1
|
Smyth J, Umapathysivam K, Hendrix I, Grantham H, Arendts G, Visvanathan R. Review article: Roles of activities of daily living and frailty assessments for residents of residential aged care services in emergency department transfers: A scoping review. Emerg Med Australas 2022; 34:675-686. [DOI: 10.1111/1742-6723.14055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 11/28/2022]
Affiliation(s)
- James Smyth
- Emergency Department The Queen Elizabeth Hospital Adelaide South Australia Australia
| | | | - Ivanka Hendrix
- Pharmacy Department The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Hugh Grantham
- School of Nursing, Midwifery and Paramedicine Curtin University Perth Western Australia Australia
| | - Glenn Arendts
- Department of Emergency Medicine, Medical School The University of Western Australia Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Western Australia Australia
| | - Renuka Visvanathan
- School of Medicine The University of Adelaide Adelaide South Australia Australia
- Aged and Extended Care Services The Queen Elizabeth Hospital Adelaide South Australia Australia
| |
Collapse
|
2
|
Chen F, Liu L, Wang Y, Liu Y, Fan L, Chi J. Delirium prevalence in geriatric emergency department patients: A systematic review and meta-analysis. Am J Emerg Med 2022; 59:121-128. [DOI: 10.1016/j.ajem.2022.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/13/2022] [Accepted: 05/29/2022] [Indexed: 10/17/2022] Open
|
3
|
Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System. J Am Med Dir Assoc 2022; 23:1322-1327.e2. [PMID: 35172165 PMCID: PMC9359928 DOI: 10.1016/j.jamda.2022.01.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services. DESIGN Pragmatic prospective cohort study of consecutive admissions to a large health care system. SETTING AND PARTICIPANTS A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014. METHODS Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI). RESULTS Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001). CONCLUSIONS AND IMPLICATIONS This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.
Collapse
|
4
|
Moccia MJ, Keyes D. Improving Care Transitions: An Initiative between the Emergency Department and Senior Care Facilities. Spartan Med Res J 2021; 6:26862. [PMID: 34532624 PMCID: PMC8405283 DOI: 10.51894/001c.26862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/29/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The transfer of individuals (i.e., residents) between senior care facilities (SCF) and the emergency department (ED) remains an ongoing healthcare quality gap as communication of key resident information is often lost. For this study, a sample of SCF representatives were invited to join a collaborative group termed Safe Transition of All Residents For yoU and Me (STARForUM, STAR-F) to improve SCF resident transitions of care. STUDY PURPOSE The purpose of this pilot study was to invite a convenience sample of SCF facilities to join a collaborative intervention named Safe Transition of All Residents For yoU and Me (STARForUM, STAR-F) to improve information exchange during SCF residents' transitions of care. The potential influence of a hospital-SCF collaboration program to improve transfer of essential SCF resident information sent to the hospital ED was used as an evaluation measure. METHODS This study project enrolled a total of 120 residents (i.e., patients) with 40 (33%) transferred from participating STAR-F facilities. RESULTS Following the authors' development of a transfer checklist, STAR-F facilities sent a significantly greater number of essential elements comprised of the resident's medical history information to the ED compared to non-STAR-F facilities. Controlling for the standard classification of skill level of the individual facility, STAR-F residents had significantly higher essential information transmission composite scores (10.5 + 2.9 for STAR-F patients vs. 7.75 + 3.1 for non-STAR-Fs p = < 0.01) that may have served to reduce number of associated transition errors. CONCLUSIONS The findings of this study suggest that a collaborative hospital-SCF initiative can significantly improve transfer of information for elderly residents during ED visits, help guide clinical decision-making and optimize care coordination.
Collapse
|
5
|
Oliveira J E Silva L, Berning MJ, Stanich JA, Gerberi DJ, Murad MH, Han JH, Bellolio F. Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2021; 78:549-565. [PMID: 34127307 DOI: 10.1016/j.annemergmed.2021.03.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/17/2021] [Accepted: 03/02/2021] [Indexed: 12/19/2022]
Abstract
We conducted a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence based medicine reviews, EMBASE, MEDLINE, Scopus, and Web of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age ≥ 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random-effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study's protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions.
Collapse
Affiliation(s)
| | - Michelle J Berning
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN; University of Minnesota Medical School, Minneapolis, MN
| | | | | | - Mohammad Hassan Murad
- Department of Internal Medicine, Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
| |
Collapse
|
6
|
Dwyer RA, Gabbe BJ, Tran T, Smith K, Lowthian JA. Residential aged care homes: Why do they call '000'? A study of the emergency prehospital care of older people living in residential aged care homes. Emerg Med Australas 2021; 33:447-456. [PMID: 33040460 DOI: 10.1111/1742-6723.13650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the clinical characteristics, medical interventions and patterns of ambulance service use related to the emergency, prehospital care of older people living in residential aged care (RAC) homes. METHODS Retrospective cohort study using secondary analyses of routinely collected clinical and administrative data from Ambulance Victoria and population data from the Australian Bureau of Statistics for the state of Victoria, Australia. Participants included people aged 65 years and over, attended by emergency ambulances from 2008 to 2013, with data captured in the Ambulance Victoria electronic record. RESULTS The mean (standard deviation) age of RAC residents attended by emergency ambulance was 85 (7.3) years and 63% were women. Common comorbidities included dementia (32.7%), ischaemic heart disease (27.7%) and osteoarthritis (24.6%). Polypharmacy was prevalent with 70% currently prescribed antibiotics, over 20% prescribed sedatives and a further 14.9% antipsychotics. Fifteen percent of attendances were for falls, which were more frequent among women than men. Other common reasons for ambulance call-out included uncontrolled pain, respiratory tract infection, non-specific febrile illness and altered conscious state. Almost 90% of people were transported to hospital from the RAC, with just over half of call-outs occurring out-of-hours. CONCLUSION This is the first study to describe emergency prehospital care, case-mix and intervention of frail, older people living in RAC. These results demonstrate a clinically complex group of people with high rates of comorbidity, cognitive impairment and polypharmacy. These valuable data will inform education and training of prehospital clinicians, assist in targeting preventative medicine and primary care programmes and further development of alternate, acute and emergency care pathways for this unique patient group.
Collapse
Affiliation(s)
- Rosamond A Dwyer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency Department, Peninsula Health, Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thach Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Judy A Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
Hathaway EE, Carnahan JL, Unroe KT, Stump TE, Phillips EO, Hickman SE, Fowler NR, Sachs GA, Bateman DR. Nursing Home Transfers for Behavioral Concerns: Findings from the OPTIMISTIC Demonstration Project. J Am Geriatr Soc 2021; 69:415-423. [PMID: 33216954 PMCID: PMC10602584 DOI: 10.1111/jgs.16920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/19/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To characterize pretransfer on-site nursing home (NH) management, transfer disposition, and hospital discharge diagnoses of long-stay residents transferred for behavioral concerns. DESIGN This was a secondary data analysis of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care project, in which clinical staff employed in the NH setting conducted medical, transitional, and palliative care quality improvement initiatives and gathered data related to resident transfers to the emergency department/hospital setting. R software and Microsoft Excel were used to characterize a subset of transfers prompted by behavioral concerns. SETTING NHs in central Indiana were utilized (N = 19). PARTICIPANTS This study included long-stay NH residents with behavioral concerns prompting transfer for acute emergency department/hospital evaluation (N = 355 transfers). MEASUREMENTS The measures used in this study were symptoms prompting transfer, resident demographics and baseline characteristics (Minimum Data Set 3.0 variables including scores for the Cognitive Function Scale, ADL Functional Status, behavioral symptoms directed toward others, and preexisting psychiatric diagnoses), on-site management (e.g., medical evaluation in person or by phone, testing, and interventions), avoidability rating, transfer disposition (inpatient vs emergency department only), and hospital discharge diagnoses. RESULTS Over half of the transfers, 56%, had a medical evaluation before transfer, and diagnostic testing was conducted before 31% of transfers. After transfer, 80% were admitted. The most common hospital discharge diagnoses were dementia-related behaviors (27%) and altered mental status (27%), followed by a number of medical diagnoses. CONCLUSION Most transfers for behavioral concerns merited hospital admission, and medical discharge diagnoses were common. There remain significant opportunities to improve pretransfer management of NH transfers for behavioral concerns.
