Singapore’s population is ageing rapidly and by 2030, around 1 in 4 citizens will be aged 65 and above.1 Older adults represent 21–40% of emergency department (ED) users and proportionally are the highest users of ED services.2
One-third of community dwellers over 65 years of age fall each year, and 50% will fall again, with 10% of falls resulting in serious injuries such as hip fractures, head injuries, injury-related disability and death.3 Frailty is common in older adults and can be prevented or at least delayed4 with ED frailty interventions and hospital avoidance.5 This letter describes Singapore’s introduction of falls interventions and osteoporosis management in older adults attending an ED short stay unit (SSU) and describes integration of geriatric services in the ED.
The ED SSU is a protocol-led unit, staffed by emergency medicine physicians, with a 23-hour maximum length of stay. The falls protocol (FP) was introduced on 10 March 2019, and operates from Sunday 12pm to Friday 9am, following a service development collaboration between geriatricians and emergency medicine physicians. Inclusion criteria identify older adults with falls and aim to avoid acute hospital admission by undertaking comprehensive geriatric assessments (CGA) in the ED SSU administered by a consultant geriatrician, geriatric resident physician and an ED nurse who has received basic training in geriatric care, called a Geriatric Care Champion. A retrospective review was undertaken after 7 months to assess effectiveness of the FP, and a comparator group (CG) was identified in falls patients admitted to SSU under the Blunt Trauma and Head Injury Protocols at our institution between 1 January 2018 and 31 December 2018. Electronic patient records were reviewed, and data collection included demographics, functional assessments, hospital utilisation and mortality. Falls history and injurious fall defined by the presence of fracture, compliance to bone health recommendations, uptake of bone mineral density (BMD) scan and anti-resorptive treatment were reviewed and assumed compliant if anti-resorptive treatment was commenced following the SSU visit. Rockwood’s Clinical Frailty Scale (CFS)6 was calculated from the CGA and/or Occupational Therapy assessments and categorised into: CFS 1–3; CFS 4–5; and CFS 6–9. Ethics review exemption was granted by the SingHealth Centralised Institutional Review Board. Descriptive statistics of demographic and clinical variables were compared between FP group and CG. The categorical outcome measures were analysed using chi-squared or Fisher’s Exact test and presented as proportions and percentages. T-test was used for continuous data and presented as means and standard deviations. Data were analysed using Stata version 14 (Stata Corp, College Station, TX, US).
The FP group comprised 96 patients and CG 121 patients. Between FP group and CG, there were similarities in average age (79.8 years vs 77.9 years, respectively; P=0.092) and median age (80 vs 78; P=0.072). There were also more females in both groups (61.5% vs 51.2%; P=0.169) (Table 1).
Comparing FP group vs CG, FP patients were more frail with CFS 1–3 (23.9% vs 37.2%, respectively), CFS 4–5 (38.5% vs 22.3%, P=0.0001) and CFS ≥6 (37.5% vs 19.0%; P=0.0001), and more dependent for instrumental and basic activities of daily living (Table 1; P<0.0001). Recurrent falls were more common in the FP group vs CG (70.8% vs 41.3%; P=0.0001); they also experienced more falls with fracture (43.8% vs 24.8%; P=0.04), which increased their likelihood of hospital admission (60% vs 30.8%, P=0.027). First falls occurred more frequently in the CG for those with CFS 4–5 (27% vs 55.6%, P<0.037), whereas recurrent falls were more common in FP patients with CFS 4–5 (72.9% vs 44.4%, P<0.037) (data not shown).
Osteoporosis was newly identified in more patients in the FP group vs CG (30.2% vs 7.4%, respectively; P<0.0001). The FP group also had a higher proportion of patients with known osteoporosis (28.1% vs 11.6%), and osteopenia (19.8% vs 2.5%; P=0.0001). BMD was undertaken for more patients in the FP group (82.3% vs 24.8%) with both vitamin D (95.8% vs 24.8%; P<0.0001) and serum calcium (96.8% vs 28.9%; P<0.0001) checked more frequently (Table 1). Following the ED visit, total antiresportive use was much higher in the FP group, 58.3% vs 19%.
