Delirium In Emergency Department Research Articles

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

Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review.

Older adults are at high risk of developing delirium in the emergency department (ED);however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs)translate evidence into recommendations to improve practice. To critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients. We conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II;and Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX)instruments. A threshold of 70% or greater in the AGREE-IIRigour of Development domain was used to define high-quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis. AGREE-IIRigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE-REXoverall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED-specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high-risk populations, and those at risk should be screened for delirium. The '4A's Test' was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short-term use of antipsychotic medication in urgent situations. This is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED. This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.

Hyperactive delirium in the emergency department: the continued case of B.M.

The prevalence of delirium in emergency department (ED) ranges from 7 to 13%; however, delirium is often underdiagnosed in that setting. This report describes two different approaches to a hypothetical case report of an old man admitted to the ED after an injurious fall, and whose clinical conditions rapidly worsen due to hyperactive delirium.

Effect of physical and occupational therapy on delirium duration in older emergency department patients who are hospitalized.

Delirium in older emergency department (ED) adults is associated with poorer long-term physical function and cognition. We sought to evaluate if the time to and intensity of physical and/or occupational therapy (PT/OT) are associated with the duration of ED delirium into hospitalization (ED delirium duration). This is a secondary analysis of a prospective cohort study conducted from March 2012 to November 2014 at an urban, academic, tertiary care hospital. Patients aged≥65 years presenting to the ED and who received PT/OT during their hospitalization were included. Days from enrollment to the first PT/OT session and PT/OT duration relative to hospital length of stay (PT/OT intensity) were abstracted from the medical record. ED delirium duration was defined as the duration of delirium detected in the ED using the Brief Confusion Assessment Method. Data were analyzed using a proportional odds logistic regression adjusted for multiple variables. Adjusted odds ratios (ORs) were calculated with 95% confidence intervals (95%CI). The median log PT/OT intensity was 0.5% (interquartile range [IQR]: 0.3%, 0.9%) and was associated with shorter delirium duration (adjusted OR,0.39; 95% CI, 0.21-0.73). The median time to the first PT/OT session was 2 days (IQR: 1, 3 days) and was not associated with delirium duration (adjusted OR, 1.02; 95% CI, 0.82-1.27). In older hospitalized adults, higher PT/OT intensity may be a useful intervention to shorten delirium duration. Time to first PT/OT session was not associated with delirium duration but was initiated a full 2 days after the ED presentation.

Association of delirium with increased short-term mortality among older emergency department patients: A cohort study

Study objectiveTo evaluate the association between delirium and subsequent short-term mortality in geriatric patients presenting to the emergency department (ED). MethodsThis was an observational cohort study of adults age ≥75 years who presented to an academic ED and were screened for delirium during their ED visit. The Delirium Triage Screen followed by the Brief Confusion Assessment Method were used to ascertain the presence of delirium. In-hospital, 7-day, and 30-day mortality were compared between patients with and without ED delirium. Odds ratios with 95% confidence intervals (CIs) were calculated through logistic regression after adjusting for confounders including age, sex, history of dementia, ED disposition, and acuity. ResultsA total of 967 ED visits were included for analysis among which delirium was detected in 107 (11.1%). The median age of the cohort was 83 years (IQR 79, 88), 526 (54.4%) were female, 285 (29.5%) had documented dementia, and 171 (17.7%) had a high acuity Emergency Severity Index triage level 1 or 2. During the hospitalization, 5/107 (4.7%) of those with delirium and 4/860 (0.5%) of those without delirium died. Within 7 days of ED departure, 6/107 (5.6%) of those with delirium and 6/860 (0.7%) of those without delirium died (unadjusted OR 8.46, 95% CI 2.68–26.71). Within 30 days, 18/107 (16.8%) of those with delirium and 37/860 (4.3%) of those without delirium died (unadjusted OR 4.50, 95% CI 2.46–8.23). ED delirium remained associated with higher 7-day (adjusted OR 5.23, 95% CI 1.44–19.05, p = 0.008) and 30-day mortality (adjusted OR 2.82, 95% CI 1.45–5.46, p = 0.002). ConclusionDelirium is an important prognostic factor that ED clinicians and nurses must be aware of to optimize delirium prevention, management, disposition, and communication with patients and families.

