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Medina Ortega JÁ, Urrutia Besaskoa A, Álvarez-Rodríguez E, Martin Carrasco P, Navas Ara MJ. [Use of physical restraints in the elderly in an emergency department. Analysis of clinical, environmental and health care team organization factors associated with decision making]. Rev Esp Geriatr Gerontol 2024; 59:101533. [PMID: 39053084 DOI: 10.1016/j.regg.2024.101533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024]
Abstract
OBJETIVE To determine the influence of different factors involved in the decision to apply physical restraints (PR) in the management the elderly people with conduct disorders in an emergency department (ED) METHODS: A prospective observational study was conducted in the ED of the Hospital Universitario Severo Ochoa (Leganés, Madrid). We included 125 elderly people with disruptive behaviors and collected clinical, patient handling, organizational and environmental variables. Individuals who had undergone PR were analyzed to learn what factors were related to the final decision to restrain. RESULTS 32.8% of the participants underwent PR. The aspects that most influenced the decision to restrain were those related to the organization and environment: specific staff training decreased the probability of restraint by 50% (P<.05) and good support from the whole team reduced the risk of using SF by up to 75% (P<.0005). Related patient handling factors such as verbal restraint, pain relief, family accompaniment and early mobilization significantly reduced the use of PR (P<.05). The only patient-dependent clinical aspect that increased the risk of SF was male sex (P<.05). Other factors unrelated to the probability of applying PR were, among others, nurse-patient ratio, type of behavior, age, or functional/cognitive status. CONCLUSIONS Exclusively clinical factors of the patient had little influence on the decision to restrain the elderly in an ED. However, environmental, organizational, and behavioral handling variables could favor more respectful alternatives and thus reduce the use of PR in the elderly with disruptive behaviors in the ED.
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Affiliation(s)
| | - Ana Urrutia Besaskoa
- Servicio de Urgencias Generales, Hospital Universitario Severo Ochoa, Leganés, Madrid, España; Fundación Cuidados Dignos
| | | | - Paloma Martin Carrasco
- Servicio de Urgencias Generales, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| | - María José Navas Ara
- Servicio de Urgencias Generales, Hospital Universitario Severo Ochoa, Leganés, Madrid, España; Metodología de las Ciencias de Comportamiento, Facultad de Psicología de la UNED, Madrid, España
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Jivalagian P, Gettel CJ, Smith CM, Robinson L, Brinker M, Shah D, Kumar A, Faustino IV, Nath B, Chang-Sing E, Taylor RA, Kennedy M, Hwang U, Wong AH. Racial, Ethnic, and Age-Related Disparities in Sedation and Restraint Use for Older Adults in the Emergency Department. Am J Geriatr Psychiatry 2024:S1064-7481(24)00398-1. [PMID: 39054237 DOI: 10.1016/j.jagp.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES Older adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS This retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015-2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint. RESULTS Among 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29-1.42); 1.82 (1.73-1.91); 2.35 (2.15-2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27-1.34); 1.55 (1.50-1.60); 1.69 (1.59-1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18-1.35); AOR 1.22 (1.15-1.29)] and physical restraint [AOR 1.12 (95% CI 1.07-1.16); 1.22 (1.18-1.26)]. CONCLUSION Approximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.
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Affiliation(s)
- Patelle Jivalagian
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Cameron J Gettel
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Colin M Smith
- Hubert-Yeargan Center for Global Health (CMS), Duke University, Durham, NC
| | - Leah Robinson
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine (MB), New Haven, CT
| | - Dhruvil Shah
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Anusha Kumar
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Isaac V Faustino
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Bidisha Nath
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Erika Chang-Sing
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - R Andrew Taylor
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT; Department of Biomedical Informatics and Data Science (RAT), Yale School of Medicine, New Haven, CT
| | - Maura Kennedy
- Department of Emergency Medicine (MK), Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine (MK), Harvard Medical School, Boston, MA
| | - Ula Hwang
- Department of Emergency Medicine (UH), New York University Grossman School of Medicine, New York, NY; Geriatric Research Education and Clinical Center (UH), James J. Peters VAMC, Bronx, NY
| | - Ambrose H Wong
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT.
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Gagliardi JP. Finding Delirium Is Necessary-But Not Sufficient-To Improve Outcomes. Am J Geriatr Psychiatry 2024; 32:852-855. [PMID: 38395729 DOI: 10.1016/j.jagp.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Jane P Gagliardi
- Department of Psychiatry and Behavioral Sciences, Department of Medicine, Psychiatry and Behavioral Sciences, Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America.
