The agitated older adult in the emergency department: a narrative review of common causes and management strategies

Optimizing older patient care in emergency departments: a comprehensive survey of current practices and challenges in Northern Italy

BACKGROUND

The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2 million people aged 65 years and older.

METHODS

An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care.

RESULTS

In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient's care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training.

CONCLUSIONS

Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.

How do emergency department staff respond to behaviour that challenges displayed by people living with dementia? A mixed-methods study

OBJECTIVES

To investigate staff experiences of, and approaches to behaviour that challenges displayed by patients with dementia in the emergency department (ED). Behaviour that challenges is defined as 'actions that detract from the well-being of individuals due to the physical or psychological distress they cause within the settings they are performed', and can take many forms including aggressive physical actions, shouting and verbal aggression and non-aggressive behaviour including repetitive questioning, inappropriate exposure and resistance to care.

DESIGN

Mixed-methods study consisting of an online survey and semistructured telephone interviews. Quantitative data were analysed and presented using descriptive statistics. Qualitative data were analysed thematically.

SETTING

The EDs of three National Health Service (NHS) Hospital Trusts in Southwest England.

PARTICIPANTS

Multidisciplinary NHS staff working in the ED.

RESULTS

Fifty-two online survey responses and 13 telephone interviews were analysed. Most (24/36, 67%) survey respondents reported that they had received general training in relation to dementia in the last 2-5 years, however, less than a fifth (4/23, 17%) had received any ED-specific dementia training. All (48/48) felt that behaviour that challenges could potentially be prevented, though resource constraints and practice variation were identified. Four main themes emerged from the qualitative data: (1) the 'perfect storm' of the ED; (2) behaviour that challenges is preventable with the right resources; (3) improvisation and (4) requirement for approaches that are specific to the ED.

CONCLUSIONS

The findings of this study suggest that ED staff do not feel that they are prepared to respond effectively to behaviour that challenges displayed by people living with dementia. Future work could adapt or develop an intervention to support ED staff in responding to behaviour that challenges.

Characterizing PRN Use of Psychotropic Medications for Acute Agitation in Canadian Long-Term Care Residents with Dementia Before and During COVID-19

Background

Agitation is a disabling neuropsychiatric symptom of dementia. Pro re nata (PRN) injections of psychotropics can be administered for severe acute agitation, but little is known about the frequency of their actual use.

Objective

Characterize actual use of injectable PRN psychotropics for severe acute agitation in Canadian long-term care (LTC) residents with dementia and compare use before and during the COVID-19 pandemic.

Methods

Residents from two Canadian LTC facilities with orders for PRN haloperidol, olanzapine, or lorazepam between January 1, 2018- May 1, 2019 (i.e., pre-COVID-19) and January 1, 2020- May 1, 2021 (i.e., COVID-19) were identified. Electronic medical records were reviewed to document PRN injections of psychotropic medications and collect data on reason and demographic characteristics. Descriptive statistics were used to characterize frequency, dose, and indications of use, and multivariate regression models were used to compare use between time periods.

Results

Of the 250 residents, 45 of 103 (44%) people in the pre-COVID-19 period and 85 of 147 (58%) people in the COVID-19 period with standing orders for PRN psychotropics received ≥1 injections. Haloperidol was the most frequently used agent in both time periods (74% (155/209 injections) pre-COVID-19; 81% (323/398 injections) during COVID-19). Residents in the COVID-19 period were almost two times more likely to receive injections compared with those in the pre-COVID-19 period (odds ratio = 1.96; 95% CI = 1.15-3.34; p = 0.01).

Conclusion

Our results suggest that use of PRN injections increased in LTC during the pandemic and contribute to the mounting evidence that agitation worsened during that time.

Agitated Geriatric Patients and Violence in the Workplace

Older adults may suddenly exhibit behaviors that are viewed as noncompliant, noncooperative, and threatening. They may even lash out verbally and physically causing injury to health care staff. In addition to taking actions that prevent harm to the staff and the patient, determining what caused this behavior (dementia vs delirium or other cases) will be critical, as well as debriefing the staff after the incident.

Updates in the Assessment and Management of Agitation

Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.

Enhancing the quality of prescribing practices for older adults discharged from the emergency department in Rhode Island

BACKGROUND

We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner.

METHODS

This study utilized a quasi-experimental interrupted time series design to implement EQUiPPED, a three-prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre-and post-intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression.

RESULTS

247 ED clinicians (48% attendings [n = 119], 27% residents [n = 67], 25% advanced practice providers [n = 61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre-implementation period (July 2018-July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post-implementation period (October 2019-January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre-implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post-implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines.

CONCLUSIONS

EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID-19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults.

Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review

OBJECTIVES

To summarize research on optimal emergency department (ED) care practices for persons living with dementia (PLWDs) and develop research priorities.

DESIGN

Systematic scoping review.

SETTINGS AND PARTICIPANTS

PLWDs in the ED.

