Article: AENJ-D-14-00013
Date: July 18, 2014
Time: 0:54
Advanced Emergency Nursing Journal Vol. 36, No. 3, pp. 209–214 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
R E S E A R C H
T O
Practice Column Editors: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, and Susan E. Shapiro, PhD, RN, FAAN
Gait Speed in the Emergency Department Improving Assessment Among Older Adults Paula R. Tucker, MSN, FNP-BC Dian Dowling Evans, PhD, MN, MS, FNP-BC, ENP-BC
Abstract The research to practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and to assist with the translation of research into practice. This column critiques the findings from a meta-analysis, “Gait speed and survival in older adults,” by S. Studenski et al. (2011). The study was designed to assess the use of gait speed as a physical performance measure that is associated with survival. The findings are reviewed in the context of increasing emergency department (ED) visits among older adults and their unique assessment needs, with implications for APRN best care practices. The implementation of gait speed as a screening tool for identifying adults 65 years of age and older in the ED who may be at risk for adverse events and functional decline will also be discussed. Key words: assessment, function, gait speed, geriatric, older adults, triage
M
R. J., AN 82-YEAR-OLD, generally healthy, White male, presents to the emergency department (ED) with his daughter, who states that she is concerned about her father’s health. Yesterday when she visited him, after not seeing him for several months, she noticed that he seemed more fatigued when walking and doing his usual
activities. She tried to get an appointment with his internist, but an appointment was not available until next week. Because she plans to travel out of the country before her father can be seen, she decided to bring him into the ED for an evaluation.
Author Affiliations: Emergency Department, Emory University Hospital (Ms Tucker and Dr Evans) and Emergency Nurse Practitioner Program, Nell Hodgson Woodruff School of Nursing, Emory University (Dr Evans), Atlanta, Georgia. Disclosure: The authors report no conflicts of interest.
Mr. J. denies shortness of breath, chest pain, syncope, dizziness, or weakness, but he admits that he is not sleeping as well as usual and might be more tired during the day. Now that the weather is colder, he states that he has not been leaving his apartment to take his daily walk. His past medical history includes hypertension, hyperlipidemia, chronic kidney disease Stage 2, osteoarthritis, and
The Case
Corresponding Author: Paula R. Tucker, MSN, FNP-BC, Emergency Department, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA 30322 ([email protected]). DOI: 10.1097/TME.0000000000000026
209
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
Date: July 18, 2014
210
lymphoma in remission for the past 10 years following chemotherapy. Surgical history includes transurethral resection of the prostate 5 years ago and right knee replacement 10 years ago. Social history includes a prior history of smoking “during the war,” but he quit more than 60 years ago. He admits to drinking one “small” glass of champagne with dinner three nights a week. He is a widower who resides alone in an apartment in an assisted living community. He states that he usually walks about 1 mile a day but lately has stopped walking because of bad weather and because his arthritis has been “acting up.” Daily medications include simvastatin 20 mg once a day, lisinopril 20 mg once a day, ergocalciferol 600 units once a day, omega 3 fatty acids, probiotic capsule, and acetaminophen 650 every 6 hours as needed for arthritis pain. On physical examination, vital signs are temperature: 36.8 ◦ F, pulse: 72 and regular, blood pressure: 132/80 mmHg, respirations: 20, and body mass index (BMI): 23. The patient is well nourished, well hydrated, and in no acute distress. He is alert and oriented to place, person, situation, and time; answers questions appropriately; and does not appear to be depressed or ill. His skin is warm and dry, sclera without icterus, and mucous membranes are moist and pink. Tympanic membranes are clear with visible landmarks and no cerumen impaction in the canals. Heart rate is regular with normal rhythm, no murmurs, gallops, or rubs. Lung sounds are clear, and further assessment reveals a soft, nontender abdomen with audible bowel sounds. Musculoskeletal examination reveals full active range of motion with 5/5 motor strength in upper and lower extremities without joint swelling, redness, tenderness, or edema. A neurological examination reveals cranial nerves II–XII intact without focal deficits, normal 2-point discrimination on fingers and toes, patellar reflexes 2+, cerebellar function also within normal limits, and a negative Romberg. As the patient stands to walk to the bathroom, you notice that he ambulates slowly but neither reports nor appears to be out of breath. Because of his daughter’s concerns, a urinalysis, chest radio-
Time: 0:54
Advanced Emergency Nursing Journal