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Gupta N, Singh S, Tiwari B, Maharana P. Postictal Agitation to Lorazepam in Patient with Active Seizure. Neurol India 2023; 71:831-832. [PMID: 37635545 DOI: 10.4103/0028-3886.383802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Affiliation(s)
- Nipun Gupta
- Department of Neuroanesthesia and Critical Care, AIIMS, New Delhi, India
| | - Shalendra Singh
- Department of Anaesthesiology and Critical Care, Command Hospital (NC), Udhampur, India
| | - Beena Tiwari
- Emergency Department, 162 Military Hospital, Army Cantt Dinjan, Assam, India
| | - Payal Maharana
- Emergency Department, 162 Military Hospital, Army Cantt Dinjan, Assam, India
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Soler-Sanchis A, Martínez-Arnau FM, Sánchez-Frutos J, Pérez-Ros P. Identification through the Manchester Triage System of the older population at risk of delirium: A case-control study. J Clin Nurs 2022; 32:2642-2651. [PMID: 35560853 DOI: 10.1111/jocn.16349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify the flow charts and discriminators of the Manchester Triage System that are most likely to identify the onset of delirium in older people. BACKGROUND Delirium is an underdiagnosed geriatric syndrome, and up to 80% of all cases of delirium go undetected in emergency departments. Patient triage seeks to manage clinical risk with a view to safely and appropriately managing patient flows. DESIGN A case-control study was performed according to the STROBE checklist. SETTING The emergency department of a secondary hospital. PARTICIPANTS Older adults aged ≥65 years and admitted from 1 January to 31 December 2020. METHODS Older patients were identified from the emergency department research database. Cases were defined as patients diagnosed with delirium (n = 128), excluding cases of delirium due to alcohol or substance abuse. Controls were randomised from the remaining patients (n = 128). RESULTS A total of 29.35% of the subjects admitted to the emergency department were older adults with an incidence of delirium of 0.7%. The flow charts with the highest probability of delirium were 'unwell adult' [OR = 3.04 (95%CI:1.82-5.1)] and 'behaving strangely' [OR = 16.06 (95%CI:3.72-69.29)], and the discriminators were 'rapid onset' [OR = 3.3 (95%CI:1.85-5.88)] and 'new neurological deficit less than 24 h old' [OR = 4.76 (95%%CI:1.01-22.5). The area under the curve for 'unwell adult' in the presence of dementia, previous stroke and fall in the previous 30 days was 0.73 (95%CI: 0.67-0.79), and that for 'behaving strangely' in the presence of diabetes was 0.75 (95%CI: 0.69-0.81). CONCLUSIONS Knowing which flow charts, discriminators and risk factors are most likely to predict delirium allows the identification of the older population at risk for triage screening in emergency departments. RELEVANCE TO CLINICAL PRACTICE Risk factors such as diabetes, dementia, previous stroke and recent fall among 'unwell adult' or 'behaving strangely' triaged older persons should be assessed for the probable presence of delirium.
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Affiliation(s)
- Angela Soler-Sanchis
- Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, Valencia, Spain.,Departament de Gandia, Hospital Francesc de Borja, Conselleria de Sanitat Universal i Salut Pública, av. de la Medicina, Valencia, Spain
| | - Francisco Miguel Martínez-Arnau
- Department of Physiotherapy, Universitat de València, Valencia, Spain.,Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, Valencia, Spain
| | | | - Pilar Pérez-Ros
- Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, Valencia, Spain.,Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, Valencia, Spain
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Senderovich H, Gardner S, Berall A, Ganion M, Zhang D, Vinoraj D, Waicus S. Benzodiazepine Use and Morbidity-Mortality Outcomes in a Geriatric Palliative Care Unit: A Retrospective Review. Dement Geriatr Cogn Disord 2022; 50:559-567. [PMID: 34942615 DOI: 10.1159/000520975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Patients often experience delirium at the end of life. Benzodiazepine use may be associated with an increased risk of developing delirium. Alternate medications used in conjunction with benzodiazepines may serve as an independent precipitant of delirium. The aim is to understand the role of benzodiazepines in precipitating delirium and advanced mortality in palliative care population at the end of life. METHODS A retrospective medical chart review was conducted at a hospice and palliative care inpatient unit between the periods of June 2017-December 2017 and October 2017-November 2018. It included patients in hospice and palliative care inpatient units who received a benzodiazepine and those who did not. Patient characteristics, as well as Palliative Performance Scale score, diagnosis, and occurrence of admission, terminal, and/or recurrent delirium, were collected and analyzed. RESULTS Use of a benzodiazepine was not significantly associated with overall mortality nor cause-specific death without terminal delirium rate. However, it was significantly associated with higher cause-specific death with terminal delirium rate and a higher recurrent delirium rate. DISCUSSION This retrospective chart review suggests an association between benzodiazepine use and specific states of delirium and cause-specific death. However, it does not provide strong evidence on the use of this drug, especially at the end of life, as it pertains to the overall mortality rate. Suggested is a contextual approach to the use of benzodiazepines and the need to consider Palliative Performance Scale score and goals of care in the administration of this drug at varying periods during patient length of stay.
