Carpenter, Christopher R.

ABSTRACT Background Geriatric screening and multidisciplinary assessment of older adults in the Emergency Department (ED) decrease hospitalizations and ED revisits. The impact on patient‐reported outcomes of health‐related quality of life (HRQoL) and functional status is not known. Methods A hybrid type II implementation/effectiveness prospective cohort study was conducted in an academic ED. The intervention bundle was geriatric screening for delirium, fall risk, and transition of care needs, and multidisciplinary assessment. All older adults (≥ 65 years) placed in the ED observation unit were eligible. HRQoL and functional status were obtained at the ED visit, 30, and 90 days, and were compared between the pre‐ and post‐intervention implementation cohorts. Secondary outcomes included ED revisits, falls, mortality, and intervention adoption measures. Results From 2019 to 2023, 368 adults participated in the study: Most were community‐dwelling (97%) and had multiple comorbidities. The pre ( n = 138) and post ( n = 230) cohorts did not differ in baseline functional status or HRQoL. The rate of geriatric screening improved from 12.3% in the pre‐implementation cohort to 91.3% in the post‐implementation cohort ( p < 0.01). Multispecialty consultation also increased (68.1%–91.3%, p < 0.01). The proportion who had a post‐ED visit decline in functional status did not differ between cohorts. Physical HRQoL declined similarly in both cohorts (−0.73 vs. −0.33, p = 0.61) at 90 days. Mental HRQoL improved in both cohorts; improvement was greater in the pre‐cohort (2.35 vs. 0.32, p = 0.02). ED revisits and re‐hospitalizations were unchanged (30 days: 23.0% vs. 17.2%, p = 0.18, and 90 days: 37.8% vs. 34.8%, p = 0.57). The intervention decreased falls at 30 and 90 days (30 days: 9.7% vs. 3.2%, p = 0.04; 90 days: 22.1% vs. 7.9%, p < 0.01). Conclusions Geriatric screening in the ED increased identification of geriatric syndromes and multidisciplinary consultation. The intervention was associated with decreased falls but did not affect HRQoL or reduce functional decline post ED visit. Trial Registration clinicaltrials.gov : NCT04068311

ABSTRACT Objectives Multicenter research of geriatric emergency department (GED) care remains limited. Our objectives were to: 1. Prospectively collect data prioritized by the Geriatric Emergency care Applied Research (GEAR) network, a transdisciplinary taskforce for GED care, and create a multicenter GED research repository of prospective and electronic health record (EHR) data, 2. Assess concordance between prospective and EHR data. Methods The GEAR Standardization Study (GEARSS) is a multicenter, prospective study of older emergency department (ED) patients (65+) focusing on the 4Ms of age‐friendly care (mobility, medication safety, mentation, what matters) and elder mistreatment. Demographic and clinical data were collected via interviews by trained research assistants (RA) on Days 0, 4, 30, and 90 and linked to EHR. Prevalence of chronic comorbidities and incident delirium were measured and reported using descriptive statistics. Prospective and EHR data concordance was assessed with Cohen's Kappa. Results 999 participants were recruited from 5 EDs (3/25/2021–6/30/2022) across 3 institutions: Grady Health System, Northwestern Memorial Hospital, and Yale New Haven Health. The cohort was 57.0% female, 55.2% White, 39.1% Black, and 3.4% Hispanic, and the mean age was 75.1 years. For rheumatologic disease, peptic ulcer disease, diabetes, renal disease, and cancer, prevalence differed between prospective and EHR data by > 10%. About two‐thirds of participants were at risk for falls. Concordance between prospective and EHR data was good for ethnicity ( K = 0.73); excellent for sex ( K = 1.00), age ( K = 1.00), and race ( K = 0.98); fair for disposition ( K = 0.53); slight for ED observation status ( K = 0.33) and dementia diagnosis ( K = 0.24); poor for delirium presence ( K = 0.07). Conclusion In GEARSS, demographic variables aligned strongly between prospective and EHR data, while diagnosis, disposition, and mentation factors did not. This multicenter data source provides preliminary findings for common geriatric syndromes and conditions. Choice of measures using these data should be driven by GED research questions.