Collapse
Affiliation(s)
- Elizabeth E. Hathaway
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jennifer L. Carnahan
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T. Unroe
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Timothy E. Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin O’Kelly Phillips
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
| | - Susan E. Hickman
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University School of Nursing, Indianapolis, IN, USA
| | - Nicole R. Fowler
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Greg A. Sachs
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel R. Bateman
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
| |
Collapse
|
8
|
Höbler F, McGilton KS, Wittich W, Dupuis K, Reed M, Dumassais S, Mick P, Pichora-Fuller MK. Hearing Screening for Residents in Long-Term Care Homes Who Live with Dementia: A Scoping Review. J Alzheimers Dis 2021; 84:1115-1138. [PMID: 34633326 PMCID: PMC8673512 DOI: 10.3233/jad-215087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hearing loss is highly prevalent in older adults, particularly among those living with dementia and residing in long-term care homes (LTCHs). Sensory declines can have deleterious effects on functioning and contribute to frailty, but the hearing needs of residents are often unrecognized or unaddressed. OBJECTIVE To identify valid and reliable screening measures that are effective for the identification of hearing loss and are suitable for use by nursing staff providing care to residents with dementia in LTCHs. METHODS Electronic databases (Embase, Medline, PsycINFO, CENTRAL, and CINAHL) were searched using comprehensive search strategies, and a stepwise approach based on Arksey & O'Malley's scoping review and appraisal process was followed. RESULTS There were 193 scientific papers included in the review. Pure-tone audiometry was the most frequently reported measure to test hearing in older adults living with dementia. However, measures including self- or other-reports and questionnaires, review of medical records, otoscopy, and the whisper test were found to be most suitable for use by nurses working with older adults living with dementia in LTCHs. CONCLUSION Although frequently used, the suitability of pure-tone audiometry for use by nursing staff in LTCHs is limited, as standardized audiometry presents challenges for many residents, and specific training is needed to successfully adapt test administration procedures and interpret results. The whisper test was considered to be more suitable for use by staff in LTCH; however, it yields a limited characterization of hearing loss. There remains an urgent need to develop new approaches to screen hearing in LTCHs.
Collapse
Affiliation(s)
- Fiona Höbler
- KITE – Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katherine S. McGilton
- KITE – Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Walter Wittich
- École d’optométrie, Université de Montréal, Montréal, QC, Canada
- Institut Nazareth et Louis-Braille du CISSS de la Montérégie-Centre, Longueuil, QC, Canada
- Centre de réadaptation Lethbridge-Layton-Mackay du CIUSSS du Centre-Ouest-de-l’Île-de-Montréal, Montréal, QC, Canada
| | - Kate Dupuis
- Sheridan Centre for Elder Research, Sheridan College, Oakville, ON, Canada
| | - Marilyn Reed
- Audiology, Baycrest Health Sciences, Toronto, ON, Canada
| | - Shirley Dumassais
- École d’optométrie, Université de Montréal, Montréal, QC, Canada
- Institut Nazareth et Louis-Braille du CISSS de la Montérégie-Centre, Longueuil, QC, Canada
| | - Paul Mick
- Department of Surgery, Faculty of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | |
Collapse
|
9
|
Kennedy M, Helfand BKI, Gou RY, Gartaganis SL, Webb M, Moccia JM, Bruursema SN, Dokic B, McCulloch B, Ring H, Margolin JD, Zhang E, Anderson R, Babine RL, Hshieh T, Wong AH, Taylor RA, Davenport K, Teresi B, Fong TG, Inouye SK. Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. JAMA Netw Open 2020; 3:e2029540. [PMID: 33211114 PMCID: PMC7677760 DOI: 10.1001/jamanetworkopen.2020.29540] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described. OBJECTIVE To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020. EXPOSURE COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases). MAIN OUTCOMES AND MEASURES The primary outcome was delirium as identified from the medical record according to a validated record review approach. RESULTS A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% CI, 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55). CONCLUSIONS AND RELEVANCE In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation.
Collapse
Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Benjamin K. I. Helfand
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester
- Department of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Ray Yun Gou
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Sarah L. Gartaganis
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Margaret Webb
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | | | | | - Belinda Dokic
- Emergency Medicine, St Mary Mercy Livonia Hospital, Livonia, Michigan
| | - Brigid McCulloch
- Emergency Medicine, St Mary Mercy Livonia Hospital, Livonia, Michigan
| | - Hope Ring
- Emergency Medicine, St Mary Mercy Livonia Hospital, Livonia, Michigan
| | - Justin D. Margolin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Ellen Zhang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Robert Anderson
- Department of Emergency Medicine, Maine Medical Center, Portland
| | - Rhonda L. Babine
- Department of Emergency Medicine, Maine Medical Center, Portland
- Department of Clinical Nursing Resources, Maine Medical Center, Portland
| | - Tammy Hshieh
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - R. Andrew Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kathleen Davenport
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Brittni Teresi
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Tamara G. Fong
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
10
|
Kapoor A, Field T, Handler S, Fisher K, Saphirak C, Crawford S, Fouayzi H, Johnson F, Spenard A, Zhang N, Gurwitz JH. Characteristics of Long‐Term Care Residents That Predict Adverse Events after Hospitalization. J Am Geriatr Soc 2020; 68:2551-2557. [DOI: 10.1111/jgs.16770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Alok Kapoor
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | - Terry Field
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | | | - Kimberly Fisher
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | | | - Sybil Crawford
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | | | | | | | - Ning Zhang
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
- University of Massachusetts Amherst Massachusetts
| | - Jerry H. Gurwitz
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| |
Collapse
|
11
|
Farasat S, Dorsch JJ, Pearce AK, Moore AA, Martin JL, Malhotra A, Kamdar BB. Sleep and Delirium in Older Adults. CURRENT SLEEP MEDICINE REPORTS 2020; 6:136-148. [PMID: 32837850 PMCID: PMC7382993 DOI: 10.1007/s40675-020-00174-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.