A Qualitative Study of Emergency Department Delirium Prevention Initiatives.

Delirium is a serious but preventable syndrome of acute brain failure. It affects 15% of patients presenting to emergency care and up to half of hospitalized patients. The emergency department (ED) often represents the entry point for hospital care for older adults and as such is an important site for delirium prevention. We sought to characterize delirium prevention initiatives in EDs in the United States and Canada. We conducted qualitative interviews with 16 ED administrators representing 14 EDs with delirium prevention initiatives. We used a combined deductive-inductive approach to code responses about involved staff, target patient population, and delirium prevention activities. ED delirium prevention initiatives were largely driven by bedside nurses and occurred on an ad hoc basis, rather than systematically. Due to resource limitations, three EDs targeted older adults with high-risk conditions for delirium, rather than all patients age 65 and over. The most common delirium prevention interventions were offering assistive sensory devices (hearing amplifiers, reading glasses), having a toileting protocol, and offering patients food and drink. As minimal evidence exists about effective ED delirium prevention practices, low-cost and low-risk activities outlined by study participants are reasonable to use to improve patient experience and staff satisfaction.

Delirium during Covid-19 pandemic: were we over-reporting an overlooked syndrome?

Objective: To compare incidence of delirium in Emergency Department in elderly patients admitted for SARS-CoV-2 infection and sepsis for other etiologies. Methods: This observational study analyzed elderly patients (>65 years) from two cohort studies that recruited patients in an urban and academic Emergency Department. The first cohort studied septic patients before Covid-19 pandemic and was conducted between September 30, 2019, and March 17, 2020. The second cohort studied Covid-19 patients between April 8, 2021, and May 28, 2021. Our primary outcome was the incidence of delirium at admission in Emergency Department, which we defined using the Confusion Assessment Method. Results: We included 141 patients in our final analysis, with a median age of 72 (interquartile range: 68 to 79) years and a predominance of the male sex (58%). We identified delirium at admission in 31 participants (21%) in septic non-Covid group and 11 (24%) in Covid-19 group (p=0.70). Conclusion: This present study does not support that elderly patients with Covid-19 have higher risk for delirium at admission in Emergency Department when compared to patients hospitalized with sepsis for other etiologies. Although sepsis for Covid-19 have had more than 28% mortality, Covid-19 was not associated with higher mortality in elderly than sepsis for other etiologies. The study protocol was approved by the local Research Ethics Committee (CAPPESq, protocol number 30417520.0.0000.0068).

170 DELIRIUM SCREENING CONCURRENT AUDIT UTILISING THE 4AT ASSESSMENT TOOL IN THE EMERGENCY DEPARTMENT

Abstract Background Delirium is an acute onset of clinical serious conditions associated with poor outcomes, seen in older patients in Emergency Department (ED). Despite its seriousness, delirium can be missed by 57-83% and 25% with unrecognised delirium discharged from ED. The audit aim is to improve delirium screening for older people in ED using the 4AT assessment tool. Methods Criteria included patients over 75 and under 75 with complaints of new confusion, history of dementia and cognitive impairment presented to ED over 20 day period in January 2022. Exclusion criteria included patients with alcohol and drug withdrawal, trauma and critically ill. Data collection through concurrent chart review using self-designed tool performed by two auditors. 30 patient charts gathered through consecutive sampling accessed in IMS Maxims (electronic patient record system) for 3 random days approved by Assistant Director of Nursing and data collected with respect and in accordance with General Data Protection Regulation. Algorithm of Early Identification and Management of Delirium in ED/AMAU (HSE 2021) and ED Delirium Screening Bundle (University Limerick Hospital Group 2021) were standards used. Results 70% were screened using the 4AT tool and 4 cases identified with delirium. 9 patients were not screened implying 30% variance against the national standard. 100% expected level of compliance but 50% failed compliance standard. Results discussed at staff meeting, daily huddles and poster presentation in ED information board. Conclusion The audit shows satisfactory results on the awareness and importance of delirium screening and moderately poor compliance on documentation. Strategies to improve practice and maintain sustainability include staff re-education, increase awareness in triage by adding blue-colored sticker “Screen me with 4AT” and rewarding staff with Delirium Champion of the Day to promote use.

