Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes.

OBJECTIVE: Older adults at the Emergency Department (ED) often present with nonspecific complaints (NSC) such as 'weakness' or 'feeling unwell'. Health care workers may underestimate illness in patients with NSC, leading to adverse health outcomes. This study compares characteristics and outcomes of NSC-patients versus specific complaints (SC) patients. METHODS: Cohort study in patients ≥ 70 years in two Dutch EDs. NSC was classified according to the BANC-study-framework based on the medical history in the ED letter, before additional diagnostics took place. A second classification was performed at the end of the ED visit/hospital admission. Primary outcomes were functional decline, institutionalization, and mortality at 30 days. RESULTS: 26% (n = 228) of a total of 888 included patients presented with NSC. Compared with SC-patients, NSC-patients were older, more frail, and more frequently female. NSC-patients had a higher risk of functional decline and institutionalization at 30 days (adjusted ORs 1.84, 95% CI 1.27 - 2.72, and 2.46, 95% CI 1.51-4.00, respectively), but not mortality (adjusted OR 1.26, 95% CI 0.58 - 2.73). Reclassification to a specific complaint after the ED visit or hospital admission occurred in 54% of NSC-patients. CONCLUSION: NSC occur especially in older, frail female patients and are associated with an increased risk of functional decline and institutionalization, even after adjustment for worse baseline status. In half of the patients, a specific complaint revealed during ED or hospital stay. Physicians at the ED should consider NSC as a red flag needing appropriate observation and evaluation of underlying serious conditions and needs of this vulnerable patient group.

Trends in data quality and quality indicators 5 years after implementation of the Dutch Hip Fracture Audit.

PURPOSE: The Dutch Hip Fracture Audit (DHFA), a nationwide hip fracture registry in the Netherlands, registers hip fracture patients and aims to improve quality of care since 2016. This study shows trends in the data quality during the first 5 years of data acquisition within the DHFA, as well as trends over time for designated quality indicators (QI). METHODS: All patients registered in the DHFA between 1-1-2016 and 31-12-2020 were included. Data quality-registry case coverage and data completeness-and baseline characteristics are reported. Five QI are analysed: Time to surgery < 48 h, assessment for osteoporosis, orthogeriatric co-management, registration of functional outcomes at three months, 30-day mortality. The independent association between QI results and report year was tested using mixed-effects logistic models and in the case of 30-day mortality adjusted for casemix. RESULTS: In 2020, the case capture of the DHFA comprised 85% of the Dutch hip fracture patients, 66/68 hospitals participated. The average of missing clinical values was 7.5% in 2016 and 3.2% in 2020. The 3 months follow-up completeness was 36.2% (2016) and 46.8% (2020). The QI 'time to surgery' was consistently high, assessment for osteoporosis remained low, orthogeriatric co-management scores increased without significance, registration of functional outcomes improved significantly and 30-day mortality rates remained unchanged. CONCLUSION: The DHFA has successfully been implemented in the past five years. Trends show improvement on data quality. Analysis of several QI indicate points of attention. Future perspectives include lowering the burden of registration, whilst improving (registration of) hip fracture patients outcomes.

Screening instruments for identification of vulnerable older adults at the emergency department: a critical appraisal.

BACKGROUND: Early detection of vulnerable older adults at the emergency department (ED) and implementation of targeted interventions to prevent functional decline may lead to better patient outcomes. OBJECTIVE: To assess the level of agreement between four frequently used screening instruments: ISAR-HP, VMS, InterRAI ED Screener and APOP. METHODS: Observational prospective cohort study in patients ≥ 70 years attending Dutch ED. RESULTS: The prevalence of vulnerability ranged from 19% (APOP) to 45% (ISAR-HP). Overall there was a moderate agreement between the screening instruments (Fleiss Kappa of 0.42 (p<0.001)). CONCLUSION: Depending on the screening instrument used, either only a small percentage or almost as many as half of the presenting patients will be eligible for targeted interventions, leading to large dissimilarities in working processes, resources and costs.

Is being malnourished according to the ESPEN definition for malnutrition associated with clinically relevant outcome measures in geriatric outpatients?

