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The following handle holds various files of this Leiden University dissertation:
http://hdl.handle.net/1887/79262
Author: Gelder, J. de
Title: Prediction of adverse health outcomes in older patients visiting the Emergency
Department: the APOP study
Abstrac
General introduction
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General introduction
Older patients experience high rates of adverse health outcomes after visiting the emergency department (ED),[1] but at the moment of acute presentation it is difficult to determine who will deteriorate. Identification of older patients at risk for adverse health outcomes with a screening instrument may be helpful to assist health care professionals to anticipate on the risk of possible deterioration and deliver care accordingly. Several screening instruments have been developed, of which the Identification of Seniors at Risk (ISAR)[2] and Triage Risk Stratification Tool (TRST)[3] are studied most. Usability of such risk stratification screening instruments is debated, due to the limitation in distinguishing low from high risk patients and because a relatively high proportion of patients is incorrectly assigned as ‘high risk’.[4, 5] To date, there still is a lack of pragmatic, accurate and reliable instruments for risk stratification of older patients in the ED.[4]
The rate of adverse health outcomes is particularly high in the first three months after the ED visit. Approximately 10% will die and up to 45% will experience functional decline. [1] A comprehensive geriatric assessment (CGA) is able to identify the older patients at increased risk and consequently improve outcomes.[6] Performing a CGA in the acute setting is virtually impossible, due to the time limitation and often the condition of the patient. Therefore, another strategy is necessary in order to identify those at high risk. A two-step approach is suggested in order to reduce the incidence of adverse health outcomes.[7] First a screening instrument is needed to identify the patients at increased risk. The second step is to target interventions in patients at highest risk. Interventions which are tailored to the individuals’ need and preferences, for example determined with a CGA, can help older patients to maintain independence.[6, 8]
The ED is designed for acutely ill and injured patients and is characterized by a high patient turnover, rapid triage, acute interventions and with a focus on disposition.[1, 9] Since the 1980’s scientists payed increasing attention to the health care needs of the older patients[10] and now in the 21st century the need to redesign the core of the ED is
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experienced as an unfamiliar noisy environment, while laying on a thin mattress in a room with little privacy, with the physical examinations being quickly performed and often with a restriction on nutrition and drinks.[19]
Multiple factors contribute to the complexity of delivering adequate care to the older patient in the ED.[18, 20] Approximately 20-40% of this population present with impaired cognition, but this is recognised only in a third of the cases.[11, 21-23] Older patients often present with atypical symptoms, resulting in incomplete resolution of their initial complaints.[1] They have a high prevalence of comorbidities, which causes that physicians have to deal with a mixture of chronic, subacute and acute issues.[22, 24, 25] The complex older patients in the ED challenges physicians to deliver adequate (after)care for the individual patient.
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Outline of the thesis
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References
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comparison between patients younger or older than 70 years. Emerg Med J, 2018. 35 (1): p. 18-27.
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