Collapse
Affiliation(s)
- Sadaf Farasat
- Division of Geriatrics and Gerontology, University of California San Diego, 9350 Campus Point Drive, La Jolla, CA 92037 USA
| | - Jennifer J Dorsch
- Johns Hopkins Medicine, Baltimore, MD USA.,Johns Hopkins Medicine, Howard County General Hospital, 5755 Cedar Ln, Columbia, MD 21044 USA
| | - Alex K Pearce
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, University of California San Diego, 9500 Gilman Drive, MC 0665, La Jolla, CA 92093-0665 USA
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer St. (11E), North Hills, CA 91343 USA.,David Geffen School of Medicine at the University of California, Los Angeles, CA USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| |
Collapse
|
12
|
Iwata E, Kondo T, Kato T, Okumura T, Nishiyama I, Kazama S, Ishihara T, Kondo S, Hiraiwa H, Tsuda T, Ito M, Aoyama M, Tanimura D, Awaji Y, Unno K, Murohara T. Prognostic Value of Delirium in Patients With Acute Heart Failure in the Intensive Care Unit. Can J Cardiol 2020; 36:1649-1657. [PMID: 32615071 DOI: 10.1016/j.cjca.2020.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 01/07/2020] [Accepted: 01/10/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Delirium is a common adverse event observed in patients admitted to the intensive care unit (ICU). However, the prognostic value of delirium and its determinants have not been thoroughly investigated in patients with acute heart failure (AHF). METHODS We investigated 408 consecutive patients with AHF admitted to the ICU. Delirium was diagnosed by means of the Confusion Assessment Method for ICU tool and evaluated every 8 hours during the patients' ICU stays. RESULTS Delirium occurred in 109 patients (26.7%), and the in-hospital mortality rate was significantly higher in patients with delirium (13.8% vs 2.3%; P < 0.001). Multivariate logistic regression analysis showed that delirium independently predicted in-hospital mortality (odds ratio [OR] 4.33, confidence interval [CI] 1.62-11.52; P = 0.003). Kaplan-Meier analysis showed that the 12-month mortality rate was significantly higher in patients with delirium compared with those without (log-rank test: P < 0.001), and Cox proportional hazards analysis showed that delirium remained an independent predictor of 12-month mortality (hazard ratio 2.19, 95% CI 1.49-3.25; P < 0.001). The incidence of delirium correlated with severity of heart failure as assessed by means of the Get With The Guidelines-Heart Failure risk score (chi-square test: P = 0.003). Age (OR 1.05, 95% CI 1.02-1.09; P = 0.003), nursing home residential status (OR 3.32, 95% CI 1.59-6.94; P = 0.001), and dementia (OR 5.32, 95% CI 2.83-10.00; P < 0.001) were independently associated with the development of delirium. CONCLUSIONS Development of delirium during ICU stay is associated with short- and long-term mortality and is predicted by the severity of heart failure, nursing home residential, and dementia status.
Collapse
Affiliation(s)
- Etsuo Iwata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan; Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | - Toshiaki Kato
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Itsumure Nishiyama
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Shingo Kazama
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Toshikazu Ishihara
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Sayano Kondo
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takuma Tsuda
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Masanori Ito
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Morihiko Aoyama
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Daisuke Tanimura
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Yoshifumi Awaji
- Department of Cardiology, Nagoya Ekisaikai Hospital, Nagoya, Aichi, Japan
| | - Kazumasa Unno
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| |
Collapse
|
13
|
Leo C, Wang Y, Mold A, Quintana J, Shi H, Abdullah M, Alaie D, Petrillo R. Noncirrhotic hyperammonemia: A factor behind dementia to alter mental status. Clin Case Rep 2019; 7:2118-2122. [PMID: 31788262 PMCID: PMC6878079 DOI: 10.1002/ccr3.2436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 07/02/2019] [Accepted: 07/22/2019] [Indexed: 11/07/2022] Open
Abstract
Healthcare givers were recommended to check serum ammonia level for elderly patients with acute-on-chronic alteration of mental status. Early initiation of antihyperammonemia therapy may benefit improvement of alteration of mental status. Baseline mental status becomes necessary for diagnose the acute alteration of mental status and monitor the therapeutic process.
Collapse
Affiliation(s)
- Christopher Leo
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| | - Yun Wang
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| | - Alexander Mold
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| | - Junik Quintana
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| | - Hong Shi
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| | - Mahdi Abdullah
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| | - Dariush Alaie
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| | - Richard Petrillo
- Department of MedicineMontefiore Mount Vernon HospitalMount VernonNY
| |
Collapse
|
14
|
Pérez-Ros P, Martínez-Arnau FM. Delirium Assessment in Older People in Emergency Departments. A Literature Review. Diseases 2019; 7:E14. [PMID: 30704024 PMCID: PMC6473718 DOI: 10.3390/diseases7010014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 12/21/2022] Open
Abstract
Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.
Collapse
Affiliation(s)
- Pilar Pérez-Ros
- School of Nursing, Universidad Católica de Valencia San Vicente Mártir, Calle Espartero, 7, 46007 València, Spain.
| | | |
Collapse
|
15
|
Mulkey MA, Hardin SR, Olson DM, Munro CL, Everhart E. Considering Causes for Hypoactive Delirium. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2019. [DOI: 10.21307/ajon-2017-015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
16
|
Hasemann W, Grossmann FF, Stadler R, Bingisser R, Breil D, Hafner M, Kressig RW, Nickel CH. Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool. Intern Emerg Med 2018; 13:915-922. [PMID: 29290048 DOI: 10.1007/s11739-017-1781-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/20/2017] [Indexed: 12/22/2022]
Abstract
Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q1 = 72.15; Q3 = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.
Collapse
Affiliation(s)
- Wolfgang Hasemann
- Department of Nursing and Allied Health Professions, University Hospital Basel, Hebelstrasse 2, Basel, 4031, Switzerland.
| | | | - Rahel Stadler
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Dieter Breil
- University Center for Medicine of Aging, Felix Platter Hospital Basel, Basel, Switzerland
| | - Martina Hafner
- University Center for Medicine of Aging, Felix Platter Hospital Basel, Basel, Switzerland
| | - Reto W Kressig
- University Center for Medicine of Aging, Felix Platter Hospital Basel, Basel, Switzerland
| | | |
Collapse
|
17
|
Hullick C, Conway J, Higgins I, Hewitt J, Stewart B, Dilworth S, Attia J. An assistant workforce to improve screening rates and quality of care for older patients in the emergency department: findings of a pre- post, mixed methods study. BMC Geriatr 2018; 18:126. [PMID: 29843623 PMCID: PMC5975558 DOI: 10.1186/s12877-018-0811-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/08/2018] [Indexed: 11/10/2022] Open
Abstract
Background Older people who present to the Emergency Department (ED) experience high rates of prevalent and incident delirium. This study aimed to determine whether an assistant workforce in the ED could effectively conduct screening to inform assessment and care planning for older people as well as enhance supportive care activities for prevention of delirium. Methods Using a pre-post design, data was collected before and after the introduction of Older Person Technical Assistants (OPTAs) in the ED. OPTA activity was recorded during the intervention period and a medical record audit undertaken prior to and 9 months after implementation. Data were analysed using descriptive statistics for OPTA activities. Weighted Kappa scores were calculated comparing concordance in screening scores between OPTAs and Aged Services Emergency Team Registered Nurses. Changes in the rates of documented screening and supportive care were analysed using Chi-square tests. Focus groups were conducted to explore clinicians’ experiences of the OPTA role. Results Three thousand five hundred fourty two people were seen by OPTAs in 4563 ED Presentations between 1st July 2011 and 2012. The reproducibility of all screening tools were found to be high between the OPTAs and the RNs, with Kappas and ICCs generally all above 0.9. The medical record audit showed significant improvement in the rates of documented screening, including cognition from 1.5 to 38% (p < 0.001) and review of pain from 29 to 75% (p < 0.001). Supportive care such as being given fluids or food also improved from 13 to 49% (p < 0.001) and pressure care from 4.8 to 30% (p < 0.001). This was accomplished with no increase in ED length of stay among this age group. Focus group interviews described mixed responses and support for the OPTA role. Conclusions An assistant workforce in an ED setting was found to provide comparable screening results and improve the rates of documented screening and supportive care provided to older people with or at risk of developing delirium in the ED. There is a need for a shared philosophy to the care of older people in the ED. Trial registration Australian New Zealand Clinical Trials Registration number is ACTRN12617000742370. It was retrospectively registered on 22nd May 2017.
