Functional decline following hospitalization remains an important problem in health care, especially for frail older adults. Modifiable factors related to reduction in harms of hospitalization are not well described. One particularly pervasive factor is emergency department (ED) boarding time; time waiting from decision to admit, until transfer to an in-patient medical unit. We sought to investigate how the functional status of frail older adults correlated with the length of time spent boarded in the ED. We found that patients who waited for 24 hours or more exhibited functional decline in both the Barthel Index and Hierarchical Assessment of Balance and Mobility and an increase in the Clinical Frailty Scale from discharge to 6 months post discharge. In conclusion, there is a need for additional investigation into ED focused interventions to reduce ED boarding time for this population or to improve access to specialized geriatric services within the ED.

Introduction: The elderly (65 yo and more) increase in Canada is well documented along with a disproportionate use of Emergency Departments after a minor injury. These patients requires specific care given a 16% risk of functional decline following a visit to ED. To prevent functional decline, a multidimensional assessment of the elderly is recommended in the emergency department. Objective: To determine if ED grip strength can predict functional decline at 3 or 6 months post-injury. Methods: A multicentre prospective study in 5 ED across Canada was realized between 2013 and 16. Patients 65 years old and over, autonomous in daily living activities and consulting the emergency department for minor trauma were recruited 7 days a week. Clinical-demographic data, functional status, fear of falling, number of falls in the last month, grip strength measurement were collected in the ED. Functional decline (loss of at least points to functional status) was calculated at 3 and 6 months. Descriptive statistics and linear regression model with repeated measurements were used to determine if the grip strength was predictive of functional decline at 3 or 6 months. Results: 387 patient were recruited. Mean age was 74 ± 7 years old, 52% were male. XXX experienced a fall in the last month. The initial maximum grip strength was (24 ± 10 intervention vs. 28 ± 13 control; p ≤ 0.05). grip strength is associated with pre-injury functional status (p < 0.0001) and fear of falling (p = 0.0001) but does not predict 3 or 6 month functional decline. Conclusion: Given the strong association with fear of falling and functional status at initial ED evaluation, we recommend that grip strength measurement could be included in a multidisciplinary geriatric emergency department assessment as needed.

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

Introduction: The CETI team has shown that around 18% of otherwise independent seniors remain in a state functional decline up to six months after a minor injury. In that context, frailty may be associated with increased likelihood of decline. As most seniors consult Emergency Departments (EDs) when injured, measuring frailty may help identify those at risk of functional decline. Objectives: This study aims to 1) describe frailty in the sub-group of independent community-dwelling seniors consulting Emergency Departments (ED) for minor injuries, 2) examine the association between frailty and functional decline three months post-injury, 3) ascertain the predictive accuracy of frailty measures and Emergency Physicians’ (EPs) for functional decline. Methods: Prospective cohort in 2011-2013 among 1072 seniors aged ≥ 65, independent in basic daily activities, evaluated in Canadian EDs for minor injuries and discharged home. Frailty was assessed at EDs using the Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) and the Study of Osteoporotic Fracture index (SOF). Functional decline was defined as a loss ≥ 2/28 on the Older American Resources Services scale three months post-injury. Generalized mixed models were used to explore differences in functional decline across frailty levels. Areas Under the Receiver operating characteristic curve (AUC) were used to ascertain the predictive accuracy of frailty measures and EPs’ clinical judgement. Results: The SOF and CSHA-CFS were available in 342 and 1058 participants, respectively. The SOF identified 55.6%, 32.7%, 11.7% patients as robust, prefrail and frail. These CSHA-CFS (n=1058) proportions were 51.9%, 38.3% and 9.9%. The 3-month incidence of functional decline was 12.1% (10.0%-14.6%). The AUCs of the CSHA-CFS and the EPs’ were similar (0.548 - 0.777), while the SOF was somewhat higher (0.704 - 0.859). Conclusion: Measuring frailty in community-dwelling seniors with minor injuries in EDs may enhance current risk screening for functional decline. However, before implementation in usual care, feasibility issues such as inter-rater reliability and acceptability of frailty tools in the EDs have to be addressed.

Introduction: Frailty is associated with mobility & physical impairment in seniors with minor injuries. Serum biomarkers have also been suggested as potential markers of these impairments in clinical studies. No study has examined if serum biomarkers could contribute to the diagnosis of frailty in seniors with minor injuries. Objectives: To explore the association between several serum biomarkers (Ferritin, Creatinine, Vitamin D, Albumin, Glucose, Estradiol, Testosterone, Thyroid Stimulating Hormone (TSH), Insulin-Growth Factor (IGF-1) C-reactive protein (CRP)) and frailty level in seniors treated in emergency department (ED) for minor injuries. Methods: Cross-sectional study within the larger CETI cohort. It includes 142 seniors discharged home from 4 EDs after treatment of minor injuries. Their frailty status was measured by the Canadian Study of Health & Aging-Clinical Frailty Scale (CSHA-CFS). Biomarkers were obtained from blood samples. Pearson’s correlations (r) were performed to examine the relation between serum biomarkers and frailty levels. Partial correlation controlled for age and sex, were also performed. Results: Due to inclusion criteria, no patient was severely frail. Overall, these preliminary analyses seem to indicate that robust patients tended to have lower Glucose & Vitamin D levels (-0.264 ≤ r ≤ -0.230; p < 0.05), higher Estradiol (r = 0,230; p < 0.05) & Testosterone (r = 0,295; p < 0.05), while prefrail/frail patients tended to have higher Glucose & Vitamin D levels (0,235 ≤ r ≤ 0,238; p < 0.05), lower Estradiol levels (r = -0,235; p < 0.05) & more elevated Ferritin levels. Due to the small number of patients, controlling for age and sex lead to non-significant results of the most associations. Conclusion: Pre-frail/frail seniors presenting to EDs with minor injuries tend to have higher Ferritin, Glucose & Vitamin D levels as well as lower sexual hormones levels than robust individuals. Larger samples are needed in order to elucidate which biomarkers could be most useful to identify frail seniors needing clinical attention and to assess a possible association with mobility impairments in this population.

Background: Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes.

Methods: The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxon's, McNemar tests, pre-post design).

Results: 332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 ± 8.3 vs. 15.0 ± 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001).

Conclusions: The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.

Background: Despite widespread use of second-generation cholinesterase inhibitors (CHEIs) for the symptomatic treatment of Alzheimer's disease (AD), little is known about possible long-term effects in different functional domains. This study seeks to assess change in activities of daily living (ADLs) over two years in AD patients treated with CHEIs matched to untreated patients in the same longitudinal cohort study.

Methods: This study is based on the two-year prospective cohort study at the Memory Clinic in Sunnybrook Health Sciences Centre, University of Toronto. Probable AD patients (N = 130: untreated = 65, treated = 65) underwent standardized neuropsychological assessments including the Disability Assessment for Dementia Scale (DAD), at baseline, one-year and two-year follow-up. Groups received a careful evaluation of comorbid illnesses, concomitant medication use, and vascular risk factors.

Results: At baseline, there were no significant differences in demographics and characteristics. Treated patients showed less decline in overall function and in instrumental and basic ADLs. Furthermore, less decline was seen in the overall scores for initiation and planning over two years with moderate to large effect sizes.

Conclusion: These findings have clinical relevance since functional ability has been increasingly recognized as a key outcome variable in AD treatment. It is also of note that the subscores reflecting executive functioning appear to drive these beneficial differences.