Abstract Background The increasing prevalence of dementia poses significant challenges for emergency department (ED) care, as persons living with dementia (PLWD) more frequently experience adverse outcomes such as delirium, prolonged stays, and higher mortality rates. Despite advancements in care strategies, a critical gap remains in understanding how ED interventions impact outcomes in this vulnerable population. This systematic review aims to identify evidence‐based ED care interventions tailored to PLWD to improve outcomes. Methods A systematic review was conducted in Ovid MEDLINE, Cochrane Library (Wiley), Scopus (Elsevier), and ProQuest Dissertations & Theses Global through September 2024. The review protocol was registered on PROSPERO (CRD42024586555). Eligible studies included randomized controlled trials, observational studies, and quality improvement initiatives focused on ED interventions for PLWD. Data extraction and quality assessment were performed independently by two reviewers, with disagreements resolved through discussion. Outcomes included patient satisfaction, ED revisits, functional decline, and mortality. Results From 3305 screened studies, six met the inclusion criteria. Interventions included nonpharmacologic therapies (e.g., music and light therapy), specialized geriatric ED units, and assessment tools, such as for pain. Tailored interventions including geriatric emergency units and community paramedic care transitions were effective in reducing 30‐day ED revisits and hospitalizations. However, heterogeneity in study designs and outcomes precluded meta‐analysis. Risk of bias ranged from low to moderate. Conclusion This review underscores the urgent need for standardized and evidence‐based interventions in ED settings for PLWD. Approaches including multidisciplinary care models and nonpharmacologic therapies demonstrated potential for improving outcomes. Future research should prioritize consistent outcome measures, interdisciplinary collaboration, and person‐centered care strategies to enhance the quality and equity of ED services for PLWD.

AbstractPersons Living with Dementia (PLWD), diagnosed or undiagnosed, have high Emergency Department (ED) use. Identification of such patients poses significant challenges for emergency clinicians with considerable downstream implications on patients, care partners, and healthcare systems. With the advent of Geriatric Emergency Departments (GEDs) there is an opportunity to understand and improve care of PLWDs in EDs with effective allocation of resources and the development of novel techniques to better support detecting those at risk, communicating findings, and coordinating care for such patients. Advances have been made leveraging Electronic Health Record (EHR) data to risk stratify patients for dementia in the hope that those at high‐risk may benefit from further evaluation. The promise of multiple blood‐base biomarkers (BBM) as a future modality to improve detection of those at risk of dementias, will also have the potential to advance the delivery of care of PLWD and their care partners in EDs.Highlights EDs have an integral role in delivering care for Person Living with Dementia and their care partners. High acuity and fast paced ED environment and other barriers makes it difficult to identify Person Living with Dementia. EHR‐based risk stratification algorithms can identify patients at risk for Dementia in ED and outpatient settings. Use of Blood‐Based Biomarkers in the ED setting is novel and considerations of its use and implications need to be studied. EHR based risk stratification algorithm and Blood Based Biomarkers when used judiciously have the potential to overcome some of the known barriers to identify and improve care for Person Living with Dementia as they transition through EDs.

ABSTRACTA core tenant of the Geriatric Emergency care Applied Research Network 2.0—Advancing Dementia Care (GEAR 2.0‐ADC) is the inclusion of community members during all stages of clinical research. As such, we deliberately integrated and supported patient and public involvement in the evaluation and selection of GEAR 2.0‐ADC Pilot Research Grants by developing and adapting traditional grant application review structures, with input from community members, to create the GEAR 2.0‐ADC Community Review Committee approach. Community members, including persons living with dementia, effectively participated in all three rounds of research grant application review and selection, complementing the traditional scientific review process. The structure and flexibility of the GEAR 2.0‐ADC Community Review Committee approach serve as a model for patient and public grant application review involvement with strong potential for applications across grant reviews in other medical specialties.

