258 Detection of Delirium among Older Adults in the Emergency Department Through the Utilization of 4AT

Abstract

Older adults make more than 20 million emergency department (ED) visits annually, accounting for over 15% of all ED visits. Among older adults, change in mental status or delirium is the frequent cause for presentation to the ED. Delirium accounts for 11-42% of hospitalizations contributing $152 billion to health care expenditures annually in the US. Overall detection of delirium in ED is poor, with ED providers missing delirium in up to 75% of cases. The goal of this study was to assess the detection of delirium among older adults through the utilization of 4AT in a high flow, high acuity ED. We conducted a single-center, retrospective chart review in a busy academic ED with 67,000 total annual visits, and 24% geriatric (age ≥ 65 y) visits, from 9/24/2019 to 5/24/2020. Prior to the study period, delirium assessment tool- 4AT was built into EMR and appropriate workflow was designed. 4AT was performed at the time of triage on patients meeting following criteria: 1) Above age 65 years old with presenting complaint of altered mental status or 2) Above age 80 years old with any clinical presentation. Delirium was defined as: Positive 4AT score regardless of chief complaint to ED. A positive 4AT score was defined as 4 or greater. A total of 2,680 eligible patients were assessed during the defined study period. 1, 596 patients underwent 4AT and in 1,084 patient 4AT was not performed. A positive 4 AT was found in 300 individuals, regardless of presenting condition. Among individuals presenting with altered mental status (according to the 4AT screening question), a positive 4AT was found in 176 individuals. A positive 4AT was found in 124 individuals not originally presenting with complaint of altered mental status (according to the 4AT screening question). Overall delirium detection rate via 4AT was found to be 18.96%.Utilization rate of 4AT for eligible patients was around 60%. Previous studies have suggested use of 4AT for rapid delirium assessment in an ED because of its ability to be performed quickly- approximately 2 minutes- and is the only scale affording high sensitivity and specificity in older adults with and without dementia. Although completed in Irish and Canadian studies, validation of the use of 4AT in an US ED environment has not yet been completed. In our study, utilizing 4AT we find a delirium detection of 18.96 %( 300) which is consistent with previous studies of rates of delirium among older adults in an ED setting. We also discovered that 7.7%(124) individuals were found to have a positive 4AT despite not originally presenting with altered mental status, indicating cases of delirium that may have been missed if a delirium evaluation (4AT)had not been completed. This study also highlights challenges in implementing delirium screening/assessment in fast-paced ED environment.