Collapse
Affiliation(s)
- Carolyn Hullick
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. .,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.
| | - Jane Conway
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,School of Health, University of New England and Conjoint Professor of Nursing, University of Newcastle, Newcastle, Australia
| | - Isabel Higgins
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.,School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia
| | - Jacqueline Hewitt
- Aged Care Emergency Service, Clinical Nurse Consultant, Patient Flow Unit, Hunter New England Local Health District, Newcastle, Australia
| | - Bernadette Stewart
- John Hunter Hospital, Hunter New England Health, Locked Bag 1, HRMC, Armidale, NSW, 2310, Australia
| | - Sophie Dilworth
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia
| | - John Attia
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia
| |
Collapse
|
18
|
Laffon de Mazières C, Romain M, Hermabessière S, Abellan G, Gerard S, Castex A, Krams T, Vellas B, Rolland Y. An Innovative Day Hospital Dedicated to Nursing Home Resident: A Descriptive Study of 1306 Residents Referred by their Physicians. J Nutr Health Aging 2018; 22:1138-1143. [PMID: 30379316 PMCID: PMC6302543 DOI: 10.1007/s12603-018-1106-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The transfer rate of residents from nursing homes (NH) to emergency rooms is high. These transfers are often inappropriate but also potentially avoidable. Recent studies have shown that in terms of methods for training NH teams, proposals for improvement of the healthcare sector must be organized. Given this observation, Gérontopôle de Toulouse (France) opened in October 2015, a responsive day hospital dedicated to NH residents (DH NH). This day hospital is characterized by its vocation, exclusively dedicated to NH residents and its ability to provide patient care within a short period of time. OBJECTIVES The purpose of this day hospital is twofold: (1) decrease the rate of inappropriate transfers for NH residents by offering general practitioners and NH teams quick access to expert advice, blood tests and radiological examinations during hospitalizations and care adapted to the characteristics of NH residents; (2) potentially reduce avoidable transfers to emergency rooms and hospitalizations by taking action to prevent acute decompensation in residents, but also for the education and training of NH healthcare teams. This manuscript aims to describe the arrangements put in place and the characteristics of the residents collected after two years of activity. DESIGN Retrospective descriptive study. SETTING Gérontopôle of Toulouse, France. PARTICIPANTS 1306 residents have been consulted at the DH NH. MEASUREMENTS Referring physicians (treating physicians, coordinating physician or emergency room physicians) send a standardized hospitalization request form to the day hospital by fax or email indicating the reason for the request, specialist opinion(s) desired and additional required examination(s). A gerontological assessment was conducted and anamnesis data was collected for each resident, on the very day of their coming to the DH NH. RESULTS In 2 years, 1306 residents from 120 NHs were sent to the DH NH. The mean age was 86.23 ± 7.05 years and the majority of patients were women (n=941, 72.22%), dependent (median ADL at 2.75, [1.25-4.5]) and malnourished (821, 63.25%). In the 3 months prior to their visit to the day hospital, 668 (57.14%) residents had been hospitalized, and one-quarter (n=336, 25.72%) had been transferred to emergency rooms. The main reasons for hospitalization included assessment of cognitive disorders (n=336, 17.52%), assistance in managing behavioral disorders (n=297, 15.48%) and bedsores and slow wound healing (n=223, 11.63%). CONCLUSION Our experience over a 2-year period suggests that the DH NH could be a practical response to the problem of inappropriate and avoidable transfers of NH residents to emergency rooms. This innovation could easily be utilized in other hospitals.
Collapse
Affiliation(s)
- C Laffon de Mazières
- Clarisse Laffon de Mazières, Department of Geriatric Medicine, Gérontopôle, Toulouse University Hospital, Cité de la santé - 20, rue du Pont Saint-Pierre - TSA 60033 - 31059 Toulouse cedex 9, France. E-mail address : . Tel: +33 (0)5 61 77 70 46
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Forsberg MM. Delirium Update for Postacute Care and Long-Term Care Settings: A Narrative Review. J Osteopath Med 2017; 117:32-38. [DOI: 10.7556/jaoa.2017.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Advances have been made in our understanding of the neuropathogenesis, recognition, and strategies for reducing the incidence of delirium in acute-care settings. However, relatively little attention has been given to delirium in elderly patients in the postacute care (PAC) and long-term care (LTC) settings. The present article reviews the most relevant current research pertaining to this population. Hospital patients with delirium are often discharged to PAC settings. Delirium that develops in the LTC setting is often more insidious and subtle in presentation. Despite incorporating systematic screening tools for delirium in PAC and LTC settings, delirium prevention strategies have not yet been shown to be beneficial beyond the acute-care setting. The management of delirium combined with dementia and guidance on when it is appropriate to use antipsychotic medications is also discussed.
Collapse
|
20
|
Australian and New Zealand Society for Geriatric Medicine Position Statement Abstract: Delirium in older people. Australas J Ageing 2016; 35:292. [DOI: 10.1111/ajag.12254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
21
|
Unplanned Transfer to Emergency Departments for Frail Elderly Residents of Aged Care Facilities: A Review of Patient and Organizational Factors. J Am Med Dir Assoc 2015; 16:551-62. [DOI: 10.1016/j.jamda.2015.03.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/07/2015] [Accepted: 03/05/2015] [Indexed: 12/20/2022]
|
22
|
Zywiel MG, Hurley RT, Perruccio AV, Hancock-Howard RL, Coyte PC, Rampersaud YR. Health economic implications of perioperative delirium in older patients after surgery for a fragility hip fracture. J Bone Joint Surg Am 2015; 97:829-36. [PMID: 25995494 DOI: 10.2106/jbjs.n.00724] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients who experience a fragility hip fracture are at high risk for perioperative delirium. The purpose of the present study was to evaluate the impact, from a hospital perspective, of perioperative delirium on the length of the hospital stay and episode-of-care costs for elderly patients who underwent surgical treatment of a fragility hip fracture. METHODS A total of 242 patients sixty-five years of age or older (mean age, eighty-two years; range, sixty-five to 103 years) who underwent surgical treatment of a fragility hip fracture at a single center between January 2011 and December 2012 were evaluated. Demographic, clinical, surgical, and adverse-events data were extracted and analyzed. The confusion assessment method (CAM) was used prospectively to detect perioperative delirium. RESULTS One hundred and sixteen (48%) of the 242 patients developed perioperative delirium during their stay in the hospital. Compared with patients with no delirium, delirium was associated with a mean incremental total length of hospital stay of 7.4 days (95% confidence interval [CI] = 3.7 to 11.2 days; p < 0.001), a mean incremental length of stay following surgery of 7.4 days (95% CI = 3.8 to 11.1 days; p < 0.001), and a mean incremental episode-of-care cost (in 2012 Canadian dollars) of $8286 (95% CI = $3690 to $12,881; p < 0.001). The total incremental episode-of-care cost attributable to delirium over the study period was $961,131 in 2012 Canadian dollars. CONCLUSIONS Nearly 50% of elderly patients who underwent surgery for a fragility hip fracture developed perioperative delirium, which was associated with a significant incremental in-hospital length of stay and significant incremental episode-of-care costs. These findings highlight the importance of implementing cost-effective interventions to reduce the prevalence of perioperative delirium in elderly patients with a low-energy hip fracture.
