Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults.

BACKGROUND: Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury. OBJECTIVE: This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall-related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages. METHODS: We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall-related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1-3), vulnerable-frail (CFS score 4-6), and severely frail (CFS score 7-9). RESULTS: A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4-16.8]; p = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44-3.45; p = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41-13.6; p = 0.34) in those considered severely frail. CONCLUSIONS: This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.

Emergency physician gender and head computed tomography orders for older adults who have fallen.

OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments.

OBJECTIVE: Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions. METHODS: The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR). RESULTS: Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic. CONCLUSION: Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Challenges and facilitators in the experience of caregiving for an older adult with traumatic brain injury: A longitudinal qualitative study in the first-year postinjury.

PURPOSE: To obtain a better understanding of the factors which complicate or facilitate the adjustment of caregivers after traumatic brain injury (TBI) in older adults. RESEARCH METHOD: At 4, 8, and 12 months post-TBI (mild to severe), 65 caregivers answered two open-ended questions regarding facilitators and challenges linked to the injury of their loved one. A thematic analysis was performed. RESULTS: Participants mentioned almost as many facilitators as challenges at each time point. Among the facilitators, we found the following themes: receiving social support, having access to rehabilitation, improvement of the injured loved one's health condition, returning to live at home, having access to home services, feeling useful, effective communication, and having time for oneself. The challenges identified were: health issues in the injured loved one, psychological impact on the caregiver, assuming a new role, relationship strain, and decrease in activities and outings. CONCLUSIONS: During the first year following TBI in older adults, caregivers were able to identify several facilitators despite the presence of challenging factors, suggesting effective coping and resilience. This knowledge can guide potential caregivers in their adaptation after TBI in an older adult, and we propose a simple tool to support this process. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Predictors of adverse outcomes in elders hospitalised for isolated orthopaedic trauma: a multicentre cohort study.

BACKGROUND: Patients >64 years of age now represent more than 51% of injury hospitalisations in Canada. The tools used to identify older patients who could benefit the most from an interdisciplinary approach include complex parameters difficult to collect in the ED, which suggests that better tools with higher accuracy and using items that can be derived from routinely collected data are needed. We aimed to identify variables that are associated with adverse outcomes in older patients admitted to a trauma centre for an isolated orthopaedic injury. METHODS: We conducted a multicentre retrospective cohort study between 1 April 2013 and 31 March 2019 on older patients hospitalised with a primary diagnosis of isolated orthopaedic injury (n=19 928). Data were extracted from the provincial trauma registry (Registre des traumatismes du Québec). We used multilevel logistic regression to estimate the associations between potential predictors and adverse outcomes (extended length of stay, mortality, complications, unplanned readmission and adverse discharge destination). RESULTS: Increasing age, male sex, specific comorbidities, type of orthopaedic injuries, increasing number of comorbidities, severe orthopaedic injury, head injuries and admission in the year before the injury were all significant predictors of adverse outcomes. CONCLUSION: We identified eight predictors of adverse outcomes in patients >64 years of age admitted to a trauma centre for orthopaedic injury. These variables could eventually be used to develop a clinical decision rule to identify elders who may benefit the most from interdisciplinary care.

Level of implementation of pain management and early mobilization strategies to prevent delirium in geriatric trauma patients: A mixed-methods study.

BACKGROUND: Pain management and early mobilization strategies are recommended in clinical practice guidelines for the prevention of delirium in older adults. However, available data on the implementation of these strategies in trauma are limited. AIMS: To describe the use of pain management and early mobilization strategies in older adults at a level I trauma center, as well as the facilitators and barriers to their implementation. METHODS: A convergent mixed methods study was used. Quantitative data were collected from sixty medical records. Qualitative data was collected through a focus group with healthcare providers to explore their perspectives regarding the use of the target practices and on barriers and facilitators to their implementation. Descriptive statistics were calculated, and a thematic analysis using an inductive and deductive interpretative descriptive approach was undertaken. RESULTS: A question on the presence/absence of pain was the most frequently documented pain assessment method. Pain assessment was poorly documented. Frequencies of non-opioid and opioid administrations were similar, but non-pharmacological strategies were not widely used. The first mobilization was performed quickly and was most commonly to a chair. The focus group discussion confirmed many of the data collected in the medical records. Barriers to implementing the targeted strategies were primarily related to organizational context and facilitation processes. CONCLUSIONS: Areas for improvement were identified including pain assessment, the use of non-pharmacological pain management strategies and ambulation as a mobilization strategy. Our findings will serve as a starting point for optimizing and adapting practices for geriatric trauma patients and evaluating their impact.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury.