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Affiliation(s)
- Helen Senderovich
- Baycrest, Faculty of Medicine, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Toronto, Ontario, Canada.,Division of Palliative Care, Toronto, Ontario, Canada
| | - Sandra Gardner
- Baycrest, Faculty of Medicine, Toronto, Ontario, Canada.,Biostatistics Division, Baycrest, Kunin-Lunenfeld Centre for Applied Research and Evaluation (KL-CARE), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Anna Berall
- Baycrest, Faculty of Medicine, Toronto, Ontario, Canada.,Biostatistics Division, Baycrest, Kunin-Lunenfeld Centre for Applied Research and Evaluation (KL-CARE), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michael Ganion
- University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Toronto, Ontario, Canada.,Bethell Hospice, Toronto, Ontario, Canada
| | - Dennis Zhang
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Danusha Vinoraj
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Waicus
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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Cano-Escalera G, Graña M, Irazusta J, Labayen I, Besga A. Survival of Frail Elderly with Delirium. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042247. [PMID: 35206439 PMCID: PMC8872606 DOI: 10.3390/ijerph19042247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023]
Abstract
This study aims to determine when frailty increases the risks of delirium mortality. Hospital patients falling into the elderly frail or pre-frail category were recruited, some without delirium, some with delirium at admission, and some who developed delirium during admission. We screened for frailty, cognitive status, and co-morbidities whenever possible and extracted drug information and mortality data from electronic health records. Kaplan–Meier estimates of survival probability functions were computed at four times, comparing delirium versus non delirium patients. Differences in survival were assessed by a log-rank test. Independent Cox’s regression was carried out to identify significant hazard risks (HR) at 1 month, 6 months, 1 year, and 2 years. Delirium predicted mortality (log-rank test, p < 0.0001) at all four censoring points. Variables with significant HRs were frailty indicators, comorbidities, polypharmacy, and the use of specific drugs. For the delirium cohort, variables with the most significant 2-year hazard risks (HR(95%CI)) were: male gender (0.43 20 (0.26,0.69)), weight loss (0.45 (0.26,0.74)), sit and stand up test (0.67 (0.49,0.92)), readmission within 30 days of discharge (0.50 (0.30,0.80)), cerebrovascular disease (0.45 (0.27,0.76)), head trauma (0.54 22 (0.29,0.98)), number of prescribed drugs (1.10 (1.03,1.18)), and the use of diuretics (0.57 (0.34,0.96)). These results suggest that polypharmacy and the use of diuretics increase mortality in frail elderly patients with delirium.
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Affiliation(s)
- Guillermo Cano-Escalera
- Department of Computer Science and Artificial Intelligence, University of the Basque Country (UPV/EHU), Paseo Manuel de Lardizabal, 1, 20018 Donostia-San Sebastian, Spain;
- Computational Intelligence Group, University of the Basque Country (UPV/EHU), 20018 Donostia-San Sebastian, Spain
- Correspondence:
| | - Manuel Graña
- Department of Computer Science and Artificial Intelligence, University of the Basque Country (UPV/EHU), Paseo Manuel de Lardizabal, 1, 20018 Donostia-San Sebastian, Spain;
- Computational Intelligence Group, University of the Basque Country (UPV/EHU), 20018 Donostia-San Sebastian, Spain
| | - Jon Irazusta
- Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48013 Bilbao, Spain;
- BioCruces Health Research Institute, 48903 Barakaldo, Spain
| | - Idoia Labayen
- Institute for Innovation & Sustainable Development in Food Chain (IS-FOOD), Public University of Navarra, 31006 Pamplona, Spain;
| | - Ariadna Besga
- BioAraba, Health Research Institute, Hospital Universitario de Araba, Department of Medicine, 01004 Vitoria, Spain;
- Biomedical Research Centre in Mental Health Network (CIBERSAM) G10, Spain
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Assis LDO, Pinto ACDS, Moraes END, Cintra MTG, Bicalho MAC. HospitalElder Life Program na unidade de urgência e emergência de um hospital público universitário: um programa de intervenção multicomponente para prevenção de delirium. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2022. [DOI: 10.1590/2526-8910.ctoao232830641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo Avaliar a viabilidade da implementação de uma adaptação do Hospital Elder Life Program (HELP) com a participação de cuidadores familiares em hospital público universitário. Método Estudo piloto descritivo exploratório desenvolvido com 30 pacientes internados e seus cuidadores. Os Formulários de Registro foram aplicados para identificar fatores de risco para delirium, selecionar protocolos de intervenção e acompanhar a implementação. Nível de satisfação dos participantes e barreiras para implementar o programa foram avaliados por meio de entrevistas qualitativas. Resultados secundários foram coletados dos prontuários médicos. Análise estatística descritiva foi realizada para caracterizar a amostra e análise de conteúdo foi usada para analisar dados qualitativos. Resultados A maioria dos pacientes era do sexo feminino (60%), com idade média de 74,3 anos, ensino fundamental incompleto (60%), viúvo/divorciado (56,7%) e morava com familiares (83,3%) em casa (93,3%). Haviam sido hospitalizados 56,7% no último ano e 93,3% tinham pelo menos um fator de risco para delirium. Assistência alimentar e reposição de líquidos foi o protocolo com maior adesão (96,2%) e orientação (76,5%) com menor. Os participantes ficaram satisfeitos e acreditam que o HELP contribuiu para melhorar os resultados dos pacientes. Os motivos para não realização da intervenção proposta estavam relacionados à estrutura ou organização hospitalar, ao paciente e ao acompanhante. Conclusão Nossos resultados sugerem que ter membros da família atuando como “voluntários” é uma estratégia viável para implementar o HELP. Essa estratégia pode promover sua implementação em hospitais públicos de países de baixa e média renda.