BACKGROUND AND AIM: A body of evidence is supporting the association between (the risk of) malnutrition in relation to physical performance, muscle strength, risk for depression and cognitive status in geriatric outpatients. Associations between being malnourished according to the newly proposed ESPEN definition for malnutrition and clinically relevant outcome measures of the aforementioned variables have not been confirmed yet. Therefore, the aim of this study was to examine the association between being malnourished according to the ESPEN definition and clinically relevant outcome measures in geriatric outpatients. METHODS: Associations between malnutrition and handgrip strength (HGS, kg), short physical performance battery (SPPB-score, points), timed up and go test (TUG, seconds), and hospital anxiety and depression scale (HADS depression score, points), were analysed using linear regression. History of falls (falls, yes/no) and a low score on the Mini Mental-State Examination (MMSE-score ≤ 24 points) were analysed using logistic regression. All analyses were adjusted for age and gender. RESULTS: A total of 185 geriatric outpatients (60% women) were included. The mean age was 82 (± 7.3) years. Being malnourished (8.2%) according to the ESPEN definition was significantly associated with a lower HGS (- 3.38 kg, p = 0.031), lower SPPB score (- 1.8 point, p = 0.025), higher TUG time (1.35 times higher time, p = 0.020) and higher HADS depression score (2.03 times higher score, p = 0.007). Being malnourished tended towards an association with falls (OR 3.84, p = 0.087). No significant association was found with low MMSE score (OR 2.61, p = 0.110). CONCLUSION: This study is the first to confirm the association between being malnourished, defined by the ESPEN definition and clinically relevant outcome measures in geriatric outpatients.

The prevalence of malnutrition according to the new ESPEN definition in four diverse populations.

BACKGROUND & AIMS: Consensus on the definition of malnutrition has not yet been reached. Recently, The European Society for Clinical Nutrition and Metabolism (ESPEN) proposed a consensus definition of malnutrition. The aim of the present study was to describe the prevalence of malnutrition according to the ESPEN definition in four diverse populations. METHODS: In total, 349 acutely ill middle-aged patients, 135 geriatric outpatients, 306 healthy old individuals and 179 healthy young individuals were included in the study. Subjects were screened for risk of malnutrition using the SNAQ. The ESPEN definition of malnutrition, i.e. low BMI (< 18.5 kg/m(2)) or a combination of unintentional weight loss and low FFMI or low BMI was applied to all subjects. RESULTS: Screening identified 0, 0.5, 10 and 30% of the healthy young, the healthy old, the geriatric outpatients and the acutely ill middle-aged patients as being at risk of malnutrition. The prevalence of malnutrition ranged from 0% in the healthy young, 0.5% in healthy old individuals, 6% in the geriatric outpatients to 14% in the acutely ill middle-aged patients. Prevalence of low FFMI was observed in all four populations (14-33%), but concurred less frequently with weight loss (0-13%). CONCLUSIONS: Using the ESPEN definition, 0%-14% malnutrition was found in the diverse populations. Further work is needed to fully address the validity of a two-step approach, including risk assessment as an initial step in screening and defining malnutrition. Furthermore, assessing the predictive validity of the ESPEN definition is needed.

Serum albumin and muscle measures in a cohort of healthy young and old participants.

Consensus on clinically valid diagnostic criteria for sarcopenia requires a systematical assessment of the association of its candidate measures of muscle mass, muscle strength, and physical performance on one side and muscle-related clinical parameters on the other side. In this study, we systematically assessed associations between serum albumin as a muscle-related parameter and muscle measures in 172 healthy young (aged 18-30 years) and 271 old participants (aged 69-81 year) from the European MYOAGE study. Muscle measures included relative muscle mass, i.e., total- and appendicular lean mass (ALM) percentage, absolute muscle mass, i.e., ALM/height(2) and total lean mass in kilograms, handgrip strength, and walking speed. Muscle measures were standardized and analyzed in multivariate linear regression models, stratified by age. Adjustment models included age, body composition, C-reactive protein and lifestyle factors. In young participants, serum albumin was positively associated with lean mass percentage (p = 0.007) and with ALM percentage (p = 0.001). In old participants, serum albumin was not associated with any of the muscle measures. In conclusion, the association between serum albumin and muscle measures was only found in healthy young participants and the strongest for measures of relative muscle mass.