Older Adult Falls in Emergency Medicine, 2023 Update.

Of 4 older adults, 1 will fall each year in the United States. Based on 2020 data from the Centers of Disease Control, about 36 million older adults fall each year, resulting in 32,000 deaths. Emergency departments see about 3 million older adults for fall-related injuries with falls having the ability to cause serious injury such as catastrophic head injuries and hip fractures. One-third of older fall patients discharged from the ED experience one of these outcomes at 3 months.

Diversity, Equity, and Inclusion: Considerations in the Geriatric Emergency Department Patient.

This article introduces core topics in health equity scholarship and provides examples of how diversity, equity, and inclusion impact the aging population and emergency care of older adults. It offers strategies for promoting diversity, equity, and inclusion to both strengthen the patient-clinician therapeutic relationship and to address operations and systems that impact care of the geriatric emergency department patient.

High touch, high trust: Using community health advocates and lawyers to address ED high utilizers.

BACKGROUND: Emergency department (ED) high utilizers are a costly group of patients due to their higher utilzation of acute care costs. At a safety-net hospital, we enrolled patients in a program which partnered with lawyers and community health advocates (CHAs) to navigate patients' social, medical and legal needs. Our aim was to decrease costs and utilization and address the patient's social determinants of heath (SDOH). METHODS: We enrolled patients with 4 or more ED visits in the prior 6 months and gave them SDOH and medical questionnaires. Patients were followed for 6 months on a weekly, then bi-monthly basis. All utilization and cost data were obtained through an internal data warehouse and evaluated using a pre-post analysis and broken down into quartiles. RESULTS: ED, admission, and total costs did not differ significantly between the 12 months pre-enrollment and the 12 months post-enrollment. Outpatient costs did increase ($2182 increase, p < 0.005). ED visits declined significantly in the post-enrollment period (IRR = 0.84, p = 0.048), with the highest impact on those with <7 ED visits. Total admissions did not decline (IRR 0.84, p = 0.059). But, among those with 4 or 5 ED visits, admission costs and visits decreased. On average, six SDOH issues were identified. Of these, approximately 30.3% were mitigated with up to 17% requiring legal help. CONCLUSION: While outpatient costs did increase, total costs did not decrease in this program. This type of non-clinical intervention may be best served for patients who are less clinically complex but significant social needs.

Emergency department falls: a longitudinal analysis of revisits and hospitalisations between patients who fall and patients who did not fall.

OBJECTIVE: Older adult falls are a national issue comprising 3 million emergency department (ED) visits and significant mortality. We sought to understand whether ED revisits and hospitalisations for fallers differed from non-fall patients through a secondary analysis of a longitudinal, statewide cohort of patients. DESIGN: We performed a secondary analysis using the non-public Patient Discharge Database and the ED data from the California Office of Statewide Health Planning and Development. This is a 5-year, longitudinal observational dataset, which was used to assess outcomes for fallers and non-fall patients, defined as anyone who did not carry a fall diagnosis during this time period. SETTING: 2005-2010 non-public Patient Discharge Database and the ED Data from the state of California. PARTICIPANTS: Older adults 65 years and older MAIN OUTCOME MEASURE: ED revisits and hospitalisations for fallers and non-fall patients. RESULTS: Patients who came to the ED with an index visit of a fall were more likely to be discharged home after their fall (61.1% vs 45.0%, p<0.001). Fallers who were discharged or hospitalised after their index visit were more likely to come back to the ED for a fall related complaint compared with non-fallers (median time: 151 days vs 352 days, p<0.001 and hospitalised: 45 days vs 119 days, p<0.01) and fallers who were initially discharged also returned to the ED sooner for a non-fall related complaint (median time: 325 days vs 352 days, p<0.001). CONCLUSION: Fall patients tend to be discharged home more often after their index visit, but returned to the ED sooner compared with their non-fall counterparts. Given a faller's rates of ED revisits and hospitalisations, EDs should consider a fall as a poor prognostic indicator for future healthcare utilisation.

Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003-2010.

INTRODUCTION: One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography. METHODS: We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region. RESULTS: Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9-68.8]) to 68.8 (95% CI [57.8-79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75-84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03). CONCLUSION: ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting.

An Integrated Approach to Falls Prevention: A Model for Linking Clinical and Community Interventions through the Massachusetts Prevention and Wellness Trust Fund.

