The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital

Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments

INTRODUCTION

Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening.

METHODS

We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds.

RESULTS

Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%.

CONCLUSIONS

The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

Delirium screening in the emergency department: evaluation and intervention

BACKGROUND

Between 8-17% of older adults, and up to 40% of those arriving from nursing homes, present with delirium upon admission to the Emergency Department (ED). However, this condition often remains undiagnosed by ED medical staff. We investigated the prevalence of delirium among patients aged 65 and older admitted to the ED and assessed the impact of a prospective study aimed at increasing awareness.

METHODS

The study was structured into four phases: a "pre-intervention period" (T0); an "awareness period" (T1), during which information about delirium and its diagnosis was disseminated to ED staff; a "screening period" (T2), in which dedicated evaluators screened ED patients aged 65 and older; and a "post-intervention period" (T3), following the departure of the evaluators. Delirium screening was conducted using the Brief Confusion Assessment Method (bCAM) questionnaire.

RESULTS

During the T0 and T1 periods, the rate of delirium diagnosed by ED staff was below 1%. The evaluators identified a delirium rate of 14.9% among the screened older adults during the T2 period, whereas the rate among those assessed by ED staff was between 1.6% and 1.9%. Following the evaluators' departure in the T3 period, the rate of delirium diagnosis decreased to 0.89%.

CONCLUSIONS

This study underscores that a significant majority of older adult delirium cases remain undetected by ED staff. Despite efforts to increase awareness, the rate of diagnosis did not significantly improve. While the presence of dedicated delirium evaluators slightly increased the diagnosis rate among patients assessed by ED staff, this rate reverted to pre-intervention levels after the evaluators left. These findings emphasize the necessity of implementing mandatory delirium screening during ED triage and throughout the patient's stay.

Delirium and Delirium Prevention in the Emergency Department

This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.

Effect of enhanced recovery after surgery nursing on the incidence of surgical site wound infection in older adults with hip fractures: A meta-analysis

This meta-analysis evaluated the effect of enhanced recovery after surgery (ERAS) nursing on the incidence surgical site wound infection in older adults with hip fractures. The PubMed, Embase, the Cochrane Library, Web of Science, China Biomedical Literature Database, Wanfang, China National Knowledge Infrastructure, and VIP databases were searched from inception up to March 2023 for articles on randomized controlled trials (RCTs) on the effect of ERAS nursing on surgical site wound infection in older adults with hip fractures. Patients in the experimental group received ERAS nursing, and patients in the control group received conventional postoperative nursing. Two researchers independently completed literature screening and data extraction. The included articles were evaluated according to Cochrane quality assessment standards and the meta-analysis was conducted using Stata 17.0 software to calculate the effect sizes and their 95% confidence intervals (CIs). Twelve RCTs were included with 1117 patients, including 559 in the experimental group and 558 in the control group. In older adults with hip fractures, ERAS nursing reduced the risk of surgical site wound infection (odds ratio [OR]: 0.26, 95% CI: 0.11-0.58, p = 0.001) and postoperative complications (OR: 0.22, 95% CI: 0.14-0.33, p < 0.001), and reduced the length of hospital stay (mean difference: -4.04 days, 95% CI: -4.33 to -3.76 days, p < 0.001). In older adults with hip fractures, ERAS nursing reduces the incidence of surgical site infection and complications and shortens the length of hospital stay.

Succinct Approach to Delirium in the Emergency Department

Purpose of Review

This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework.

Recent Findings

Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers' primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort.

Summary

Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement

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.

Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients

OBJECTIVE

This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians.

METHODS

We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement.

RESULTS

Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67.

DISCUSSION

This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.

Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia

The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.

Delirium and Dementia

Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.

Undiagnosed delirium is frequent and difficult to predict: Results from a prevalence survey of a tertiary hospital

AIMS AND OBJECTIVES

To study the prevalence and determinants of undiagnosed delirium in a tertiary hospital.

BACKGROUND

Delirium is a common inpatient condition. It is frequently undiagnosed in a variety of settings, but determinants of undiagnosed delirium are largely unknown, and the frequency of undiagnosed delirium across all inpatient units is uncertain. The utility of hospital-wide screening then is also uncertain.