Approximately 15 % of individuals who sustained a mild Traumatic Brain Injury (TBI) develop persistent post-concussion symptoms (PPCS). We hypothesized that blood biomarkers drawn in the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and PPCS at 90 days post mild TBI. We conducted a prospective cohort study in seven Canadian EDs. Patients aged ≥ 14 years presenting to the ED within 24 h of a mild TBI who were discharged were eligible. Clinical data and blood samples were collected in the ED, and a standardized questionnaire was administered 90 days later to assess the presence of symptoms. The following biomarkers were analyzed: S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial Fibrillary Acidic Protein (GFAP). The primary outcome measure was the presence of PPCS at 90 days after trauma. Relative risks and Areas Under the Curve (AUC) were computed. A total of 595 patients were included, and 13.8 % suffered from PPCS at 90 days. The relative risk of PPCS was 0.9 (95 % CI: 0.5-1.8) for S100B ≥ 20 pg/mL, 1.0 (95 % CI: 0.6-1.5) for NSE ≥ 200 pg/mL, 3.4 (95 % CI: 0.5-23.4) for GFAP ≥ 100 pg/mL, and 1.0 (95 % CI: 0.6-1.8) for C-Tau ≥ 1500 pg/mL. AUC were 0.50, 0.50, 0.51 and 0.54, respectively. Among mild TBI patients, S100B protein, NSE, c-Tau or GFAP do not seem to predict PPCS. Future research testing of other biomarkers is needed to determine their usefulness in predicting PPCS.

Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study.

INTRODUCTION: Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs. METHODS: This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65 years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse. RESULTS: A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]). CONCLUSION: When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.

RéSUMé: INTRODUCTION: La maltraitance des personnes âgées est associée à une détérioration de la santé physique et psychologique. Elle est cependant rarement identifiée dans les services d'urgence. L'objectif était de déterminer la prévalence et les prédicteurs de l'abus envers les aînés chez les personnes âgées qui consultent dans un service d'urgence. MéTHODES: Cette étude de cohorte prospective a été menée dans huit services d'urgence canadiens entre mai et août 2021. Les patients étaient éligibles s'ils étaient âgés de ≥ 65 ans, s'ils étaient orientés vers le temps et s'ils avaient un score de 3, 4 ou 5 sur l'échelle canadienne de triage et d'acuité. Dans un cadre privé, les participants ont été interrogés directement sur la maltraitance dans le cadre d'un questionnaire plus large explorant 10 problèmes non médicaux. Nous avons utilisé une régression logistique multivariable pour identifier les facteurs prédictifs de la maltraitance envers les personnes âgées. RéSULTATS: Au total, 1 061 participants ont été recrutés (âge moyen : 77,1 (SD 7,6) ans, sexe féminin : 55,7 %, vivant seul : 42,5 %). Les patients se sont surtout rendus aux urgences pour des douleurs (19,6 %), des symptômes neurologiques (11,3 %) ou cardiovasculaires (8,4 %). Les comorbidités préexistantes les plus fréquentes étaient l'hypertension (67,2 %), les problèmes de santé mentale (33,3 %) et l'insuffisance cardiaque (29,6 %). Les problèmes de mobilité à l'extérieur (41,0 %) ou à l'intérieur du domicile (30,7 %) et la solitude (29,4 %) sont également fréquents. Cinquante-quatre (5,1 %) participants ont signalé des cas de maltraitance des personnes âgées, dont 34,3 % connaissaient les ressources communautaires disponibles. Les facteurs prédictifs identifiés de maltraitance envers les personnes âgées étaient le sexe féminin (RC 2,8 [IC 95 % 1,4 ; 5,6]), les difficultés financières (RC 3,6 [IC 95 % 1,8 ; 7,3]), l'insécurité alimentaire (RC 2,7 [IC 95 % 1,2 ; 5,6]), besoin d'un aidant (RC 2,7 [IC 95 % 1,5 ; 5,0]) et au moins un problème de santé mentale préexistant (RC 2,6 [IC 95 % 1,4 ; 4,9]). CONCLUSION: Interrogées directement, 5,1 % des personnes âgées fréquentant les urgences ont déclaré avoir été victimes de maltraitance. Le sexe féminin, les déficits fonctionnels, la vulnérabilité sociale et les problématiques de santé mentale sont associés à la maltraitance des personnes âgées. Compte tenu de son importance et de sa prévalence relativement élevée, les professionnels des urgences ne devraient pas hésiter à poser directement des questions sur la maltraitance aux personnes âgées.