Collapse
Affiliation(s)
- Michael G Zywiel
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, 1E441, Toronto, ON M5T 2S8, Canada. E-mail address for M.G. Zywiel: . E-mail address for Y.R. Rampersaud:
| | - Richard T Hurley
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, 1E441, Toronto, ON M5T 2S8, Canada. E-mail address for M.G. Zywiel: . E-mail address for Y.R. Rampersaud:
| | - Anthony V Perruccio
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, 1E441, Toronto, ON M5T 2S8, Canada. E-mail address for M.G. Zywiel: . E-mail address for Y.R. Rampersaud:
| | - Rebecca L Hancock-Howard
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th floor, Toronto, ON M5T 3M6, Canada
| | - Peter C Coyte
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th floor, Toronto, ON M5T 3M6, Canada
| | - Y Raja Rampersaud
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, 1E441, Toronto, ON M5T 2S8, Canada. E-mail address for M.G. Zywiel: . E-mail address for Y.R. Rampersaud:
| |
Collapse
|
23
|
Schnitker LM, Martin-Khan M, Burkett E, Brand CA, Beattie ERA, Jones RN, Gray LC. Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments. Acad Emerg Med 2015; 22:273-84. [PMID: 25754936 DOI: 10.1111/acem.12617] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 08/25/2014] [Accepted: 10/15/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). METHODS A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. RESULTS At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors; and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. CONCLUSIONS This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.
Collapse
Affiliation(s)
- Linda M. Schnitker
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
| | - Melinda Martin-Khan
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
- Centre for Online Health; The University of Queensland; Brisbane Australia
| | - Ellen Burkett
- The Department of Emergency Medicine; Princess Alexandra Hospital; Brisbane Australia
| | - Caroline A. Brand
- The Centre for Research Excellence in Patient Safety; Monash University; Melbourne Australia
| | - Elizabeth R. A. Beattie
- The School of Nursing and Midwifery; Queensland University of Technology; Brisbane Australia
| | - Richard N. Jones
- Hebrew SeniorLife; Institute for Aging Research; Harvard Medical School; Boston MA
| | - Len C. Gray
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
- Centre for Online Health; The University of Queensland; Brisbane Australia
| | | |
Collapse
|
24
|
Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations. Alzheimers Dement 2014; 10:835-43. [PMID: 25028060 DOI: 10.1016/j.jalz.2014.03.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 03/13/2014] [Accepted: 03/31/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services. METHODS We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation. RESULTS Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant. CONCLUSIONS Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.
Collapse
Affiliation(s)
- Caroline E Stephens
- Department of Community Health Systems, UCSF School of Nursing, San Francisco, CA, USA; Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA.
| | - Robert Newcomer
- Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA
| | - Mary Blegen
- Department of Community Health Systems, UCSF School of Nursing, San Francisco, CA, USA
| | - Bruce Miller
- Department of Neurology, UCSF School of Medicine, San Francisco, CA, USA
| | - Charlene Harrington
- Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA
| |
Collapse
|
25
|
Grossmann FF, Hasemann W, Graber A, Bingisser R, Kressig RW, Nickel CH. 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). Scand J Trauma Resusc Emerg Med 2014; 22:19. [PMID: 24625212 PMCID: PMC3975151 DOI: 10.1186/1757-7241-22-19] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 02/25/2014] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
|
26
|
Kennedy M, Enander RA, Tadiri SP, Wolfe RE, Shapiro NI, Marcantonio ER. Delirium risk prediction, healthcare use and mortality of elderly adults in the emergency department. J Am Geriatr Soc 2014; 62:462-9. [PMID: 24512171 DOI: 10.1111/jgs.12692] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To create a risk prediction rule for delirium in elderly adults in the emergency department (ED) and to compare mortality and resource use of elderly adults in the ED with and without delirium. DESIGN Prospective observational study. SETTING Urban tertiary care ED. PARTICIPANTS Individuals aged 65 and older presenting for ED care (N = 700). MEASUREMENTS A trained research assistant performed a structured mental status assessment and attention tests, after which delirium was determined using the Confusion Assessment Method. Data were collected on participant demographics, comorbidities, medications, ED course, hospital and intensive care unit (ICU) admission, length of stay, hospital charges, 30-day rehospitalization, and mortality. RESULTS Nine percent of elderly study participants had delirium. Using logistic regression, a delirium prediction rule consisting of older age, prior stroke or transient ischemic attack, dementia, suspected infection, and acute intracranial hemorrhage was created had good predictive accuracy (area under the receiver operating characteristic curve = 0.77). Admitted participants with ED delirium had longer median lengths of stay (4 vs 2 days) and were more likely to require ICU admission (13% vs 6%) and to be discharged to a new long-term care facility (37% vs 9%) than those without. In all participants, ED delirium was associated with higher 30-day mortality (6% vs 1%) and 30-day readmission (27% vs 13%). CONCLUSION This risk prediction rule may help identify a group of individuals in the ED at high risk of developing delirium who should undergo screening, but it requires external validation. Identification of delirium in the ED may enable physicians to implement strategies to decrease delirium duration and avoid inappropriate discharge of individuals with acute delirium, improving outcomes.
Collapse
Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | | |
Collapse
|
27
|
Han JH, Wilson A, Graves AJ, Shintani A, Schnelle JF, Dittus RS, Powers JS, Vernon J, Storrow AB, Ely EW. Validation of the Confusion Assessment Method for the Intensive Care Unit in older emergency department patients. Acad Emerg Med 2014; 21:180-7. [PMID: 24673674 DOI: 10.1111/acem.12309] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/09/2013] [Accepted: 08/22/2013] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jin H. Han
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Amanda Wilson
- Department of Psychiatry; Vanderbilt University School of Medicine; Nashville TN
| | - Amy J. Graves
- Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN
| | - Ayumi Shintani
- Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN
| | - John F. Schnelle
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Division of General Internal Medicine and Public Health; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
| | - Robert S. Dittus
- Division of General Internal Medicine and Public Health; Vanderbilt University School of Medicine; Nashville TN
- Center for Health Services Research; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
| | - James S. Powers
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Division of General Internal Medicine and Public Health; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
| | - John Vernon
- Department of Psychiatry; Virginia Commonwealth University Medical Center; Richmond VA
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - E. Wesley Ely
- Center for Quality Aging; Vanderbilt University School of Medicine; Nashville TN
- Center for Health Services Research; Vanderbilt University School of Medicine; Nashville TN
- Division of Allergy, Pulmonary; and Critical Care Medicine; Vanderbilt University School of Medicine; Nashville TN
- Geriatric Research, Education, and Clinical Center; Department of Veterans Affairs Medical Center; Tennessee Valley Health Care Center; Nashville TN
| |
Collapse
|
28
|
LaMantia MA, Messina FC, Hobgood CD, Miller DK. Screening for delirium in the emergency department: a systematic review. Ann Emerg Med 2013; 63:551-560.e2. [PMID: 24355431 DOI: 10.1016/j.annemergmed.2013.11.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 10/09/2013] [Accepted: 11/11/2013] [Indexed: 01/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Michael A LaMantia
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN.
| | - Frank C Messina
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Cherri D Hobgood
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Douglas K Miller
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
| |
Collapse
|
29
|
Martin-Khan M, Burkett E, Schnitker L, Jones RN, Gray LC. Methodology for developing quality indicators for the care of older people in the Emergency Department. BMC Emerg Med 2013; 13:23. [PMID: 24314126 PMCID: PMC4029470 DOI: 10.1186/1471-227x-13-23] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 10/31/2013] [Indexed: 01/01/2023] Open
Abstract
Background Compared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department. Methods/design Following input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process. Discussion The predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.