REcognizing DElirium in geriatric Emergency Medicine: The REDEEM risk stratification score.

The objective was to derive a risk score that uses variables available early during the emergency department (ED) encounter to identify high-risk geriatric patients who may benefit from delirium screening. This was an observational study of older adults age≥75years who presented to an academic ED and who were screened for delirium during their ED visit. Variable selection from candidate predictors was performed through a LASSO-penalized logistic regression. A risk score was derived from the final prediction model, and predictive accuracy characteristics were calculated with 95% confidence intervals (CIs). From the 967 eligible ED visits, delirium was detected in 107 (11.1%). The area under the curve for the REcognizing DElirium in Emergency Medicine (REDEEM) score was 0.901 (95% CI=0.864-0.938). The REEDEM risk score included 10 different variables (seven based on triage information and three obtained during early history taking) with a score ranging from -3 to 66. Using an optimal cutoff of ≥11, we found a sensitivity of 84.1% (90 of 107 ED delirium patients, 95% CI=75.5%-90.2%) and a specificity of 86.6% (745 of 860 non-ED delirium patients, 95% CI=84.1%-88.8%). A lower cutoff of ≥5 was found to minimize false negatives with an improved sensitivity at 91.6% (98 of 107 ED delirium patients, 95% CI=84.2%-95.8%). A risk stratification score was derived with the potential to augment delirium recognition in geriatric ED patients. This has the potential to assist on delirium-targeted screening of high-risk patients in the ED. Validation of REDEEM, however, is needed prior to implementation.

60 EVALUATING THE TIME THAT PATIENT’S WITH DEMENTIA/DELIRIUM SPEND IN THE EMERGENCY DEPARTMENT PRIOR TO TRANSFER TO A WARD

Abstract Background Patients with dementia and delirium are often waiting long times in the emergency department (ED) prior to being transferred to a ward bed during an acute hospital admission. This may be associated with increased morbidity and mortality. Best practice is for rapid triage to an appropriate bed via a delirium/dementia pathway. Our aim was to document the patient experience time (PET) for older patients with a diagnosis of dementia or delirium in ED in an urban tertiary-referral hospital. Methods Over a two-week period 07/12/20–21/12/20, we identified all patients admitted under a general medical specialty through ED, aged ≥65 years, with a diagnosis of dementia or delirium on the admission sheet. Patients admitted with a stroke or hip fracture were excluded. ED PET was recorded, as well as final ward destination. Results We included 29 patients in the study—median age was 82 years (range 71–92); 19 (66%) were female. Delirium was the presenting complaint in 79.31% (n = 23) of cases. Sixteen (55%) patients presented between 8 am-5 pm. The average time spent from triage to ED doctor review was 1 hour 48 minutes; from ED doctor review to medical referral −1 hour 27 minutes; from medical referral to decision for medical admission—2 hours 28 minutes; from decision for medical admission to ward admission- 5 hours. Overall, the average ED PET for these patients was 10 hours 42 minutes. Five patients (17%) were admitted directly to a Specialist Geriatric Ward (SGW). Twenty patients (69%) did not reach a SGW during the study period. Conclusion Patients with dementia and delirium may spend prolonged periods of time in the ED putting them at risk for multiple complications. We hope that by introduction of a dementia/delirium combined pathway and care bundle that we can reduce PET for these vulnerable patients.