METHODS

Hospital-wide prevalence study conducted over 4 months, using a chart-based method. Gender, age, admitting unit, history of dementia and comorbidity were used in univariate and multivariate analyses to search for differences in patients with no delirium, with undiagnosed delirium and with diagnosed delirium. Sensitivity, specificity and number needed to screen were calculated from proportions in each group. Study was conducted in concordance with STROBE guidelines.

RESULTS

Delirium was prevalent in 12.5% of all patients and undiagnosed in 24.1% of patients. Only age ≥65 years and a history of dementia predicted delirium, and undiagnosed delirium in both univariate and multivariate analyses. Age ≥65 years accounts for 92.3% sensitivity and 50.8% specificity for undiagnosed delirium in this group. History of dementia had a 23.0% sensitivity and 97.0% specificity. Twenty-eight patients would need to be screened to detect a case of undiagnosed delirium.

DISCUSSION

There was a high rate of delirium and undiagnosed delirium in this cohort. Known risk factors for delirium also independently predict undiagnosed delirium; other factors were not found.

CONCLUSION

Undiagnosed delirium is common and difficult to predict from patient baseline characteristics other than age.

RELEVANCE TO CLINICAL PRACTICE

Assessment of all inpatients for delirium is recommended.

Increased Readmission Risk and Healthcare Cost for Delirium Patients without Immediate Hospitalization in the Emergency Department

OBJECTIVE

Hospitalization of patients with delirium after visiting the emergency department (ED) is often required. However, the readmission risk after discharge from the ED should also be considered. This study aimed to explore whether (i) immediate hospitalization influences the readmission risk of patients with delirium; (ii) the readmission risk is affected by various risk factors; and (iii) the healthcare cost differs between groups within 28 days of the first ED visit.

METHODS

Using the National Health Insurance Research Database, the data of 2,780 subjects presenting with delirium at an ED visit from 2000 to 2008 were examined. The readmission risks of the groups of patients (i.e., patients who were and were not admitted within 24 hours of an ED visit) within 28 days were compared, and the effects of the severities of different comorbidities (using Charlson's comorbidity index, CCI), age, gender, diagnosis and differences in medical healthcare cost were analyzed.

RESULTS

Patients without immediate hospitalization had a higher risk of readmission within 3, 7, 14, or 28 days of discharge from the ED, especially subjects with more severe comorbidities (CCI≥3) or older patients (≥65 years). Subjects with more severe comorbidities or older subjects who were not admitted immediately also incurred a greater healthcare cost for re-hospitalization within the 28-day follow-up period.

CONCLUSION

Patients with delirium with a higher CCI or of a greater age should be carefully considered for immediate hospitalization from ED for further examination in order to reduce the risk of re-hospitalization and cost of healthcare.

Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department

OBJECTIVES

To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).

DESIGN

Preplanned, secondary analysis of a prospective observational study.

SETTING

Tertiary care, academic ED.

PARTICIPANTS

A total of 424 patients in the ED, 65 years or older, including all chief complaints.

MEASUREMENTS

We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.

RESULTS

Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.

CONCLUSIONS

The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

Validation of Caregiver-Centered Delirium Detection Tools: A Systematic Review

OBJECTIVES

To summarize the validity of caregiver-centered delirium detection tools in hospitalized adults and assess associated patient and caregiver outcomes.

DESIGN

Systematic review.

SETTING

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus from inception to May 15, 2017.

PARTICIPANTS

Hospitalized adults.

INTERVENTION

Caregiver-centered delirium detection tools.

MEASUREMENTS

We drafted a protocol from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers independently completed abstract and full-text review, data extraction, and quality assessment. We summarized findings using descriptive statistics including mean, median, standard deviation, range, frequencies (percentages), and Cohen's kappa. Studies that reported on the validity of caregiver-centered delirium detection tools or associated patient and caregiver outcomes and were cohort or cross-sectional in design were included.

RESULTS

We reviewed 6,056 titles and abstracts, included 6 articles, and identified 6 caregiver-centered tools. All tools were designed to be administered in several minutes or less and had 11 items or fewer. Three tools were caregiver administered (completed independently by caregivers): Family Confusion Assessment Method (FAM-CAM), Informant Assessment of Geriatric Delirium (I-AGeD), and Sour Seven. Three tools were caregiver informed (administered by a healthcare professional using caregiver input): Single Question in Delirium (SQiD), Single Screening Question Delirium (SSQ-Delirium), and Stressful Caregiving Response to Experiences of Dying. Caregiver-administered tools had better psychometric properties (FAM-CAM sensitivity 75%, 95% confidence interval (CI)=35-95%, specificity 91%, 95% CI=74-97%; Sour Seven positive predictive value 89.5%, negative predictive value 90%) than caregiver-informed tools (SQiD: sensitivity 80%, 95% CI=28.4-99.5%; specificity 71%, 95% CI=41.9-91.6%; SSQ-Delirium sensitivity 79.6%, specificity 56.1%).

