Hwang, Ula

This study examines the patient- and hospital-level variation in time to initiation of inpatient management among patients admitted to general medical services.

Abstract Over 50% of older adults in the US take ≥5 medications, with prevalence reaching 76.8% in the emergency department (ED) setting. However, little is known about their medication self-efficacy (the ability to understand and follow medication regimens), which may influence adherence and adverse drug events when new prescriptions are added during ED visits. Our objective was to determine whether polypharmacy and potentially inappropriate medication (PIM) are associated with self-efficacy. We performed a logistic regression analysis using 5-site multicenter ED survey data linked to electronic health records from patients aged ≥65 years with baseline ED visits during 2019-2021. The predictors were polypharmacy (≥5 medications) and PIM use (≥1 high-risk medication, GEMRx criteria) of prescriptions taken within 1 year of the ED visit. The outcome was low medication self-efficacy (< 11 points MUSE-taking score) assessed at the ED visit. Covariates included insurance, education, marital status, race/ethnicity, caregiver support, dementia status, and frailty. Among 921 patients, 249 (27.0%) had polypharmacy and 66 (7.2%) had PIM use. Low medication self-efficacy was reported by 76 (37.8%) with polypharmacy and 26 (12.9%) with PIM use versus 125 (62.2%) and 40 (5.6%) without. Both polypharmacy (aOR 6.12, 95% CI 2.05-18.22, p = 0.001) and PIM use (aOR 33.65, 95% CI 5.81-214.35, p < 0.001) were associated with greater adjusted odds of low medication self-efficacy. Frailty modified this association, with weaker effects in more frail patients (OR 5.51, 95% CI 2.57-11.8, p = 0.003). These findings suggest that the ED is an important setting to identify older adults who may struggle with medication use.

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.

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.

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 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.

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.

Abstract Introduction The Geriatric Emergency Care Applied Research Network 2.0‐Advancing Dementia Care (GEAR 2.0‐ADC) aims to advance research efforts to improve the emergency care of persons living with dementia (PLWDs). Objective To support this objective, GEAR 2.0‐ADC convened a virtual consensus conference to prioritize emergency care research opportunities for PLWDs inclusive of perspectives of PLWDs to ensure identification of research gaps in response to their experiences and priorities. Inclusion of PLWDs as research partners is increasingly recognized as a best practice, however, approaches to facilitating consensus participation are lacking. Methods Best practices for supporting the engagement of PLWDs in a consensus conference, applied across its three phases (pre‐conference, during the conference, and post‐conference), include: establishing a learning environment focused on research priorities before the event, presenting information in ways that align with participants' learning preferences while accommodating cognitive impairments, and providing multiple opportunities and methods for gathering post‐conference feedback from PLWDs. Results These strategies were identified by PLWDs and care partners (CPs) through semi‐structured interviews, who were involved in the convening process, aimed at exploring ways to enhance facilitation techniques for participants. Conclusion Additionally, these summarized insights aim to encourage the use of community‐engaged approaches in discussions and consensus‐building around research priorities in emergency care, particularly for PLWDs and their CPs.