIONS: Among older adults treated in the ED following MVC, clinically significant PTSD symptoms at 6 months were present in 21% of patients and were associated with adverse health outcomes. Increased risk for PTSD development can be identified with moderate accuracy using information readily available in the ED.

Restricted activity and persistent pain following motor vehicle collision among older adults: a multicenter prospective cohort study.

BACKGROUND: Restricted physical activity commonly occurs following acute musculoskeletal pain in older adults and may influence long-term outcomes. We sought to examine the relationship between restricted physical activity after motor vehicle collision (MVC) and the development of persistent pain. METHODS: We examined data from a prospective study of adults ≥65 years of age presenting to the emergency department (ED) after MVC without life-threatening injuries. Restricted physical activity 6 weeks after MVC was defined in three different ways: 1) by a ≥25 point decrease in Physical Activity Scale in the Elderly (PASE) score, 2) by the answer "yes" to the question, "during the past two weeks, have you stayed in bed for at least half a day?", and 3) by the answer "yes" to the question, "during the past two weeks, have you cut down on your usual activities as compared to before the accident?" We examined relationships between each definition of restricted activity and pain severity, pain interference, and functional capacity at 6 months with adjustment for confounders. RESULTS: Within the study sample (N = 164), adjusted average pain severity scores at 6 months did not differ between patients with and without restricted physical activity based on decreased PASE score (2.54 vs. 2.07, p = 0.32). In contrast, clinically and statistically important differences in adjusted average pain severity at 6 months were observed for patients who reported spending half a day in bed vs. those who did not (3.56 vs. 1.91, p < 0.01). In adjusted analyses, both decreased PASE score and cutting down on activity were associated with functional capacity at 6 months, but only decreased PASE score was associated with increased ADL difficulty at 6 months (0.70 vs. -0.01, p = 0.02). CONCLUSIONS: Among older adults experiencing MVC, those reporting bed rest or reduced activity 6 weeks after the collision reported higher pain and pain interference scores at 6 months. More research is needed to determine if interventions to promote activity can improve outcomes after MVC in older adults.

Geriatrics Scholarly Concentration Programs Among U.S. Medical Schools.

OBJECTIVES: To identify and describe geriatric scholarly concentration programs (GSCPs) among U.S. medical schools. DESIGN: Survey and interview. SETTING: Allopathic and osteopathic medical schools in the United States. PARTICIPANTS AND METHODS: We used a systematic internet search, forum postings, and word of mouth to identify all U.S. allopathic and osteopathic medical schools with existing GSCPs. GSCP directors completed an online survey. We conducted interviews with key faculty of two representative programs. MEASUREMENTS: GSCP size, goals, duration of activity, requirements, funding sources, and student outcomes. RESULTS: Nine GSCPs were identified, and eight responded to the survey. The number of current medical student participants ranged from 0 to 28, with a mean cohort size of 23. All programs included the following components: formal mentoring, clinical experiences in geriatric medicine beyond the standard medical school curriculum, and research. Half required students to complete an independent research project. GSCPs reported challenges, including low student interest, lack of availability of faculty mentors, and budget constraints; however, student satisfaction was high. Among three programs that reported on the residency matches of their graduates, half matched into a residency with a geriatric subspecialty training option. CONCLUSIONS: Among U.S. medical schools, there are few GSCPs. The GSCP model may help compensate for limited exposure to geriatric competencies in the standard medical school curriculum for a subset of interested students and may increase interest in geriatrics subspecialty training.

Ability of Older Adults to Report Elder Abuse: An Emergency Department-Based Cross-Sectional Study.

OBJECTIVES: To characterize assessments of a patient's ability to report elder abuse within the context of an emergency department (ED)-based screen for elder abuse. DESIGN: Cross-sectional study in which participants were screened for elder abuse and neglect. SETTING: Academic ED in the United States. PARTICIPANTS: Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses. MEASUREMENTS: All patients completed the four-item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient's ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients. RESULTS: Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient's ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient's ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5). CONCLUSIONS: In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment. J Am Geriatr Soc 68:170-175, 2019.

Patient health literacy and the receipt of opioids in the emergency department.

