Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma

Transcription

1 D. Eagles et al. 20. Fuller LM, Button B, Tarrant B et al. Patients expectations and experiences of rehabilitation following lung transplantation. Clin Transplant 2014; 28: Meis JJM, Bosma CB, Spruit MA et al. A qualitative assessment of COPD patients experiences of pulmonary rehabilitation and guidance by healthcare professionals. Resp Med 2014; 108: Raymond MJ, Burge AT, Soh SE, Jeffs KJ, Winter A, Holland AE. Experiences of older adults in a group physiotherapy program at a rehabilitation hospital: a qualitative study. J Hosp Med 2016; 11: Galvão DA, Taaffe DR. Resistance training for the older adult: manipulating training variables to enhance muscle strength. Strength Cond J 2005; 27: de Morton NA, Berlowitz DJ, Keating JL. A systematic review of mobility instruments and their measurement properties for older acute medical patients. Health Qual Life Outcomes 2008; 6: 44. Received 18 June 2016; editorial decision 22 September 2016 Age and Ageing 2017; 46: The Author Published by Oxford University Press on behalf of the British Geriatrics Society. doi: /ageing/afw184 All rights reserved. For Permissions, please journals.permissions@oup.com Published electronically 19 October 2016 Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma DEBRA EAGLES 1,2,JEFFREY J. PERRY 2,MARIE-JOSÉE SIROIS 1,EDDY LANG 3,RAOUL DAOUST 4,JACQUES LEE 5, LAUREN GRIFFITH 6,LAURA WILDING 2,XAVIER NEVEU 7,MARCEL EMOND 1 1 Université Laval, Québec City, Québec, Canada 2 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada 3 Alberta Health Science Center, Calgary, Alberta, Canada 4 Hôpital du Sacre-Coeur de Montreal, Montreal, Québec, Canada 5 Sunnybrook Research Institute, Toronto, Ontario, Canada 6 McMaster University, Hamilton, Ontario, Canada 7 Research Center, CHU de Québec, Québec City, Québec, Canada Presented at: Canadian Association of Emergency Physicians Scientific Assembly, Edmonton, AB, June Address correspondence to: D. Eagles, Université Laval, Québec City, Québec; University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario, Canada. Tel: ext ; Fax: deagles@toh.ca Abstract Background: there is no standardised test for assessing mobility in the Emergency Department (ED). Objective: we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma. Methods: this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated. Results: TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores seconds, seconds and 30 seconds, respectively: (i) frailty RR (95% CI): 1.8 ( ), 3.0 ( ) and 3.7 ( ); (ii) functional decline RR (95% CI): 2.7 ( ), 5.5 ( ) and 8.9 ( ); (iii) falls RR (95% CI): 0.9 ( ), 1.3 ( ) and 1.1 ( ). 214

2 Timed Up and Go predicts functional decline in older patients Conclusion: in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline. Keywords: functional decline, emergency department, trauma, geriatrics, older people Introduction Trauma accounts for 25% of all Emergency Department (ED) visits by Canadians 65 years and older [1]. Eighty percent of these injuries are secondary to a fall [2]. The majority, 65 79%, of these older patients are discharged home [3, 4]. Unfortunately, even in community dwelling functionally independent older persons, minor trauma is a precursor to functional decline and ultimately diminished quality of life [2, 5]. The Timed Up and Go (TUG) was originally described by Podsiadlo et al. as a mobility test for frail older persons [6]. The test consists of the time it takes for the patient to rise from an armed chair, walk 3 metres at their usual speed and with their usual gait aid, turn and return to the seated position in the chair. The American College of Emergency Physicians, the American Geriatrics Society, the Emergency Nurses Association and the Society for Academic Emergency Medicine recently published Geriatric Emergency Medicine Guidelines in which they recommended a gait evaluation using the TUG as part of a safety assessment in older patients considered for discharge from the ED following a fall [7]. Studies have shown that most patients do not receive care consistent with guideline recommendations for the management of patients sustaining a fall [4, 8]. Sirois et al. found that the suboptimal ED care for independent injured seniors originates from the ED physicians difficulty to discriminate between patients at risk of decline from those who are not [9]. Emergency visits are missed opportunities for interventions and seniors discharged without receiving optimal care are at risk of functional decline [4, 10, 11]. There have been few studies that have evaluated use of the TUG in