Gettel, Cameron J.

Background New antiamyloid therapies (AAT) for treating patients with early Alzheimer disease (AD) have become available in the past 3 years. Although AAT can be beneficial in slowing progression of AD, they also come with potentially serious side effects, particularly for patients requiring anticoagulation or thrombolysis for cardiovascular conditions. Given that most patients with AD are older and likely to have cardiovascular risk factors, there is urgent need for additional guidance for clinicians about potential risks and benefits associated with AAT for patients with cardiovascular comorbidities, best practices for management of these patients, and special considerations with respect to emergency evaluation and treatment of patients on AAT who develop acute neurological symptoms. Methods The American Heart Association convened 75 multidisciplinary experts for the Amyloid‐Related Imaging Abnormalities Summit: Cardiovascular and Stroke Considerations for β‐Amyloid Immunotherapy in AD in July 2025. These experts were divided into 8 work groups to evaluate the current evidence related to AAT usage in patients with cardiovascular risk factors and conditions and develop consensus‐based guidance for clinicians. Results This statement outlines the outcomes of the Summit, including considerations for prescribers, primary care professionals, emergency personnel, and health care system stakeholders. These considerations are intended to improve identification of patients as appropriate candidates for AAT, management of patients with co‐occurring AD and cardiovascular conditions, and their emergency evaluation and treatment. The statement also includes guidance for shared decision‐making, implementation of system changes for improving dementia care, and recommendations for future research and data collection to add to the body of evidence for treating patients with concomitant AD and cardiovascular conditions. Conclusions Building on lessons learned from the establishment of stroke systems of care, the consensus‐based considerations outlined in this document can serve as a foundation for AD systems of care aimed at ensuring optimal use of these ground‐breaking therapies.

Abstract Inpatient boarding (holding patients in the emergency department [ED] while awaiting an inpatient bed) is associated with increased risk of delirium, medication safety events, and hospital mortality in older adults. We investigated boarding trends across age strata to determine if older patients had elevated rates compared to younger patients. Administrative data for ED encounters resulting in admission from 3 healthcare systems (2 Midwest, 1 Northeast) from 1/1/19 to 12/31/24 were reviewed. Age was categorized by strata: < 21, 21-64, 65-74, 75-84, and ≥ 85. Based on the CMS Age Friendly Hospital Measures, the proportion of patients boarding for 3+ hours was calculated within each year and age strata. Boarding rates varied substantially by system and age group. At Systems 1 (S1) and 3 (S3), ≥ 85 patients had the highest rates (S1: 54.9%, S3: 70.9% in 2024) and, at System 2 (S2), all adult patients (21+) had similar rates (20.5-22.4% in 2024). Boarding rates increased in all systems over the study period. At S1 and S3, < 21 patients had the highest average yearly increase in boarding (S1: 7.4%, S3: 3.9%). At S2, boarding increased most in ≥ 85 (23.9%). In this multisystem evaluation, approximately one in two older adults experience ED boarding, with the oldest patients (≥ 85) facing the greatest exposure to boarding in recent years. These findings taken alongside known delays and safety risks associated with boarding and patient care complexity amongst the oldest adults may result in disproportionate harm to some of the most vulnerable patients.

Abstract Introduction The rapidly ageing population and multimorbidity are associated with increased emergency department (ED) visits by older adults. In the ED, older adults have higher risk of hospitalization, functional and cognitive decline, and mortality. Boarding, holding admitted patients in the ED awaiting a hospital bed, exacerbates these negative outcomes, which disproportionately affect older adults. Methods We conducted a cross-sectional analysis to investigate US boarding trends by age using clinical administrative data from 5 health systems and publicly available NHAMCS data from 2018 to 2024. Results Boarding ≥3 h in the ED has increased across diverse hospital types, with oldest adults (85+) facing the greatest risk (System 4: IRR [95% CI] = 1.18 [1.15-1.20], System 5: IRR [95% CI] = 1.20 [1.17-1.23], System 3 [Community Hospital]: IRR [95% CI] = 1.25 [1.19-1.33]). These results were recapitulated at the national level in NHAMCS (IRR [95% CI] = 1.30 [1.05-1.61]). Discussion The trend of increased boarding has serious implications for patients, caregivers, and health systems. The 2025 CMS Age-Friendly Hospital Measure offers opportunities to improve processes and procedures to mitigate the negative effects of hospital boarding on older patients. We highlight opportunities to address this challenge, including ongoing quality improvement initiatives, bed prioritization algorithms, and alternate admission pathways.