Collapse
Affiliation(s)
- Melinda Martin-Khan
- Centre for Research in Geriatric Medicine, Level 2, Building 33, Princess Alexandra Hospital, The University of Queensland, Ipswich Road, Woolloongabba QLD 4102, Australia.
| | | | | | | | | |
Collapse
|
30
|
Lamantia MA, Stewart PW, Platts-Mills TF, Biese KJ, Forbach C, Zamora E, McCall BK, Shofer FS, Cairns CB, Busby-Whitehead J, Kizer JS. Predictive value of initial triage vital signs for critically ill older adults. West J Emerg Med 2013; 14:453-60. [PMID: 24106542 PMCID: PMC3789908 DOI: 10.5811/westjem.2013.5.13411] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 04/24/2013] [Accepted: 05/21/2013] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Triage of patients is critical to patient safety, yet no clear information exists as to the utility of initial vital signs in identifying critically ill older emergency department (ED) patients. The objective of this study is to evaluate a set of initial vital sign thresholds as predictors of severe illness and injury among older adults presenting to the ED. METHODS We reviewed all visits by patients aged 75 and older seen during 2007 at an academic ED serving a large community of older adults. Patients' charts were abstracted for demographic and clinical information including vital signs, via automated electronic methods. We used bivariate analysis to investigate the relationship between vital sign abnormalities and severe illness or injury, defined as intensive care unit (ICU) admission or ED death. In addition, we calculated likelihood ratios for normal and abnormal vital signs in predicting severe illness or injury. RESULTS 4,873 visits by patients aged 75 and above were made to the ED during 2007, and of these 3,848 had a complete set of triage vital signs. For these elderly patients, the sensitivity and specificity of an abnormal vital sign taken at triage for predicting death or admission to an ICU were 73% (66,81) and 50% (48,52) respectively (positive likelihood ratio 1.47 (1.30,1.60); negative likelihood ratio 0.54 (0.30,0.60). CONCLUSION Emergency provider assessment and triage scores that rely primarily on initial vital signs are likely to miss a substantial portion of critically ill older adults.
Collapse
Affiliation(s)
- Michael A Lamantia
- Indiana University Center for Aging Research and Regenstrief Institute, Indianapolis, Indiana
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Flaherty JH, Morley JE. Delirium in the Nursing Home. J Am Med Dir Assoc 2013; 14:632-4. [DOI: 10.1016/j.jamda.2013.06.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
|
32
|
Abstract
OBJECTIVE To compare the recognition of delirium by emergency physicians based on observations made during routine clinical care with concurrent ratings made by a trained researcher after formal cognitive assessment and to examine each of the four individual features of delirium separately to determine the variation in identification across features. METHODS In a prospective study, a convenience sample of 259 patients, aged ≥65 years, who presented to two urban, teaching hospital emergency departments (EDs) in Western Pennsylvania between 21 June and 29 August 2011, underwent paired delirium ratings by an emergency physician and a trained researcher. Emergency physicians were asked to use their clinical judgment to decide whether the patient had any of the following delirium features: (1) acute change in mental status, (2) inattention, (3) disorganised thinking and (4) altered level of consciousness. Questions were prompted with examples of delirium features from the Confusion Assessment Method. Concurrently, a trained researcher interviewed surrogates to determine feature 1, conducted a cognitive test for delirium (Confusion Assessment Method for the intensive care unit) to determine delirium features 2 and 3 and used the Richmond Agitation and Sedation Scale to determine feature 4. RESULTS In the 2-month study period, trained researchers identified delirium in 24/259 (9%; 95% CI 0.06 to 0.13) older patients admitted to the ED. However, attending emergency physicians recognised delirium in only 8 of the 24 and misidentified delirium in a further seven patients. Emergency physicians were particularly poor at recognising altered level of consciousness but were better at recognising acute change in mental status and inattention. CONCLUSIONS When emergency physicians use routine clinical observations, they may miss diagnosing up to two-thirds of patients with delirium. Recognition of delirium can be enhanced with standardised cognitive testing.
Collapse
Affiliation(s)
- Brian Suffoletto
- Department of Emergency Medicine, University of Pittsburgh, , Pittsburgh, Pennsylvania, USA
| | | | | | | |
Collapse
|
33
|
Watson PL, Ceriana P, Fanfulla F. Delirium: is sleep important? Best Pract Res Clin Anaesthesiol 2013; 26:355-66. [PMID: 23040286 DOI: 10.1016/j.bpa.2012.08.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 08/01/2012] [Indexed: 10/27/2022]
Abstract
Delirium and poor sleep quality are common and often co-exist in hospitalised patients. A link between these disorders has been hypothesised but whether this link is a cause-and-effect relationship or simply an association resulting from shared mechanisms is yet to be determined. Potential shared mechanisms include: abnormalities of neurotransmitters, tissue ischaemia, inflammation and sedative exposure. Sedatives, while decreasing sleep latency, often cause a decrease in slow wave sleep and stage rapid eye movement (REM) sleep and therefore may not provide the same restorative properties as natural sleep. Mechanical ventilation, an important cause of sleep disruption in intensive care unit (ICU) patients, may lead to sleep disruption not only from the discomfort of the endotracheal tube but also as a result of ineffective respiratory efforts and by inducing central apnoea events if not properly adjusted for the patient's physiologic needs. When possible, efforts should be made to optimise the patient-ventilator interaction to minimise sleep disruptions.
Collapse
Affiliation(s)
- Paula L Watson
- Department of Medicine, Division of Allergy, Pulmonary, Critical Care and Sleep Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | | | | |
Collapse
|
34
|
Abstract
Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.