graphy, electrocardiogram, complete blood cell count, comprehensive serum chemistry panel, and troponin level are ordered to rule out electrolyte imbalances, infection, pneumonia, urinary tract infection, or cardiac issues. Three hours later, his diagnostic studies return within normal limits. You return to tell the patient and his daughter about his results and discover that he has eaten lunch and is now ready to go home to watch an upcoming football game. The daughter tells you that she has a bad feeling about her father’s condition, but because his work-up is essentially normal, she will take him home and make sure that the assisted living facility takes him to his appointment with his internist next week. Mr. J. tells you that he is fine and that his daughter worries too much. As they leave the ED, you notice, again, that Mr. J. is walking more slowly and with more hesitancy than expected for someone who claims he typically walks a mile a day. After they leave the ED, you wonder whether there was something else that you failed to consider in his evaluation that may have altered his disposition or treatment/follow-up plan. RESEARCH ARTICLE Studenski, S., Perera, S., Patel, K., Rosano, C., Faulkner, K., Inzitari, M., . . . Guralnik, J. (2011). Gait speed and survival in older adults. The Journal of the American Medical Association, 305(1), 50–58. Using a combined analysis of 9 cohort studies, Studenski et al. (2011) established a correlation between gait speed and survival among 34,485 adults, 65 years and older, living in community settings. In this article, gait speed is defined as a physical performance measure that is associated with survival, health, and functional status, and may serve clinically in identifying the risk of early mortality and frailty among older adults. PURPOSE/METHODS This meta-analysis was designed to evaluate the relationship between gait speed and
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
July–September 2014
r Vol. 36, No. 3
survival among a population of community dwelling seniors. After controlling for age and sex, Studenski et al. (2011) examined whether a person’s gait speed was predictive of 5 and 10-year survival rates. Gait speed was measured in meters per seconds with walking distance that varied from 2.4 to 6 m. Study participants were tested by starting in an upright position while being timed walking the designated distance at a normal pace. Participants were then followed for 6 to 21 years, and survival was monitored with the National Death Index using individual study continuation data (Studenski et al., 2011). From the initial gait speed reference point until death, time was computed to days, and the majority of the participants (99%) sustained the 5-year survival point. In addition to gait speed, the researchers also studied the effects of age, sex, race or ethnicity, height, weight, BMI, smoking, mobility assistance, systolic blood pressures, self-reported well-being, hospital admission within the year, and morbidities (Studenski et al., 2011). Dependence versus independence in basic activities of daily living (ADLs) was also analyzed as a dichotomous variable using participant self-report. Participants were then grouped for separate data analysis as either needing assistance with ADLs, having some difficulty performing ADLs requiring some physical demands, or self-sufficient in ADLs. The relationship between gait speed and 5and 10-year survival rates was determined using Cox modeling (Studenski et al., 2011). A Cox model is a statistical technique that estimates survival on the basis of specific independent variables using regression statistics to control for the effects of other factors. Individual hazard ratios, similar to odds ratios, were calculated for each independent variable, with time of death as the outcome variable. RESULTS Throughout the 9 studies (n = 34,485), the overall mortality rate totaled 49% among study participants (n = 17,528). Total survival
Date: July 18, 2014
Time: 0:54
Gait Speed in the Emergency Department
211
rates were (84.8%) at 5 years and (59.7%) at 10 years. In each of the studies, gait speeds faster than 1m/s reliably predicted longevity across all age groups. Furthermore, Studenski et al. (2011) found that gait speed in conjunction with age and sex was as reliable in predicting survival as were other factors associated with health status such as chronic conditions, hospitalization, and self-reported function. CONCLUSIONS Studenski et al. (2011) concluded that gait speed may prove clinically useful as an additional measure of health status and frailty in older adults. For instance, the authors suggest that gait speed could assist in distinguishing older adults with a high probability of surviving for 5 to 10 more years where targeted health promotion approaches could be beneficial. Similarly, the finding of a gait speed of 0.5 m/s or less indicates risk for worsening of an existing medical problem, change in mental status, injury, or mortality, and could prompt further evaluation or supportive care. Therefore, as a global indicator of physical function and overall health status, gait speed as a rapid, valid, and standardized method for assessing frailty and functional decline could add to medical decision making to improve patient care and reduce adverse clinical outcomes (Studenski et al., 2011). STRENGTHS/LIMITATIONS The strengths of this study include the substantial number of study participants representing a diverse sample of communitydwelling older adults followed longitudinally. The study also used reliable measures of function to calculate life expectancy predictions associated with various gait speeds. In contrast to smaller gait speed studies with limited statistical resources to evaluate for variability, the investigators successfully evaluated numerous effect measures using subgroup analysis (Studenski et al., 2011). Study limitations are consistent with those typically associated