345 Delirium Prevention and Treatment in the Emergency Department: A Systematic Review

Delirium is a dangerous syndrome of acute brain dysfunction and is common in the emergency department (ED), especially among the older adults. Most systematic reviews of interventions for delirium prevention and treatment, however, have focused on inpatient settings. The objective of this systematic review was to synthesize the existing evidence on pharmacologic and non-pharmacologic interventions to prevent incident delirium or decrease the severity or shorten the duration of prevalent delirium in older adults presenting to the ED. Inclusion criteria included any study of an intervention to prevent or treat delirium in older ED and inpatient settings. Searches using subject headings and keywords were conducted from database inception through June 2020 in Ovid MEDLINE, EMBASE, PsychINFO, CINAHL, ProQuest Dissertations and Theses Global, and Cochrane CENTRAL, as well as grey literature. Database searches were not limited by date or language. Two reviewers identified studies describing any interventions for delirium prevention and/or treatment in the ED. Disagreements were settled by a third reviewer. The risk of bias was evaluated by the Cochrane risk of bias tool or Newcastle-Ottawa (NOS) scale. We described the overall findings from selected articles for this systematic review instead of a planned meta-analysis. Our search strategy yielded 6, 838 studies of which 12 met study inclusion criteria. Our observed kappa was 0.79 (95% CI:0.56 - 1.0). Half of these studies were available in abstract only. Of included studies, two were randomized controlled trials (RCT): A total of seven studies used mixed study settings including ED. Two RCTs evaluated pharmacologic interventions for delirium prevention, three non-RCTs employed a multifactorial delirium prevention program, three non-RCTs evaluated regional anesthesia for hip fractures, two studies evaluated the implementation of delirium screening, and one study evaluated the use of Foley catheter, medication exposure, and risk of delirium (Table). Of the 12 studies included only four studies demonstrated a significant impact on a delirium incidence and duration – one RCT of melatonin, two non-RCT studies on multifactorial program, and one case control study on the use of Foley catheter. Our review demonstrated that research into delirium prevention and treatment in the ED setting is still in its infancy. Older adults with hip fracture appear to be a target population; however, interventions studied to date have not demonstrated a significant impact. Further research is needed into effective delirium prevention and treatment interventions in the ED.

Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis

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.

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

Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

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

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.

Plasma biomarkers of inflammation, coagulation, and brain injury as predictors of delirium duration in older hospitalized patients.

BackgroundDelirium's pathophysiology is poorly understood. We sought to determine if plasma biomarkers of inflammation, coagulation, endothelial activation, and blood brain barrier (BBB) injury were associated with emergency department (ED) delirium duration.MethodsWe enrolled hospitalized patients who were 65 years or older from the ED. Plasma biomarkers of inflammation (interleukin-6 [IL-6], IL-8, soluble tumor necrosis factor receptor I [sTNFRI]), coagulation (Protein C), endothelial activation (plasminogen activating inhibitor-1 [PAI-1]), and BBB injury (S100B) at were measured using blood obtained at enrollment. The dependent variable was ED delirium duration which was determined by the Brief Confusion Assessment Method assessed in the ED and hospitalization. Proportional odds logistic regression analyses were performed adjusted for relevant confounders and allowing for interaction by baseline dementia status.ResultsA total of 156 patients were enrolled. IL-6 (POR = 1.59, 95%CI: 1.09–2.32) and PAI-1 (POR = 2.96, 95%CI: 1.48 to 6.85) were independently associated with more prominent ED delirium duration in subjects without dementia only. No significant associations between IL-8, Protein C, sTNRFI, and S100B and ED delirium duration were observed.ConclusionsPlasma Biomarkers of systemic inflammation and endothelial activation are associated with ED delirium duration in older ED patients without dementia.

Supratherapeutic Psychotropic Drug Levels in the Emergency Department and Their Association with Delirium Duration: A Preliminary Study.