older patients presenting to the ED [12 14]. The TUG assesses immediate mobility status to inform discharge dispositions in older patients who have fallen. It is unclear if it can also be used to identify those at increased risk who may benefit from further evaluation or treatment programs in an effort to mitigate poor outcomes in older patients who have experienced minor trauma. Our study objective is to evaluate the relationship between the TUG and frailty, functional decline and future falls up to 6 months, in older community dwelling patients presenting to the ED following minor trauma. Methods Study design This research was conducted as part of the Canadian Emergency Team Initiative in mobility in aging. It was a secondary analysis of a large Canadian multi-centre prospective cohort study examining functional decline in older community dwelling patients presenting to the ED following minor trauma, the full details of which have been previously described [2]. The study was approved by Research Ethics Boards at all sites. Study setting and population The study was conducted from March 2011 to June 2015 at eight Canadian EDs. Patients, 65 years and older, who presented to the ED for evaluation of minor trauma they had sustained within the prior 2 weeks, who were independent in activities of daily living and discharged home from the ED were eligible for the main study. Minor trauma was defined on the basis of the ED physician assessment as an anatomical lesion which: (i) did not require a period of in-hospital observation for possible medico-surgical deterioration/complication; or (ii) may require minor outpatient procedures after ED medical evaluation. It was pre-specified in the protocol that approximately 1/3 of enrolled patients would be recruited to participate in the in-person interviews and physical measures (including the TUG). Eligibility was based on availability of research assistants, thus did not occur in late evening or overnight hours. Only those patients whose assessment included a TUG, were included in this substudy. Patients were excluded if they were from long-term care, admitted to hospital, non-english or French speaking, unable to give consent or return for follow-up assessments. Study protocol Physicians enrolled eligible patients 24 hours per day, 7 days per week by completing the study enrolment form. The comprehensive study evaluation was completed by: (i) a Geriatric Emergency Management nurse, or (ii) a research assistant. Inperson or phone evaluations were conducted at the time of the ED visit (or within 3 days) and at 3 and 6 months. Study measures Patient evaluation consisted of the following measures: (1) The TUG was used to measure mobility. Scores were categorised as <10 seconds, seconds, seconds and 30 seconds as originally described by Podsialo [6]. (2) The Older Americans Resources and Service Scale was used to measure functional status, with a decrease of 2/28 points on the Scale defined as functional decline [15 17]. 215

3 D. Eagles et al. (3) Short Falls Efficacy Scale International was used to measure fear of falling. A cut-off >9.8 was used. (4) The Study of Osteoporotic Fractures Frailty Index (SOF) was used to determine frailty at the time of the ED visit [18, 19]. There are three components: unintentional weight loss 10 pounds, inability to rise from chair five times and self-identified poor energy. Patients are categorised as robust if they did not have any components of the Index and are categorised as prefrail/ frail if they had one or more components in the Index. (5) The Montreal Cognitive Assessment was used to measure cognitive impairment. A score of 22 or less signified cognitive impairment [20]. (6) Self-report falls. Patients were asked since the last time they were assessed, if they have fallen hard enough to feel pain afterwards. If they answered yes, they were asked to recall how many times they had fallen. Data analysis Descriptive statistics were used to describe patient demographics. Generalised linear modelling with log-binomial distribution was used to evaluate the association between TUG scores and our study measures. Relative risk (RR) with 95% confidence intervals were calculated, using TUG <10 seconds as our reference standard [6]. Data were analyzed using SAS software version 9.02 (SAS Institute, Inc., Cary, NC). Results Of the possible 4,088 eligible patients that presented during the study period, 2,918 (71.4%) were enrolled. TUG scores on initial presentation to the ED were recorded for 911 patients (31.2%). These 911 patients compose the patient cohort for this study. There were 203 (40.3%) and 163 (32.3%) patients