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Assis LDO, Pinto ACDS, Moraes END, Cintra MTG, Bicalho MAC. Modified Hospital Elder Life Program in the emergency department of a public university hospital: a multicomponent intervention program for preventing delirium. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2022. [DOI: 10.1590/2526-8910.ctoao232830642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Objective To evaluate the feasibility of implementing an adaptation of the Hospital Elder Life Program (HELP) with the participation of family caregivers in a public university hospital. Method Descriptive exploratory pilot study developed with 30 hospitalized patients and their caregivers. Registration Forms were applied to identify risk factors for delirium, to select intervention protocols, and track implementation. Participants' level of satisfaction and barriers to implementing the program were assessed through qualitative interviews. Secondary results were collected from medical records. Descriptive statistical analysis was performed to characterize the sample and content analysis was used to analyze qualitative data. Results Most patients were female (60%), with a mean age of 74.3 years, incomplete elementary school (60%), widowed/divorced (56.7%) and living with family members (83.3%) at home (93.3%). 56.7% had been hospitalized in the last year and 93.3% had at least one risk factor for delirium. Food assistance and fluid replacement was the protocol with the highest adherence (96.2%) and guidance (76.5%) with the lowest. Participants were satisfied and believe that HELP contributed to improving patient outcomes. The reasons for not performing the proposed intervention were related to the hospital structure or organization, the patient and the companion. Conclusion Our results suggest that having family members act as “volunteers” is a viable strategy to implement HELP. This strategy can promote its implementation in public hospitals in low and middle-income countries.
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10
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Sofortige ultraschallgestützte Femoralisblockade bei proximalen Femurfrakturen in der Notaufnahme. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00781-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Pinnell RAM, Ramsay T, Wang H, Joo P. Urinary Tract Infection Investigation and Treatment in Older Adults Presenting to the Emergency Department with Confusion: a Health Record Review of Local Practice Patterns. Can Geriatr J 2021; 24:341-350. [PMID: 34912489 PMCID: PMC8629500 DOI: 10.5770/cgj.24.518] [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] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The rate of urinary tract infection (UTI) investigation and treatment in confused older emergency department (ED) patients has not been described in the literature. We aim to describe the pattern of practice in an academic tertiary care ED for this common presentation. METHODS A health record review was conducted on 499 adults aged ≥65 presenting to academic EDs with confusion. Exclusion criteria: Glasgow Coma Scale < 13, current treatment for UTI, indwelling catheters, nephrostomy tubes, transfer from another hospital. Outcomes were the prevalence of UTI investigation, diagnosis and antibiotic treatment. RESULTS 64.9% received urine tests, 11.4% were diagnosed with UTI, and 35.2% were prescribed antibiotics. In the subgroup with no urinary symptoms, fever, or other obvious indication for antibiotics, these numbers were 58.2%, 7.6%, and 18.1%, respectively. Patients who had urine tests or received antibiotics were older than those who did not (p values < .01). Patients receiving antibiotics had higher admission rates and 30-day and six-month mortality (OR of 2.9 [2.0-4.3], 4.0 [1.6-11], and 2.8 [1.4-5.8], respectively). CONCLUSION Older patients presenting to ED with confusion were frequently investigated and treated for UTI, even in the absence of urinary symptoms. Antibiotic treatment was associated with higher hospitalization and mortality.
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Affiliation(s)
| | - Tim Ramsay
- Ottawa Hospital Research, Institute, Ottawa, ON
| | - Han Wang
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Pil Joo
- Ottawa Hospital Research, Institute, Ottawa, ON
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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Kennedy M, Webb M, Gartaganis S, Hwang U, Biese K, Stuck A, Lesser A, Hshieh T, Inouye SK. ED-DEL: Development of a change package and toolkit for delirium in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12421. [PMID: 33969341 PMCID: PMC8082702 DOI: 10.1002/emp2.12421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/05/2021] [Accepted: 03/05/2021] [Indexed: 12/14/2022] Open
Abstract
Delirium is a common and deadly problem in the emergency department affecting up to 30% of older adult patients. The 2013 Geriatric Emergency Department guidelines were developed to address the unique needs of the growing older population and identified delirium as a high priority area. The emergency department (ED) environment presents unique challenges for the identification and management of delirium, including patient crowding, time pressures, competing priorities, variable patient acuity, and limitations in available patient information. Accordingly, protocols developed for inpatient units may not be appropriate for use in the ED setting. We created a Delirium Change Package and Toolkit in the Emergency Department (ED-DEL) to provide protocols and guidance for implementing a delirium program in the ED setting. This article describes the multistep process by which the ED-DEL program was created and the key components of the program. Our ultimate goal is to create a resource that can be disseminated widely and used to improve delirium identification, prevention, and management in older adults in the ED.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Margaret Webb
- Aging Brain CenterMarcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
| | - Sarah Gartaganis
- Aging Brain CenterMarcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
| | - Ula Hwang
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Geriatric Research, Education and Clinical CenterJames J. Peters VA Medical CenterBronxNew YorkUSA
| | - Kevin Biese
- Department of Emergency MedicineDivision of Geriatric Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Amy Stuck
- Strategy DepartmentWest Health InstituteSan DiegoCaliforniaUSA
| | - Adriane Lesser
- Clinical Research DepartmentWest Health InstituteSan DiegoCaliforniaUSA
| | - Tammy Hshieh
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineDivision of AgingBrigham and Women's HospitalBostonMassachusettsUSA
| | - Sharon K. Inouye
