Delirium In Older Emergency Department Patients Research Articles

Understanding why delirium is often missed in older emergency department patients: a qualitative descriptive study.

Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients. We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration. We interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or "functional" understanding of delirium that includes its consequences. Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.

Delirium in Older Patients With COVID-19 Presenting to the Emergency Department

Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described. To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes. This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020. COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases). The primary outcome was delirium as identified from the medical record according to a validated record review approach. A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% CI, 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55). In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation.

Relationship Between Pain, Opioid Treatment, and Delirium in Older Emergency Department Patients.

Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) increase the risk of delirium in older patients. Poorly controlled pain and paradoxically opioid pain treatment have also been identified as triggers for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in older ED patients. A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged≥65years old, waiting for hospital admission between Marchand July2015, who were nondelirious upon ED arrival, who were independent or semi-independent in their daily living activities, and who had an ED stay of at least 8hours were included. Delirium assessments were conducted twice a day during the patient's entire ED stay and their first 24hours on the hospital ward using the Confusion Assessment Method. Pain intensity was evaluated using a visual analog scale (VAS= 0-100) during the initial interview, and all opioid treatments were documented. A total of 338 patients were included; 51% were female, and mean(±SD) age was 77(±8)years. Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean (±SD) delay of 47(±19)hours after ED admission. Among patients with pain intensity≥65 from VAS (0-100), 26% experienced delirium compared to 11% for patients with pain<65 (p<0.01), and no significant association was found between opioid consumption and delirium (p=0.31). Logistic regression controlling for confounding factors showed that patients with pain intensity≥65 are 3.3 (95% confidence interval= 1.4 to 7.9) times more likely to develop delirium than patients who had painintensity of <65. Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to a decrease in delirium episodes.

Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers.

delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients. to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients. a prospective observational multicenter cohort study. four Quebec EDs. independent or semi-independent older patients (age ≥ 65years) with an ED stay of at least 8 hours that required hospitalisation. eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated. we enrolled 301 patients (mean age 77years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%). serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool.

Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q1=72.15; Q3=86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.

Performance of the modified Richmond Agitation Sedation Scale in identifying delirium in older ED patients

BackgroundDelirium in older emergency department (ED) patients is associated with severe negative patient outcomes and its detection is challenging for ED clinicians. ED clinicians need easy tools for delirium detection. We aimed to test the performance criteria of the modified Richmond Agitation Sedation Scale (mRASS) in identifying delirium in older ED patients. MethodsThe mRASS was applied to a sample of consecutive ED patients aged 65 or older by specially trained nurses during an 11-day period in November 2015. Reference standard delirium diagnosis was based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria, and was established by geriatricians. Performance criteria were computed. Analyses were repeated in the subsamples of patients with and without dementia. ResultsOf 285 patients, 20 (7.0%) had delirium and 41 (14.4%) had dementia. The sensitivity of an mRASS other than 0 to detect delirium was 0.70 (95% confidence interval, CI, 0.48; 0.85), specificity 0.93 (95% CI 0.90; 0.96), positive likelihood ratio 10.31 (95% CI 6.06; 17.51), negative likelihood ratio 0.32 (95% CI 0.16; 0.63). In the sub-sample of patients with dementia, sensitivity was 0.55 (95% CI 0.28; 0.79), specificity 0.83 (95% CI 0.66; 0.93), positive likelihood ratio 3.27 (95% CI 1.25; 8.59), negative likelihood ratio 0.55 (95% CI 0.28; 1.06). ConclusionThe sensitivity of the mRASS to detect delirium in older ED patients was low, especially in patients with dementia. Therefore its usefulness as a stand-alone screening tool is limited.

The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients.