at 3- and 6-month follow-up, respectively. Supplementary Figure S1, available in Age and Ageing online, illustrates the patient flow diagram. Table 1 shows characteristics of all enrolled patients, those with TUG and without TUG attempted. Patients with TUG scores had a mean age of 76.2 (SD 7.8) years and 57.9% were female. Although 37.1% had five or more co-morbidities, the majority (59.9%) were considered robust, as per the Study of Osteoporotic Fracture Frailty Index. Falling was the most common cause of injury, with 29.9% sustaining a fracture as a result of their minor trauma. Patients that did not have a TUG completed were more likely to be female (68.4% versus 57.9%), have a fear of falling (49.8% versus 44.4%) and occasional use of a walking aid (21.5% versus 18.2%). Patient characteristics stratified by initial TUG time can be found in Supplementary Table S1, available in Age and Ageing online. Figure 1 illustrates progression over time in patients whose initial TUG times were <10 seconds, seconds, seconds and 30 seconds. The TUG times at 3 and 6 months remain relatively stable in those with time <20 seconds. TUG times improve over time in those with initial TUG times 20 seconds. The number of patients in each TUG category at 0, 216 Table 1. Characteristics of older, independent patients presenting to the ED following minor trauma Characteristic, TUG attempted No TUG attempted P-value N (%) a N = 911 (31.2%) N = 2007 (68.8%)... Age Mean (SD) 76.2 (7.8) 76.4 (7.5) years 433 (47.5) 898 (44.7) years 323 (35.5) 794 (39.5) 85+ years 155 (17.0) 315 (15.7) Gender Female 527 (57.9) 1373 (68.4) < Number of co-morbidities (15.7) 326 (16.3) (47.2) 952 (47.6) (37.1) 723 (36.1) Short falls efficacy 403 (44.4) 991 (49.8) 0.01 scale <9.8 Montreal cognitive 225 (27.2) 24 (29.3) 0.69 assessment 22 SOF b frailty index 393 (59.9) 21 (61.8) 0.83 Robust Occasional use of a 164 (18.2) 425 (21.5) 0.04 walking aid Mechanism of injury Falls own height 565 (64.9) 1270 (65.4) 0.07 Falls high height 92 (10.6) 252 (13.0) Motor vehicle 30 (3.5) 77 (4.0) accident Other 183 (21.0) 341 (17.6) Type of injury c Tear 32 (3.6) 61 (3.1) 0.45 Abrasion 57 (6.5) 174 (8.8) 0.03 Luxation 22 (2.5) 54 (2.7) 0.71 Laceration 233 (26.5) 501 (25.4) 0.56 Contusion 324 (36.8) 728 (36.9) 0.94 Sprain 101 (11.5) 213 (10.8) 0.60 Fracture 263 (29.9) 586 (29.7) 0.95 Avulsion 3 (0.3) 12 (0.6) 0.58 d Traumatic brain injury 152 (17.2) 343 (17.4) 0.92 Location (injured body region) c Head / neck/ 298 (32.7) 735 (36.6) 0.04 face Spine 43 (4.7) 80 (4.0) 0.36 Upper limb 330 (36.2) 711 (35.4) 0.67 Thorax 110 (12.1) 206 (10.3) 0.14 Abdomen 11 (1.2) 36 (1.8) 0.24 Lower limb 250 (27.4) 592 (29.5) 0.26 Multiple 149 (16.4) 389 (19.4) 0.05 Number of self-reported falls 1 fall 135 (75.0) 332 (77.9) falls 45 (25.0) 94 (22.1) Functional decline at 3 or 6 months 107 (13.4) 301 (17.6) 0.01 a Because of missing data, the number of patients does not always add up to the total. b Study of Osteoporotic Fracture Frailty Index. c Not mutually exclusive. d Fisher exact test. 3 and 6 months is shown in Supplementary Table S2, available in Age and Ageing online. RRs of frailty, functional decline and falls is shown in Table 2. An older patient who was previously independent,

4 Timed Up and Go predicts functional decline in older patients with a TUG score 30 seconds has 3.7 times the risk of frailty compared with patients with a normal TUG score of <10 seconds. Likewise, the risk of functional decline at 3 and 6 months increases with increasing TUG times, such that the RR of functional decline at 3 months is 8.9 times greater in those with the highest TUG times. There was no association between TUG times and self-reported falls. Discussion This is the largest prospective multi-centre study to assess use of the TUG in independent community dwelling older persons presenting to the ED following minor trauma. We found that the longer it took to complete the TUG test, the greater the patients RR of frailty at baseline and functional decline at 3 and 6 months. Our findings are consistent with studies conducted in non-ed settings. Clegg et al. conducted a systematic review to evaluate the diagnostic accuracy of various instruments for identifying frailty in older community dwelling individuals. Using a cut-off of <10 seconds, they found the TUG had a sensitivity of 0.93 and a specificity of 0.62 to predict frailty [21]. Our study found that the risk of frailty increases as time to complete TUG increases. The TUG s inability to TIME IN SECONDS MONTH 0 MONTH 3 MONTH 6 <10 sec sec sec. 30 sec. unable to perform Figure 1. Mean TUG scores over time for older, minor trauma