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
Date: July 18, 2014
212
with observational research, including the inability to prove underlying associations and subject bias resulting from healthy volunteers. Although this study was substantial and diverse, the study cohorts did not include hospitalized or institutionalized older adults; therefore, survival averages represent estimates for only healthy, community-dwelling older men and women of varying ages living in the United States. Other limitations included methodological issues relating to actual gait speed procedures (Studenski et al., 2011), and that validation studies using gait speed assessments in the ED setting are lacking. The authors suggest that further work to determine the associations between gait speed, disability, and health care usage, such as ED admissions, is needed. PAULA’S COMMENTS Adults 65 years and older account for an increasing proportion of ED visits. According to Albert, McCaig, and Ashman (2013) among ED visits occurring between 2009 and 2010 (19.6 million) in the United States, 15% were adults aged 65 years and older. Average ED visit rates also increase as age increases (Albert et al., 2013). Once in the ED, older adults are more likely be admitted to the hospital, intensive care units, or return to the ED than younger cohorts (Meldon et al., 2003). Furthermore, older adults often experience a decline in functional status, health, and quality of life following an ED visit (Meldon et al., 2003). In light of this reality, improved and more comprehensive evaluations are needed for this population. Unfortunately, the identification of easy and trouble-free assessment tools to evaluate geriatric patients with increased risk of poor outcomes if discharged is lacking (Meldon et al., 2003). In a previous editorial, Studenski (2009) discussed how the physical requirements needed to walk place demands on multiple body systems. Consequently, diminished organ system function will ultimately impact and slow a person’s gait speed. Therefore, gait speed is helpful in identifying an estab-
Time: 0:54
Advanced Emergency Nursing Journal
lished or unrecognized health-related problem. In fact, the appearance of gait difficulties may be such a sensitive indicator of overall dysfunction that it can be described as the “sixth vital sign” (p. 39) serving as a powerful marker of well-being, frailty, and physical performance in older adults (Peel, Kuys, & Klein, 2012). The findings by Studenski et al. (2011) support this point. Furthermore, a systematic review of gait speed screening among communitydwelling adults indicates that the tool demonstrates better test–retest reliability and construct and predictive validity than other disability measures (Munoz-Mendoza, CabreroGarcia, Reig-Ferrer, & Cabanero-Martinez, 2010). As an indicator of well-being and functional ability, gait speed could be useful in identifying those patients needing prompt evaluation and management of cardiopulmonary, neurological, or musculoskeletal conditions in the primary care setting or those requiring close follow-up after discharge from the ED. By uncovering geriatric patients at risk for poor clinical outcomes, prompting close medical and social follow-up, gait speed improves the comprehensive evaluation of older adults by setting the trajectory for the ED course and disposition (Meldon et al., 2003). In conclusion, the implementation of gait speed assessment in the ED has the potential to improve outcomes by alerting providers to those patients who may require ancillary services following discharge to sustain or improve their health status and to those who may be experiencing new or worsening musculoskeletal, cardiopulmonary, or neurological conditions. This study (Studenski et al., 2011) provides support that adding gait speed, a low risk, easy to incorporate change into the routine ED assessment of older adults may improve the timeliness and appropriateness of care. DIAN’S COMMENTS As Paula indicated, ED census rates for older adults are increasing along with overall U.S.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
July–September 2014
r Vol. 36, No. 3
census trends. Older adults pose a unique challenge to ED providers because of their range of functional ability, from frail to active and healthy. A comprehensive ED assessment of the older adult requires an understanding of normal age-related changes, functional capabilities, and atypical presentations. Multiple resources are available to nurses and advanced practice registered nurses (APRNs) to enhance awareness and knowledge of the unique needs of older adults in the ED. One excellent resource is the Emergency Nurses Association’s (ENA, 2014) Geriatric Emergency Nursing Education course offered as a series of 17 online modules for continuing education. These modules discuss normal agerelated changes, atypical presentations, and the types of screening tools to assist in assessing function and cognitive status in the ED. Another excellent resource for APRNs is The Primary Care for Older Adults ELearning series modules available through the Hartford Institute for Geriatric Nursing/New York University College of Nursing (n.d.). The Hartford Institute also publishes best practice, evidence-based guidelines to promote the care of older adults that can be useful in the ED setting. In 2013, the ENA, The American Geriatric Society, the American College of Emergency Physicians, and the Society for Academic Emergency Medicine published updated, standardized guidelines to improve the care of geriatric patients in the ED (The American Geriatric Society, 2014). These guidelines include recommendations for staffing, policies and procedures, and performance improvement measures including use of functional assessment screening tools, specifically the Triage Risk Assessment Tool and the Initial Screening Questionnaire. These instruments include questions related to medication use, recent hospitalization, cognitive impairment, and falls predictive of adverse health outcomes. However, neither instrument includes an objective assessment of function like gait speed. Although the validity of using gait speed in clinical settings is still being investigated, incorporating gait speed into