CONCLUSION

Delirium detection is essential for appropriate delirium management. Caregiver-centered delirium detection tools show promise in improving delirium detection and associated patient and caregiver outcomes. Comparative studies using larger sample sizes and multiple centers are required to determine validity and reliability characteristics.

Exploratory and Confirmatory Factor Analyses of Delirium Symptoms in a Sample of Nursing Home Residents

OBJECTIVE

This study examined the latent constructs of delirium symptoms among nursing home (NH) residents in the United States.

METHOD

Cross-sectional NH assessment data (Minimum Data Set 2.0) from the 2009 Medicare Current Beneficiary Survey were used. Data from two independent, randomly selected subsamples of residents ≥65 years were analyzed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

RESULTS

There were 367 and 366 individuals in the EFA and CFA, respectively. Assessment of multiple model fit statistics in CFA indicated that the two-factor structure provided better fit for the data than a one-factor solution. The two factors represented cognitive and behavioral latent constructs as suggested by the related literature. A correlation of .72 between these constructs suggested moderate discriminant validity.

CONCLUSION

This finding emphasizes the importance of health care providers to be attentive to both cognitive and behavioral symptoms when diagnosing, treating, and managing delirium.

Attention! A good bedside test for delirium?

BACKGROUND

Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective 'confusion'.

METHODS

We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method.

RESULTS

265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity.

CONCLUSIONS

Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.

Screening, detection and management of delirium in the emergency department - a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED)

BACKGROUND

Delirium in emergency department (ED) patients occurs frequently and often remains unrecognized. Most instruments for delirium detection are complex and therefore unfeasible for the ED. The aims of this pilot study were first, to confirm our hypothesis that there is an unmet need for formal delirium assessment by comparing informal delirium ratings of ED staff with formal delirium assessments performed by trained research assistants. Second, to test the feasibility of an algorithm for delirium screening, detection and management, which includes the newly developed modified Confusion Assessment Method for the Emergency Department (mCAM-ED) at the ED bedside. Third, to test interrater reliability of the mCAM-ED.

METHODS

This was a pilot study with a pre-post-test design with two data collection periods before and after the implementation of the algorithm. Consecutive ED patients aged 65 years and older were screened and assessed in the ED of a tertiary care center by trained research assistants. The delirium detection rate of informal ratings by nurses and physicians was compared with the standardized mCAM-ED assessment performed by the research assistants. To show the feasibility at the ED bedside, defined as adherence of ED staff to the algorithm, only post-test data were used. Additionally, the ED nurses' assessments were analyzed qualitatively. To investigate the agreement between research assistants and the reference standard, the two data sets were combined.

RESULTS

In total, 207 patients were included in this study. We found that informal delirium assessment was inappropriate, even after a teaching intervention: Sensitivity of nurses to detect delirium without formal assessment was 0.27 pretest and 0.40 post-test, whilst sensitivity of physicians' informal rating was 0.45 pre-test and 0.6 post-test. ED staff demonstrated high adherence to the algorithm (76.5%). Research assistants assessing delirium with the mCAM-ED demonstrated a high agreement compared to the reference standard (kappa = 0.729).

CONCLUSIONS

Informal assessment of delirium is inadequate. The mCAM-ED proved to be useful at the ED bedside. Performance criteria need to be tested in further studies. The mCAM-ED may contribute to early identification of delirious ED patients.

Validation of the Confusion Assessment Method for the Intensive Care Unit in older emergency department patients

OBJECTIVES

In the emergency department (ED), health care providers miss delirium approximately 75% of the time, because they do not routinely screen for this syndrome. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a brief (<1 minute) delirium assessment that may be feasible for use in the ED. The study objective was to determine its validity and reliability in older ED patients.

