GAPcareAD: A Brief Emergency Department Intervention to Address Post-Fall Care Needs of Persons Living with Dementia and Care Partners
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PROJECT SUMMARY Older adults with Alzheimer’s disease and related dementias (ADRD) fall up to eight times more often than older adults with normal cognition, incur higher fall treatment costs, and 40% experience adverse outcomes after emergency department (ED) visits (e.g., ED revisits, hospitalizations). Although up to 40% of older ED patients have ADRD and falls are the #1 reason why persons living with dementia (PLWD) visit EDs, most ED- based fall studies exclude PLWD and none meaningfully include caregivers. The ED visit is a high yield, under engaged opportunity to address fall prevention. In GAPcare, the Geriatric Acute & Post-acute Care Coordination Program for Fall Prevention in the ED (R03 AG056349; K76 AG059983), fall prevention efforts are initiated in the ED immediately after a fall. Pharmacists identify patients’ fall risk increasing medication and suggest modifications using medication therapy management. Physical therapists (PTs) perform a brief assessment of fall risk and create plans to improve gait, balance, and mobility. Action plans co-created with patients and caregivers are electronically transmitted to outpatient clinicians at the end of the ED visit. The GAPcare randomized controlled trial (RCT) had high patient and caregiver satisfaction, did not prolong ED length of stay, and resulted in 66% fewer 6-month fall-related ED visits compared to usual ED care. Informed by patient and caregiver interviews (R61 AG069822 pilot) we adapted GAPcare for PLWD using Castro’s framework for prevention interventions. Seizing the momentum of our prior research and RCTs and harnessing the strengths of our team in ADRD clinical trials and Medicare analyses, we propose a multisite RCT to test the efficacy of GAPcareAD (intervention) versus usual care in 350 PLWD and their caregivers presenting to the ED for a fall. We will pursue the following three specific aims: (1) conduct a RCT (n=350) in three EDs of community-dwelling persons with ADRD to test the efficacy of GAPcareAD on patient and caregiver outcomes including a reduction in recurrent ED visits for falls at 6 months (primary), falls, serious injuries; improvement of caregiver burden, care transitions, and patients’ quality of life, (2) determine post-ED engagement with pharmacy and PT recommendation including whether medication changes were made, when, and by whom, and dose of outpatient PT, and (3) effect modification by participant (e.g. age, sex, race) and community characteristics (e.g., area deprivation index, social capital). GAPcareAD uses administrative data to pragmatically measure utilization and patient/caregiver centered outcomes. This study addresses a serious problem – high and increasing rates of ED visits for falls – and tests the efficacy of a brief, on-the-spot in-ED intervention in PLWD who have previously been excluded from interventional fall studies. GAPcareAD addresses three major priorities of the NIA: 1) dementia care, 2) improving ED-to-home care transitions, and 3) caregiver support. GAPcareAD’s pragmatic design prepares us for future widespread implementation in multiple EDs nationwide.
