Estimating the risk of functional decline in the elderly after discharge from an Australian public tertiary hospital emergency departmentKaren Grimmer A E , Kate Beaton A , Saravana Kumar A , Kevan Hendry A , John Moss B , Susan Hillier A , John Forward C and Louise Gordge D
B Discipline of Public Health, University of Adelaide, Level 7, 178 North Terrace, Mail Drop DX650 550, Adelaide, SA, Australia. Email: John.email@example.com
C Aged Care, Rehabilitation & Palliative Care Division, Northern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia. Email: firstname.lastname@example.org
D Royal Adelaide Hospital, North Terrace, SA Health, Adelaide, SA, Australia. Email: email@example.com
E Corresponding author. Email: firstname.lastname@example.org
Australian Health Review 37(3) 341-347 http://dx.doi.org/10.1071/AH12034
Submitted: 25 June 2012 Accepted: 17 December 2012 Published: 24 May 2013
Objective. To estimate the risk of functional decline after discharge for older people presenting to, and discharged from, a large emergency department (ED) of a tertiary hospital.
Methods. The cohort was generated by consecutive sampling of non-Indigenous males and females aged 65 years or over or Aboriginal and Torres Strait Islander males and females aged 45 years or more, without diagnosed dementia, who were living independently in the community before presenting at ED and who were not admitted to hospital as an inpatient after presenting to ED. The hospital assessment risk profile (HARP) was administered to all eligible participants. Sociodemographic information was collected.
Results. Approximately 40 patients per day over two 14-week data collection periods were potentially eligible for inclusion in the study. In total, 597 (17.6% of individuals who presented to ED) were eligible, agreed to participate and continued to be eligible on discharge from ED. Their HARP scores suggested that ~52% were at-risk of functional decline (14.1% high risk, 38.5% intermediate risk).
Conclusions. Elderly patients present to and are discharged from ED every day. The routinely administered HARP instrument scores suggested that approximately half these individuals were at-risk of functional decline in one large hospital ED. Given this instrument’s moderate diagnostic accuracy, the true figure may be higher. We suggest that all over-65 year olds presenting at ED without being admitted as an inpatient should be considered for routine screening for potential downstream functional decline, and for intervention if indicated.
What is known about the topic? Older individuals often present to ED in lieu of consulting a general medical practitioner, and are not admitted to a hospital bed. Patient demographics, functional and mental capacity and reasons for presentation may be flags for functional decline in the coming months. These could be used by ED staff to implement targeted assessment and intervention.
What does this paper add? This paper highlights the high percentage of older individuals who, at time of ED presentation, are at-risk of downstream functional decline.
What are the implications for practitioners? Older people who are discharged from ED without a hospital admission may ‘slip through the net’, as an ED presentation presents a limited window of opportunity for ED staff to undertake targeted assessment, and intervention, to address the potential for downstream functional decline. The busy nature of ED, resource implications and the range of presenting conditions of older people may preclude this. This research suggests a reality that a large percentage of older people who present at ED but do not require a subsequent hospital admission have the potential for functional decline after discharge. Addressing this, in terms of specific screening processes and interventions, requires a rethink of hospital and community resources, and relationships.
References Covinsky KE, Justice AC, Rosenthal GE. Measuring prognosis and casemix in hospitalized elders: the importance of functional status. J Gen Intern Med 1997; 12 203–8.
| 1:STN:280:DyaK2s3nt1GitQ%3D%3D&md5=a897bb5e1bab9c77693f2509d15ee711CAS | 9127223PubMed |
 Mehta KM, Yaffe K, Covinsky KE. Cognitive impairment, depressive symptoms, and functional decline in older people. J Am Geriatr Soc 2002; 50 1045–50.
| Cognitive impairment, depressive symptoms, and functional decline in older people.CrossRef | 12110064PubMed |
 Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: she was probably able to ambulate, but I’m not sure. J Am Med Assoc JAMA 2011; 306 1782–93.
| Hospitalization-associated disability: she was probably able to ambulate, but I’m not sure. J Am Med Assoc CrossRef | 1:CAS:528:DC%2BC3MXhtl2ktrrK&md5=4becc5c866b9387737df60652c2bf402CAS | 22028354PubMed |
 Fortinsky RH, Covinsky KE, Palmer RM. Effect of functional changes before and during hospitalization on nursing home admission of older adults. J Gerontol A Biol Sci Med Sci 1999; 54A M521–6.
| Effect of functional changes before and during hospitalization on nursing home admission of older adults.CrossRef |
 Inouye SK, Wagner DR, Acampora D, Horwitx RI, Cooney LM, Hurst LD, et al A predictive index for functional decline in hospitalized elderly patients. J Gen Intern Med 1993; 8 645–52.
| A predictive index for functional decline in hospitalized elderly patients.CrossRef | 1:STN:280:DyaK2c7msFynug%3D%3D&md5=3d0233fee823d46fce779f19c7a73922CAS | 8120679PubMed |
 Boyd CM, Landefeld CS, et al Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc 2008; 56 2171–9.