METHODS

In this prospective observational cohort study, patients aged 65 years or older were enrolled at an academic, tertiary care ED from July 2009 to February 2012. An emergency physician (EP) and research assistants (RAs) performed the CAM-ICU. The reference standard for delirium was a comprehensive (~30 minutes) psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were blinded to each other and were conducted within 3 hours. Sensitivities, specificities, and likelihood ratios were calculated for both the EP and the RAs using the psychiatrist's assessment as the reference standard. Kappa values between the EP and RAs were also calculated to measure reliability.

RESULTS

Of 406 patients enrolled, 50 (12.3%) had delirium. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, and 57 (14.0%) were nonwhite. The CAM-ICU's sensitivities were 72.0% (95% confidence interval [CI] = 58.3% to 82.5%) and 68.0% (95% CI = 54.2% to 79.2%) in the EP and RAs, respectively. The CAM-ICU's specificity was 98.6% (95% CI = 96.8% to 99.4%) for both raters. The negative likelihood ratios (LR-) were 0.28 (95% CI = 0.18 to 0.44) and 0.32 (95% CI = 0.22 to 0.49) in the EP and RAs, respectively. The positive likelihood ratios (LR+) were 51.3 (95% CI = 21.1 to 124.5) and 48.4 (95% CI = 19.9 to 118.0), respectively. The kappa between the EP and RAs was 0.92 (95% CI = 0.85 to 0.98), indicating excellent interobserver reliability.

CONCLUSIONS

In older ED patients, the CAM-ICU is highly specific, and a positive test is nearly diagnostic for delirium when used by both the EP and RAs. However, the CAM-ICU's sensitivity was modest, and a negative test decreased the likelihood of delirium by a small amount. The consequences of a false-negative CAM-ICU are unknown and deserve further study.

Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method

STUDY OBJECTIVE

Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium in 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 2-step approach to delirium surveillance for the ED.

METHODS

This prospective observational study was conducted at an academic ED in patients aged 65 years or older. A research assistant and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were independently conducted within 3 hours of one another. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95% CIs) were calculated.

RESULTS

Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% sensitive (95% CI 89.5% to 99.5%), with an expected specificity of approximately 55% for both raters. The DTS's negative likelihood ratio was 0.04 (95% CI 0.01 to 0.25) for both raters. As the complement, the bCAM had a specificity of 95.8% (95% CI 93.2% to 97.4%) and 96.9% (95% CI 94.6% to 98.3%) and a sensitivity of 84.0% (95% CI 71.5% to 91.7%) and 78.0% (95% CI 64.8% to 87.2%) when performed by the physician and research assistant, respectively. The positive likelihood ratios for the bCAM were 19.9 (95% CI 12.0 to 33.2) and 25.2 (95% CI 13.9 to 46.0), respectively. If the research assistant DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95% CI 71.5% to 91.7%) and specificity was 95.8% (95% CI 93.2% to 97.4%). If the research assistant performed both the DTS and bCAM, this combination was 78.0% sensitive (95% CI 64.8% to 87.2%) and 97.2% specific (95% CI 94.9% to 98.5%). If the physician performed both the DTS and bCAM, this combination was 82.0% sensitive (95% CI 69.2% to 90.2%) and 95.8% specific (95% CI 93.2% to 97.4%).

CONCLUSION

In older ED patients, this 2-step approach (highly sensitive DTS followed by highly specific bCAM) may enable health care professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multicenter trials are needed to confirm these findings and to determine the effect of these assessments on delirium recognition in the ED.

Care of the older adult in the emergency department: nurses views of the pressing issues

PURPOSE

The purpose of the study was to describe nurses' views of the issues to be addressed to improve care of the older adult in the emergency department (ED).

DESIGN AND METHODS

An exploratory content analysis examined the qualitative responses of 527 registered nurses from 49 U.S. hospitals who completed the Geriatric Institutional Profile.

RESULTS

5 central themes emerged from the analysis, representing a lack of older person hospital environment fit in the ED: (a) respect for the older adult and carers, (b) correct and best procedures and treatment, (c) time and staff to do things right, (d) transitions, and (e) a safe and enabling environment. The nurses offered solutions to address lack of fit, including modifications to the social climate, policies and procedures, care systems and processes, and physical design.

IMPLICATIONS

The nurses' descriptions of the pressing issues surrounding care of older adults in the ED provide useful information to consider when developing a senior-friendly ED. Results also illuminate solutions that can be taken to address issues. These solutions give direction for future intervention research.

