Trial
Population
Intervention
Team
Readmission
Hospitalisation
Functional decline
Admission to LTC
Mortality
CGA in the ED
Miller [29]
65+
Geriatric case finding and liaison service:
Geriatric nurse
3 m ↔
N/A
N/A
↔
↔
Non-randomised controlled trial
CGA → team discussion → further work-up in the ED—evaluations during hospitalisation—referral → information transfer → telephone follow-up
Consultation with ED staff
65+, ISAR ≥2, expected to be discharged
CGA → problem identification → team discussion → referral → limited follow-up after the ED visit
Nurses
30d ↑
N/A
4 m ↓
N/A
N/A
RCT
Consultation with ED staff and geriatric staff
Mion [27]
65+, living at home, expected to be discharge home
CGA → identification of unmet needs → team discussion → discharge plan → information transfer → referral → short-term telephone follow-up
Advanced practice nurse specialised in geriatrics
30d ↔
N/A
N/A
30d ↓
30d ↔
RCT
Consultation with ED staff
120d ↔
120d ↔
120d ↔
Caplan [28]
75+, discharged from the ED
CGA on the ED or at home → discussion with GP + weekly interdisciplinary team meeting → care plan—initiation of urgent interventions → referrals → follow-up for 4 weeks
Nurse
30d ↓
N/A
6 m ↓
↔
↔
RCT
Consultation with geriatric team
18 m ↓
Basic [35]
Older people AND
CGA → problem identification → referral when discharged—suggestions and recommendations in the file when admitted
Geriatric nurse
N/A
↔
During HOS ↔
N/A
N/A
RCT
Functional impairment OR psychological disability OR social disability OR active multisystem disease OR readmission
Foo [36]
65+, living at home
CGA → problem list → team discussion → intervention if necessary → referral or admission
ED nurse trained in geriatric care
3 m ↓
N/A
N/A
N/A
↔
6 m ↓
Pre-post evaluation
Consultation with ED physician or geriatric nurse clinician
9 m ↓
12 m ↓
65+ and criteria based on clinical presentation
Early allied health intervention:
Allied health personnel
28d ↓
↓
N/A
N/A
28d ↔
Non-randomised trial
Comprehensive functional assessment → initiation of services based on identified needs
Other specialists when required
1y ↑
1y ↔
Wright [23]
70+ with complex medical and social needs
CGA → prompt intervention → referral → follow-up at home
Multidisciplinary geriatric team
N/A
↓
N/A
N/A
N/A
Pre-post cohort study
Foo [39]
65+, TRST ≥2, living at home, planned for discharge
Focused geriatric screening (15-item screening form) → intervention if necessary → referral
GEM nurse
3 m, 6 m, 9 m, 12 m ↔
N/A
3 m ↓
N/A
↔
6 m ↓
9 m ↓
Quasi RCT
12 m ↓
Embedded CGA—service in the ED
Ellis [31]
65+ AND
ACE unit: rapid and thorough CGA → admission avoidance or specialty admission
Geriatrician and experienced older people nurse
7d ↔
↔
N/A
12m ↔
12m ↔
Pre-post evaluation
Functional impairment OR cognitive impairment OR falls or other GER syndromes OR care home pat
Specific policy, geriatric infrastructure
30d ↔
Keyes [32]
65+
Senior ED:
Nurses, social workers, pharmacist and physician
30d ↔
↓
N/A
N/A
N/A
CGA → problem identification → case management
(Retrospective) pre-post evaluation
Staff training and education, geriatric infrastructure
Conroy [33]
Frail older people
Emergency frailty unit:
Geriatrician + ED staff
7d ↔
↓
N/A
N/A
N/A
Embedded CGA service—vertically integrated care pathways
30d ↔
Pre-post cohort study
Staff education
90d ↓
The current evidence base is limited by methodological issues and overall poor quality of the studies (e.g. lack of power), and heterogeneity in intervention and outcomes makes the comparison of the existing literature difficult. Positive elements include interventions with targeting of a population at risk, discrete beds for geriatric patient on the ED, specialised trained caregivers, a multidisciplinary approach and home-based follow-up to improve adherence to the given recommendations.
6.5 Practical Examples of Comprehensive Geriatric Assessment
Before CGA
Vera, an 80-year-old lady, attended the ED following a fall. A primary survey revealed no major injuries, and there was no evidence of any head trauma. The assessing doctor felt that the fall was ‘mechanical’ and that there was no suggestion of any syncope. Near-patient tests revealed slightly low sodium. The doctor assessing Vera felt that she was safe to go home and arranged for her daughter to collect her and asked that they see the GP in a week to get the sodium levels looked into.
Vera was taken home by her daughter feeling reassured but had a second fall 2 days later; on this occasion she injured her hip; she was again taken to the ED where an X-ray revealed a hip fracture that required surgery. The surgery was successful, but post-operatively Vera developed delirium thought to be related to infection; antibiotics were given which caused some diarrhoea, but all eventually settled. After a period of convalescence in a community hospital, Vera returned home after 6 weeks, although her confidence remained low.