Collapse
Affiliation(s)
- Jin H. Han
- Center for Quality Aging, Assistant Professor of Emergency Medicine, Vanderbilt University School of Medicine, Department of Emergency Medicine, 703 Oxford House, Nashville, TN 37232-4700, Phone: 615-936-1434, Fax: 615-936-1316
| | - Scott T. Wilber
- Emergency Medicine Research Center, Associate Professor of Emergency Medicine, Summa Akron City Hospital, Northeastern Ohio Medical University, 525 East Market Street, Akron, Ohio 44309, Phone: 330-375-7530, Fax: 330-375-7564
| |
Collapse
|
35
|
Frisch A, Miller T, Haag A, Martin-Gill C, Guyette FX, Suffoletto BP. Diagnostic Accuracy of a Rapid Checklist to Identify Delirium in Older Patients Transported by EMS. PREHOSP EMERG CARE 2013; 17:230-4. [DOI: 10.3109/10903127.2012.744785] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Adam Frisch
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Thomas Miller
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Adam Haag
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| | - Brian P. Suffoletto
- From the Department of Emergency Medicine, University of Pittsburgh (AF, AH, CM-G, FXG, BPS), Pittsburgh, Pennsylvania; and the University of Pittsburgh School of Medicine (TM), Pittsburgh, Pennsylvania
| |
Collapse
|
36
|
Gower LEJ, Gatewood MO, Kang CS. Emergency department management of delirium in the elderly. West J Emerg Med 2012; 13:194-201. [PMID: 22900112 PMCID: PMC3415810 DOI: 10.5811/westjem.2011.10.6654] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 03/06/2011] [Accepted: 10/03/2011] [Indexed: 11/16/2022] Open
Abstract
An increasing number of elderly patients are presenting to the emergency department. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly. These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly.
Collapse
Affiliation(s)
- Lynn E J Gower
- Madigan Army Medical Center, Department of Emergency Medicine, Fort Lewis (Tacoma), Washington
| | | | | |
Collapse
|
37
|
Wang HE, Shah MN, Allman RM, Kilgore M. Emergency department visits by nursing home residents in the United States. J Am Geriatr Soc 2011; 59:1864-72. [PMID: 22091500 DOI: 10.1111/j.1532-5415.2011.03587.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterize emergency department (ED) use by nursing home residents in the United States. DESIGN Analysis of the National Hospital Ambulatory Medical Care Survey. SETTING U.S. EDs from 2005 to 2008. PARTICIPANTS Individuals visiting U.S. EDs stratified according to nursing home residency. MEASUREMENTS All ED visits by nursing home residents were identified. The demographic and clinical characteristics and ED resource utilization, length of stay, and outcomes of nursing home residents and nonresidents were compared. RESULTS During 2005 to 2008, nursing home residents accounted for 9,104,735 of 475,077,828 U.S. ED visits (1.9%; 95% confidence interval (CI) = 1.8-2.1%). The annualized number of ED visits by nursing home residents was 2,276,184. Most nursing home residents were older (mean age 76.7, 95% CI = 75.8-77.5), female (63.3%), and non-Hispanic white (74.8%). Nursing home residents were more likely to have been discharged from the hospital in the prior 7 days (adjusted odds ratio (aOR = 1.4, 95% CI = 1.1-1.9), to present with fever (aOR = 1.9, 95% CI = 1.5-2.4) or hypotension (systolic blood pressure ≤90 mmHg, aOR = 1.8, 95% CI = 1.5-2.2), and to receive diagnostic tests (OR = 1.9, 95% CI = 1.6-2.2), imaging (OR = 1.5, 95% CI = 1.3-1.7), or procedures (OR = 1.6, 95% CI = 1.4-1.7) in the ED. Almost half of nursing home residents visiting the ED were admitted to the hospital. Nursing home residents were more likely to be admitted to the hospital (aOR = 1.8, 95% CI = 1.6-2.0) and to die (aOR = 2.3, 95% CI = 1.6-3.3). CONCLUSION Nursing home residents account for more than 2.2 million ED visits annually in the United States. Nursing home residents have greater medical acuity and complexity. These observations highlight the national challenges of organizing and delivering ED care to nursing home residents in the United States.
Collapse
Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Alabama, Birmingham, Alabama 35249, USA.
| | | | | | | |
Collapse
|
38
|
Evaluation of two intensive care delirium screening tools for non-critically ill hospitalized patients. PSYCHOSOMATICS 2011; 52:133-40. [PMID: 21397105 DOI: 10.1016/j.psym.2010.12.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 08/03/2010] [Accepted: 08/03/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Delirium is a common, yet frequently under-recognized medical/psychiatric complication for hospitalized patients, associated with substantial morbidity and mortality. While easy-to-use delirium screening tools exist for ventilated patients, their use in non-critically ill, hospitalized patients has not been validated. METHODS This prospective 4-week comparison of daily delirium status, using screening tools (Confusion Assessment Method for the Intensive Care Unit [CAM-ICU] and Intensive Care Delirium Screening Checklist [ICDSC]) vs. a daily neuropsychiatric examination as a reference standard, was conducted in 139 inpatients in two medical oncology units at a large teaching hospital during July, 2009. RESULTS Based on neuropsychiatric examination, 36 (26%) patients had at least 1 day of delirium during their hospital admission. For 21 (15%) patients, delirium was present at the initial assessment, while 15 (11%) developed delirium at a median (IQR) of three (2-7) subsequent assessments. Delirium was present on 20% of all patient-days. For the initial evaluation, the CAM-ICU had a sensitivity of 18% (95% confidence interval [CI], 5%-44%), and a sensitivity of 18% (9% -32%) when using all assessments, adjusting for repeated measures on each patient. The ICDSC had sensitivities of 47% (24%-72%) and 62% (49%-74%). The specificity of both instruments was very high (≥98%). CONCLUSIONS This study suggests that in non-critically ill hospitalized patients, the CAM-ICU and ICDSC intensive care delirium screening tools are not adequately sensitive for use in routine clinical practice. Further work is needed to develop more sensitive, efficient tools in this population.
Collapse
|
39
|
Carpenter CR, Shah MN, Hustey FM, Heard K, Gerson LW, Miller DK. High yield research opportunities in geriatric emergency medicine: prehospital care, delirium, adverse drug events, and falls. J Gerontol A Biol Sci Med Sci 2011; 66:775-83. [PMID: 21498881 PMCID: PMC3143344 DOI: 10.1093/gerona/glr040] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 02/10/2011] [Indexed: 11/13/2022] Open
Abstract
Emergency services constitute crucial and frequently used safety nets for older persons, an emergency visit by a senior very often indicates high vulnerability for functional decline and death, and interventions via the emergency system have significant opportunities to change the clinical course of older patients who require its services. However, the evidence base for widespread employment of emergency system-based interventions is lacking. In this article, we review the evidence and offer crucial research questions to capitalize on the opportunity to optimize health trajectories of older persons seeking emergency care in four areas: prehospital care, delirium, adverse drug events, and falls.