Home discharge was lower in the FP group vs CG (35.4% vs 63.9%, respectively; P<0.0001), but more patients transferred directly to St Andrew’s Community Hospital, Singapore for subacute care (33.3% vs 3.4%; P<0.0001). Acute hospital admission was similar in both groups (31.3% vs 32.8%), as was hospital length of stay (15.3 SD 12.4 vs 11.6 days; SD 13.7 P=0.164). For both FP group and CG, there was low ED re-attendance at 7 days (1% vs 4.1%, P=0.231), 30 days (10.4% vs 11.6%, P=0.831), and 30-day unplanned hospital re-admission (6% vs 9%; P=0.612) that remained similar between both groups at 6 months (30.2 % vs 26.5%; P=0.547). Mortality was low in both groups (2.1% vs 4.1%; P=0.468) at 6 months.
Geriatric emergency medicine is gaining traction as an opportunity to identify frailty and improve patients’ function by avoiding hospital admission.5 A CGA undertaken at ED reduces both admission and re-admission rates.7 Adverse outcomes occur in one-third of older patients after ED discharge,8 but a CGA undertaken after discharge from the ED can lower 30- day hospital re-admissions (16.5% vs 22.2%; P=0.048), with improvements in both physical and mental functions compared to standard care.9 In this review, FP patients were more frail and functionally impaired compared with CG, experienced more recurrent falls (70.8% vs 41.3%, respectively; P=0.0001) and more falls with fracture (43.8% vs 24.8%; P=0.004), which typically result in hospital admissions. However, FP patients achieved the same low 7 and 30-day ED re-attendance, unplanned hospital re-admissions and mortality rates as the CG, suggesting geriatric assessment can help older patients destined for hospital admission to discharge safely from the SSU. The CG was discharged home more frequently than FP patients (35.4% vs 63.9%; P<0.0001), but over time home discharges from the SSU for FP patients increased from 35.4% to 75% (unpublished data from internal audit for the Geriatric Emergency Medicine Service, Changi General Hospital, January 2022). CG patients are not routinely screened for falls risk and osteoporosis, but many pre-frail patients frequently fall and would benefit from early interventions to prevent falls and osteoporotic fractures. Osteoporosis treatments have a strong evidence base10 and the FP enables earlier falls interventions, as well as higher rates of identification and treatment of osteoporosis.
The FP offers an opportunity to prevent hospital admission in older patients, provide treatment recommendations and onward referrals to mitigate falls risk and prevent future osteoporotic fractures.
The work was funded by the Health Services Development Programme Grant from the Singapore Ministry of Health.
- National Population and Talent Division. Population in Brief 2022. https://www.strategygroup.gov.sg/media-centre/publications/ population-in-brief/. Accessed 12 June 2023.
- Lowthian J, Curtis A, Stoelwinder J, et al. Emergency demand and repeat attendances by older patients. Intern Med J 2013;43:554-60.
- Soriano TA, DeCherrie LV, Thomas DC. Falls in the community-dwelling older adult: a review for primary-care providers. Clin Interv Aging 2007;2:545-54.
- Soong JTY, Poots AJ, Bell D. Finding consensus on frailty assessment in acute care through Delphi method. BMJ Open 2016;6:1-8.
- Chong E, Zhu B, Tan H, et al. Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions. J Am Med Dir Assoc 2021;22:923-8.e5.
- Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489-95.
- Conroy SP, Ansari K, Williams M, et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: The “Emergency Frailty Unit.” Age Ageing 2014;43:109-14.
- Carpenter CR, Avidan MS, Wildes T, et al. Predicting geriatric falls following an episode of emergency department care: A systematic review. Acad Emerg Med 2014;21:1069-82.
- Caplan GA, Williams AJ, Daly B, et al. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department — The DEED II study. J Am Geriatr Soc 2004;52:1417-23.
- Compston J, Cooper A, Cooper C, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017;12:43.