ABSTRACT Background Dementia often goes undetected in hospital settings, where cognitive assessments are challenging due to illness severity and delirium. This study aimed to (1) evaluate the accuracy of the Clinical Dementia Rating (CDR), based solely on knowledgeable informant reports, for detecting preexisting dementia and cognitive impairment in hospitalized patients compared to a gold‐standard diagnosis, (2) and compare its performance to the 16‐item Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE‐16). Methods This cross‐sectional study assessed consecutive patients aged ≥ 65 admitted to inpatient units from five hospitals in Brazil. The informant‐based CDR was administered to knowledgeable informants within 48 h of admission, capturing patients' cognitive status 3 months before hospitalization to avoid the influence of acute cognitive impairments. Blinded experts provided a gold standard clinical diagnosis of dementia or cognitive impairment no dementia (CIND) based on a 90‐min comprehensive assessment, including a standardized neuropsychology battery. Areas under the curve (AUC) examined diagnostic accuracy. Results Of 65 participants (mean age = 79.4 years; women = 54%), 34% had dementia and 32% had CIND . Compared to the gold standard, the informant‐based CDR showed excellent diagnostic accuracy for detecting dementia ( AUC = 0.92; 95% confidence interval [ CI ] = 0.86–0.98) and cognitive impairment ( AUC = 0.93; 95% CI = 0.88–0.98), with a cutoff of ≥ 1 showing 98% specificity for dementia and a cutoff of ≥ 0.5 showing 98% sensitivity for cognitive impairment. Compared to the IQCODE ‐16, the informant‐based CDR had similar performance in detecting dementia and a nonsignificant slight advantage in identifying cognitive impairment ( AUC = 0.93 vs. 0.84, p = 0.069), reducing unrecognized cognitive impairment based on medical record documentation from 70% to 2%. Conclusions Informant‐based CDR is a valid and efficient tool for detecting dementia and cognitive impairment in hospitalized older adults, supporting early diagnosis and guiding multidisciplinary interventions in acute care. Its use in routine hospitals may help clinicians reduce undetected cognitive impairment, enhance decision making, and improve patient care.

The Enhancing the Quality and Transparency of Health Research (EQUATOR) Network indexes over 600 reporting guidelines designed to improve the reproducibility of manuscripts across medical fields and study designs. Although several such reporting guidelines touch on adverse events that may occur in the context of a study, there is a large body of research whose primary focus is on adverse events, near-misses and medical errors that do not currently have a dedicated reporting guideline to help set reporting standards and facilitate comparisons across studies. As part of the process prescribed by EQUATOR for developing such a reporting guideline, we performed a needs assessment, evaluating whether existing standards address key features of a proposed reporting guideline in development, entitled Standard Elements in Studies of Adverse Events and Medical Error (SESAME). We evaluated 12 EQUATOR reporting guidelines for the presence of eight key features of SESAME. Five of the 12 failed to include any of these key features. None of the remaining seven incorporated more than four of the eight SESAME key components, confirming the need for a dedicated reporting guideline for studies of adverse events and medical errors.

ABSTRACT Background Existing risk scores assessing geriatric vulnerability in the emergency department (ED) have shown limited predictive power, especially in diverse populations. We investigated the relationship of a quick and easy‐to‐administer geriatric vulnerability scoring system with functional decline and mortality in older patients admitted to multiple hospitals through the ED in the United States (US) and Brazil (BR). Method Federated, international, multicenter observational study of hospitalized ED patients aged ≥ 65 from US and BR. The six criteria from the PRO‐AGE score (Physical impairment, Recent hospitalization, Older age [≥ 90], Acute mental alteration, Getting thinner, and Exhaustion; 0–8; higher scores = greater vulnerability) were assessed on admission. We used proportional hazards models to investigate the relationships between PRO‐AGE score groups and 90‐day mortality and functional decline, defined as new dependence in activities of daily living (ADL) and instrumental ADL (IADL), after adjusting for age, sex, race and ethnicity, education, Charlson comorbidity score, and study site. Death was considered a competing event for the functional decline outcome. Results A total of 1390 patients were included (US = 560; Brazil = 830). The 90‐day risk of death was higher for the upper compared with the lower (reference) PRO‐AGE group in both cohorts (US: HR = 11.76; 95% confidence interval [CI] = 2.56–54.04; BR: HR = 12.29; 95% CI = 3.54–42.59), whereas the risk of new 90‐day ADL disability was higher for upper (HR = 2.08; 95% CI = 1.21–3.56) and middle groups (HR = 2.10; 95% CI = 1.35–3.27) in the US but only the upper group in BR (HR = 1.70; 95% CI = 1.02–2.85). Conclusion A higher PRO‐AGE score was associated with mortality and functional decline in older ED patients admitted to hospitals in the US and BR, demonstrating its generalizability as a geriatric vulnerability risk score.