Decline in activities of daily living after a visit to a Canadian emergency department for minor injuries in independent older adults: are frail older adults with cognitive impairment at greater risk?

Abstract

Objectives: To compare functional decline in activities of daily living (ADLs) of older adults visiting emergency departments (EDs) for minor injuries according to frailty and cognitive status.

Design: Prospective cohort study.

Setting: Seven Canadian EDs.

Participants: Individuals aged 65 and older who were independent in ADLs at baseline were recruited between March 2011 and March 2013 (N=1,114).

Measurements: The Older American Resources and Services (OARS) questionnaire was completed during the ED visit or within 7 days and 3 and 6 months after a minor injury to ascertain functional decline (≥1-point drop in ADL score). Participants were considered frail based on the Canadian Study of Health and Aging Clinical Frailty Scale (≥Level 4, vulnerable). Cognitive impairment was defined as performing below cutoffs on the Montreal Cognitive Assessment (<23/30) or Telephone Interview for Cognitive Status (≤31/50). Four subgroups were created: frail with cognitive impairment, frail without cognitive impairment, nonfrail with cognitive impairment, nonfrail without cognitive impairment. Sociodemographic and health data were also collected.

Results: Information on OARS, frailty, and cognitive impairment were available for 850 at 3 months and 728 at 6 months; 19.9% of participants showed declining function at 3 months and 25.3% at 6 months. After adjusting for age, number of comorbidities, and instrumental activity of daily living disability at baseline, frail participants with cognitive impairment were at significantly greater risk of functional decline at 3 (adjusted risk ratio (aRR)=1.89; 95% confidence interval (CI)=1.38-2.59) and 6 (aRR=2.09; 95% CI=1.45-3.00) months than nonfrail participants without cognitive impairment.

Conclusion: Easy-to-administer frailty and cognitive screening tools should be included in ED assessments to identify independent older adults at high risk of functional decline after minor injury so that appropriate services may be provided to prevent deterioration in ADLs.

Keywords: activity of daily living; cognitive impairment; elderly; emergency service; frail; geriatric assessment.