Evaluation of physicians' current practices and awareness regarding the treatment of acute uncomplicated diverticulitis: results of a provincial survey.

OBJECTIVE: International guidelines now recommend nonantibiotic treatment of uncomplicated diverticulitis. We assessed physicians' current management strategies for uncomplicated diverticulitis, their awareness of the updated recommendations, and barriers to practice change. METHODS: A 21-question web-based survey conducted between 09/2022 and 11/2022 was sent to participants through their respective Quebec provincial associations or working groups. Participants included general surgeons, emergency physicians, gastroenterologists and general practitioners. Physicians who did not treat diverticulitis were excluded. The main outcomes were awareness of guideline recommendations on uncomplicated diverticulitis treatment, the use of nonantibiotic management for uncomplicated diverticulitis and identification of perceived barriers to practice change. RESULTS: The participation rate was 15.9%. The 465 participants consisted primarily of general practitioners (41.7%), general surgeons (29.2%) and emergency physicians (17.8%). Eighty-two percent had heard of the nonantibiotic treatment strategy for uncomplicated diverticulitis; 7.5% were "uncomfortable" and 44.6% "somewhat uncomfortable" with this practice. A third (31.8%) of all physicians had no knowledge of the updated guidelines on uncomplicated diverticulitis treatment. Most reported "never" (41.6%) or "rarely" (25.1%) omitting antibiotics for uncomplicated diverticulitis. When informed about nonantibiotic treatment, 28.7% and 51.4% of all physicians, respectively, indicated that this "will" change or "may" change their practice. Common perceived barriers to nonantibiotic treatment were concerns about treatment failure (69.6%), unawareness of updated recommendations (67.0%), difficulty in ensuring proper follow-up (59.0%) and workplace culture (54.9%). CONCLUSION: Physicians' awareness of practice guidelines recommending nonantibiotic treatment for uncomplicated diverticulitis and their application are suboptimal. Knowledge transfer activities, educational interventions and optimization of local protocols are needed to ensure the rational use of antibiotics.

RéSUMé: OBJECTIF: Les lignes directrices internationales recommandent désormais un traitement non antibiotique de la diverticulite non compliquée. Nous avons évalué les stratégies de traitement actuelles des médecins pour la diverticulite non compliquée, leur connaissance des recommandations mises à jour et les obstacles au changement de pratique. MéTHODES: Un sondage en ligne de 21 questions mené entre le 09/2022 et le 11/2022 a été envoyé aux participants par l'intermédiaire de leurs associations ou groupes de travail provinciaux respectifs au Québec. Les participants comprenaient des chirurgiens généraux, des urgentologues, des gastroentérologues et des médecins de famille. Les médecins qui ne traitaient pas de diverticulite ont été exclus. Les principales issues étaient la connaissance des recommandations des lignes directrices sur le traitement de la diverticulite non compliquée, l'utilisation du traitement non antibiotique pour la diverticulite non compliquée et l'identification des obstacles perçus au changement de pratique. RéSULTATS: Le taux de participation était de 15,9 %. Les 465 participants étaient principalement des médecins de famille (41,7 %), des chirurgiens généraux (29,2 %) et des urgentologues (17,8 %). Quatre-vingt-deux pour cent avaient entendu parler de la stratégie de traitement non antibiotique pour la diverticulite non compliquée; 7,5% étaient "inconfortables" et 44,6% "quelque peu inconfortables" avec cette pratique. Un tiers (31,8 %) des médecins ne connaissaient pas les lignes directrices mises à jour sur le traitement de la diverticulite non compliquée. La plupart ont rapporté "jamais" (41,6%) ou "rarement" (25,1%) omettre les antibiotiques pour la diverticulite non compliquée. Lorsqu'ils ont été informés du traitement non antibiotique, 28,7 % et 51,4 % de tous les médecins ont indiqué que cela «changera¼ ou «pourrait changer¼ leur pratique. Les fréquents obstacles au traitement non antibiotique étaient les préoccupations concernant l'échec du traitement (69,6 %), l'ignorance des recommandations mises à jour (67,0 %), la difficulté d'assurer un suivi approprié (59,0 %) et la culture en milieu de travail (54,9 %). CONCLUSIONS: La connaissance des lignes directrices recommandant un traitement non antibiotique pour la diverticulite non compliquée et leur application sont sous-optimales. Des activités de transfert de connaissances, des interventions éducatives et des protocoles locaux sont nécessaires pour assurer l'utilisation rationnelle des antibiotiques.