Date: July 18, 2014
Time: 0:54
Gait Speed in the Emergency Department
213
an ED assessment may improve discharge planning and, therefore, should be further studied. Gait speed may offer a better screening assessment of geriatric function than those typically recommended because it is objective, takes less than 2 minutes to complete, requires only a stopwatch and a 4-m walking area, and can also be performed by nonnursing personnel (Peel et al., 2012). Gait speed testing could be incorporated either at triage or during the medical screening examination. The predictive validity of gait speed for early mortality has been demonstrated across race, gender, and age. Normative data are also available for inpatient as well as for healthy community-dwelling populations (Fritz & Luscardi, 2009; Peel et al., 2012). Furthermore, Fritz and Lusardi (2009) include evidencebased reference norms in their article that can be applied in clinical settings to identify older adults at risk. The norms have been correlated with ADL dependency, need for hospitalization, rehabilitation needs, and discharge location that can be used for discharge planning. Advanced practice nurses should consider adding a gait speed when assessing older adults; particularly those with vague complaints and inconclusive findings. By identifying patients who may be at risk, this simple measure can assist the clinician in selecting additional outpatient services to reduce readmission and optimize outcomes. CASE REVISITED As Mr. J. and his daughter prepare to be discharged, you ask Mr. J. to perform the gait speed 4-m walk and note his speed as 0.7 m/s; slower than the expected norm. Although slow gait speed is not sufficient for an admission, it alerts you that his functional status is suboptimal. Therefore, you make a social service referral, relate your concerns to the social worker, and together with the daughter identify a home health agency and physical therapy agency that can make a home visit to Mr. J.’s assisted living facility within 24 hours
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
Date: July 18, 2014
214
to determine whether additional resources are warranted to address potential worsening conditions. By adding an evidence-based assessment of Mr. J.’s overall functional status, the gait speed assessment provides you and Mr. J’s daughter with more information for transitioning his care at discharge than would otherwise have been warranted on the basis of his ED evaluation alone, hopefully improving his course of care and reducing his risk for readmission. REFERENCE Albert, M., McCaig, L. F., & Ashman, J. J. (2013). Emergency department visits by persons aged 65 and over: United States, 2009–2010. NCHS data brief, no 130. Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/ data/databriefs/db130.pdf Emergency Nurses Association. (2014). Geriatric Emergency Nursing Education. Retrieved from http://www.ena.org/education/education/GENE/ Pages/default.aspx Fritz, S., & Luscardi, M. (2009). White paper: Walking speed: The sixth vital sign. Journal of Geriatric Physical Therapy, 32(2), 2–4. Hartford Institute for Geriatric Nursing/New York University College of Nursing. (n.d.). Primary care
Time: 0:54
Advanced Emergency Nursing Journal
for older adults PCOA: The e-learning modules pilot testing. Retrieved from http://consultgerirn.org/ uploads/File/PCOA/story.html Meldon, S. W., Mion, L. C., Palmer, R. M., Drew, B. L., Connor, J. T., Lewicki, L. J., . . . Emerman, C. L. (2003). A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Academic Emergency Medicine, 10(3), 224–232. Munoz-Mendoza, C., Cabrero-Garcia, J., Reig-Ferrer, A., & Cabanero-Martinez, M. (2010). Evaluation of walking speed tests as a measurement of functional limitations in elderly people: A structured review. International Journal of Clinical and Health Psychology, 10(2), 359–378. Peel, N. M., Kuys, S. S., & Klein, K. (2012). Gait speed as a measure in geriatric assessment in clinical settings: A systematic review. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 68(1), 39–46. doi:10.1093/Gerona/gls174 Studenski, S. (2009). Bradypedia: Is gait speed ready for clinical use? The Journal of Nutrition, Health & Aging, 13(10), 878–880. Studenski, S., Perera, S., Patel, K., Rosano, C., Faulkner, K., Inzitari, M., . . . Guralnik, J. (2011). Gait speed and survival in older adults. The Journal of the American Medical Association, 305(1), 50–58. The American Geriatric Society. (2014). Geriatric emergency department guidelines. Retrieved from http://geriatricscareonline.org/ProductAbstract/ geriatric-emergency-department-guidelines/CL013
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Date: July 18, 2014
