Special Circumstances: Agitation with Dementia in Emergency Departments

Abstract

AbstractBackgroundOlder persons presenting to the emergency department (ED) with agitation have a high prevalence of cognitive impairment which may not have been previously diagnosed.. Agitation in the ED may have many causes, one of the most prominent of which is delirium which occurs in 8–10% of older persons in the ED, and is often not diagnosed till hospital admission . The recently developed IPA algorithm for diagnosis and management of agitation in dementia is applicable to the ED environment particularly as it applies to delirium.MethodThis abstract describes the application of the IPA algorithm to the ED settingResultsOne of the major challenges of agitation management in the ED is taking a history, particularly for patients coming from a LTC environment. LTC staff can readily describe the index episode of agitation, but what is often missing is understanding the timeframe of agitation, including provoking and mitigating factors and any history of prior episodes and their causes. This makes it difficult to know if cognitive impairment is chronic or acute, the hallmark of delirium. A systematic approach to diagnosis and management is required. EDs are making increased use of well‐validated delirium screening assessments such as the Confusion Assessment Method (CAM). Other useful tools for management of delirium in the ED include ADEPT and the Delirium Triage Screen (DTS).Nonpharmacologic strategies have an important role in treatment of agitated patients in the ED. Interventions to prevent or reduce delirium in acute care environments are becoming increasingly effective: a recent Cochrane review supported the effectiveness of interventions including re‐orientation (including use of familiar objects), cognitive stimulation, sleep hygiene, attention to nutrition and hydration, oxygenation, medication review, assessment of mood, and bowel and bladder care. EDs increasingly incorporate these interventions into routine care including the use of delirium‐focused order sets and deployment of geriatric management teams which have been shown to reduce 30‐day ED readmission rates.ConclusionFurther studies should integrate diagnostic workflows and algorithms for behavioral interventions developed for both agitation and delirium management in the ED.