Appraisal of the quality of care of older adults with cognitive impairment in the emergency department

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: a social ecological study

BACKGROUND

Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting.

METHOD

Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis.

RESULTS

Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs.

CONCLUSIONS

In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.

Contextual factors influencing success or failure of emergency department interventions for cognitively impaired older people: a scoping and integrative review

AIM

This paper is a report of a scoping review of research on cognitive impairment in older adults who visit Emergency Departments of acute care hospitals, followed by an integrative review that included a quality assessment to determine the effectiveness of interventions for this population.

BACKGROUND

Being old and cognitively impaired in the Emergency Department--a fast-paced intervention system--is a complex phenomenon that challenges many healthcare professionals. The rise in the incidence and prevalence of dementia will have a large impact on healthcare systems.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycInfo, AgeLine, Abstracts in Social Gerontology, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and Google Scholar between 1990 and 2008, for qualitative or quantitative studies reporting extractable data on delirium or dementia in non-institutionalized older people (65+ years) in the Emergency Department.

REVIEW METHODS

Titles screened by a project researcher and checked against inclusion criteria by another researcher. Two reviewers completed independent data extraction and synthesis of included studies. Quality assessment occurred using the Critical Appraisal Skills Programme Tools.

RESULTS

Fifteen studies met the inclusion criteria for integrative review. Analysis of these studies indicates that the prevalence of cognitive impairment is high and improvements are needed. Contextual details and relevant features of an appropriate intervention are poorly explained.

CONCLUSION

Although the prevalence and incidence of cognitive impairment is recognized, appropriate interventions and programmatic responses remain elusive. Quality improvements require more thorough examination of emergency department context to identify modifiable influencing factors that are transferable across settings.

Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes

OBJECTIVES

Missing delirium in the emergency department (ED) has been described as a medical error, yet this diagnosis is frequently unrecognized by emergency physicians (EPs). Identifying a subset of patients at high risk for delirium may improve delirium screening compliance by EPs. The authors sought to determine how often delirium is missed in the ED and how often these missed cases are detected by admitting hospital physicians at the time of admission, to identify delirium risk factors in older ED patients, and to characterize delirium by psychomotor subtypes in the ED setting.

METHODS

This cross-sectional study was a convenience sample of patients conducted at a tertiary care, academic ED. English-speaking patients who were 65 years and older and present in the ED for less than 12 hours at the time of enrollment were included. Patients were excluded if they refused consent, were previously enrolled, had severe dementia, were unarousable to verbal stimuli for all delirium assessments, or had incomplete data. Delirium status was determined by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants (RAs). Recognition of delirium by emergency and hospital physicians was determined from the medical record, blinded to CAM-ICU status. Multivariable logistic regression was used to identify independent delirium risk factors. The Richmond Agitation and Sedation Scale was used to classify delirium by its psychomotor subtypes.

RESULTS

Inclusion and exclusion criteria were met in 303 patients, and 25 (8.3%) presented to the ED with delirium. The vast majority (92.0%, 95% confidence interval [CI] = 74.0% to 99.0%) of delirious patients had the hypoactive psychomotor subtype. Of the 25 patients with delirium, 19 (76.0%, 95% CI = 54.9% to 90.6%) were not recognized to be delirious by the EP. Of the 16 admitted delirious patients who were undiagnosed by the EPs, 15 (93.8%, 95% CI = 69.8% to 99.8%) remained unrecognized by the hospital physician at the time of admission. Dementia, a Katz Activities of Daily Living (ADL) < or = 4, and hearing impairment were independently associated with presenting with delirium in the ED. Based on the multivariable model, a delirium risk score was constructed. Dementia, Katz ADL < or = 4, and hearing impairment were weighed equally. Patients with higher risk scores were more likely to be CAM-ICU positive (area under the receiver operating characteristic [ROC] curve = 0.82). If older ED patients with one or more delirium risk factors were screened for delirium, 165 (54.5%, 95% CI = 48.7% to 60.2%) would have required a delirium assessment at the expense of missing 1 patient with delirium, while screening 141 patients without delirium.

CONCLUSIONS

Delirium was a common occurrence in the ED, and the vast majority of delirium in the ED was of the hypoactive subtype. EPs missed delirium in 76% of the cases. Delirium that was missed in the ED was nearly always missed by hospital physicians at the time of admission. Using a delirium risk score has the potential to improve delirium screening efficiency in the ED setting.