Polypharmacy is associated with delirium, but the mechanisms for this connection are unclear. Our goal was to determine the frequency of supratherapeutic psychotropic drug levels (SPDLs) in older hospitalized patients and if it is associated with the duration of emergency department (ED) delirium. Secondary analysis of a prospective cohort study. Tertiary care academic medical center. ED patients 65 years or older who were admitted to the hospital. Delirium was assessed in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. Drug concentrations were determined in serum samples collected at enrollment via a novel platform based on liquid chromatography-tandem mass spectrometry capable of identifying and quantitating 78 clinically approved medications including opioids, benzodiazepines, antidepressants, antipsychotics, and amphetamines. Patients with serum psychotropic drug concentrations above established reference ranges were considered supratherapeutic and have a SPDL. We performed proportional odds logistic regression to determine if SPDLs were associated with ED delirium duration adjusted for confounders. Medical record review was performed to determine if the doses of medications associated with SPDLs were adjusted at hospital discharge. A total of 158 patients were enrolled; of these, 66 were delirious in the ED. SPDLs were present in 11 (17%) of the delirious and 4 (4%) of the non-delirious ED patients. SPDLs were significantly associated with longer ED delirium duration (adjusted proportional odds ratio = 6.0; 95% confidence interval = 2.1-17.3) after adjusting for confounders. Of the 15 medications associated with SPDLs, 9 (60%) were prescribed at the same or higher doses at the time of hospital discharge. SPDLs significantly increased the odds of prolonged ED delirium episodes. Approximately half of the medications associated with SPDLs were continued after hospital discharge at the same or higher doses. J Am Geriatr Soc 67:2387-2392, 2019.

Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department.

Delirium is very frequent in older patients presenting to the emergency department (ED), but is often undetected. The purpose of this study was to evaluate the performance of the French version of the 4 A’s Test (4AT-F) for the detection of delirium and cognitive impairment in older patients. The study was conducted in four Canadian ED. Participants (n= 320) were independent or semi-independent patients (able to perform ≥5 activities of daily living) aged 65 and older and had an 8-hour exposure to the ED environment. The Telephone Interview for Cognitive Status (TICS-m), the Confusion Assessment Method (CAM) as well as the 4AT-F were administered to patients at the initial interview. The CAM and 4AT-F were then administered twice a day during the patients’ ED or hospital stay. The 4AT-F’s sensitivity and specificity were compared to those of the CAM (for delirium), and to that of the TICS (for cognitive impairment). Our results suggest that the 4AT-F has a sensitivity of 84% (95% CI: [76, 93]) and a specificity of 74% (95% CI: [70, 78]) for delirium, as well as a sensitivity of 49% (95% CI: [34, 64]) and a specificity of 87% (95% CI: [82, 92]) for cognitive impairment. The 4AT-F is a fast and reliable screening tool for delirium and cognitive impairment in ED. Due to its quick administration time, it allows a systematic screening of patients at risk of delirium, without significantly increasing the workload of the ED staff.

Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees.

Backgroundscreening for cognitive impairment in Emergency Department (ED) requires short, reliable tools.Objectiveto validate the 4AT and 6-Item Cognitive Impairment Test (6-CIT) for ED dementia and delirium screening.Designdiagnostic accuracy study.Setting/subjectsattendees aged ≥70 years in a tertiary care hospital’s ED.Methodstrained researchers assessed participants using the Standardised Mini Mental State Examination, Delirium Rating Scale-Revised 98 and Informant Questionnaire on Cognitive Decline in the Elderly, informing ultimate expert diagnosis using Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for dementia and delirium (reference standards). Another researcher blindly screened each participant, within 3 h, using index tests 4AT and 6-CIT.Resultof 419 participants (median age 77 years), 15.2% had delirium and 21.5% had dementia. For delirium detection, 4AT had positive predictive value (PPV) 0.68 (95% confidence intervals: 0.58–0.79) and negative predictive value (NPV) 0.99 (0.97–1.00). At a pre-specified 9/10 cut-off (9 is normal), 6-CIT had PPV 0.35 (0.27–0.44) and NPV 0.98 (0.95–0.99).Importantly, 52% of participants had no family present. A novel algorithm for scoring 4AT item 4 where collateral history is unavailable (score 4 if items 2–3 score ≥1; score 0 if items 1–3 score is 0) proved reliable; PPV 0.65 (0.54–0.76) and NPV 0.99 (0.97–1.00). For dementia detection, 4AT had PPV 0.39 (0.32–0.46) and NPV 0.94 (0.89–0.96); 6-CIT had PPV 0.46 (0.37–0.55) and NPV 0.94 (0.90–0.97).Conclusion6-CIT and 4AT accurately exclude delirium and dementia in older ED attendees. 6-CIT does not require collateral history but has lower PPV for delirium.