Time: 0:54
Advanced Emergency Nursing Journal Vol. 36, No. 3, pp. 209–214 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
R E S E A R C H
T O
Practice Column Editors: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, and Susan E. Shapiro, PhD, RN, FAAN
Gait Speed in the Emergency Department Improving Assessment Among Older Adults Paula R. Tucker, MSN, FNP-BC Dian Dowling Evans, PhD, MN, MS, FNP-BC, ENP-BC
Abstract The research to practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and to assist with the translation of research into practice. This column critiques the findings from a meta-analysis, “Gait speed and survival in older adults,” by S. Studenski et al. (2011). The study was designed to assess the use of gait speed as a physical performance measure that is associated with survival. The findings are reviewed in the context of increasing emergency department (ED) visits among older adults and their unique assessment needs, with implications for APRN best care practices. The implementation of gait speed as a screening tool for identifying adults 65 years of age and older in the ED who may be at risk for adverse events and functional decline will also be discussed. Key words: assessment, function, gait speed, geriatric, older adults, triage
M
R. J., AN 82-YEAR-OLD, generally healthy, White male, presents to the emergency department (ED) with his daughter, who states that she is concerned about her father’s health. Yesterday when she visited him, after not seeing him for several months, she noticed that he seemed more fatigued when walking and doing his usual
activities. She tried to get an appointment with his internist, but an appointment was not available until next week. Because she plans to travel out of the country before her father can be seen, she decided to bring him into the ED for an evaluation.
Author Affiliations: Emergency Department, Emory University Hospital (Ms Tucker and Dr Evans) and Emergency Nurse Practitioner Program, Nell Hodgson Woodruff School of Nursing, Emory University (Dr Evans), Atlanta, Georgia. Disclosure: The authors report no conflicts of interest.
Mr. J. denies shortness of breath, chest pain, syncope, dizziness, or weakness, but he admits that he is not sleeping as well as usual and might be more tired during the day. Now that the weather is colder, he states that he has not been leaving his apartment to take his daily walk. His past medical history includes hypertension, hyperlipidemia, chronic kidney disease Stage 2, osteoarthritis, and
The Case
Corresponding Author: Paula R. Tucker, MSN, FNP-BC, Emergency Department, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA 30322 ([email protected]). DOI: 10.1097/TME.0000000000000026
209
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
Date: July 18, 2014
210
lymphoma in remission for the past 10 years following chemotherapy. Surgical history includes transurethral resection of the prostate 5 years ago and right knee replacement 10 years ago. Social history includes a prior history of smoking “during the war,” but he quit more than 60 years ago. He admits to drinking one “small” glass of champagne with dinner three nights a week. He is a widower who resides alone in an apartment in an assisted living community. He states that he usually walks about 1 mile a day but lately has stopped walking because of bad weather and because his arthritis has been “acting up.” Daily medications include simvastatin 20 mg once a day, lisinopril 20 mg once a day, ergocalciferol 600 units once a day, omega 3 fatty acids, probiotic capsule, and acetaminophen 650 every 6 hours as needed for arthritis pain. On physical examination, vital signs are temperature: 36.8 ◦ F, pulse: 72 and regular, blood pressure: 132/80 mmHg, respirations: 20, and body mass index (BMI): 23. The patient is well nourished, well hydrated, and in no acute distress. He is alert and oriented to place, person, situation, and time; answers questions appropriately; and does not appear to be depressed or ill. His skin is warm and dry, sclera without icterus, and mucous membranes are moist and pink. Tympanic membranes are clear with visible landmarks and no cerumen impaction in the canals. Heart rate is regular with normal rhythm, no murmurs, gallops, or rubs. Lung sounds are clear, and further assessment reveals a soft, nontender abdomen with audible bowel sounds. Musculoskeletal examination reveals full active range of motion with 5/5 motor strength in upper and lower extremities without joint swelling, redness, tenderness, or edema. A neurological examination reveals cranial nerves II–XII intact without focal deficits, normal 2-point discrimination on fingers and toes, patellar reflexes 2+, cerebellar function also within normal limits, and a negative Romberg. As the patient stands to walk to the bathroom, you notice that he ambulates slowly but neither reports nor appears to be out of breath. Because of his daughter’s concerns, a urinalysis, chest radio-
Time: 0:54
Advanced Emergency Nursing Journal