Collapse
Affiliation(s)
| | - Manish N. Shah
- Department of Emergency Medicine, University of Rochester, New York
| | | | - Kennon Heard
- Rocky Mountain Poison and Drug Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado, Aurora
| | - Lowell W. Gerson
- Department of Emergency Medicine, Summa Health System, Akron Ohio
- Department of Behavioral and Community Health Sciences, Northeastern Ohio Universities Colleges of Medicine and Pharmacy, Rootstown
| | - Douglas K. Miller
- Center for Aging Research, Indiana University, Indianapolis
- Regenstrief Institute, Inc., Indianapolis, Indiana
| |
Collapse
|
40
|
Han JH, Eden S, Shintani A, Morandi A, Schnelle J, Dittus RS, Storrow AB, Ely EW. Delirium in older emergency department patients is an independent predictor of hospital length of stay. Acad Emerg Med 2011; 18:451-7. [PMID: 21521405 DOI: 10.1111/j.1553-2712.2011.01065.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The consequences of delirium in the emergency department (ED) remain unclear. This study sought to determine if delirium in the ED was an independent predictor of prolonged hospital length of stay (LOS). METHODS This prospective cohort study was conducted at a tertiary care, academic ED from May 2007 to August 2008. The study included English-speaking patients aged 65 and older who were in the ED for less than 12 hours at enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or did not have a delirium assessment performed by the research staff. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to determine delirium status. Patients who were discharged directly from the ED were considered to have a hospital LOS of 0 days. To determine if delirium in the ED was independently associated with time to discharge, Cox proportional hazard regression was performed adjusted for age, comorbidity burden, severity of illness, dementia, functional impairment, nursing home residence, and surgical procedure. A sensitivity analysis, which included admitted patients only, was also performed. RESULTS A total of 628 patients met enrollment criteria. The median age was 75 years (interquartile range [IQR] = 69-81), 365 (58%) patients were female, 111 (18%) were nonwhite, 351 (56%) were admitted to the hospital, and 108 (17%) were delirious in the ED. Median LOS was 2 days (IQR = 0-5.5) for delirious ED patients and 1 day (IQR = 0-3) for nondelirious ED patients (p < 0.001). The hazard ratio (HR) of delirium for time to discharge was 0.71 (95% confidence interval [CI] = 0.57 to 0.89) after adjusting for confounders, and indicated that ED patients with delirium were more likely to have prolonged hospital LOS compared with those without delirium. For the sensitivity analysis, which included only hospitalized patients, the adjusted HR was 0.76 (95% CI = 0.58 to 0.99). CONCLUSIONS Delirium in older ED patients has negative consequences and is an independent predictor of prolonged hospitalizations.
Collapse
Affiliation(s)
- Jin H Han
- Department of Emergency Medicine (JHH, ABS, Division of General Internal Medicine and Public Health (JS, RSD), Vanderbilt University Medical Center, Nashville, TN, USA.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med 2011; 18:374-84. [PMID: 21496140 DOI: 10.1111/j.1553-2712.2011.01040.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cognitive dysfunction, including dementia and delirium, is prevalent in geriatric emergency department (ED) patients, but often remains undetected. One barrier to reliable identification of acutely or chronically impaired cognitive function is the lack of an acceptable screening tool. While multiple brief screening instruments have been derived, ED validation trials have not previously demonstrated tools that are appropriately sensitive for clinical use. OBJECTIVES The primary objective was to evaluate and compare the Ottawa 3DY (O3DY), Brief Alzheimer's Screen (BAS), Short Blessed Test (SBT), and caregiver-completed AD8 (cAD8) diagnostic test performance for cognitive dysfunction in geriatric ED patients using the Mini Mental Status Exam (MMSE) as the criterion standard. A secondary objective was to assess the diagnostic accuracy for the cAD8 (which is an informant-based instrument) when used in combination with the other performance-based screening tools. METHODS In an observational cross-sectional cohort study at one urban academic university-affiliated medical center, trained research assistants (RAs) collected patients' responses on the Confusion Assessment Method for the Intensive Care Unit, BAS, and SBT. When available, reliable caregivers completed the cAD8. The MMSE was then obtained. The O3DY was reconstructed from elements of the MMSE and the BAS. Consenting subjects were non-critically ill, English-speaking adults over age 65 years, who had not received potentially sedating medications prior to or during cognitive testing. Using an MMSE score of ≤23 as the criterion standard for cognitive dysfunction, the sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) area under the curve (AUC) were computed. Venn diagrams were constructed to quantitatively compare the degree of overlap among positive test results between the performance-based instruments. RESULTS The prevalence of cognitive dysfunction for the 163 patients enrolled with complete data collection was 37%, including 5.5% with delirium. Dementia was self-reported in 3%. Caregivers were available to complete the cAD8 for 56% of patients. The SBT, BAS, and O3DY each demonstrated 95% sensitivity, compared with 83% sensitivity for the cAD8. The SBT had a superior specificity of 65%. No combination of instruments with the cAD8 significantly improved diagnostic accuracy. The SBT provided the optimal overlap with the MMSE. CONCLUSIONS The SBT, BAS, and O3DY are three brief performance-based screening instruments to identify geriatric patients with cognitive dysfunction more rapidly than the MMSE. Among these three instruments, the SBT provides the best diagnostic test characteristics and overlap with MMSE results. The addition of the cAD8 to the other instruments does not enhance diagnostic accuracy.
Collapse
Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, MO, USA.
| | | | | | | | | | | |
Collapse
|
42
|
Affiliation(s)
- Andrew Clegg
- Academic Unit of Elderly Care & Rehabilitation, Bradford Institute for Health Research, Bradford, West Yorkshire, UK.
| | | | | |
Collapse
|
43
|
Abstract
Delirium is defined as an acute change in cognition that cannot be better accounted for by a preexisting or evolving dementia. This form of organ dysfunction commonly occurs in older patients in the emergency department (ED) and is associated with a multitude of adverse patient outcomes. Consequently, delirium should be routinely screened for in older ED patients. Once delirium is diagnosed, the ED evaluation should focus on searching for the underlying cause. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.
Collapse
|
44
|
Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, Dittus RS, Storrow AB, Ely EW. Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med 2010; 56:244-252.e1. [PMID: 20363527 DOI: 10.1016/j.annemergmed.2010.03.003] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 02/02/2010] [Accepted: 03/01/2010] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE Delirium's adverse effect on long-term mortality in older hospitalized patients is well documented, whereas its effect in older emergency department (ED) patients remains unclear. Similarly, the consequences of delirium on nursing home patients treated in the ED are also unknown. As a result, we seek to determine whether delirium in the ED is independently associated with 6-month mortality in older patients and whether this relationship is modified by nursing home status. METHODS Our prospective cohort study was conducted at a tertiary care, academic ED, using convenience sampling, and included English-speaking patients who were aged 65 years and older and were in the ED for less than 12 hours at enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or had incomplete data. The Confusion Assessment Method for the Intensive Care Unit was used to determine delirium and was administered by trained research assistants. Cox proportional hazard regression was performed to determine whether delirium in the ED was independently associated with 6-month mortality after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. To test whether the effect of delirium in the ED on 6-month mortality was modified by nursing home residence, an interaction term (delirium*nursing home) was incorporated into the multivariable model. Hazard ratios with their 95% confidence intervals were reported. RESULTS Of the 628 patients enrolled, 108 (17.2%) were delirious in the ED and 58 (9.2%) were from the nursing home. For the entire cohort, the 6-month mortality rate was higher in the delirious group compared with the nondelirious group (37.0% versus 14.3%). Delirium was an independent predictor of increased 6-month mortality (hazard ratio=1.72; 95% confidence interval 1.04 to 2.86) after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. The "delirium*nursing home" interaction was nonsignificant (P=.86), indicating that place of residence had no effect on the relationship between delirium in the ED and 6-month mortality. CONCLUSION Delirium in older ED patients is an independent predictor of increased 6-month mortality, and this relationship appears to be present regardless of nursing home status.
Collapse
Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-4700, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Morandi A, Han JH, Callison C, Ely EW, Schnelle JF. Delirium in nursing home residents across care transitions: a preliminary report. J Am Geriatr Soc 2009; 57:1956-8. [PMID: 19807810 DOI: 10.1111/j.1532-5415.2009.02472.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|