Delirium is frequently missed in older emergency department (ED) patients. Brief (<2minutes) delirium assessments have been validated for the ED, but some ED health care providers may consider them to be cumbersome. The Richmond Agitation Sedation Scale (RASS) is an observational scale that quantifies level of consciousness and takes less than 10seconds to perform. The authors sought to explore the diagnostic accuracy of the RASS for delirium in older ED patients. This was a preplanned analysis of a prospective observational study designed to validate brief delirium assessments for the ED. The study was conducted at an academic ED and enrolled patients who were 65years or older. Patients who were non-English-speaking, deaf, blind, comatose or had end-stage dementia were excluded. A research assistant (RA) and a physician performed the RASS at the time of enrollment. Within 3hours, a consultation-liaison psychiatrist performed his or her comprehensive reference standard assessment for delirium using Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR) criteria. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (CIs) were calculated. Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the consult-liaison psychiatrist reference rater. When performed by the RA, a RASS other than 0 (RASS > 0 or < 0) was 84.0% sensitive (95% CI=73.8% to 94.2%) and 87.6% specific (95% CI=84.2% to 91.1%) for delirium. When performed by physician, a RASS other than 0 was 82.0% sensitive (95% CI=71.4% to 92.6%) and 85.1% specific (95% CI=81.4% to 88.8%) for delirium. Using a RASS > +1 or < -1 as the cutoff, the specificity improved to approximately 99% for both raters at the expense of sensitivity; the sensitivities were 22.0% (95% CI=10.5% to 33.5%) and 16.0% (95% CI=5.8% to 25.2%) in the RAs and physician raters, respectively. The positive likelihood ratio was 19.6 (95% CI=6.5 to 59.1) when performed by the RA and 57.0 (95% CI=7.3 to 445.9) when performed by the physician, indicating that a RASS > +1 or < -1 strongly increased the likelihood of delirium. The weighted kappa was 0.63, indicating moderate interobserver reliability. In older ED patients, a RASS other than 0 has very good sensitivity and specificity for delirium as diagnosed by a psychiatrist. A RASS > +1 or < -1 is nearly diagnostic for delirium, given the very high positive likelihood ratio.

The relationship between a chief complaint of "altered mental status" and delirium in older emergency department patients.

Altered mental status is a common chief complaint among older emergency department (ED) patients. Patients with this chief complaint are likely delirious, but to the authors' knowledge, this relationship has not been well characterized. Additionally, health care providers frequently ascribe "altered mental status" to other causes, such as dementia, psychosis, or depression. The objective was to determine the relationship between altered mental status as a chief complaint and delirium. This was a secondary analysis of a cross-sectional study designed to validate three brief delirium assessments, conducted from July 2009 to March 2012. English-speaking patients who were 65 years or older and in the ED for <12 hours were included. Patients who were comatose or nonverbal or unable to follow simple commands prior to the acute illness were excluded. Chief complaints were obtained from the ED nurse triage assessment. The reference standard for delirium was a comprehensive psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivity, specificity, positive likelihood ratio (LR), and negative LR with their 95% confidence intervals (CIs) were calculated using the psychiatrist's assessment as the reference standard. A total of 406 patients were enrolled. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, 57 (14.0%) were nonwhite race, and 50 (12.3%) had delirium. Twenty-three (5.7%) of the cohort had chief complaints of altered mental status. The presence of this chief complaint was 38.0% sensitive (95% CI = 25.9% to 51.9%) and 98.9% specific (95% CI = 97.2% to 99.6%). The negative LR was 0.63 (95% CI = 0.50 to 0.78), and the positive LR was 33.82 (95% CI = 11.99 to 95.38). The absence of a chief complaint of altered mental status should not reassure the clinician that delirium is absent. This syndrome will be missed unless it is actively looked for using a validated delirium assessment. However, patients with this chief complaint are highly likely to be delirious, and no additional delirium assessment is necessary.

Delirium in Older Emergency Department Patients Is an Independent Predictor of Hospital Length of Stay

The consequences of delirium in the emergency department (ED) remain unclear. This study sought to determine if delirium in the ED was an independent predictor of prolonged hospital length of stay (LOS). This prospective cohort study was conducted at a tertiary care, academic ED from May 2007 to August 2008. The study included English-speaking patients aged 65 and older who were in the ED for less than 12 hours at enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or did not have a delirium assessment performed by the research staff. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to determine delirium status. Patients who were discharged directly from the ED were considered to have a hospital LOS of 0 days. To determine if delirium in the ED was independently associated with time to discharge, Cox proportional hazard regression was performed adjusted for age, comorbidity burden, severity of illness, dementia, functional impairment, nursing home residence, and surgical procedure. A sensitivity analysis, which included admitted patients only, was also performed. A total of 628 patients met enrollment criteria. The median age was 75 years (interquartile range [IQR] = 69-81), 365 (58%) patients were female, 111 (18%) were nonwhite, 351 (56%) were admitted to the hospital, and 108 (17%) were delirious in the ED. Median LOS was 2 days (IQR = 0-5.5) for delirious ED patients and 1 day (IQR = 0-3) for nondelirious ED patients (p < 0.001). The hazard ratio (HR) of delirium for time to discharge was 0.71 (95% confidence interval [CI] = 0.57 to 0.89) after adjusting for confounders, and indicated that ED patients with delirium were more likely to have prolonged hospital LOS compared with those without delirium. For the sensitivity analysis, which included only hospitalized patients, the adjusted HR was 0.76 (95% CI = 0.58 to 0.99). Delirium in older ED patients has negative consequences and is an independent predictor of prolonged hospitalizations.