OBJECTIVE: Assess relationships between patient health literacy and formal education and use of opioids during and following an emergency department (ED) visit. DESIGN: Prospective, cross-sectional study. SETTING: Academic ED. PARTICIPANTS: Adults aged ≥ 60 years presenting to the ED with musculoskeletal pain. MAIN OUTCOME MEASURES: Opioid use during and after an ED visit. RESULTS: In a sample of 136 patients, patients with low health literacy were more likely to receive an opioid in the ED than patients with high health literacy (70 percent vs 52 percent; 18 percent difference, 95% confidence interval [CI]: -1 percent, 35 percent), receive an opioid prescription (63 percent vs 44 percent; 19 percent difference, 95% CI: 1 percent, 37 percent), and take opioids during the week following the ED visit (48 percent vs 29 percent; 18 percent difference, 95% CI: 0 percent, 36 percent). CONCLUSIONS: A greater proportion of older adults receiving ED care for musculoskeletal pain with low health literacy receive and use opioids during and following an ED visit.

Social Support and Pain Outcomes After Trauma Exposure Among Older Adults: A Multicenter Longitudinal Study.

OBJECTIVES: Certain forms of social support have been shown to improve pain-coping behaviors and pain outcomes in older adults with chronic pain, but little is known about the effect of social support on pain outcomes in older adults following trauma exposure. METHODS: We analyzed data from a prospective longitudinal study of adults aged 65 years and older presenting to an emergency department after a motor vehicle collision (MVC) to characterize the relationship between perceived social support and MVC-related pain after trauma overall and by subgroups based on sex, depressive symptoms, and marital status. RESULTS: In our sample (N=176), patients with low perceived social support had higher pain severity 6 weeks after MVC than patients with high perceived social support after adjustment for age, sex, race, and education (4.2 vs. 3.2, P=0.04). The protective effect of social support on pain severity at 6 weeks was more pronounced in men and in married individuals. Patients with low social support were less likely to receive an opioid prescription in the emergency department (15% vs. 32%, P=0.03), but there was no difference in opioid use at 6 weeks (22% vs. 20%, P=0.75). DISCUSSION: Among older adults experiencing trauma, low perceived social support was associated with higher levels of pain at 6 weeks.

Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study.

INTRODUCTION: Increasing advance care planning (ACP) among older adults is a national priority. Documentation of ACP in the electronic health record (EHR) is particularly important during emergency care. OBJECTIVE: We sought to characterize completion and availability of ACP among a subset of older patients at an academic emergency department (ED) with an integrated EHR. METHODS: In this cross-sectional study, patients were eligible if aged ≥80 years or aged 65-79 with ≥1 indicator of high risk for short-term mortality. Patient-reported completion of ACP and availability of ACP documentation in the EHR were assessed. RESULTS: Among study patients (n = 104), 59% reported completing some form of ACP: living will 52%, heathcare power of attorney 54%, do not resuscitate 38%, and medical orders for scope of treatment or physician orders for life-sustaining treatment 6%. Whites were more likely to report having some form of ACP than minorities (66% vs. 37%, p < 0.01), as were patients aged ≥80 years than those aged 65-79 (79% vs. 44%, p < 0.01). Only 13% of all patients had either a current code status or any other current ACP documentation in the EHR. Among patients whose primary care provider uses the same EHR system as the study ED, only 19% had a current code status or any other ACP documentation in the EHR. CONCLUSION: In a sample of older ED patients likely to benefit from ACP, few patients had documented end-of-life care preferences in the EHR.

Risk Factors for Malnutrition among Older Adults in the Emergency Department: A Multicenter Study.

