Screening for Delirium in the Emergency Department: A Systematic Review (original) (raw)
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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
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
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.
Academic Emergency Medicine, 2020
Background: Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. Methods: GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. Results: In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. Conclusions: Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies. Delirium occurs in 8% to 10% of older adults in the emergency department (ED) and is the underlying reason for about 1.5 million ED visits annually in the United States. 1-4 Delirium manifests clinically as sudden onset neuropsychiatric dysfunction with a waxing and waning course characterized by inattention, disorganized thinking, and changes in level of consciousness. Delirium is not attributable to an established neurocognitive disorder, but is a direct consequence of one or more medical conditions. 5 Older adults are susceptible to developing delirium while in the ED. 6,7 Delirium is often missed in the ED, because emergency staff are only 35% sensitive in detecting delirium. 1,8-12 Even when recognized, delirium may lead to prolonged hospital stay, functional decline, accelerated cognitive decline, and postdischarge depression. 13-16 When unrecognized in the ED, delirium is associated with increased 6-month mortality. 8 In 2007, the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force identified cognitive impairment (including delirium) as one of three conditions with substantial quality gaps for geriatric ED patients. 17 In 2010, this SAEM Task Force identified four high-priority delirium research foci: 1) optimal methods of screening for and diagnosing delirium in the ED, 2) risk factors for delirium in the ED and interventions for prevention and moderation, 3) criteria for safe discharge for older ED patients with delirium, and 4) interventions to improve outcomes for older patients with delirium in the ED. 18 In Carpenter et al.
Systematic Reviews
Background Up to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients. Methods We will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Rese...
Current Translational Geriatrics and Experimental Gerontology Reports, 2012
This paper presents an overview of systematic reviews related to the identification and prevention of acute delirium in the hospitalized elderly. The need to build an evidence base in these areas is heightened by reports that delirium is associated with high rates of readmission, and increases in mortality, length of stay, and cost. We searched MEDLINE, CINAHL, Academic Search Premiere, the Cochrane Database of Systematic Reviews (CDSR) and the Joanna Briggs Institute Library of Systematic Reviews. The search strategy was designed to find systematic reviews, a form of secondary research that synthesizes findings from primary studies in an attempt to identify best practice. A total of 13 systematic reviews were retrieved. Of these, seven were focused on risk factors, three on screening, and three on prevention strategies. Recommendations related to best practice for the identification, screening and prevention of delirium in hospitalized patients over 65 years are provided.
Age and ageing, 2016
screening all unscheduled older adults for delirium is recommended in national guidelines, but there is no consensus on how to perform initial assessment. to evaluate the test accuracy of five brief cognitive assessment tools for delirium diagnosis in routine clinical practice. a consecutive cohort of non-elective, elderly care (older than 65 years) hospital inpatients admitted to a geriatric medical assessment unit of an urban teaching hospital. Reference assessments were clinical diagnosis of delirium performed by elderly care physicians. Routine screening tests were: Abbreviated Mental Test (AMT-10, AMT-4), 4 A's Test (4AT), brief Confusion Assessment Method (bCAM), months of the year backwards (MOTYB) and informant Single Question in Delirium (SQiD). we assessed 500 patients, mean age 83 years (range = 66-101). Clinical diagnoses were: 93 of 500 (18.6%) definite delirium, 104 of 500 (20.8%) possible delirium and 277 of 500 (55.4%) no delirium; 266 of 500 (53.2%) were identif...
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.