- Aging Brain CenterMarcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineDivision of Gerontology, Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
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Kennedy M, Koehl J, Shenvi CL, Greenberg A, Zurek O, LaMantia M, Lo AX. The agitated older adult in the emergency department: a narrative review of common causes and management strategies. J Am Coll Emerg Physicians Open 2020; 1:812-823. [PMID: 33145525 PMCID: PMC7593470 DOI: 10.1002/emp2.12110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022] Open
Abstract
Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life-threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non-pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non-opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric-specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non-pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Jennifer Koehl
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of PharmacyMassachusetts General HospitalBostonMassachusettsUSA
| | - Christina L. Shenvi
- Department of Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Allyson Greenberg
- Department of PharmacyNorthwestern Memorial HospitalChicagoIllinoisUSA
- Department of Emergency MedicineNorthwestern Memorial HospitalChicagoIllinoisUSA
| | - Olivia Zurek
- Department of PsychiatryMassachusetts General HospitalBostonMassachusettsUSA
- Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Michael LaMantia
- Division of Geriatric MedicineUniversity of VermontBurlingtonVermontUSA
| | - Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med 2020; 75:136-145. [PMID: 31563402 PMCID: PMC7945005 DOI: 10.1016/j.annemergmed.2019.07.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022]
Abstract
Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.
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Affiliation(s)
- Christina Shenvi
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC.
| | - Maura Kennedy
- Massachusetts General Hospital Department of Emergency Medicine and Harvard Medical School, Boston, MA
| | - Charles A Austin
- Department of Internal Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, AR
| | - Michael Gerardi
- Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ; Coalition on Psychiatric Emergencies
| | - Sandy Schneider
- American College of Emergency Physicians, Irving, TX; Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX; Hofstra Northwell School of Medicine, Hempstead, NY
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Bédard C, Boucher V, Voyer P, Yadav K, Eagles D, Nadeau A, Carmichael PH, Pelletier M, Gouin E, Berthelot S, Daoust R, Laguë A, Gagné AJ, Émond M. Validation of the O3DY French Version (O3DY-F) for the Screening of Cognitive Impairment in Community Seniors in the Emergency Department. J Emerg Med 2019; 57:59-65. [DOI: 10.1016/j.jemermed.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 02/07/2019] [Accepted: 02/10/2019] [Indexed: 12/25/2022]
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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.
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Affiliation(s)
- Pilar Pérez-Ros
- School of Nursing, Universidad Católica de Valencia San Vicente Mártir, Calle Espartero, 7, 46007 València, Spain.
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Ohl ICB, Chavaglia SRR, Ohl RIB, Lopes MCBT, Campanharo CRV, Okuno MFP, Batista REA. Evaluation of delirium in aged patients assisted at emergency hospital service. Rev Bras Enferm 2019; 72:153-160. [DOI: 10.1590/0034-7167-2018-0386] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 02/26/2019] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: identify the occurrence of delirium in aged patients assisted in emergency services and verify its relationship with sociodemographic and clinical variables. Method: cross-sectional, prospective study with a quantitative approach. Two hundred aged hospitalized patients participated. The Confusion Assessment Method was used for data collection. For statistical analysis, chi-square tests, likelihood ratio and Fisher’s test were used, with a significance level of 5%. Results: male gender and mean age of 71.8 years were predominant. In the first 24 hours of hospitalization, 56 (28%) aged individuals presented delirium. An association of the disease with lack of physical activity, presence of a caregiver, hypertension, dyslipidemia and cerebrovascular diseases was identified. Conclusion: Delirium was associated with no physical activity, the need of a caregiver, and the presence of comorbidities. The importance of conducting other studies that may lead to early identification of the condition to prevent its complications is emphasized.
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Ma IC, Chen KC, Chen WT, Tsai HC, Su CC, Lu RB, Chen PS, Chang WH, Yang YK. Increased Readmission Risk and Healthcare Cost for Delirium Patients without Immediate Hospitalization in the Emergency Department. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2018; 16:398-406. [PMID: 30466212 PMCID: PMC6245300 DOI: 10.9758/cpn.2018.16.4.398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/26/2018] [Accepted: 03/05/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Hospitalization of patients with delirium after visiting the emergency department (ED) is often required. However, the readmission risk after discharge from the ED should also be considered. This study aimed to explore whether (i) immediate hospitalization influences the readmission risk of patients with delirium; (ii) the readmission risk is affected by various risk factors; and (iii) the healthcare cost differs between groups within 28 days of the first ED visit. METHODS Using the National Health Insurance Research Database, the data of 2,780 subjects presenting with delirium at an ED visit from 2000 to 2008 were examined. The readmission risks of the groups of patients (i.e., patients who were and were not admitted within 24 hours of an ED visit) within 28 days were compared, and the effects of the severities of different comorbidities (using Charlson's comorbidity index, CCI), age, gender, diagnosis and differences in medical healthcare cost were analyzed. RESULTS Patients without immediate hospitalization had a higher risk of readmission within 3, 7, 14, or 28 days of discharge from the ED, especially subjects with more severe comorbidities (CCI≥3) or older patients (≥65 years). Subjects with more severe comorbidities or older subjects who were not admitted immediately also incurred a greater healthcare cost for re-hospitalization within the 28-day follow-up period. CONCLUSION Patients with delirium with a higher CCI or of a greater age should be carefully considered for immediate hospitalization from ED for further examination in order to reduce the risk of re-hospitalization and cost of healthcare.