BACKGROUND: Among older adults, malnutrition is common, often missed by healthcare providers, and influences recovery from illness or injury. OBJECTIVE: To identify modifiable risk factors associated with malnutrition in older patients. DESIGN: Prospective cross-sectional multicenter study. SETTING: 3 EDs in the South, Northeast, and Midwest. PARTICIPANTS: Non-critically ill, English-speaking adults aged ≥65 years. MEASUREMENTS: Random time block sampling was used to enroll patients. The ED interview assessed malnutrition using the Mini Nutritional Assessment Short-Form. Food insecurity and poor oral health were assessed using validated measures. Other risk factors examined included depressive symptoms, limited mobility, lack of transportation, loneliness, and medication side effects, qualified by whether the patient reported the risk factor affected their diet. The population attributable risk proportion (PARP) for malnutrition was estimated for each risk factor. RESULTS: In our sample (n = 252), the prevalence of malnutrition was 12%. Patient characteristics associated with malnutrition included not having a college degree, being admitted to the hospital, and residence in an assisted living facility. Of the risk factors examined, the PARPs for malnutrition were highest for poor oral health (54%; 95% CI 16%, 78%), food insecurity (14%; 95% CI 3%, 31%), and lack of transportation affecting diet (12%; 95% CI 3%, 28%). CONCLUSION: Results of this observational study identify multiple modifiable factors associated with the problem of malnutrition in older adults.

Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda.

Older emergency department patients have high rates of serious illness and injury, are at high risk for side effects and adverse events from treatments and diagnostic tests, and in many cases, have nuanced goals of care in which pursuing the most aggressive approach is not desired. Although some forms of shared decision making (SDM) are commonly practiced by emergency physicians caring for older adults, broader use of SDM in this setting is limited by a lack of knowledge of the types of patients and conditions for which SDM is most helpful and the approaches and tools that can best facilitate this process. We describe a research agenda to generate new knowledge to optimize the use of SDM during the emergency care of older adults.

Prevalence of nonmedical problems among older adults presenting to the emergency department.

OBJECTIVES: Health outcomes among older emergency department (ED) patients may be influenced by physical, economic, and psychological problems not routinely identified during the ED visit. The objective of this study was to characterize such problems among older adults presenting to the ED. METHODS: This was a prevalence study with enrollment during 4-hour periods randomly selected between 9 a.m. and 9 p.m. on random days of the week over a period of 8 weeks at an academic ED in the southeast United States. Participants were noninstitutionalized, cognitively intact adults aged 65 years or older without life-threatening illness or injury. Consenting patients were asked about the frequency of 10 prespecified problems during the past year. RESULTS: Patients (N = 138) were non-Hispanic white (69%) and female (57%) and almost all had primary providers (95%) and health insurance (98%). Forty percent reported their overall health as fair (21%) or poor (19%). Hazardous drinking habits were reported by 10% of patients. The prevalence of problems occurring either "sometimes" or "often" in the past year were pain (60%), difficulty walking (47%), lack of money (32%), isolation and loneliness (14%), lack of transportation (12%), difficulty scheduling a doctor's appointment (4%), difficulty getting prescriptions filled (4%), and lack of dental care (6%). Nine patients (7%) reported experiencing physical or psychological abuse at some point in the past year. Females, minorities, and individuals living in urban areas reported higher rates of most problems. CONCLUSIONS: Nonmedical problems are common among cognitively intact, independent living, non-critically ill older patients presenting to an ED in the southeast United States.

Primary care availability and emergency department use by older adults: a population-based analysis.

OBJECTIVES: To assess the relationship between the number of primary care providers (PCPs) in an area and emergency department (ED) visits by older adults. DESIGN: Population-based cross-sectional observational study. SETTING: Nonfederal EDs in North Carolina in 2010. PARTICIPANTS: All older adults (n = 640,086) presenting to a nonfederal ED in North Carolina in 2010. MEASUREMENTS: The primary outcome was the number of ED visits by older adults in each ZIP code per 100 adults aged 65 and older living in that ZIP code. A secondary outcome was the number of ED visits not resulting in hospital admission per 100 older adults. The primary predictor variable was the number of PCPs per 100 older residents for each ZIP code. Covariates included those representing healthcare need (Medicare hospitalizations, nursing home beds), predisposing factors for healthcare use (race, education, population density of older adults), and enabling factors (distance to the nearest ED). RESULTS: In a multivariable regression model corrected for spatial clustering, ZIP code characteristics associated with ED visits included more hospitalizations by Medicare beneficiaries, more nursing home beds, and closer proximity to an ED. Number of PCPs per 100 older adult residents in each ZIP code was not associated with ED use, and the 95% confidence limit indicates at most a small effect of PCP availability on ED use. CONCLUSION: These findings suggest that primary care availability has at most a limited effect on ED use by older adults in North Carolina.