Older adult falls continue to be a public health priority across the United States-Massachusetts (MA) being no exception. The MA Prevention and Wellness Trust Fund (PWTF) program within the MA Department of Public Health aims to reduce the physical and economic burdens of chronic health conditions by linking evidence-based clinical care with community intervention programs. The PWTF partnerships that focused on older adult falls prevention integrated the Centers for Disease Control and Prevention's Stopping Elderly Accidents, Death and Injuries toolkit into clinical settings. Partnerships also offer referrals for home safety assessments, Tai Chi, and Matter of Balance programs. This paper describes the PWTF program implementation process involving 49 MA organizations, while highlighting the successes achieved and lessons learned. With the unprecedented expansion of the U.S. Medicare beneficiary population, and the escalating incidence of falls, widespread adoption of effective prevention strategies will become increasingly important for both public health and for controlling healthcare costs. The lessons learned from this PWTF initiative offer insights and recommendations for future falls prevention program development and implementation.

Exploring Older Adult ED Fall Patients' Understanding of Their Fall: A Qualitative Study.

OBJECTIVE: We sought to understand older patients' perspectives about their fall, fall risk factors, and attitude toward emergency department (ED) fall-prevention interventions. METHODS: We conducted semistructured interviews between July 2015 and January 2016 of community-dwelling, nondemented patients in the ED, who presented with a fall to an urban, teaching hospital. Interviews were halted once we achieve thematic saturation with the data coded and categorized into themes. RESULTS: Of the 63 patients interviewed, patients blamed falls on the environment, accidents, a medical condition, or themselves. Three major themes were generated: (1) patients blamed falls on a multitude of things but never acknowledged a possible multifactorial rationale, (2) patients have variable level of concerns regarding their current fall and future fall risk, and (3) patients demonstrated a range of receptiveness to ED interventions aimed at preventing falls but provided little input as to what those interventions should be. CONCLUSIONS: Many older patients who fall do not understand their fall risk. However, based on the responses provided, older adults tend to be more receptive to intervention and more concerned about their future fall risk, making the ED an appropriate setting for intervention.

OPEN ACCESS TO DIABETES CENTER FROM THE EMERGENCY DEPARTMENT REDUCES HOSPITALIZATIONS IN THE SUSEQUENT YEAR.

OBJECTIVE: Patients who present to the emergency department (ED) for diabetes without hyperglycemic crisis are at risk of unnecessary hospitalizations and poor outcomes. To address this, the ED Diabetes Rapid-referral Program (EDRP) was designed to provide ED staff with direct booking into the diabetes center. The objective of this study was to determine the effects of the EDRP on hospitalization rate, ED utilization rate, glycemic control, and expenditures. METHODS: We conducted a single-center analysis of the EDRP cohort (n = 420) and compared 1-year outcomes to historic controls (n = 791). We also compared EDRP patients who arrived (ARR) to those who did not show (NS). The primary outcome was hospitalization rate over 1 year. Secondary outcomes included ED recidivism rate, hemoglobin A1c (HbA1c), and healthcare expenditures. RESULTS: Compared with controls, the EDRP cohort was less likely to be hospitalized (27.1% vs. 41.5%, P<.001) or return to the ED (52.2% vs. 62.3%, P = .001) at the end of 1 year. Total hospitalizations were also lower in the EDRP (157 ± 19 vs. 267 ± 18 per 1,000 persons per year, P<.001). The EDRP cohort had a greater reduction in HbA1c (-2.66 vs. -2.01%, P<.001), which was more pronounced when ARR patients were compared with NS (-2.71% vs. -1.37%, P<.05). The mean per patient institutional healthcare expenditures were lower by $5,461 compared with controls. CONCLUSION: Eliminating barriers to scheduling diabetes-focused ambulatory care for ED patients was associated with significant reductions in hospitalization rate, ED recidivism rate, HbA1c, and healthcare expenditures in the subsequent year. ABBREVIATIONS: ARR = arrived ED = emergency department EDRP = emergency department diabetes rapid-referral Program HbA1c = hemoglobin A1c NS = no show.

Current Trends in Geriatric Emergency Medicine.

The number of geriatric visits to United States emergency departments continues to rise. This article reviews demographics, statistics, and future projections in geriatric emergency medicine. Included are discussions of US health care spending, geriatric emergency departments, prehospital care, frailty of geriatric patients, delirium, geriatric trauma, geriatric screening and prediction tools, medication safety, long-term care, and palliative care.