graphy, electrocardiogram, complete blood cell count, comprehensive serum chemistry panel, and troponin level are ordered to rule out electrolyte imbalances, infection, pneumonia, urinary tract infection, or cardiac issues. Three hours later, his diagnostic studies return within normal limits. You return to tell the patient and his daughter about his results and discover that he has eaten lunch and is now ready to go home to watch an upcoming football game. The daughter tells you that she has a bad feeling about her father’s condition, but because his work-up is essentially normal, she will take him home and make sure that the assisted living facility takes him to his appointment with his internist next week. Mr. J. tells you that he is fine and that his daughter worries too much. As they leave the ED, you notice, again, that Mr. J. is walking more slowly and with more hesitancy than expected for someone who claims he typically walks a mile a day. After they leave the ED, you wonder whether there was something else that you failed to consider in his evaluation that may have altered his disposition or treatment/follow-up plan. RESEARCH ARTICLE Studenski, S., Perera, S., Patel, K., Rosano, C., Faulkner, K., Inzitari, M., . . . Guralnik, J. (2011). Gait speed and survival in older adults. The Journal of the American Medical Association, 305(1), 50–58. Using a combined analysis of 9 cohort studies, Studenski et al. (2011) established a correlation between gait speed and survival among 34,485 adults, 65 years and older, living in community settings. In this article, gait speed is defined as a physical performance measure that is associated with survival, health, and functional status, and may serve clinically in identifying the risk of early mortality and frailty among older adults. PURPOSE/METHODS This meta-analysis was designed to evaluate the relationship between gait speed and
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
July–September 2014
r Vol. 36, No. 3
survival among a population of community dwelling seniors. After controlling for age and sex, Studenski et al. (2011) examined whether a person’s gait speed was predictive of 5 and 10-year survival rates. Gait speed was measured in meters per seconds with walking distance that varied from 2.4 to 6 m. Study participants were tested by starting in an upright position while being timed walking the designated distance at a normal pace. Participants were then followed for 6 to 21 years, and survival was monitored with the National Death Index using individual study continuation data (Studenski et al., 2011). From the initial gait speed reference point until death, time was computed to days, and the majority of the participants (99%) sustained the 5-year survival point. In addition to gait speed, the researchers also studied the effects of age, sex, race or ethnicity, height, weight, BMI, smoking, mobility assistance, systolic blood pressures, self-reported well-being, hospital admission within the year, and morbidities (Studenski et al., 2011). Dependence versus independence in basic activities of daily living (ADLs) was also analyzed as a dichotomous variable using participant self-report. Participants were then grouped for separate data analysis as either needing assistance with ADLs, having some difficulty performing ADLs requiring some physical demands, or self-sufficient in ADLs. The relationship between gait speed and 5and 10-year survival rates was determined using Cox modeling (Studenski et al., 2011). A Cox model is a statistical technique that estimates survival on the basis of specific independent variables using regression statistics to control for the effects of other factors. Individual hazard ratios, similar to odds ratios, were calculated for each independent variable, with time of death as the outcome variable. RESULTS Throughout the 9 studies (n = 34,485), the overall mortality rate totaled 49% among study participants (n = 17,528). Total survival
Date: July 18, 2014
Time: 0:54
Gait Speed in the Emergency Department
211
rates were (84.8%) at 5 years and (59.7%) at 10 years. In each of the studies, gait speeds faster than 1m/s reliably predicted longevity across all age groups. Furthermore, Studenski et al. (2011) found that gait speed in conjunction with age and sex was as reliable in predicting survival as were other factors associated with health status such as chronic conditions, hospitalization, and self-reported function. CONCLUSIONS Studenski et al. (2011) concluded that gait speed may prove clinically useful as an additional measure of health status and frailty in older adults. For instance, the authors suggest that gait speed could assist in distinguishing older adults with a high probability of surviving for 5 to 10 more years where targeted health promotion approaches could be beneficial. Similarly, the finding of a gait speed of 0.5 m/s or less indicates risk for worsening of an existing medical problem, change in mental status, injury, or mortality, and could prompt further evaluation or supportive care. Therefore, as a global indicator of physical function and overall health status, gait speed as a rapid, valid, and standardized method for assessing frailty and functional decline could add to medical decision making to improve patient care and reduce adverse clinical outcomes (Studenski et al., 2011). STRENGTHS/LIMITATIONS The strengths of this study include the substantial number of study participants representing a diverse sample of communitydwelling older adults followed longitudinally. The study also used reliable measures of function to calculate life expectancy predictions associated with various gait speeds. In contrast to smaller gait speed studies with limited statistical resources to evaluate for variability, the investigators successfully evaluated numerous effect measures using subgroup analysis (Studenski et al., 2011). Study limitations are consistent with those typically associated
