Part of our role as emergency physician is risk stratification. Like for acute coronary syndrome, TIA, pulmonary embolism, frail older adults can be screened in the ED. Not only they can be screened, but the screening can start at triage.
Why should we screen frail older adults? Great question! It is important because it has been shown that vulnerable elderly are at higher risk of adverse event like death (now you are listening are you?), functional decline, admission and long-term care facility disposition.
There are many tools; here are my top 4 and a summary of their features.
Identification of Senior At Risk. Probably the most well studied and used in various senior-friendly ED. It was designed for patient 65 years and older, presenting in the emergency department. Keep in mind that it is les well studied for patient from long-term care (LTC) or nursing home.
It is simple, six questions, easy asked, easy answered, in less then 2 minutes. It has the ability to predict admission, LTC disposition, even death. Its sensitivity with a score of 2 or more out of six is variable (from 72% to 94%) (1). There are some discrepancy results in the literature. A recent systematic review does not recommend it (2).
In some ED, a score of 2 or more can trigger a consultation with a GEM nurse.
This screening test was developed in Quebec by sending questionnaire to the elderly of the community. Seven of these questions were found to be predictive of functional decline with a sensitivity of 78% and a specificity of 75% at a threshold of 3 positive answers of more (3).
It is also simple, could easily be done at triage, but the thing is, it has never been validated for patient in the emergency department (to my knowledge anyway). Another potential bias is the first question; Are you aged of 85 years or older. Is age really a factor of vulnerability? Probably at some point, probably, but it is not necessarily the case.
It is also a serie of six questions, comparable to the ISAR, with equivalent performance (4).
This one is also Canadian, developed by the group InterRAI. It is easy to perform; there is a free app for that. It is designed for 75 years and older. However, I do not have any information about its performance. Probably those data are coming soon. Interesting!
Whatever screener tool you will choose, it does not have to be perfect, it is a tool, not a rule! Which one WILL be your pick?
- McCusker J, Bellavance F, Cardin S, Belzile E. Validity of an activities of daily living questionnaire among older patients in the emergency department. Journal of clinical epidemiology. 1999 Nov;52(11):1023-30. PubMed PMID: 10526995.
- Thiem U, Heppner HJ, Singler K. Instruments to identify elderly patients in the emergency department in need of geriatric care. Zeitschrift fur Gerontologie und Geriatrie. 2015 Jan;48(1):4-9. PubMed PMID: 25592177.
- Hebert R, Bravo G, Korner-Bitensky N, Voyer L. Predictive validity of a postal questionnaire for screening community-dwelling elderly individuals at risk of functional decline. Age and ageing. 1996 Mar;25(2):159-67. PubMed PMID: 8670547.
- Salvi F, Morichi V, Lorenzetti B, Rossi L, Spazzafumo L, Luzi R, et al. Risk stratification of older patients in the emergency department: comparison between the Identification of Seniors at Risk and Triage Risk Screening Tool. Rejuvenation research. 2012 Jun;15(3):288-94. PubMed PMID: 22730956.