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Three Part Question

In [Elderly patients attending Emergency Department] is [the presence of poor social circumstances (such as poor social support/ social isolation)] associated with [decreased rates of discharge from ED and/or increased rates of the unplanned re-attendance]

Clinical Scenario

A 79 year old patient attends the ED for a minor medical problem. While taking the history it becomes apparent that this patient lives alone, with no relatives nearby and no social support. You wonder if this finding alone increases the risk of re-attendance and the length of stay for this patient.

Search Strategy

BNI,Medline,PsycInfo,CINAHL, 2000-present. Interface: nhs libraries
({old$.ti,ab OR eld$.ti,ab OR geriatric.ti,ab OR aged.ti,ab(mesh)} AND {(socialANDbehaviour).ti,ab OR mobility.ti,ab OR Social.ti,ab (mesh) OR independen*.ti,ab OR dependen*.ti,ab OR care$.ti,ab OR} AND {(emergencyANDmedicine).ti,ab OR (EmergencyANDService).ti,ab(mesh) OR (accidentsANDemergency).ti,ab OR (emergencyANDdepartment).ti,ab } AND {discharge.ti,ab OR return.ti,ab OR re-attendance.ti,ab OR (PatientANDDischarge).ti,ab OR $attendance.ti,ab})
Papers concentrating only on frailty were excluded (these papers were more associated with medical risks of frailty). Papers concentrating on psychiatric illnesses in elderly also excluded.
Papers assessing the effectiveness of tools and interventions on patients with poor social circumstances were also excluded (our BET question was interested in baseline risk, not the efficacy of any particular intervention).

BNI,Medline,PsycInfo,CINAHL, 2000-present. Interface: nhs libraries
({old$.ti,ab OR eld$.ti,ab OR geriatric.ti,ab OR aged.ti,ab(mesh)} AND {(socialANDbehaviour).ti,ab OR mobility.ti,ab OR Social.ti,ab (mesh) OR independen*.ti,ab OR dependen*.ti,ab OR care$.ti,ab OR} AND {(emergencyANDmedicine).ti,ab OR (EmergencyANDService).ti,ab(mesh) OR (accidentsANDemergency).ti,ab OR (emergencyANDdepartment).ti,ab } AND {discharge.ti,ab OR return.ti,ab OR re-attendance.ti,ab OR (PatientANDDischarge).ti,ab OR $attendance.ti,ab})
Papers concentrating only on frailty were excluded (these papers were more associated with medical risks of frailty). Papers concentrating on psychiatric illnesses in elderly also excluded.
Papers assessing the effectiveness of tools and interventions on patients with poor social circumstances were also excluded (our BET question was interested in baseline risk, not the efficacy of any particular intervention).

Search Outcome

1068 papers
3 relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Corina Naughton et al 2010 Ireland	306 patients over 65, interviewed after the attendance to ED	Interview/ Case Control study (4 CEBM)	Vulnerable network as a predictor of re-attendance (local self-contained; private restricted networks)	:OR of re attendance 2.32 CI 95% (1.12 to 4.81)	No clearly identified objectives or design. No Control group. Significant dredging of data
McCusker et al march 2000 Canada	1122 cognitively intact patients older than 65, followed up for 6 month after index visit	Observational prospective cohort study (3B CEBM)	Early Return (within 30 days) (multiple predictors incl. marital status)	Widowed highest rate of return- p 0.03	Multiple outcomes (>20) with no clearly defined primary objectives. Data dredging.
			Frequent Return (3 or more) (multiple predictors incl. marital status)	No difference p-0.4
Landeiro et al 2015 Portugal	278 patients, older than 75 admitted for hip fractures. Three cohorts of patients compared: high, medium and low risk of social isolation as defined by Luben social network scale.	Prospective Cohort study (2ACEBM)	Delay in discharges. Delayed discharges were calculated as the difference between the time a patient was deemed medically fit for discharge and the actual time of discharge.	Odds to have a delayed discharge in high risk of social isolation patients vs Low Risk OR 3.5, CI95% (1.6-7.7) (3.5 times more likely to have delayed discharge) Moderate vs Low OR 1.4, CI95% (0.6-3.4)	Population of Hip fracture patient may be different to baseline population. No Sample size estimate.
			Length of delay in discharge in different risk groups of social isolation	High Risk vs low risk- additional 2.6 days CI95% (0.4-4.7) Moderate vs low risk additional 1.5 days CI95% (0.5-3.3)

Comment(s)

The studies identified suggested a trend towards increased re-attendance of older people with a self-reported lack of social support. The quality of the data is limited and the research methods are not sufficiently robust to draw any definitive conclusions.

Clinical Bottom Line

There is a suggestion supported by limited low level evidence that poor social circumstances are associated with increased risk of re-attendance and length of stay in older people attending the ED. Further research is needed.

References

1. Corina Naughton, Jonathan Drennan, Pearl Treacy et al The role of health and non-health-related factors in repeat emergency department visits in an elderly urban population Emerg Med Journal 2010 27:683e687. doi:10.1136/emj.2009.077917
2. McCusker J., Cardin S., Bellavance O.. Return to the Emergency Department among Elders: Patterns And Predictors ACADEMIC EMERGENCY MEDICINE , March 2000 Volume 7, Number 3.
3. 3. Landeiro F., Leal J., Gray A. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs Osteoporosis Int (2016) 27:737-745. DOI 10.1007/s00198-015-3293-9