ABSTRACTObjectivesWe describe the types of emergency department (ED) visits managed by non‐physician providers (NPPs), including physician assistants and nurse practitioners, and emergency medicine (EM) physicians, assessing shifts in care patterns over time.MethodsWe used data from the National Hospital Ambulatory Medical Care Survey collected from 2009 to 2021. We classified visits by provider type: physician only, physician with resident, physician with NPP, and NPP only. We described characteristics of visits by provider type, including patient demographics, triage urgency, imaging, length of stay, and disposition, and analyzed using Poisson regression. We described the change in type of provider seen over this study period and further analyzed by triage urgency and hospital location.ResultsOf 1.684 billion estimated ED visits from 2009 to 2021, 1.171 billion were managed by physicians without residents or NPPs (physicians only), 136.3 million by physicians with residents, 209.1 million by physicians with NPPs, and 167.4 million by NPPs only. Patients seen by physicians only were older, were triaged as having more urgent needs, had a longer ED length of stay, and were more likely to be admitted compared to those seen by NPPs only. Physician‐only visits decreased from 77% to 62%, while NPP‐only visits increased from 6% to 11%. The physician with the NPP group similarly grew from 9% to 17%. For visits assigned a triage urgency level of 2 (“emergent”), physician‐only visits decreased by 20%, physician with NPP visits increased by 13%, and NPP‐only visits increased by 3%. In metropolitan areas, physician‐only visits dropped 14%, with a 5% increase in NPP‐only visits. In non‐metropolitan areas, physician‐only visits decreased 17%, with a 9% increase in NPP‐only visits.ConclusionsThe EM workforce has shifted, with NPPs seeing a higher percentage of patients, including both lower‐ and higher‐acuity patients. This shift is particularly prominent in rural areas but is evident across all regions.

AbstractBackgroundImpaired cognition is prevalent in older adults in the emergency department (ED), but many cases go unrecognized. The Ascertain Dementia 8 (AD8) is a validated, self‐administered screening tool that can be used by patients and caregivers to assess for early cognitive changes associated with dementia. However, little is known regarding the degree of alignment between respondents in the ED setting. Our objective was to assess the agreement between the patient‐(pAD8) versus caregiver‐completed AD8 (cAD8).MethodsWe conducted a prospective observational study of community‐dwelling older adults aged 65+ years seeking emergency care and their caregivers between October 2021 and November 2023. Patients with a diagnosis of dementia indicated in the electronic health record were excluded. Collected by trained research assistants, AD8 scores ranged from 0‐8, with scores 2+ indicating cognitive impairment. Patients and caregivers were blinded to the others’ AD8 rating. The intraclass correlation coefficient (ICC) was used to assess the agreement of the presence or absence of cognitive impairment based on pAD8 and cAD8 scores.ResultsOur analytic sample included 538 dyads, of which 34.7% of patients were male with a mean age of 73.5. A total of 132 (24.5%) patients scored themselves as cognitively impaired versus 201 (37.4%) patients were scored as cognitively impaired by their caregivers. Between groups, an ICC of 0.519 (95% CI 0.454‐0.578) demonstrated moderate agreement in identifying cognitive impairment based on pAD8 and cAD8 scores.ConclusionApproximately 1 in 4 older adults without a dementia diagnosis in the emergency department identified themselves as having cognitive impairment, with caregivers even more likely to identify cognitive impairment in accompanied older adult patients. With current guidance suggesting that the pAD8 be used in the absence of the cAD8, these findings highlight important differences to account for based on the respondent when screening for cognitive impairment.

AbstractIntroductionOlder adults are at high risk of adverse health outcomes in the post–emergency department (ED) discharge period. Prior work has shown that discharged older adults have variable understanding of their discharge instructions which may contribute to these outcomes. To identify discharge comprehension gaps amenable to future interventions, we utilize meta‐analysis to determine patient comprehension across five domains of discharge instructions: diagnosis, medications, self‐care, routine follow‐up, and return precautions.MethodsUsing Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, two reviewers sourced evidence from databases including Medline (PubMed), EMBASE, Web of Science, CINAHL, and Google Scholar (for gray literature). Publications or preprints appearing before April 2024 were included if they focused on geriatric ED discharge instructions and reported a proportion of patients with comprehension of at least one of five predefined discharge components. Meta‐analysis of eligible studies for each component was executed using random‐effects modeling to describe the proportion of geriatric ED cases understanding the discharge instructions; where appropriate we calculated pooled estimates, reported as percentages with 95% confidence interval (CI).ResultsOf initial records returned (N = 2898), exclusions based on title or abstract assessment left 51 studies for full‐text review; of these, seven constituted the study set. Acceptable heterogeneity and absence of indication of publication bias supported pooled estimates for proportions comprehending instructions on medications (41%, 95% CI 31%–50%, I2 = 43%), self‐care (81%, 95% CI 76%–85%, I2 = 43%), and routine follow‐up (76%, 95% CI 72%–79%, I2 = 25%). Key findings included marked heterogeneity with respect to comprehending two discharge parameters: diagnosis (I2 = 73%) and return precautions (I2 = 95%).ConclusionsOlder patients discharged from the ED had greater comprehension of self‐care and follow‐up instructions than about their medications. These findings suggest that medication instructions may be a priority domain for future interventions.

AbstractBackgroundPatient‐reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care.MethodsWith the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science‐Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post–emergency care time period. Independent reviewers performed title/abstract review, full‐text screening, data extraction, study characteristic summarization, and risk‐of‐bias (RoB) assessments.ResultsOur search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1–3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4–6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality.ConclusionsPROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.