Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121

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Journal of Clinical Gerontology & Geriatrics

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Original article Risk factors for frequent emergency department visits of veterans home residents in Northern

Cheng-Hung Chiang, MD a, Ming-Yueh Chou, MD b,c,d, Shang-Lin Chou, MD e,f, Chih-Kuang Liang, MD c,d,g, Liang-Kung Chen, MD d,h,*, David Hung-Tsang Yen, MD, PhD f,i, Ming-Shium Tu, MD b a Division of Internal Medicine, Veterans General Hospital, Pingtung Branch, Pingtung , Taiwan b Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan c Geriatric Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan d National Yang-Ming University, School of Medicine, , Taiwan e Department of Emergency Medicine, Fooyin University Hospital, Pingtung County, Taiwan f Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan g Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan h Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan i Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan article info abstract

Article history: Purpose: The purpose of this study was to evaluate risk factors for frequent emergency department (ED) Received 19 June 2011 visits among older Chinese men living in a veterans home in northern Taiwan Received in revised form Methods: In 2006, all residents of Banciao Veterans Home were invited for study. Minimum Data Set 10 August 2011 Nursing Home 2.1 Chinese version, Chinese version of Geriatric Depression Scale (GDS) short form, mini- Accepted 30 August 2011 mental status examinations (MMSE), and Charlson Comorbidity Index (CCI) were used for study. ED records of all study participants were obtained from Taipei Veterans General Hospital, and frequent ED Keywords: visitors were defined as who visited ED for three times or more in 1 year. Elderly ¼ Emergency department Results: Overall, 609 residents (mean age 80.9 5.3 years, all men) were enrolled, and 169 (27.8%) of Frequent visits them visited the ED for at least once. Among all participants, 30 (4.9%) were frequent ED visitors. Long-term care Frequent ED visitors were significantly older, disabled, cognitively impaired, depressed, urinary incon- tinent, having poorer social engagement score, and higher Charlson’s comorbidity index (CCI). Adjust- ments for age, activities of daily living, depression, cognitive impairment (adjusted odds ratio: 3.19; 95% confidence interval: 1.37e7.46, p ¼ 0.004) and higher CCI (adjusted odds ratio: 1.69; 95% confidence interval: 1.20e2.39, p ¼ 0.003) were independent risk factors for frequent ED visits. Conclusion: The cumulative incidence of ED visit was 51 visits per 100 person-years, and the prevalence of frequent ED visitors was 4.9% among older veterans living in a Veterans Home. Cognitive impairment and higher Charlson’s comorbidity index were independent risk factors for frequent ED visitors. Further study is needed to explore the unmet health-care needs for frequent ED visitors in the veterans home. Copyright Ó 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.

1. Introduction doubled from 2010 to 2025.1 The escalation of elderly population may cause various challenges to health-care systems, which also Population aging is a global phenomenon that affects both includes emergency department (ED) services. In Taiwan, the ED developing and developed countries, and Taiwan is no exception. was overcrowded nationwide,2 and frequent ED visitors may Taiwan was estimated to become the fastest aging country in the aggravate this situation. It was generally agreed that older people world, and the percentage of elderly population in Taiwan will be were more prone to visit the ED by ambulance with high-priority triage, longer ED stay, more costly care, and are more likely to be e hospitalized.3 5 Although the ED has become the main entry for acute medical services for older people,6,7 one-half of ED physicians * Corresponding author. Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Number 201, Section 2, Shih-Pai Road, Taipei, Taiwan. reported that they lack proper knowledge and skills to manage 8 E-mail address: [email protected] (L.-K. Chen). older patients and often felt uneasy to treat older patients. Further,