| Recovery of activities of daily living in older adults after hospitalization for acute medical illness.CrossRef | 19093915PubMed |
 Brand C, Martin-Khan M, et al Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: study protocol. BMC Health Serv Res 2011; 11 281
| Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: study protocol.CrossRef | 22014061PubMed |
 Buurman H, Hoogerduijn JG, van Gemert EA, de Haan RJ, Schuurmans MJ, et al Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: a prospective cohort study. PLoS ONE 2012; 7
| Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: a prospective cohort study.CrossRef | 1:CAS:528:DC%2BC38XptF2kuw%3D%3D&md5=e2e5ed7637af71b4408753b5836b2722CAS |
 Braes T, Flamaing J, et al Predicting the risk of functional decline in older patients admitted to the hospital: a comparison of three screening instruments. Age Ageing 2009; 38 600–3.
| Predicting the risk of functional decline in older patients admitted to the hospital: a comparison of three screening instruments.CrossRef | 19556324PubMed |
 Joyce C, Piterman L. Trends in home visits. Aust Fam Physician 2008; 37 1039–41.
| 19142281PubMed |
 Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department–the DEED II study. J Am Geriatr Soc 2004; 52 1417–23.
| A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department–the DEED II study.CrossRef | 15341540PubMed |
 Australian Institute of Health and Welfare (AIHW). Older Australia at a glance: 4th edition. Canberra: AIHW; 2007: Cat. No. AGE 52.
 Australian Institute of Health and Welfare (AIHW). Older people leaving hospital: a statistical overview of the Transition Care Program in 2008–09 Canberra: Australian Institute of Health and Welfare 2011: Cat. no. AGE 64.2011.
 AHMAC Care of Older Australian Working Group. A guide for assessing older people in hospitals. Available from: www.health.gov.au/internet/main/publishing.nsf/Content/hcoasc-resourcestoassist.htm. t[verified 20 April 2012].
 Grimmer K, May E, Dawson A, Peoples C. Informing discharge plans. Assessments of elderly patients in Australian public hospitals: a field study. Internet J Allied Health Sci Pract 2004; 2 1–10.
 Hustey FM, Mion LC, Connor JT, Emerman CL, Campbell J, Palmer RM. A brief risk stratification tool to predict functional decline in Older Adults Discharged from Emergency Departments. J Am Geriatr Soc 2007; 55 1269–74.
| A brief risk stratification tool to predict functional decline in Older Adults Discharged from Emergency Departments.CrossRef | 17661968PubMed |
 17 Hordacre A, Hurst B, Taylor A. Aboriginal and Torres Strait Islander pilot survey report: South Australian patient evaluation of hospital services (PEHS) survey. 2006. Available at: http://health.adelaide.edu.au/pros/docs/reports/general/atsi_pilot_survey.pdf
 Moss JE. A multidisciplinary care coordination team improves emergency department discharge planning practice. Med J Aust 2002; 177 435
| 12381253PubMed |
 Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al Comprehensive discharge planning and home follow-up of hospitalised elders. A randomised clinical trial. JAMA 1999; 282 1129
 Sager MA, Rudberg MA, Jalaluddin M, Franke T, Inouye SK, Landefeld CS, et al Hospital Admission Risk Profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc 1996; 44 251
| 1:STN:280:DyaK287osVKrsg%3D%3D&md5=7248297ac0bf959f933afc025cf9929cCAS | 8600192PubMed |
 Faraggi D, Reiser B. Estimation of the area under the ROC curve. Stat Med 2002; 21 3093–106.
| Estimation of the area under the ROC curve.CrossRef | 12369084PubMed |
 Sutton M, Grimmer-Somers K, Jeffries L. Screening tools to identify hospitalized elders at risk of functional decline: a systematic review. Int J Clin Pract 2008; 62 1900–9.
| Screening tools to identify hospitalized elders at risk of functional decline: a systematic review.CrossRef | 1:STN:280:DC%2BD1M%2FpsV2gtQ%3D%3D&md5=e93a2777dd15e519a3ff280b5ba88d3dCAS | 19166437PubMed |
 Koenig HG. An abbreviated Mini-Mental State Exam for medically ill older adults. J Am Geriatr Soc 1996; 44 215–16.
| 1:STN:280:DyaK287msFeisg%3D%3D&md5=e849e1fcb3ad757826e1a6ea41d32df8CAS | 8576520PubMed |
 Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969; 9 179–86.
| Assessment of older people: self-maintaining and instrumental activities of daily living.CrossRef | 1:STN:280:DyaE3c%2FivV2kug%3D%3D&md5=e9edb5db4f198632d84002c24612d310CAS | 5349366PubMed |
 Information paper: an introduction to socio-economic indexes for areas (SEIFA); 2006. Available at: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/2039.0Main%20Features42006?opendocument&tabname=Summary&prodno=2039.0&issue=2006&num=&view= [verified xxx].
 International Classification of Diseases and Related Health Problems Version 10 http://apps.who.int/classifications/icd10/browse/2010/en
 de Saint-Hubert M, Jamart J. Comparison of three tools predicting functional decline after hospitalization of older patients. J Am Geriatr Soc 2010; 58 1003–5.
| Comparison of three tools predicting functional decline after hospitalization of older patients.CrossRef | 20722840PubMed |
 Graf C. Try this: best practices in nursing care to older adults. The Hospital Admission Risk Profile (HARP). Annals of long term care. 2009; 17(4):43-4. Available at: http://consultgerirn.org/uploads/File/trythis/try_this_24.pdf
 Costa N, Sullivan M, Walker R, Robertson KM. Emergency department presentations of Victorian Aboriginal and Torres Strait Islander people. Health Inf Manag 2008; 37 15–25.