After CGA
…same doctor assessment….
The admitting nurse had completed a frailty screening tool which indicated that Vera had some cognitive impairment and polypharmacy and needed help with activities of daily living indicating that she was at high risk of readmission (ISAR score 3). Whilst the doctor was awaiting the blood test results, the nurse arranged for a review by the frailty team. The frailty nurse undertook a holistic assessment, which revealed that Vera had significant cognitive impairment (MMSE 24/30). The frailty nurse phoned Vera’s daughter who confirmed what appeared to be a history of undiagnosed dementia and also mentioned how stressed she had been over recent weeks, as she was the main carer for her mum. There had been several falls, and Vera’s confusion had been worsening over the last few days. The frailty nurse asked the duty geriatrician to review Vera; this led to diuretics being stopped as a likely cause of the low sodium. A referral to the falls service was made; in addition, the intermediate care team were asked to see Vera at home and support her for a few weeks. The geriatricians discussed Vera’s case with her GP, who was happy to monitor the sodium levels and fluid status—he also agreed to refer to the memory clinic. Vera left the department and made a gradual but uneventful recovery at home without readmission.
6.6 How to Conduct Comprehensive Geriatric Assessment in the Emergency Department
The ED provides an early opportunity to initiate CGA in a targeted population of frail older patients. Within the ED, it is possible and useful to initiate CGA and to identify domains at risk within the older patient and identify management strategies; these might be delivered in the acute hospital or in the community according to individual needs. A suggested approach to delivering CGA in the ED is outlined here.
6.6.1 Problem Detection
6.6.1.1 Problem Detection: Identification of the High-Risk Population
Older people are a heterogeneous group. Current triage at the front door of the hospital prioritises using physiological parameters. Conventional triage often fails to detect and identify the complexity seen in frail older people; frailty itself is a marker of poor outcomes following an acute care episode [40]. The identification of high-risk patients using the frailty paradigm during the ED visit is important to identify the need for additional assessment.
Frailty has an important role in the identification of patients at risk for adverse events following discharge from ED. Many tools have been developed, but they have significant limitations when operationalised in the ED. Examples include the identification of seniors at risk (ISAR) and the triage risk-stratification tool (TRST) [41–45]. The tools are relatively easy to use but have limitations in their predictive accuracy, as mentioned above. Those instruments can give some direction but cannot be used as a stand-alone test and should be combined with clinical judgement.
6.6.1.2 Problem Detection: Domains of Assessment
As the most important tasks of the ED are focused on diagnosis and appropriate discharge management, e.g. discharge home with referral for ambulatory follow-up or admission to an acute geriatric unit for the high-risk patients, the assessment of functional problems, cognitive impairment, polypharmacy, falls and existing help must be seen as essential information in the ED. During the ED admission, it is important to detect those problems and manage them as where possible within the complex ED environment.
6.6.1.2.1 Functionality
Loss of function can lead to a loss of self-care and lead to a risk of loss of independence and institutionalisation. Functional decline is nearly always related to an underlying disease process and should be interpreted accordingly [46]. It is important to compare the premorbid function with function at the time of the ED visit. After the diagnosis and treatment of underlying diseases, interventions including rehabilitation and optimisation of home care can be initiated in the ED. Different, easy-to-complete scales (such as Katz [10] and/or Barthel [47]) can be used to map the functional evolution of the patient.
6.6.1.2.2 Cognition
The identification of cognitive impairment , whether dementia or delirium, is essential in the ED. The detection of previously unknown subclinical cognitive impairment is very useful in the ED. A positive screen requires further evaluation, first differentiating delirium (see Chap. 13) from dementia (see Chap. 13). Several short instruments can be used, e.g. 4-AT and Mini-Cog [48, 49]. In addition to identifying the immediate clinical scenario, diagnosing cognitive impairment may well have an impact on clinical decision-making and prognosis.
Delirium is associated with poor outcomes and may be related to the underlying disorders. It is associated with a longer length of stay, in-patient harm, reduced quality of life and death [50]. Early detection of symptoms and a search for the underlying cause must be started as soon as possible in the first few hours after ED admission.
6.6.1.2.3 Depression
Depression is the most common mental health problem in old age, and aetiological factors such as social isolation and chronic physical illness mean that an ageing population will be a more depressed one too. The Geriatric Depression Scale-5 [51] is a quick useful tool to screen for depression. Older people who self-harm have high levels of suicidal intent [52, 53] and often have ongoing suicidal ideation after presentation. The adverse effects on cognitive function of common drugs used in self-harm, such as tricyclic antidepressants, may make detection of the act more difficult. Additionally, older people with delirium or dementia may present with unintentional self-harm which, if undetected, could have adverse consequences.
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