Predictors of mortality among older major trauma patients.

BACKGROUND: Older trauma patients have a higher mortality yet are more likely to be under-triaged compared to younger patients. Studies have suggested that current trauma team activation criteria are suboptimal for older patients. OBJECTIVES: The objective was to describe trauma care delivered, patient outcomes, and to identify variables independently associated with mortality. METHODS: We performed a health records review from 2014 to 2020 of older (age ≥ 65 years) trauma patients presenting to a level one trauma centre with any of the following: injury severity score (ISS) > 12, and all trauma team activations or admission to the trauma ward. The primary outcome was 30-day all-cause mortality. Secondary outcomes included injury mechanism and trauma care delivered. Multivariable logistic regression was used to identify factors independently associated with 30-day all-cause mortality. Multiple imputation was used to deal with missing data. RESULTS: We enrolled 1,380 patients (mean age 80 years, mean ISS 18); 26.8% had multimorbidity (≥ 2 chronic conditions) and 65.9% met criteria for polypharmacy (≥ 5 medications). The most common mechanism was fall from standing height (61.1%). Thirty-day all-cause mortality occurred in 239 (17.3%) patients. A Glasgow coma scale (GCS) < 15 (odds ratio [OR] = 5.55; 95% CI 3.73-8.24), ISS > 15 (OR = 3.75, 95% CI 2.35-6.01), age ≥ 85 years (OR = 2.04, 95% CI 1.29-3.22), anticoagulation with a direct oral anticoagulant (DOAC) or warfarin (OR = 1.59, 95% CI 1.08-2.35) and multimorbidity (OR = 1.53, 95% CI 1.06-2.22) were significantly associated with increased risk 30-day mortality (C-statistic = 0.82, 95% CI 0.79-0.85). Dementia (OR = 0.61, 95% CI 0.40-0.95) and time to CT scan > 60 min (OR = 0.50, 95% CI 0.34-0.74) were associated with decreased mortality risk. CONCLUSION: We identified five factors associated with increased 30-day mortality in older trauma patients: GCS < 15, ISS > 15, age ≥ 85 years, anticoagulation, and multimorbidity. These factors should be considered when developing modified trauma team activation criteria for older adults.