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Affiliation(s)
- I Chun Ma
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
| | - Kao Chin Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
| | - Wei Tseng Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
| | - Hsin Chun Tsai
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
- Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin,
Taiwan
| | - Chien-Chou Su
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
| | - Ru-Band Lu
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
| | - Po See Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
| | - Wei Hung Chang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
| | - Yen Kuang Yang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
- Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin,
Taiwan
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan,
Taiwan
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Baten V, Busch H, Busche C, Schmid B, Heupel‐Reuter M, Perlov E, Brich J, Klöppel S. Validation of the Brief Confusion Assessment Method for Screening Delirium in Elderly Medical Patients in a German Emergency Department. Acad Emerg Med 2018; 25:1251-1262. [PMID: 29738102 DOI: 10.1111/acem.13449] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/17/2018] [Accepted: 04/26/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is frequent in elderly patients presenting in the emergency department (ED). Despite the severe prognosis, the majority of delirium cases remain undetected by emergency physicians (EPs). At the time of our study there was no valid delirium screening tool available for EDs in German-speaking regions. We aimed to evaluate the brief Confusion Assessment Method (bCAM) for a German ED during the daily work routine. METHODS We implemented the bCAM into practice in a German interdisciplinary high-volume ED and evaluated the bCAM's validity in a convenience sample of medical patients aged ≥ 70 years. The bCAM, which assesses four core features of delirium, was performed by EPs during their daily work routine and compared to a criterion standard based on the criteria for delirium as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. RESULTS Compared to the criterion standard, delirium was found to be present in 46 (16.0%) of the 288 nonsurgical patients enrolled. The bCAM showed 93.8% specificity (95% confidence interval [CI] = 90.0%-96.5%) and 65.2% sensitivity (95% CI = 49.8%-78.7%). Positive and negative likelihood ratios were 10.5 and 0.37, respectively, while the odds ratio was 28.4. Delirium was missed in 10 of 16 cases, since the bCAM did not indicate altered levels of consciousness and disorganized thinking. The level of agreement with the criterion standard increased for patients with low cognitive performance. CONCLUSION This was the first study evaluating the bCAM for a German ED and when performed by EPs during routine work. The bCAM showed good specificity, but only moderate sensitivity. Nevertheless, application of the bCAM most likely improves the delirium detection rate in German EDs. However, it should only be applied by trained physicians to maximize diagnostic accuracy and hence improve the bCAM's sensitivity. Future studies should refine the bCAM.
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Affiliation(s)
- Verena Baten
- Department of Neurology and Neuroscience Medical Center University of Freiburg FreiburgGermany
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Hans‐Jörg Busch
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Caroline Busche
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Miriam Heupel‐Reuter
- Center of Geriatrics and Gerontology Freiburg Medical Center University of Freiburg Freiburg Germany
| | - Evgeniy Perlov
- Department of Psychiatry and Psychotherapy Faculty of Medicine University of Freiburg FreiburgGermany
- Clinic for Psychiatry Luzern St. UrbanSwitzerland
| | - Jochen Brich
- Department of Neurology and Neuroscience Medical Center University of Freiburg FreiburgGermany
| | - Stefan Klöppel
- Department of Psychiatry and Psychotherapy Faculty of Medicine University of Freiburg FreiburgGermany
- Center for Geriatric Medicine and Gerontology Faculty of Medicine University of Freiburg FreiburgGermany
- University Hospital of Old Age Psychiatry and Psychotherapy University of Bern Bern Switzerland
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Israni J, Lesser A, Kent T, Ko K. Delirium as a predictor of mortality in US Medicare beneficiaries discharged from the emergency department: a national claims-level analysis up to 12 months. BMJ Open 2018; 8:e021258. [PMID: 29730630 PMCID: PMC5942463 DOI: 10.1136/bmjopen-2017-021258] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/08/2018] [Accepted: 03/19/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Delirium is common among seniors discharged from the emergency department (ED) and associated with increased risk of mortality. Prior research has addressed mortality associated with seniors discharged from the ED with delirium, however has generally relied on data from one or a small number of institutions and at single time points. OBJECTIVES Analyse mortality rates among seniors discharged from the ED with delirium up to 12 months at the national level. DESIGN Retrospective cohort study. SETTING Analysed data from the Centers for Medicare & Medicaid Services limited data sets for 2012-2013. PARTICIPANTS Medicare fee-for-service beneficiaries aged 65 years or older discharged from the ED. We focused on new incident cases of delirium, patients with any prior claims for delirium, hospice claims or end-stage renal disease were excluded. Sample size included 26 245 delirium claims, and a randomly selected sample of 262 450 controls. OUTCOME MEASURES Mortality within 12 months after discharge from the ED, excluding patients transferred or admitted as inpatients. RESULTS Among all beneficiaries, 46 508 (16.1%) died within 12 months, of which 39 404 (15.0%) were in the non-delirium (ie, control group) and 7104 (27.1%) were in the delirium cohort, respectively. Mortality was strongest at 30 days with an adjusted HR of 4.82 (95% CI 4.60 to 5.04). Over time, delirium was consistently associated with increased mortality risk compared with controls up to 12 months (HR 2.07; 95% CI 2.01 to 2.13). Covariates that affected mortality included older age, comorbidity and presence of dementia. CONCLUSIONS Our results demonstrate delirium is a significant marker of mortality among seniors in the ED, and mortality risk is most salient in the first 3 months following an ED visit. Given the significant clinical and financial implications, there is a need to increase delirium screening and management within the ED to help identify and treat this potentially fatal condition.