Rates of Delirium Diagnosis Do Not Improve with Emergency Risk Screening: Results of the Emergency Department Delirium Initiative Trial

To determine whether a bundled risk screening and warning or action card system improves formal delirium diagnosis and person-centered outcomes in hospitalized older adults. Prospective trial with sequential introduction of screening and interventional processes. Two tertiary referral hospitals in Australia. Individuals aged 65 and older presenting to the emergency department (ED) and not requiring immediate resuscitation (N = 3,905). Formal ED delirium screening algorithm and use of a risk warning card with a recommended series of actions for the prevention and management of delirium during the subsequent admission MEASUREMENTS: Delirium diagnosis at hospital discharge, proportion discharged to new assisted living arrangements, in-hospital complications (use of sedation, falls, aspiration pneumonia, death), hospital length of stay. Participants with a positive risk screen were significantly more likely (relative risk = 6.0, 95% confidence interval = 4.9-7.3) to develop delirium, and the proportion of at-risk participants with a positive screen was constant across three study phases. Delirium detection rate in participants undergoing the final intervention (Phase 3) was 12.1% (a 2% absolute and 17% relative increase from the baseline rate) but this was not statistically significant (P = .29), and a similar relative increase was seen over time in participants not receiving the intervention CONCLUSION: A risk screening and warning or action card intervention in the ED did not significantly improve rates of delirium detection or other important outcomes.

MP30: Validation of the 4AT questionnaire in the emergency department

Introduction: Delirium is a very prevalent cognitive impairment in elderly inpatients, but it often goes undetected, especially in the emergency department (ED). The tools currently available to screen or diagnose patients at risk of delirium are very time-consuming and are impossible to systematically perform in the ED environment. For this reason, short tests are necessary to screen for delirium in this fast-paced setting. The objective of this study was to evaluate the performance of the French version of the Rapid Assessment Test for Delirium (4AT) for the detection of delirium and cognitive impairment in older patients. The 4AT takes less than 2 minutes to administer, which is a great advantage on the others tests. Methods: The study was conducted in four emergency departments across the province of Québec. Participants were independent or semi-independent patients aged 65 and older, admitted to hospital and who had an 8-hour exposure to the ED. The Telephone Interview for Cognitive Status (TICS) was administered at the initial interview and the Confusion Assessment Method (CAM) as well as the 4AT were administered to patients twice a day during their ED or hospital stay. The 4AT’s sensitivity and specificity were compared to that of the CAM (for delirium), and to that of the TICS (for cognitive impairment). Results: 324 patients were included in the study, with a mean age of 76 years old. Among the recruited participants, 21 (6.5%) had a prevalent delirium according to the CAM, and 30 (10.2%) had an incident delirium. According to the 4AT, 48 patients (14.9%) had cognitive impairment and 81 (25.2%) had a prevalent delirium. According to the TICS, 87 patients (29.2%) have cognitive impairment. The 4AT has a sensitivity of 68,4% (IC 95% : 47,5-89,3) and a specificity of 73.2% (IC 95% : 67,8-78,7) for delirium, and a sensitivity of 50% (IC 95% : 35,9-64,1) and a specificity of 87,0% (IC 95% : 81,2-92) for cognitive impairment. Conclusion: The French Version of the 4AT could be a fast and reliable screening tool for delirium and cognitive impairment in ED. Further research is necessary for its validation in the ED.