Frequency of ED revisits and death among older adults after a fall.

INTRODUCTION: Falls among older adults (aged ≥65 years) are the leading cause of both injury deaths and emergency department (ED) visits for trauma. We examine the characteristics and prevalence of older adult ED fallers as well as the recurrent ED visit and mortality rate. METHODS: This was a retrospective analysis of a cohort of elderly fall patients who presented to the ED between 2005 and 2011 of 2 urban, level 1 trauma, teaching hospitals with approximately 80000 to 95000 annual visits. We examined the frequency of ED revisits and death at 3 days, 7 days, 30 days, and 1 year controlling for certain covariates. RESULTS: Our cohort included 21340 patients. The average age was 78.6 years. An increasing proportion of patients revisited the ED over the course of 1 year, ranging from 2% of patients at 3 days to 25% at 1 year. Death rates increased from 1.2% at 3 days to 15% at 1 year. A total of 10728 patients (50.2%) returned to the ED at some point during our 7-year study period, and 36% of patients had an ED revisit or death within 1 year. In multivariate logistic regression, male sex and comorbidities were associated with ED revisits and death. CONCLUSION: More than one-third of older adult ED fall patients had an ED revisit or died within 1 year. Falls are one of the geriatric syndromes that contribute to frequent ED revisits and death rates. Future research should determine whether falls increase the risk of such outcomes and how to prevent future fall and death.

Burden in caregivers of cognitively impaired elderly adults at time of hospitalization: a cross-sectional analysis.

OBJECTIVES: To describe the factors associated with burden that caregivers of cognitively impaired older adults (dementia, delirium, or both) at the time of hospitalization experienced. DESIGN: Cross-sectional data analyses. SETTING: Three hospitals-one academic tertiary hospital and two associated community hospitals. PARTICIPANTS: Caregivers (N = 495) of cognitively impaired older adults at the time of hospital admission. MEASUREMENTS: Multivariable linear regression was performed to analyze the effect of the independent variables (caregiver: demographic characteristics, depressive symptoms, self-efficacy; older adult: neuropsychiatric symptoms, delirium, functional deficits) on caregiver burden. RESULTS: Higher burden was associated with younger caregiver age (P = .02), being a spouse (P = .03), depressive symptoms (P < .001), caregivers' lower perceived self-efficacy in managing care recipient symptoms (P = .002), and limited finances at the end of the month (P = .01). Caregiver burden was also strongly associated with the care recipient factors distressing neuropsychiatric symptoms (P = .001), delirium (P = .001), and greater functional deficits in basic activities of daily living (P = .001). CONCLUSION: These findings suggest that caregivers of older adults who were cognitively impaired at hospital admission experience burden. Understanding the factors that contribute to burden at the time of hospitalization for caregivers of persons with cognitive impairment can inform the development of interventions targeted throughout the hospitalization that have the potential to decrease burden.

Toward patient-centered care: a systematic review of older adults' views of quality emergency care.

STUDY OBJECTIVE: Observers have cited a quality gap between the current emergency care and the needs of elderly adults in the emergency setting. The Institute of Medicine identified patient-centeredness as a vital aim of quality health care. To develop a patient-centered approach in the emergency setting, we must first understand the elderly patients' views of their emergency care. Thus, we performed a systematic review to synthesize the current knowledge about the elderly patient's preferences and views of their emergency care. METHODS: Systematic review of qualitative studies and surveys addressing the elderly patients' views of their emergency care using PUBMED and CINAHL. Using meta-ethnography, we identified 6 broad themes about the elderly's perspectives of hospital-based emergency care. RESULTS: Of the 81 articles initially identified, our final review included 28 articles. We developed 6 themes of quality emergency care: (1) role of health care providers; (2) content of communication and patient education; (3) barriers to communication; (4) wait times; (5) physical needs in the emergency care setting; and (6) general elder care needs. Key findings were that emergency staff should (1) assume a leadership role with both the medical and social needs; (2) initiate communication frequently; (3) minimize potential barriers to communication; (4) check on patients during prolonged periods of waiting; (5) attend to distress caused by physical discomforts in the emergency care setting; and (6) address general elder care needs, including the care transition and involvement of caregivers when necessary. CONCLUSION: Current qualitative research on the views of the elderly patient to hospital-based emergency care reveals common themes that should be considered in efforts to improve delivery of care to the elderly patient.