METHODS

The following Patient-Intervention-Comparison-Outcome (PICO) questions were developed: PICO 1, What components of emergency department care improve patient-centered outcomes for persons with dementia? PICO 2, How do emergency care needs for persons with dementia differ from other patients in the emergency department? A scoping review was conducted following PRISMA-ScR guidelines and presented to the Geriatric Emergency care Applied Research 2.0 Advancing Dementia Care network to inform research priorities.

RESULTS

From the 6348 publications identified, 23 were abstracted for PICO 1 and 26 were abstracted for PICO 2. Emergency care considerations for PLWDs included functional dependence, behavioral and psychological symptoms of dementia, and identification of and management of pain. Concerns regarding ED care processes, the ED environment, and meeting a PWLD's basic needs were described. A comprehensive geriatric assessment and dedicated ED unit, a home hospital program, and a low-stimulation bed shade and contact-free monitor all showed improvement in patient-centered or health care use outcomes. However, all were single-site studies evaluating different outcomes. These results informed the following research priorities: (1) training and dementia care competencies; (2) patient-centric and care partner-centric evaluation interventions; (3) the impact of community- and identity-based factors on ED care for PLWDs; (4) economic or other implementation science measures to address viability; and (5) environmental, operational, personnel, system, or policy changes to improve ED care for PLWDs.

CONCLUSIONS AND IMPLICATIONS

A wide range of components of both ED care practices and ED care needs for PLWDs have been studied. Although many interventions show positive results, the lack of depth and reproducible results prevent specific recommendations on best practices in ED care for PLWDs.

Can we improve delirium prevention and treatment in the emergency department? A systematic review

BACKGROUND

This systematic review was conducted to evaluate any interventions to prevent incident delirium, or shorten the duration of prevalent delirium, in older adults presenting to the emergency department (ED).

METHODS

Health sciences librarian designed electronic searches were conducted from database inception through September 2021. Two authors reviewed studies, and included studies that evaluated interventions for the prevention and/or treatment of delirium and excluded non-ED studies. The risk of bias (ROB) was evaluated by the Cochrane ROB tool or the Newcastle-Ottawa (NOS) scale. Meta-analysis was conducted to estimate a pooled effect of multifactorial programs on delirium prevention.

RESULTS

Our search strategy yielded 11,900 studies of which 10 met study inclusion criteria. Two RCTs evaluated pharmacologic interventions for delirium prevention; three non-RCTs employed a multi-factorial delirium prevention program; three non-RCTs evaluated regional anesthesia for hip fractures; and one study evaluated the use of Foley catheter, medication exposure, and risk of delirium. Only four studies demonstrated a significant impact on delirium incidence or duration of delirium-one RCT of melatonin reduced the incidence of delirium (OR 0.19, 95% CI 0.06 to 0.62), one non-RCT study on a multi-factorial program decreased inpatient delirium prevalence (41% to 19%) and the other reduced incident delirium (RR 0.37, 95% CI 0.22 to 0.61). One case-control study on the use of ED Foley catheters in the ED increased the duration of delirium (proportional OR 3.1, 95% CI 1.3 to 7.4). A pooled odds ratio for three multifactorial programs on delirium prevention was 0.46 (95% CI 0.31-0.68, I2  = 0).

CONCLUSION

Few interventions initiated in the ED were found to consistently reduce the incidence or duration of delirium. Delirium prevention and treatment trials in the ED are still rare and should be prioritized for future research.

In an Emergency Setting, What Is the Best Intramuscular Pharmacological Treatment to Give to an Agitated Geriatric Patient?

Herein, we describe an agitated geriatric patient who suffered an adverse outcome due to treatment for agitation in an emergency setting. This led to the prompt review of the current literature on best-practice medication to use in this population. After careful review, the authors recommend olanzapine as the first-line medication for agitation due to its lower risk-averse effect profile when compared to other medications used for this patient population.

COVID-19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end-of-life care

OBJECTIVE

To characterize the national distribution of COVID-19 hospital and emergency department visitor restriction policies across the United States, focusing on patients with cognitive or physical impairment or receiving end-of-life care.

METHODS

Cross-sectional study of visitor policies and exceptions, using a nationally representative random sample of EDs and hospitals during the first wave of the COVID-19 pandemic, by trained study investigators using standardized instrument.

RESULTS

Of the 352 hospitals studied, 326 (93%) had a COVID-19 hospital-wide visitor restriction policy and 164 (47%) also had an ED-specific policy. Hospital-wide policies were more prevalent at academic than non-academic (96% vs 90%; P < 0.05) and at urban than rural sites (95% vs 84%; P < 0.001); however, the prevalence of ED-specific policies did not significantly differ across these site characteristics. Geographic region was not associated with the prevalence of any visitor policies. Among all study sites, only 58% of hospitals reported exceptions for patients receiving end-of-life care, 39% for persons with cognitive impairment, and 33% for persons with physical impairment, and only 12% provided policies in non-English languages. Sites with ED-specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end-of-life care (26%).