patients with initial mean TUG times <10 seconds, seconds, seconds and >30 seconds. Table 2. Crude RR of frailty, functional decline and self-reported falls predict future fall risk in our study was also demonstrated in recent meta-analyses involving community dwelling elders [22 24]. There are few studies that report use of the TUG within the ED. Boye et al. found that mean TUG times in patients with history of recurrent falls was higher than in patients with history of a single fall [5]. Russell et al. reported on functional decline in previously independent older ED patients following a fall [25]. There are several differences in the study methodology. Russell et al. did not use a validated functional decline measure, instead they defined functional decline as requiring assistance with at least one domestic and/or personal ADL that the participant did not require with prior to the fall ; theyuseda TUG cut-off of >12 seconds; and patients were assessed on average 20 days post ED visit). They noted that a slower TUG time was associated with functional decline. Caterino et al. evaluated patients 60 years and older discharged from the ED and found no relationship between TUG times and self-reported history of falling in the previous year [26]. This study has several limitations. Those with a TUG completed were less likely to be female, to have a fear of falling and use a gait aid occasionally. Overall, patients enrolled in the TUG substudy (attempted TUG) were similar in terms of age, co-morbidities, frailty and cognitive status to those who did not attempt the TUG. It is likely therefore that the results from the substudy of patients that were evaluated with the TUG are generalisable to our larger population. At 911 patients, it is one of the largest ED studies to evaluate mobility in older ED patients following minor trauma. However, the number of patients with completed TUG scores decreased at each time point. It is possible that patients who completed the TUG at 3 and 6 months had better functional outcomes than those that did not (and thus were able to attend their follow-up evaluations). If this were the case, the functional decline might in fact be underestimated in this study. The lack of association between TUG scores and future falls may be in part due to limited power of the study. The TUG has various cut-off times that have been utilised within the literature. It is unclear what the optimal cut point is. It may vary depending on the outcome and the study population [24, 27, 28]. We chose to use <10 Relative risk (95% confidence interval) P-value TUG <10 s N = 201 TUG s N = 397 TUG s N = 78 TUG 30 s N = 24 Unable to perform N = Frailty Reference 1.8 ( ) 3.0 ( ) 3.7 ( ) 2.6 ( ) < Functional decline 3 months Reference 2.7 ( ) 5.5 ( ) 8.9 ( ) 5.4 ( ) < months Reference 2.4 ( ) 5.5 ( ) 7.3 ( ) 3.8 ( ) Self-reported falls 3 months Reference 0.9 ( ) 1.3 ( ) 1.1 ( ) 0.9 ( ) months Reference 1.2 ( ) 1.0 ( ) 1.5 ( ) 0.9 ( )

5 D. Eagles et al. seconds as this is what was originally described by Podsiadlo et al. [6]. Our results suggest that the TUG is a useful test for use in the ED in older patients following minor trauma. No specialised equipment is required to perform the test. In those who were asked to perform the TUG, greater than 76% were able to complete the test initially, and the test took less than 30 seconds to complete 97% of the time. Further studies that evaluate the feasibility of implementation of the TUG, prior to discharge in older minor trauma patients are warranted. More importantly, evaluating the impact that this implementation has on subsequent referral for specialised geriatric programs, including falls programs is necessary. The TUG test should be used to assess functionally independent, community dwelling older persons presenting to the ED following minor trauma. Increased time to complete the test is associated with increased risk of frailty and functional decline at 3 and 6 months. Early identification of a high risk patient should trigger referrals to more comprehensive geriatric or falls prevention in order to optimise safety and long-term functioning. This is the first step towards improving care following minor trauma and may help decrease the negative outcomes associated with this common ED presentation in older patients. Key points Mobility evaluations are recommended as part of guideline care in older patients who have sustained a fall. This multi-centre prospective cohort study examined use of the TUG in older, community dwelling patients that presented to the ED following minor trauma. TUG scores were associated with functional decline at 3 and 6 months and frailty but not self-reported falls. Use of the TUG in older, minor trauma ED patients will help identify frail patients at risk of functional decline. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Acknowledgements We would like to thank all the emergency and research professionals who participated at all our study sites. Funding We acknowledge the Canadian Institutes of Health Research for funding this study through their emerging team grant in mobility in ageing (CIHR-91752). 218 REFERENCES 1. Canadian Institute for Health Information Highlights of Inpatient Hospitalizations and Emergency Department Visits. Ottawa, Ontario, Canada: Canadian Institute for Health Information, Sirois MJ, Emond M, Ouellet MC et al. Cumulative incidence of functional decline after minor injuries in previously independent older Canadian individuals in the emergency department. J Am Geriatr Soc 2013; 61: Scott V, Pearce M, Pengelly C. Technical report: Injury resulting from falls among Canadians 65 and over. 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6 Predicting functional decline in older emergency patients 17. Bissett M, Cusick A, Lannin NA. Functional assessments utilised in emergency departments: a systematic review. Age Ageing 2013; 42: Ensrud KE, Ewing SK, Taylor BC et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Intern Med 2008; 168: Kiely DK, Cupples LA, Lipsitz LA. Validation and comparison of two frailty indexes: the MOBILIZE Boston Study. J Am Geriatr Soc 2009; 57: Rossetti HC, Lacritz LH, Cullum CM, Weiner MF. Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample. Neurology 2011; 77: Clegg A, Rogers L, Young J. Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review. Age Ageing 2015; 44: Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr 2014; 14: Beauchet O, Fantino B, Allali G, Muir SW, Montero-Odasso M, Annweiler C. Timed Up and Go test and risk of falls in older adults: a systematic review. J Nutr Health Aging 2011; 15: Schoene D, Wu SM, Mikolaizak AS et al. Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc 2013; 61: Russell MA, Hill KD, Blackberry I, Day LL, Dharmage SC. Falls risk and functional decline in older fallers discharged directly from emergency departments. J Gerontol A Biol Sci Med Sci 2006; 61: Caterino JM, Karaman R, Arora V, Martin JL, Hiestand BC. Comparison of balance assessment modalities in emergency department elders: a pilot cross-sectional observational study. BMC Emerg Med 2009; 9: Kojima G, Masud T, Kendrick D et al. Does the timed up and go test predict future falls among British communitydwelling older people? Prospective cohort study nested within a randomised controlled trial. BMC Geriatr 2015; 15: Kim MJ, Yabushita N, Kim MK, Nemoto M, Seino S, Tanaka K. Mobility performance tests for discriminating high risk of frailty in community-dwelling older women. Arch Gerontol Geriatr 2010; 51: Received 10 May 2016; accepted in revised form 27 September 2016 Age and Ageing 2017; 46: The Author Published by Oxford University Press on behalf of the British Geriatrics Society. doi: /ageing/afw210 All rights reserved. For permissions, please journals.permissions@oup.com Published electronically 7 December 2016 Predicting functional decline in older emergency patients the Safe Elderly Emergency Discharge (SEED) project JUDY A. LOWTHIAN 1,LAHN D. STRANEY 1,CAROLINE A. BRAND 1,ANNA BARKER 1,P.DE VILLIERS SMIT 2, HARVEY NEWNHAM 3,PETER HUNTER 4,CATHIE SMITH 2,PETER A. CAMERON 1,2 1 Department of Epidemiology & Preventive Medicine, Monash University, Level 6, Alfred Centre 99 Commercial Road, Melbourne, Victoria 3004, Australia 2 Alfred Health, Emergency & Trauma Centre, Melbourne, Victoria, Australia 3 The Alfred Hospital, Victoria, Australia 4 Caulfield Hospital, Alfred Health, Department of Aged Care, Melbourne, Victoria, Australia Address correspondence to: J. Lowthian. Tel: (+61) ; Fax: (+61) judy.lowthian@monash.edu Abstract Objective: to profile the trajectory of, and risk factors for, functional decline in older patients in the 30 days following Emergency Department (ED) discharge. Methods: prospective cohort study of community-dwelling patients aged 65 years, discharged home from a metropolitan Melbourne ED, 31 July 2012 to 30 November The primary outcome was functional decline, comprising either increased dependency in personal activities of daily living (ADL) or in skills required for living independently instrumental ADL (IADL), deterioration in cognitive function, nursing home admission or death. Univariate analyses were used to select risk factors and logistic regression models constructed to predict functional decline. 219