A Brief Risk Stratification Tool to Predict Functional Decline in Older Adults Discharged from Emergency Departments

Authors

  • Fredric M. Hustey MD,

    1. From the *Department of Emergency Medicine and ††Section of Geriatric Medicine, Cleveland Clinic, Cleveland, OhioLerner College of Medicine, Cleveland Clinic and §School of Medicine, Case Western Reserve University, Cleveland, OhioDepartment of Nursing Research, MetroHealth Medical Center, Cleveland, OhioBerry Consultants, Noblesville, Indiana; and Departments of Emergency Medicine**Geriatric Medicine, MetroHealth Medical Center, Cleveland, Ohio.
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  • Lorraine C. Mion PhD, RN,

    1. From the *Department of Emergency Medicine and ††Section of Geriatric Medicine, Cleveland Clinic, Cleveland, OhioLerner College of Medicine, Cleveland Clinic and §School of Medicine, Case Western Reserve University, Cleveland, OhioDepartment of Nursing Research, MetroHealth Medical Center, Cleveland, OhioBerry Consultants, Noblesville, Indiana; and Departments of Emergency Medicine**Geriatric Medicine, MetroHealth Medical Center, Cleveland, Ohio.
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  • Jason T. Connor PhD,

    1. From the *Department of Emergency Medicine and ††Section of Geriatric Medicine, Cleveland Clinic, Cleveland, OhioLerner College of Medicine, Cleveland Clinic and §School of Medicine, Case Western Reserve University, Cleveland, OhioDepartment of Nursing Research, MetroHealth Medical Center, Cleveland, OhioBerry Consultants, Noblesville, Indiana; and Departments of Emergency Medicine**Geriatric Medicine, MetroHealth Medical Center, Cleveland, Ohio.
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  • Charles L. Emerman MD,

    1. From the *Department of Emergency Medicine and ††Section of Geriatric Medicine, Cleveland Clinic, Cleveland, OhioLerner College of Medicine, Cleveland Clinic and §School of Medicine, Case Western Reserve University, Cleveland, OhioDepartment of Nursing Research, MetroHealth Medical Center, Cleveland, OhioBerry Consultants, Noblesville, Indiana; and Departments of Emergency Medicine**Geriatric Medicine, MetroHealth Medical Center, Cleveland, Ohio.
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  • James Campbell MD, MS,

    1. From the *Department of Emergency Medicine and ††Section of Geriatric Medicine, Cleveland Clinic, Cleveland, OhioLerner College of Medicine, Cleveland Clinic and §School of Medicine, Case Western Reserve University, Cleveland, OhioDepartment of Nursing Research, MetroHealth Medical Center, Cleveland, OhioBerry Consultants, Noblesville, Indiana; and Departments of Emergency Medicine**Geriatric Medicine, MetroHealth Medical Center, Cleveland, Ohio.
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  • Robert M. Palmer MD, MPH

    1. From the *Department of Emergency Medicine and ††Section of Geriatric Medicine, Cleveland Clinic, Cleveland, OhioLerner College of Medicine, Cleveland Clinic and §School of Medicine, Case Western Reserve University, Cleveland, OhioDepartment of Nursing Research, MetroHealth Medical Center, Cleveland, OhioBerry Consultants, Noblesville, Indiana; and Departments of Emergency Medicine**Geriatric Medicine, MetroHealth Medical Center, Cleveland, Ohio.
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Address correspondence to Fredric M. Hustey, MD, Department of Emergency Medicine-E-19, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: husteyf@ccf.org

Abstract

OBJECTIVES: To determine the effectiveness of the six-item Triage Risk Screening Tool (TRST) to assess baseline functional status and predict subsequent functional decline in older community-dwelling adults discharged home from the emergency department (ED).

DESIGN: Secondary data analysis of a randomized, controlled trial.

SETTING: EDs of two urban academic hospitals.

PARTICIPANTS: Six hundred fifty community-dwelling adults aged 65 and older presenting to the ED and discharged home. Patients were categorized a priori as “high risk” if they had cognitive impairment or two or more risk factors on the TRST.

MEASUREMENTS: Functional status: summed activity of daily living (ADL) and instrumental activity of daily living (IADL) scores at baseline, 30 days, and 120 days. Self-perceived physical health: standardized physical health component of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Functional decline: loss of one or more ADLs and one or more IADLs from ED baseline at 30 and 120 days. Decline in self-perceived physical health: follow-up SF-36 standardized physical health component scores four or more points lower than baseline.

RESULTS: TRST scores correlated with baseline ADL impairments, IADL impairments, and self-perceived physical health at all endpoints (P<.001). A TRST score of two or more was moderately predictive of decline in ADLs or IADLs (30-day ADL area under the receiver operating characteristic curve (AUC)=0.64; 95% confidence interval (CI)=0.56–0.72; 120-day ADL AUC=0.66; 95% CI=0.58–0.74) but not perceived physical health.

CONCLUSION: The TRST identifies baseline functional impairment in older ED patients and is moderately predictive of subsequent functional decline after an initial ED visit. The TRST provides a valid proxy measure for assessing functional status in the ED and may be useful in identifying high-risk patients who would benefit from referrals for further evaluation or surveillance upon ED discharge.

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