2210-8335/$ e see front matter Copyright Ó 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.jcgg.2012.09.001 C.-H. Chiang et al. / Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121 119 frequent ED visits were associated with higher medical expendi- concentration, delayed recall, naming, verbal repetition, verbal tures, and the lack of proper access to health care,9 which may comprehension, writing, reading a sentence, and constructional result in a vicious cycle in health care services. Frequent ED visitors praxis.20 The score of <24 was considered cognitive impairment. were also heavy users of other health-care services and the overall mortality rate was high, suggesting that they were poorer in health 2.2.5. Comorbidity status and resources of care than others.10 Common features of The Charlson Comorbidity Index (CCI) was used to evaluate frequent ED visits included men, African Americans, presence of comorbidity in this study, which consisted of 19 categories of psychosocial and economic problems, and alcohol-dependence in disease entities, and each disease entity had an associated weight. e previous studeis,11 13 but little was known regarding to the risk The overall CCI score reflected the cumulative increased likelihood factors of frequent ED visits among older people in Taiwan. of 1-year mortality.21 In Taiwan, older veterans living in the veteran homes were often 14 functionally dependent with multiple medical care needs. For 2.3. Statistical analysis veteran home residents, they would be sent to nearby veterans hospitals for further medical care if ED care was needed. All continuous variables were expressed as mean standard In northern Taiwan, residents of veteran homes were sent to Taipei deviation, and categorical data were expressed as frequency. Veterans General Hospital, a tertiary medical center, for ED Analyses of categorical variables were performed by Chi-square or 15 services. Therefore, the main purpose of this study was to explore Fisher’s exact test when appropriate. The independent Student the characteristics of frequent ED visitors among residents in t-test was used to compare continuous variables. The Statistical a veteran home to identify those with high risk of frequent ED Package for the Social Sciences (SPSS) version 17.0 software (SPSS, visits. Chicago, IL, USA) was used to perform all statistical analyses. For all tests, a two-tailed p < 0.05 was considered statistically significant. 2. Materials and methods 3. Results 2.1. Participants In total, 609 residents (mean age: 80.9 5.3 years, all males) From January to December of 2006, all residents living Banciao were enrolled for study. Among them, 169 residents (27.8%) had Veterans Home were invited for study and participants were visited the ED at least once during the study period and 30 enrolled if they agreed to participate. Those who had altered residents (4.9%) were frequent ED visitors by definition. The consciousness, severe hearing impairment, and communication cumulative incidence of ED visits in this study was 51 visits per 100 fi dif culties were excluded for study. Minimum Data Set (MDS) person-years. Univariate analysis showed that frequent ED visitors Nursing Home 2.1 Chinese version was systematically implemented were significantly older than non-frequent ED visitors (82.9 5.6 for all participants. Besides, well-trained research nurses periodi- vs. 80.8 5.3 years, p ¼ 0.032). In addition, frequent ED visitors cally visited participants and completed following questionnaire: were having higher CCI (1.5 1.0 vs. 0.7 0.9, p ¼ 0.001), MDS RUG Chinese version Geriatric Depression Scale (GDS) short form, ADL score (5.9 3.1 vs. 4.3 1.5, p < 0.001), prevalence of Chinese version of mini-mental status examinations (MMSE), and depression (20% vs. 8%, p ¼ 0.023), cognitive impairment (53.3% vs. Charlson Comorbidity Index. In addition, medical records of 16.8%, p < 0.001), urinary incontinence (23.3% vs. 9.2%, p ¼ 0.012), participants visiting the ED of Taipei Veterans General Hospital and lower MDS social engagement score (0.9 1.2 vs. 1.6 1.3, fi were collected. Frequent ED visits were de ned as those who p ¼ 0.008; Table 1). Table 2 shows the independent risk factors for visited the ED for three times or more in 1 year.16 frequent ED visitors by using multivariate logistic regression, which found that cognitive impairment [adjusted odds ratio (OR): 3.19; 2.2. Measures 95% confidence interval (CI): 1.37e7.46, p ¼ 0.004] and higher CCI (adjusted OR: 1.69; 95% CI: 1.20e2.39, p ¼ 0.003) were both inde- 2.2.1. Social engagement pendent risk factors for frequent ED visits. Social engagement was evaluated by MDS social engagement score, which has been reported as the surrogate of quality of life.17 4. Discussion The summation of social engagement score was between zero and six, and the score of six indicated normal social interaction, and Taiwan became the aging country (percentage of elderly people a lower score suggested poorer social engagement. exceeding 7% of total population) in 1993, and was estimated to 2.2.2. Physical function Table 1 In this study, physical function was evaluated by the MDS Univariate analysis of participants’ characteristics and their frequency of ED visits in Resource Utilization Group Activities of Daily Living (RUG ADL) 1 year. score, which consisted of eating, bed mobility, transferring and < toileting.18 The summation of RUG ADL score (range, 4e18) was Characteristics ED visit three ED visit three p value times times used to evaluate physical function of the resident, and the lower (N ¼ 30) (N ¼ 579) MDS RUG ADL score was considered less physical dependence. Age (yr) 82.9 5.6 80.8 5.3 0.032 Charlson comorbidity index 1.5 1.0 0.7 0.9 0.001 2.2.3. Depression MDS RUG ADL score 5.9 3.1 4.3 1.5 <0.001 GDS short form has been validated as a reliable depression MDS social engagement score 0.9 1.2 1.6 1.3 0.008 a screening tool,19 a cut-off of six or more was considered depression. Depression 20.0% 8.0% 0.023 Cognitive impairmentb 53.3% 16.8% <0.001 Urinary incontinence 23.3% 9.2% 0.012 2.2.4. Cognitive function ED ¼ emergency department; MDS RUG ADL score ¼ minimum data set resource The Chinese version of MMSE was used to assess cognitive utilization group activity of daily living score. function for all participants, which included items of temporal a Depression was defined as 15-items geriatric depression scale score 5. orientation, spatial orientation, immediate memory, attention/ b Cognitive impairment was defined as minimal-mental status examination 24. 120 C.-H. Chiang et al. / Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121

Table 2 living in the veteran care homes were frequent ED visitors. Results of multivariate logistic regression model of factors related to frequent ED Cognitive impairment and higher Charlson’s comorbidity index visits. were both independent risk factors for frequent ED visits. Further Adjusted 95% confidence p value study is needed to evaluate main health care problems of odds ratio interval frequent ED visits and the effectiveness of intervention programs Cognitive impairment 3.19 1.37e7.46 0.004 to improve quality of care. Charlson comorbidity index 1.69 1.20e2.39 0.003 ¼ ED emergency department. References become the aged country (elderly population exceeding 14% of total 1. Lin MH, Chou MY, Liang CK, Peng LN, Chen LK. Population aging and its population) by 2019, which made Taiwan the fastest aging country impacts: strategies of the health-care system in Taipei. Ageing Res Rev 9 e in the world.1 The escalating elderly population in Taiwan may 2010; (Suppl. 1):S23 7. 22,23 2. 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