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Affiliation(s)
- Juhi Israni
- West Health Institute, San DIego, California, USA
| | | | - Tyler Kent
- West Health Institute, San DIego, California, USA
| | - Kelly Ko
- West Health Institute, San DIego, California, USA
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Peri- and postoperative cognitive and consecutive functional problems of elderly patients. Curr Opin Crit Care 2018; 22:406-11. [PMID: 27272100 DOI: 10.1097/mcc.0000000000000327] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW From an elderly patient's perspective, acute and chronic cognitive disturbances are among the most harmful complications that can occur following surgery. For elderly patients, these complications often mean the end of an independent life. This article focuses on this serious aspect, which is increasingly prevalent in our aging society. Cognitive disturbances are associated with severe outcome impairments and increased mortality. This article aims to provide a current overview regarding the diagnosis, pathophysiology, prevention, and treatment of this severe social problem. RECENT FINDINGS The current knowledge of risk factors, diagnosis, prevention, and treatment of postoperative delirium and postoperative cognitive dysfunction should help to raise awareness and improve the outcome of delirious patients, particularly in the elderly population. SUMMARY Especially in elderly patients, postoperative delirium constitutes a common, severe complication. Early diagnosis and supportive treatment are essential to improve outcome. To date, no pharmacological treatment strategy was effective, so that further research about the underlying pathophysiology and the development of treatment strategies are urgently required.
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Singler K, Dormann H, Dodt C, Heppner HJ, Püllen R, Burkhardt M, Swoboda W, Roller-Wirnsberger RE, Pinter G, Mrak P, Münzer T. Der geriatrische Patient in der Notaufnahme. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0216-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
As the population ages, nurses in various clinical settings must identify high-risk groups that are vulnerable to delirium and dementia. They also must be able to provide psychosocial and pharmacologic interventions that promote comfort and safety for patients and their families experiencing these distressful medical conditions. Efforts to facilitate health resolution and restore the patient and caregivers to an optimal level of functioning must be priorities.
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Affiliation(s)
- Carolyn Seeganna
- US Department of Veterans Affairs, Mat-Su Community Based Outpatient Clinic, 865 North Seward Meridian Parkway, Wasilla, AK 99654, USA.
| | - Deborah Antai-Otong
- Department of Veterans Affairs, Veterans Integrated Service Networks-(VISN-17), 2301 E. Lamar Boulevard, Arlington, TX 76006, USA
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Moyo P, Huang TY, Simoni-Wastila L, Harrington D. Exploratory and Confirmatory Factor Analyses of Delirium Symptoms in a Sample of Nursing Home Residents. J Appl Gerontol 2016; 37:228-255. [PMID: 27006431 DOI: 10.1177/0733464816633859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study examined the latent constructs of delirium symptoms among nursing home (NH) residents in the United States. METHOD Cross-sectional NH assessment data (Minimum Data Set 2.0) from the 2009 Medicare Current Beneficiary Survey were used. Data from two independent, randomly selected subsamples of residents ≥65 years were analyzed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). RESULTS There were 367 and 366 individuals in the EFA and CFA, respectively. Assessment of multiple model fit statistics in CFA indicated that the two-factor structure provided better fit for the data than a one-factor solution. The two factors represented cognitive and behavioral latent constructs as suggested by the related literature. A correlation of .72 between these constructs suggested moderate discriminant validity. CONCLUSION This finding emphasizes the importance of health care providers to be attentive to both cognitive and behavioral symptoms when diagnosing, treating, and managing delirium.