ABSTRAIT: CONTEXTE: Les patients traumatisés âgés ont une mortalité plus élevée, mais sont plus susceptibles d'être sous-triés que les patients plus jeunes. Des études ont suggéré que les critères actuels d'activation des équipes de traumatologie sont sous-optimaux pour les patients âgés. OBJECTIFS: L'objectif était de décrire les soins traumatologiques dispensés, les résultats pour les patients et d'identifier les variables associées indépendamment à la mortalité. MéTHODES: De 2014 à 2020, nous avons effectué un examen des dossiers médicaux de patients de plus de 65 ans qui ont subi un traumatisme et qui se sont présentés à un centre de traumatologie de niveau 1 avec l'un ou l'autre des éléments suivants: le score de gravité de la blessure (SSI) > 12, et toutes les activations de l'équipe de traumatologie ou l'admission au service de traumatologie. Le critère de jugement principal était la mortalité toutes causes confondues de 30 jours. Les critères de jugement secondaires comprenaient le mécanisme de blessure et les soins prodigués en cas de traumatisme. La régression logistique multivariée a été utilisée pour identifier les facteurs indépendamment associés à la mortalité toutes causes confondues sur 30 jours. L'imputation multiple a été utilisée pour traiter les données manquantes. RéSULTATS: Nous avons recruté 1380 patients (âge moyen 80 ans, SSI moyenne 18); 26.8% avaient une multimorbidité (2 maladies chroniques) et 65.9% répondaient aux critères de polypharmacie (5 médicaments). Le mécanisme le plus courant était la chute de la hauteur debout (61.1%). Une mortalité toutes causes confondues sur 30 jours est survenue chez 239 (17.3%) patients. Une échelle de coma de Glasgow (GCS) < 15 (rapport de cotes [OR] = 5.55; 95% CI 3.73­8.24), ISS > 15 (OR = 3.75, 95% CI 2.35­6.01), âge 85 ans (OR = 2.04, 95% CI 1.29­3.22), anticoagulation avec un anticoagulant oral direct (DOAC) ou la warfarine (RC = 1.59, IC à 95%, de 1,08 à 2.35) et la multimorbidité (RC = 1.53, IC à 95%, de 1.06 à 2.22) étaient significativement associées à un risque accru de mortalité à 30 jours (C-statistic = 0.82, IC à 95%, de 0.79 à 0.85). Démence (RC = 0.61, IC à 95%, 0.40 à 0.95) le temps de TDM > 60 min (OR = 0.50, IC à 95%, 0.34 à 0.74) était associé à une diminution du risque de mortalité.

Relationship between systolic blood pressure and mortality in older vs younger trauma patients - a retrospective multicentre observational study.

BACKGROUND: The population of older trauma patients is increasing. Those patients have heterogeneous presentations and need senior-friendly triaging tools. Systolic blood pressure (SBP) is commonly used to assess injury severity, and some authors advocated adjusting SBP threshold for older patients. We aimed to describe and compare the relationship between mortality and SBP in older trauma patients and their younger counterparts. METHODS: We included patients admitted to three level-I trauma centres and performed logistic regressions with age and SBP to obtain mortality curves. Multivariable Logistic regressions were performed to measure the association between age and mortality at different SBP ranges. Subgroup analyses were conducted for major trauma and severe traumatic brain injury admissions. RESULTS: A total of 47,661 patients were included, among which 12.9% were aged 65-74 years and 27.3% were ≥ 75 years. Overall mortality rates were 3.9%, 8.1%, and 11.7% in the groups aged 16-64, 65-74, and ≥ 75 years, respectively. The relationship between prehospital SBP and mortality was nonlinear (U-shape), mortality increased with each 10 mmHg SBP decrement from 130 to 50 mmHg and each 10-mmHg increment from 150 to 220 mmHg across all age groups. Older patients were at higher odd for mortality in all ranges of SBP. The highest OR in patients aged 65-74 years was 3.67 [95% CI: 2.08-6.45] in the 90-99 mmHg SBP range and 7.92 [95% CI: 5.13-12.23] for those aged ≥ 75 years in the 100-109 mmHg SBP range. CONCLUSION: The relationship between SBP and mortality is nonlinear, regardless of trauma severity and age. Older age was associated with a higher odd of mortality at all SBP points. Future triage tools should therefore consider SBP as a continuous rather than a dichotomized predictor.

Subjective and objective burden and psychological distress in care partners of older adults with traumatic brain injury.

PURPOSE/OBJECTIVE: In care partners of older persons (65 years and older) having sustained traumatic brain injury (TBI), the objectives were (a) to describe subjective burden (emotional, social, financial, and physical burden), objective burden (new roles and responsibilities), and psychological distress at 4 months postinjury, and (b) to explore the predictors of subjective burden and psychological distress. RESEARCH METHOD/DESIGN: This is an observational study of care partners of older adults with TBI (n = 46; Mage = 65.2 years, SD = 11.2, 87% female). Participants completed the Zarit Burden Interview, the Hospital Anxiety and Depression Scale, the Brain Injury Complaint Questionnaire (measuring difficulties of the injured older adult perceived by the care partner), and the modified Medical Outcomes Study Social Support Survey. RESULTS: A majority of care partners (88%) reported at least one form of objective burden (e.g., increased/decreased time spent in certain activities post-TBI), 29% perceived at least mild subjective burden, and 27% reported either significant anxiety or depressive symptoms. Linear regressions indicated that a higher number of difficulties reported regarding the injured person and poorer perceived social support predicted higher subjective burden and psychological distress. A younger age of the care partner also predicted a higher subjective burden. CONCLUSIONS/IMPLICATIONS: This study provides a better understanding of the potential impacts of TBI in older age for care partners. Future research should examine how to support adequately care partners in their psychological adaptation after TBI in an elderly person. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study.

Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n  = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P  < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P  < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.

Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol.

INTRODUCTION: Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint. METHODS AND ANALYSIS: We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain. ETHICS AND DISSEMINATION: This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER: NCT05555576 ClinicalTrials.Gov PRS.

Ninety-Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke.

Background For patients with atrial fibrillation seen in the emergency department (ED) following a transient ischemic attack (TIA) or minor stroke, the impact of initiating oral anticoagulation immediately rather than deferring the decision to outpatient follow-up is unknown. Methods and Results We conducted a planned secondary data analysis of a prospective cohort of 11 507 adults in 13 Canadian EDs between 2006 and 2018. Patients were eligible if they were aged 18 years or older, with a final diagnosis of TIA or minor stroke with previously documented or newly diagnosed atrial fibrillation. The primary outcome was subsequent stroke, recurrent TIA, or all-cause mortality within 90 days of the index TIA diagnosis. Secondary outcomes included stroke, recurrent TIA, or death and rates of major bleeding. Of 11 507 subjects with TIA/minor stroke, atrial fibrillation was identified in 11.2% (1286, mean age, 77.3 [SD 11.1] years, 52.4% male). Over half (699; 54.4%) were already taking anticoagulation, 89 (6.9%) were newly prescribed anticoagulation in the ED. By 90 days, 4.0% of the atrial fibrillation cohort had experienced a subsequent stroke, 6.5% subsequent TIA, and 2.6% died. Results of a multivariable logistic regression indicate no association between prescribed anticoagulation in the ED and these 90-day outcomes (composite odds ratio, 1.37 [95% CI, 0.74-2.52]). Major bleeding was found in 5 patients, none of whom were in the ED-initiated anticoagulation group. Conclusions Initiating oral anticoagulation in the ED following new TIA was not associated with lower recurrence rates of neurovascular events or all-cause mortality in patients with atrial fibrillation.

Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature.

OBJECTIVES: Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs. DESIGN: Scoping review of the scientific and gray literature. METHODS: Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives. RESULTS: Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy. CONCLUSION AND IMPLICATIONS: Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.

A Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions to assess the accuracy of prehospital trauma triage protocols: a modified Delphi study.

BACKGROUND: Injury severity scales have traditionally been used to assess the performance of prehospital trauma triage protocols, but they correlate weakly with the urgent needs of specialized trauma care interventions. This study aimed to develop a list of in-hospital urgent and specialized trauma care interventions that require direct transport to the highest-level trauma centre within the catchment area. METHODS: Based on a list of potential participants we obtained using data on training, experience, geographic location, affiliations and role within key trauma organizations, we recruited multidisciplinary trauma experts (including prehospital, emergency, surgery and intensive care clinicians, epidemiologists and clinician/decision-makers) from across Canada to complete a 3-round modified Delphi survey. We conducted a literature review of the criteria used to define urgent and specialized trauma care, and included all diagnostic and therapeutic interventions presented in previously published studies in the list of interventions to present to the panellists. The final list was determined by our advisory committee, 5 clinicians with experience in trauma care. Participants were asked to rate their level of agreement for potentially including the 38 items as urgent and specialized trauma care interventions on a 9-point Likert scale. Interventions were retained if more than 67% of participants moderately or strongly agreed (7-9 on the Likert scale). Interventions that did not reach consensus were presented again in the subsequent round. RESULTS: Twenty-three panellists were recruited. The response rate was 91%, 96% and 83% for the 3 rounds. After the Delphi process, 30 of the 38 interventions, including endotracheal intubation, blood product administration and angioembolization, and abdominal, thoracic, neurosurgical, spinal and/or orthopedic operations (excluding hip or limb surgery, and toe or finger amputation), were selected. Hospital admission to the intensive care unit and/or for observation of brain, spinal, thoracic or abdominal injuries were also retained. CONCLUSION: We developed a Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions requiring direct transportation to a major trauma centre. This list should help standardize assessments of current protocols and derive new triage tools.