CONCLUSION

Although the benefits of visitor policies towards curbing COVID-19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end-of-life care were predominantly lacking, as were policies in non-English languages.

Use of antipsychotic and sedative medications in older patients in the emergency department

BACKGROUND

Antipsychotics and sedatives are used to treat agitation in the emergency department (ED) but carry significant risk in older adults. Our objective was to determine factors associated with their administration to older ED patients.

METHODS

This was an observational study using data from the 2014-2017 National Hospital Ambulatory Medical Care Survey. We identified ED visits for patients aged ≥65 years and determined whether an antipsychotic or sedative was administered. Visits related to substance use/withdrawal, other psychiatric complaints, and intubation were excluded. We performed multivariable logistic regression to identify risk factors for antipsychotic or sedative administration.

RESULTS

Of the 78.7 million ED visits that met inclusion criteria, 3.5% involved at least one dose of antipsychotic or sedative medication; 13% involved an antipsychotic and 92% a sedative. Factors associated with antipsychotic administration included nursing home residence (adjusted odds ratio [aOR]: 2.67; 95% CI: 1.05-6.80), dementia (aOR: 5.62; 95% CI: 2.44-12.94), and delirium (aOR: 7.33; 95% CI: 2.21-24.32). Sedative administration was positively associated with CT or MR imaging (aOR: 1.86; 95% CI: 1.42-2.43), urbanicity of ED (aOR: 1.46; 95% CI: 1.02-2.08), and female gender (aOR: 1.47; 95% CI: 1.08-1.99) and negatively associated with older age (age: 75-84; aOR: 0.67; 95% CI: 0.49-0.91; age: 85+; aOR: 0.63; 95% CI: 0.45-0.88; reference age: 65-74 years). Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.

CONCLUSION

We identified patient- and facility-level factors associated with sedative and antipsychotic administration in older ED patients. Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.

Evaluating older adults with cognitive dysfunction: A qualitative study with emergency clinicians

BACKGROUND

Evaluating older adults with cognitive dysfunction in emergency departments (EDs) requires obtaining collateral information from sources other than the patient. Understanding the challenges emergency clinicians face in obtaining collateral information can inform development of interventions to improve geriatric emergency care and, more specifically, detection of ED delirium. The objective was to understand emergency clinicians' experiences obtaining collateral information on older adults with cognitive dysfunction, both before and during the COVID-19 pandemic.

METHODS

From February to May 2021, we conducted semi-structured interviews with a purposive sample of 22 emergency physicians and advanced practice providers from two urban academic hospitals and one community hospital in the Northeast United States. Interviews lasted 10-20 min and were digitally recorded and transcribed. Interview transcripts were analyzed for dominant themes using a combined deductive-inductive approach. Responses regarding experiences before and during the pandemic were compared.

RESULTS

Five major challenges emerged regarding (1) availability of caregivers, (2) reliability of sources, (3) language barriers, (4) time constraints, and (5) incomplete transfer documentation. Participants perceived all challenges, but those relating to transfer documentation were amplified by the COVID-19 pandemic.

CONCLUSION

Emergency clinicians' perspectives can inform efforts to support caregiver presence at bedside and develop standardized communication tools to improve recognition of delirium and, more broadly, geriatric emergency care.

Factors associated with Emergency Medical Dispatcher request and residents' inappropriate transfers from Nursing Homes to Emergency Department

PURPOSE

In the last decades, the amount of emergency department (ED) transfers of nursing home (NH) residents has disproportionally increased in western countries. The main role of emergency medical dispatcher (EMD) among this population is to refer residents to EDs in the most appropriate way. The aim of this study was to assess risk factors of inappropriate transfers from NH to ED after EMD request.

METHODS

This research was a secondary analysis of a prospective observational multicenter study carried out in 17 EDs entitled FINE aimed to assess potentially inappropriate transfer prevalence among this population. Inappropriate transfers were determined in the FINE study threw a standardized approach by a unique expert team.

RESULTS

Overall, 572/1037 (55.2%) of residents were transferred to the ED after an EMD's decision. Among them, 92/572 (16.1%) transfers was defined as inappropriate. The average age was 87.3 years old (SD = 0.3). The main reason for ED transfer were falls (217/572, 37.9%). In multivariate analysis, the presence of a Special Care Unit in NH was significantly associated with a high rate of inappropriate transfer (OR 1.78; 95 CI [1.07-2.93]; p = 0.02) whereas a medical examination by a general practitioner before the transfer (OR 0.55; 95 CI [0.33-0.83]; p = 0.02) and a prompt access to psychiatric advice (OR 0.54; 95 CI [0.33-0.84]; p = 0.007) were associated with a low rate of potentially inappropriate transfer.

CONCLUSION

Promoting onsite medical assessment and partnership thanks to available geriatrician's advice may help the emergency medical dispatcher to improve the appropriateness of residents' transfer from Nursing Home to the emergency department.