Delirium in Older Emergency Department Patients: Recognition, Risk Factors, and Psychomotor Subtypes (original) (raw)
Related papers
The Missed and the Misdiagnosed: Geriatric Delirium in the Emergency Department
Journal of Geriatric Emergency Medicine
Introduction Older patients with delirium are at increased risk for prolonged hospitalization, poor outcomes, higher costs and a greater risk for institutionalization. By identifying those at risk early, interventions can be implemented to prevent or minimize the severity of the delirium. Per hospital policy, our geriatric emergency department (ED) screens for delirium by performing a 4AT only if changes in mental status are noted by caregivers or healthcare providers familiar with the patient. We hypothesize this approach underestimates the prevalence of delirium on presentation to the ED, particularly among high-risk older patients. The aim of this study is to determine how many cases of delirium that are present on admission are missed using this traditional approach. Methods High risk older patients presenting to the ED were identified using an internally devised Electronic Medical Record (EMR) based risk stratification algorithm with known risk factors for delirium including age (>65 years old), polypharmacy (>10 medications), dementia history, sensory impairment and repeat ED visits or hospitalizations (>5 over the preceding year). Of these high-risk patients, 100 patients were randomly selected to undergo a 4AT delirium screen in the ED on presentation, regardless of whether mental status changes were noted in triage. Incidence of delirium and cognitive impairment on presentation using the 4AT score was calculated and contrasted with the traditional approach using the McNemer test to detect any statistical difference. Results The average age was 74 years old (65-95 years old), outpatient medication count was 15 (0-40) and average prior ED visits/hospitalizations over the preceding year was 3 (1-68). Seven had a known prior history of dementia, 56 were male and 44 were female. Of the 100 patients screened, 14 scored 4 or above on the 4AT; indicating delirium on arrival. Of these 14, only 3 were detected using the traditional approach. The difference between the number of cases detected by the traditional approach and the EMR based risk stratification method was noted to be significant (p<0.05). 27 of those screened scored 1-3; indicating likely underlying cognitive impairment not meeting criteria for delirium. None of these patients were detected by the traditional method. Conclusion All high-risk older patients, as identified by the EMR, should be screened for delirium on presentation to the ED at the time of triage using the 4AT screen or comparable screening test. This screening should not be dependent only on report of acute mental status changes by patient or caregivers. Patients with underlying cognitive impairment who do not screen positive for delirium but score 1-3 on 4AT are likely to benefit from the early implementation of delirium prevention strategies.
Annals of Emergency Medicine, 2013
Background-Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel two-step approach to delirium surveillance for the ED. Methods-This prospective observational study was conducted at an academic ED in patients ≥ 65 years old. A research assistant (RA) and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment
Evaluation of delirium in aged patients assisted at emergency hospital service
Revista Brasileira de Enfermagem
Objective: identify the occurrence of delirium in aged patients assisted in emergency services and verify its relationship with sociodemographic and clinical variables. Method: cross-sectional, prospective study with a quantitative approach. Two hundred aged hospitalized patients participated. The Confusion Assessment Method was used for data collection. For statistical analysis, chi-square tests, likelihood ratio and Fisher’s test were used, with a significance level of 5%. Results: male gender and mean age of 71.8 years were predominant. In the first 24 hours of hospitalization, 56 (28%) aged individuals presented delirium. An association of the disease with lack of physical activity, presence of a caregiver, hypertension, dyslipidemia and cerebrovascular diseases was identified. Conclusion: Delirium was associated with no physical activity, the need of a caregiver, and the presence of comorbidities. The importance of conducting other studies that may lead to early identification ...
Unrecognized delirium in ED geriatric patients
The American Journal of Emergency Medicine, 1995
To determine the sensitivity of an emergency physician's conventional evaluation compared with the validated Confusion Assessment Method (CAM) regarding the recognition of acute confusional states (delirium) in elderly Emergency Department (ED) patients, a cohort of 385 patients presenting to an urban teaching hospital ED was systematically assembled. Patients had to be conscious, able to speak and older than 64 years of age. After the ED physician had examined the patient and test results had been obtained, a series of geriatric assessment results, including one for the likely presence of delirium, was made available to the ED physician; however, no result was specifically highlighted. All patients were assessed by an attending ED physician in the customary fashion. In addition, a study nurse interviewed patients using the CAM and followed patient outcomes for three months. The ED record for all patients with delirium or "probable" delirium, as determined by the CAM, were reviewed for physician diagnosis and disposition to determine how often delirium had been recognized by the emergency physician. Thirty-eight of the 385 patients screened (10%) met criteria for delirium or "probable" delirium; ED charts were complete for 35 of these, which constituted the study sample. The ED diagnosis included delirium or an acceptable synonym in 6 (17%) of these patients. In the 21 patients (62%) admitted to the hospital, the most common ED diagnosis was infection "rule out sepsis" (n = 7). Six of 13 patients discharged (46%) were diagnosed as "status post fall" without evidence of significant injury. The 3-month mortality rate for patients with delirium or "probable" delirium was 14% versus 8% for the non-delirium group (P = .20). These results suggest that the diagnosis of delirium may frequently be missed by the use of a conventional work-up in elderly patients who present to the ED. Educational efforts and/or use of formal assessment instruments may improve diagnostic sensitivity; however, formal evaluations of these strategies will be required. (Am J Emerg Med 1995;13:142-145. Copyright © 1995 by W.B. Saunders)