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
Date: July 18, 2014
212
with observational research, including the inability to prove underlying associations and subject bias resulting from healthy volunteers. Although this study was substantial and diverse, the study cohorts did not include hospitalized or institutionalized older adults; therefore, survival averages represent estimates for only healthy, community-dwelling older men and women of varying ages living in the United States. Other limitations included methodological issues relating to actual gait speed procedures (Studenski et al., 2011), and that validation studies using gait speed assessments in the ED setting are lacking. The authors suggest that further work to determine the associations between gait speed, disability, and health care usage, such as ED admissions, is needed. PAULA’S COMMENTS Adults 65 years and older account for an increasing proportion of ED visits. According to Albert, McCaig, and Ashman (2013) among ED visits occurring between 2009 and 2010 (19.6 million) in the United States, 15% were adults aged 65 years and older. Average ED visit rates also increase as age increases (Albert et al., 2013). Once in the ED, older adults are more likely be admitted to the hospital, intensive care units, or return to the ED than younger cohorts (Meldon et al., 2003). Furthermore, older adults often experience a decline in functional status, health, and quality of life following an ED visit (Meldon et al., 2003). In light of this reality, improved and more comprehensive evaluations are needed for this population. Unfortunately, the identification of easy and trouble-free assessment tools to evaluate geriatric patients with increased risk of poor outcomes if discharged is lacking (Meldon et al., 2003). In a previous editorial, Studenski (2009) discussed how the physical requirements needed to walk place demands on multiple body systems. Consequently, diminished organ system function will ultimately impact and slow a person’s gait speed. Therefore, gait speed is helpful in identifying an estab-
Time: 0:54
Advanced Emergency Nursing Journal
lished or unrecognized health-related problem. In fact, the appearance of gait difficulties may be such a sensitive indicator of overall dysfunction that it can be described as the “sixth vital sign” (p. 39) serving as a powerful marker of well-being, frailty, and physical performance in older adults (Peel, Kuys, & Klein, 2012). The findings by Studenski et al. (2011) support this point. Furthermore, a systematic review of gait speed screening among communitydwelling adults indicates that the tool demonstrates better test–retest reliability and construct and predictive validity than other disability measures (Munoz-Mendoza, CabreroGarcia, Reig-Ferrer, & Cabanero-Martinez, 2010). As an indicator of well-being and functional ability, gait speed could be useful in identifying those patients needing prompt evaluation and management of cardiopulmonary, neurological, or musculoskeletal conditions in the primary care setting or those requiring close follow-up after discharge from the ED. By uncovering geriatric patients at risk for poor clinical outcomes, prompting close medical and social follow-up, gait speed improves the comprehensive evaluation of older adults by setting the trajectory for the ED course and disposition (Meldon et al., 2003). In conclusion, the implementation of gait speed assessment in the ED has the potential to improve outcomes by alerting providers to those patients who may require ancillary services following discharge to sustain or improve their health status and to those who may be experiencing new or worsening musculoskeletal, cardiopulmonary, or neurological conditions. This study (Studenski et al., 2011) provides support that adding gait speed, a low risk, easy to incorporate change into the routine ED assessment of older adults may improve the timeliness and appropriateness of care. DIAN’S COMMENTS As Paula indicated, ED census rates for older adults are increasing along with overall U.S.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
July–September 2014
r Vol. 36, No. 3
census trends. Older adults pose a unique challenge to ED providers because of their range of functional ability, from frail to active and healthy. A comprehensive ED assessment of the older adult requires an understanding of normal age-related changes, functional capabilities, and atypical presentations. Multiple resources are available to nurses and advanced practice registered nurses (APRNs) to enhance awareness and knowledge of the unique needs of older adults in the ED. One excellent resource is the Emergency Nurses Association’s (ENA, 2014) Geriatric Emergency Nursing Education course offered as a series of 17 online modules for continuing education. These modules discuss normal agerelated changes, atypical presentations, and the types of screening tools to assist in assessing function and cognitive status in the ED. Another excellent resource for APRNs is The Primary Care for Older Adults ELearning series modules available through the Hartford Institute for Geriatric Nursing/New York University College of Nursing (n.d.). The Hartford Institute also publishes best practice, evidence-based guidelines to promote the care of older adults that can be useful in the ED setting. In 2013, the ENA, The American Geriatric Society, the American College of Emergency Physicians, and the Society for Academic Emergency Medicine published updated, standardized guidelines to improve the care of geriatric patients in the ED (The American Geriatric Society, 2014). These guidelines include recommendations for staffing, policies and procedures, and performance improvement measures including use of functional assessment screening tools, specifically the Triage Risk Assessment Tool and the Initial Screening Questionnaire. These instruments include questions related to medication use, recent hospitalization, cognitive impairment, and falls predictive of adverse health outcomes. However, neither instrument includes an objective assessment of function like gait speed. Although the validity of using gait speed in clinical settings is still being investigated, incorporating gait speed into