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Delaney M, Pepin J, Somes J. Emergency Department Delirium Screening Improves Care and Reduces Revisits for the Older Adult Patient. J Emerg Nurs 2015; 41:521-4. [PMID: 26409656 DOI: 10.1016/j.jen.2015.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rosen T, Connors S, Clark S, Halpern A, Stern ME, DeWald J, Lachs MS, Flomenbaum N. Assessment and Management of Delirium in Older Adults in the Emergency Department: Literature Review to Inform Development of a Novel Clinical Protocol. Adv Emerg Nurs J 2015; 37:183-96; quiz E3. [PMID: 26218485 PMCID: PMC4633298 DOI: 10.1097/tme.0000000000000066] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Delirium occurs frequently in older patients in the emergency department (ED), is underrecognized, and has potentially serious consequences. Despite its seriousness, delirium is frequently missed by emergency providers, and patients with unrecognized delirium are often discharged from the ED. Even when it is appropriately recognized, managing delirium in older adults poses a significant challenge for ED providers. Geriatric delirium is typically caused by the interaction of multiple factors, including several that are commonly missed: pain, urinary retention, constipation, dehydration, and polypharmacy. Appropriate management includes nonpharmacological management with medication intervention reserved for emergencies. We have developed a new, comprehensive, evidence-based protocol for diagnosis/recognition, management, and disposition of geriatric delirium patients in the ED with a focus on identifying and treating commonly missed contributing causes.
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Affiliation(s)
- Tony Rosen
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Scott Connors
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Sunday Clark
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Alexis Halpern
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Michael E. Stern
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Jennifer DeWald
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Mark S. Lachs
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Neal Flomenbaum
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
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Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol 2015; 14:823-832. [PMID: 26139023 DOI: 10.1016/s1474-4422(15)00101-5] [Citation(s) in RCA: 338] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/27/2015] [Accepted: 05/18/2015] [Indexed: 02/02/2023]
Abstract
Delirium and dementia are two of the most common causes of cognitive impairment in older populations, yet their interrelation remains poorly understood. Previous studies have shown that dementia is the leading risk factor for delirium and that delirium is an independent risk factor for subsequent development of dementia. However, a major area of controversy is whether delirium is simply a marker of vulnerability to dementia, whether the effect of delirium is solely related to its precipitating factors, or whether delirium itself can cause permanent neuronal damage and lead to dementia. Ultimately, all of these hypotheses are likely to be true. Emerging evidence from epidemiological, clinicopathological, neuroimaging, biomarker, and experimental studies lends support to a strong relation between delirium and dementia, and to both shared and distinct pathological mechanisms. New preventive and therapeutic approaches that target delirium might offer a sought-after opportunity for early intervention, preservation of cognitive reserve, and prevention of irreversible cognitive decline in ageing.
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Affiliation(s)
- Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, UCL, London, UK
| | - Matthew E Growdon
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
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McClelland M, Sorrell JM. Enhancing care of older adults in the emergency department: old problems and new solutions. J Psychosoc Nurs Ment Health Serv 2015; 53:18-21. [PMID: 25643374 DOI: 10.3928/02793695-20150127-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The dramatic increase in the number of older adults in our society is creating greater demand for age-appropriate health care services. Because older adults use proportionally more emergency services than any other age group, it is important to address problems and find solutions to emergency care for this vulnerable population. Older adults often need specialized care to meet complex physical and psychological needs in an emergency department (ED). A new focus on establishing geriatric EDs holds promise for reducing barriers to ED access and decreasing suboptimal outcomes. Recently published geriatric ED guidelines provide health care professionals with recommendations to systematically improve emergency care for older adults.
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Gignon M, Verheye JC, Manaouil C, Ammirati C, Turban-Castel E, Ganry O. Fighting violence against health workers: a way to improve quality of care? Workplace Health Saf 2014; 62:220-2. [PMID: 24971816 DOI: 10.1177/216507991406200601] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 04/29/2014] [Indexed: 11/15/2022]
Abstract
Violence against health care workers impairs the quality of care. In one university medical center in France, 46% of the health care workers were physically assaulted at some point in the previous 12 months and 79% were verbally insulted. This article describes a participatory approach that was used to ensure health care workers take an active role in designing and implementing anti-violence measures. In each unit, a working group of health care professionals and managers developed an action plan for reducing violence-generating practices. This proactive approach is a powerful tool for motivating health care professionals to improve quality of care.
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Gignon M, Verheye JC, Manaouil C, Ammirati C, Turban-Castel E, Ganry O. Fighting Violence Against Health Workers: A Way to Improve Quality of Care? Workplace Health Saf 2014. [DOI: 10.3928/21650799-20140514-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Liferidge AT, Dark JEP. Fever and neurologic conditions. Emerg Med Clin North Am 2013; 31:987-1017. [PMID: 24176475 DOI: 10.1016/j.emc.2013.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neurologic conditions are categorized as either those that cause a change in mental status or those that create a focal finding on physical examination. Neurologic abnormality associated with fever can be caused by a primary neurologic condition or one that does not originate in the central nervous system. Optimal management of such conditions requires high clinical suspicion and a broad differential diagnosis, which facilitates rapid recognition and effective treatment. A thorough history and physical examination are key determinants in accurately diagnosing neurologic conditions associated with fever, often requiring acquisition of collateral information from persons other than the patient.
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Affiliation(s)
- Aisha T Liferidge
- Department of Emergency Medicine, George Washington University School of Medicine, 2120 L Street Northwest, Suite 450, Washington, DC 20037, USA.
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