Background: Emergency care systems are at the core of modern healthcare and are the " point-of-entry/admission " into the hospital for many older/elderly patients. Among these, it is estimated that 15% to 30% will have delirium on admission and that over 50% will develop it during their stay. However, appropriate delirium diagnostic and screening still remains a critical area of need. The goal of this review is to update the field, exploring target areas in screening methods for delirium in the Emergency Department (ED), and/or acute care units, in the older population. Methods: A systematic review was conducted to search screening/diagnostic methods for delirium in the ED and/or acute care units within the ED. Results: Seven different scales were identified. Of the identified instruments, the Confusion Assessment Method (CAM) for the Intense Care Unit (CAM-ICU) was the most widely used. Of note, a brief two-step approach for delirium surveillance was defined with the Delirium Triage Screen (DTS) and the Brief Confusion Assessment Method (bCAM), and the diagnostic accuracy of the Richmond Agitation-Sedation Scale (RASS) for delirium had a good sensitivity and specificity in older patients. Conclusion: The CAM-ICU appears as the potential reference standard for use in the ED, but research in a global approach of evaluation of actual and past cognitive changes is still warranted. Emergency care systems are at the core of modern healthcare. Their primary role is to provide high-quality care to patients regardless of when they need medical help or what they present with [1]. In the Emergency Department (ED) (and/or intermediate or acute care units within these), much of the problem regarding delirium incidence and prevalence relates, in great part, to the unique environment: intense time demands on providers and high volume of patients. Together, these aspects can both: (i) render the caring for older adults challenging; and (ii) hinder the use and validation of screening tools. This occurs despite any positive impact that this latter work would in itself yield, including early identification of delirium and translation into appropriate treatment measures. Regarding delirium, the problem is compounded when considering that the older/elderly population uses emergency care facilities more often than younger individuals [2] and age is one of the principal
Delirium Risk Prediction, Healthcare Use and Mortality of Elderly Adults in the Emergency Department
Journal of the American Geriatrics Society, 2014
Background/Objectives-Delirium is common and under-diagnosed in elderly Emergency Department (ED) patients. The primary aim of this study is to create a risk prediction rule for ED delirium. The secondary aim is to compare the mortality rates and resource utilization of delirious versus non-delirious elderly ED patients. Design-Prospective observational study. Setting-An urban tertiary care emergency department. Participants-700 patients 65 years of age or older and presenting for ED care. Measurements-A trained research assistant performed a structured mental status assessment and attention tests, after which delirium was determined using the Confusion Assessment Method. We collected data on patient demographics, comorbidities, medications and ED course, hospital and Intensive Care Unit (ICU) admission, length of stay, hospital charges, and 30-day rehospitalization and mortality. Results-Nine percent of elderly study participants were delirious. Using logistic regression, we created a delirium prediction rule consisting of older age, prior stroke or transient ischemic attack, dementia, suspected infection and acute intracranial hemorrhage with good predictive accuracy (AUC=0.77). Among admitted patients, those with ED delirium had longer median lengths of stay (4 versus 2 days), and were more likely to require ICU admission (13% versus 6%) and to be discharged to a new long-term care facility (37% versus 9%). Among all patients, ED delirium was associated with higher 30-day mortality (6% vs. 1%) and 30-day readmissions (27% vs. 13%). Conclusion-Our risk prediction rule may help identify a group of high risk ED patients that should undergo screening for delirium, but requires external validation. Identification of delirium in the ED may enable physicians to implement strategies to decrease delirium duration and avoid inappropriate discharge of acutely delirious patients, thereby improving patient outcomes.
Screening for Delirium in the Emergency Department: A Systematic Review
Annals of Emergency Medicine, 2014
Older adults who visit emergency departments (EDs) often experience delirium, but it is infrequently recognized. A systematic review was therefore conducted to identify what delirium screening tools have been used in ED-based epidemiologic studies of delirium, whether there is a validated set of screening instruments to identify delirium among older adults in the ED or prehospital environments, and an ideal schedule during an older adult's visit to perform a delirium evaluation. MEDLINE/EMBASE, Cochrane, PsycINFO, and CINAHL databases were searched from inception through February 2013 for original, English-language research articles reporting on the assessment of older adults' mental status for delirium. Twenty-two articles met all study inclusion criteria. Overall, 7 screening instruments were identified, though only 1 has undergone initial validation for use in the ED environment and a second instrument is currently undergoing such validation. Minimal information was identified to suggest the ideal scheduling of a delirium assessment process to maximize the recognition of this condition in the ED. Study results indicate that several delirium screening tools have been used in investigations in the ED, though validation of these instruments for this particular environment has been minimal to date. The ideal interval(s) during which a delirium screening process should take place has yet to be determined. Research will be needed both to validate delirium screening instruments to be used for investigation and clinical care in the ED and to define the ideal timing and form of the delirium assessment process for older adults.
Delirium in the elderly admitted to an emergency hospital service
Revista Brasileira de Enfermagem, 2022
Objective: To check for the presence of delirium in the elderly entering the emergency room (ER) of the University Hospital of Santa Maria (HUSM) and their relationship with sociodemographic variables, reason and time of hospitalization, comorbidities, and death. Methods: A quantitative, cross-sectional exploratory study, which analyzed data from the sociodemographic profile, Confusion Assessment Method, Charlson Comorbidities Index, and follow-up of the outcomes “in-hospital death” and “length of hospitalization.” The period analyzed in the study was between July and December 2019. Results: Of the 732 participants, 394 (53.90%) were men, with an average age of 72 years. The study identified Delirium in 99 (13.52%) participants, and death, in 120 (16.39%). There was an association of this disorder with age, comorbidities, length of hospitalization, death, and some reasons for hospitalization, such as diseases of the circulatory, respiratory and genitourinary systems. Conclusion: The...