Date: July 18, 2014
Time: 0:54
Gait Speed in the Emergency Department
213
an ED assessment may improve discharge planning and, therefore, should be further studied. Gait speed may offer a better screening assessment of geriatric function than those typically recommended because it is objective, takes less than 2 minutes to complete, requires only a stopwatch and a 4-m walking area, and can also be performed by nonnursing personnel (Peel et al., 2012). Gait speed testing could be incorporated either at triage or during the medical screening examination. The predictive validity of gait speed for early mortality has been demonstrated across race, gender, and age. Normative data are also available for inpatient as well as for healthy community-dwelling populations (Fritz & Luscardi, 2009; Peel et al., 2012). Furthermore, Fritz and Lusardi (2009) include evidencebased reference norms in their article that can be applied in clinical settings to identify older adults at risk. The norms have been correlated with ADL dependency, need for hospitalization, rehabilitation needs, and discharge location that can be used for discharge planning. Advanced practice nurses should consider adding a gait speed when assessing older adults; particularly those with vague complaints and inconclusive findings. By identifying patients who may be at risk, this simple measure can assist the clinician in selecting additional outpatient services to reduce readmission and optimize outcomes. CASE REVISITED As Mr. J. and his daughter prepare to be discharged, you ask Mr. J. to perform the gait speed 4-m walk and note his speed as 0.7 m/s; slower than the expected norm. Although slow gait speed is not sufficient for an admission, it alerts you that his functional status is suboptimal. Therefore, you make a social service referral, relate your concerns to the social worker, and together with the daughter identify a home health agency and physical therapy agency that can make a home visit to Mr. J.’s assisted living facility within 24 hours
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00013
Date: July 18, 2014
214
to determine whether additional resources are warranted to address potential worsening conditions. By adding an evidence-based assessment of Mr. J.’s overall functional status, the gait speed assessment provides you and Mr. J’s daughter with more information for transitioning his care at discharge than would otherwise have been warranted on the basis of his ED evaluation alone, hopefully improving his course of care and reducing his risk for readmission. REFERENCE Albert, M., McCaig, L. F., & Ashman, J. J. (2013). Emergency department visits by persons aged 65 and over: United States, 2009–2010. NCHS data brief, no 130. Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/ data/databriefs/db130.pdf Emergency Nurses Association. (2014). Geriatric Emergency Nursing Education. Retrieved from http://www.ena.org/education/education/GENE/ Pages/default.aspx Fritz, S., & Luscardi, M. (2009). White paper: Walking speed: The sixth vital sign. Journal of Geriatric Physical Therapy, 32(2), 2–4. Hartford Institute for Geriatric Nursing/New York University College of Nursing. (n.d.). Primary care
Time: 0:54
Advanced Emergency Nursing Journal
for older adults PCOA: The e-learning modules pilot testing. Retrieved from http://consultgerirn.org/ uploads/File/PCOA/story.html Meldon, S. W., Mion, L. C., Palmer, R. M., Drew, B. L., Connor, J. T., Lewicki, L. J., . . . Emerman, C. L. (2003). A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Academic Emergency Medicine, 10(3), 224–232. Munoz-Mendoza, C., Cabrero-Garcia, J., Reig-Ferrer, A., & Cabanero-Martinez, M. (2010). Evaluation of walking speed tests as a measurement of functional limitations in elderly people: A structured review. International Journal of Clinical and Health Psychology, 10(2), 359–378. Peel, N. M., Kuys, S. S., & Klein, K. (2012). Gait speed as a measure in geriatric assessment in clinical settings: A systematic review. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 68(1), 39–46. doi:10.1093/Gerona/gls174 Studenski, S. (2009). Bradypedia: Is gait speed ready for clinical use? The Journal of Nutrition, Health & Aging, 13(10), 878–880. Studenski, S., Perera, S., Patel, K., Rosano, C., Faulkner, K., Inzitari, M., . . . Guralnik, J. (2011). Gait speed and survival in older adults. The Journal of the American Medical Association, 305(1), 50–58. The American Geriatric Society. (2014). Geriatric emergency department guidelines. Retrieved from http://geriatricscareonline.org/ProductAbstract/ geriatric-emergency-department-guidelines/CL013
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
